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(05/01/16) A summary of 'Cochrane Collaboration systematic review of water fluoridation 2015' has been posted in Reports.
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(16/04/14) A critique of 'One in a Million: The Facts' has been posted in Reports.
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(16/04/14) 'Fluoridation: Popularity' has been posted in the Archive.
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(18/04/10) New fluoridation scheme for Southampton

(18/04/10) The Reports and Archive sections have been updated with further documents and links

(11/07/09) A critique of Prof. Newton's report to South Central SHA has been posted in Reports.
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(28/09/08) A critique of the South Central Strategic Health Authority Consultation Paper on Water Fluoridation in Southampton, has been posted in Reports.
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(07/09/08) A response to the Chief Dental Officer's 'Dear Colleague' letter of guidance for new schemes, endorsed by scientists from the York review, has been posted in Reports.
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(23/06/08) Isle of Man has announced on 12th June that it will not be fluoridating its water supply
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Southampton consultation: Summary of responses

1. South Central SHA commissioned an 'Independent summary of consultation responses' by The Evidence Centre to help it decide on 26th February 2009 whether or not to fluoridate. This 80-page document is a "compilation of the responses", summarising the most common comments and noting any evidence cited. It did not judge or weigh responses: that was the task of the SHA, which had to assess the level of support for fluoridation, the cogency/coherence of the arguments, the extent to which they were based on evidence, and whether the health benefits outweighed all other potential concerns. The summary appears to be impartial. The following points from a long report may highlight some areas of interest and/or concern.

2. 10,203 responses were received, of which 93% were from members of the public. 72% of those within the areas to be fluoridated opposed fluoridation; 28% supported it. Institutions, and those who wrote in from outside (in some cases from the other side of the world), were keenest to see Southampton fluoridated. Less than 5% of responses provided supporting evidence. The worst offenders were supporters of fluoridation, by whom the evidence base was "taken for granted": "The little evidence that was mentioned tended to involve observational studies or opinion pieces". "Those who opposed fluoridation were more likely to cite evidence to back up their claims . ."

3. A separate telephone survey of 2,060 randomly selected local residents was conducted by ICM Research in order to get a more representative view, recognising that responders to the consultation might be limited to those who held firm opinions. 38% of these opposed; 32% supported; 19% did neither; 10% "do not know". 27% strongly opposed; 12% strongly supported. "Those who say they know a great deal or fair amount about the subject are more likely than those with minimal knowledge to oppose fluoridation . ." Older residents are more opposed than younger; the unemployed are more opposed than others; ethnic minorities are more supportive than others.

4. The Evidence Centre showed some worrying confusion about the purposes of consultation. The Chief Dental Officer's February 2008 letter to SHAs and PCTs, which is undisguisedly pro-fluoridation, states that "The response to the consultations will indicate the extent of support for a proposal"; "the extent of support", with "the cogency of the arguments", are crucial elements under the Water Fluoridation Regulations 2005. But TEC's summary states that the aim of the consultations was "to give people the opportunity to express different perspectives and issues for the SHA Board to consider", not to discover proportions of supporters and opponents: it was the telephone survey that assessed "levels of support". The public may be surprised to learn that "The Board will not use the consultation feedback as a proxy to represent the wider population's views". It seems that the SHA have redefined the groundrules. The CDO's 2008 letter includes opinion surveys as only one kind of "response to the consultations"; TEC however suggests that it may be the whole story.

TEC also (but in one place only, under 'Next steps'), misstates the 2005 Regulations by restricting "all arguments against proceeding" to the scientific and medical, thus taking ethical objections out of the equation. It makes a further mistake under 'Analysis' when, having said that decisions cannot be based "solely" on a count of opponents and supporters, it states that "Instead" the SHA must consider cogency. The Regulations demand both.

5. The views of people living and working in the area were to be prioritised. The SHA stated that it might or might not consider out-of-area submissions, but that it would consider dental and professional ones. This approach gave the SHA free rein to favour the "professional orthodoxy", an accurate description of fluoridation given by the Regional Director of Public Health in his own paper to the Board, at the expense of other views.

6. The reasons given for and against were many and interlinking. Broadly summarised, opponents objected on principle to mass medication and the abolition of choice, and in detail to the weak evidence for safety and efficacy and the existence of other approaches. Evidence on potential harm made up the largest proportion of all evidence submitted. The seminal 'York' review was cited by opponents and supporters. The latter favoured the preventative principle and reduction of inequalities. Organisations which favoured fluoridation often focused on the philosophy behind it (making "minimal demands in terms of compliance" is an Orwellian way of describing compulsion in taking fluoride). It was seen as (cost-)effective, for an area with "serious dental health problems", safe, and evidence-based, but without stating what the evidence was.

7. The summary ends with 23 pages of studies that were most frequently cited. Almost all of them pre-dated the York review, and so they are of little value in scientific terms since York has already given the most expert assessment of the world literature to the year 2000, and since then an Australian systematic review in 2007 has confirmed York's findings. Any studies that did not meet York's inclusion criteria can only lower the reliability of the overall evidence base.

Edward Baldwin.
April 2009.

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