Notes for tomorrow's F-debate

Editor's note: this post was originally published at Myles Kitagawa's personal blog space.

I guess it’s not going to be my first debate on CityTV’s breakfast television tomorrow morning ~ but it’s been a while.  The all-candidate’s forums of the 2001 municipal elections had a definite debate-like quality to them.  And one year Edmonton’s academic highschool debate champions challenged my MLA (member of the legislative assembly) and myself to a debate on climate change.  

So, tomorrow at 9am, CityTV is going to air a feature story on water fluoridation in Edmonton and producers decided to accompany it with a live debate on the issue featuring a local dentist and me.

I actually think it’s going to be kind of fun.

I’m not an anti-F activist.  All of the AlexJonesian idiocy about fluoride being a tool of the NewWorldOrder and it’s global depopulation project really annoys me. In fact, I believe that water fluoridation probably doesn’t hurt most people.

But just because something doesn’t hurt people isn’t an argument for public dollars being spent on it.

Topical application of fluoride is good for your dental health.  I think that is a fact and it is undisputed.  Applying fluoride to the surface of your dental enamel prevents tooth decay.

The issue is this: in a developed country like Canada, in a fluoridated community like Edmonton, we are paying three times for essentially the same treatment.  I pay my dentist for fluoride treatments once per year.  I pay for my toothpaste that I apply to my teeth twice per day.  And I pay as a citizen for the extremely weak fluoride solution of that passes over my teeth whenever I drink tap water.  The question is, is there any value to this extra water fluoridation expense that we’re all forced to pay collectively, when we already pay for more effective treatments individually.

I think a big part of the answer is found by looking at the last 30 years of dental health data for developed countries as gathered by the World Health Organization.  This information looks at 18 countries, 14 that do not add fluoride to their water and 4 that do.  What we see is a comparable improvement in dental health across all countries.  So, I think this third payment is actually wasted money.

But then we should consider that there are some people who should not be drinking fluoridated water.  American Dental Association and the Canadian Pediatric Society both advise that infant formula not be prepared with fluoridated water. So now we have people, the parents of newborns, who must in a sense pay a fourth time for fluoridation – this time to avoid it.

Then there are the people who wish to avoid fluoridated water because of the unanswered questions on how it might affect human health. There is really interesting research on the associations with silicofluorides in drinking water and human health effects.  There are several – including cancer and bone health - but I’ll only mention the ones that I think are really interesting and that’s those are the associations between fluoridated water and IQ – where fluoridated water reduces children’s ability to evacuate lead from their bodies, and an association with hyperactivity and reduced impulse control – both of which would indirectly lead to learning problems. 

Now Health Canada is correct – on a weight-of-evidence approach- there isn’t enough information in this research to make definitive conclusions.  But we’re discussing a treatment which is probably inferior, definitely redundant, to things were are already doing so there is no reason to continue to run this risk while the research continues.  And from an economic perspective,  we’re spending $600,000 per year in direct costs on this probably inferior, definitely redundant activity.  Which City Council could easily find other uses for that would be more appreciated by Edmontonians.

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The trouble with arguments that seek to remove fluoride from the water supply is the negative health outcomes for lower income people. While you might be paying for fancy fluoride toothpaste and bi-yearly dentist visits the poor often are not.

Jane Brody makes an excellent case for fluoridated water as one of the ten best public health measures of the past century and I tend to agree with her

http://well.blogs.nytimes.com/2012/01/23/dental-exam-went-well-thank-flu...

It also makes a lot of sense from an economic point of view.

"Every $1 invested in fluoridation saves approximately $38 in dental treatment costs, according to the C.D.C. The cost of a single filling averages $140, and that’s only the beginning. Through the years, a filled tooth is likely to require further repairs and maybe even extraction and replacement with a bridge or implant costing thousands of dollars."

"Fluoridation confers the greatest benefit to those who need it most: the poor and poorly educated and those with limited access to regular dental care. In the years ahead, removal of fluoride from drinking water will almost certainly cost taxpayers millions of dollars in increased Medicaid expenditures."

The category of poor who are not able to brush their teeth twice per day are those who do not own toothbrushes or have a sink to spit in. Students and the housed working poor are capable of brushing their teeth.

In 2010, according to the homeless count at http://homewardtrust.ca/programs/homeless-count.php, they numbered 2,421 persons.

The argument that the most effective investment of $600,000 per year to help 2,421 people is to fluoridate everyone's drinking water strikes me as nonsensical. The toothbrushless-poor have higher order, systemic problems which $600,000/year would likely be useful in remedying. And are the sort of "other uses" which I had in mind with the post.

I get the poverty argument for crumbling-empire USA, but in Edmonton, it seems to me that $75k for a staff person plus $100k on toothpaste, and you're done.

And then parents don't have to buy a reverse-osmosis system (or bottled water) to follow Pediatric Society recommendations on how to feed their babies.

Capable of brushing your teeth and brushing your teeth are two entirely different things. Unfortunately we are not as homo economicus. There is a large body of scholarly evidence that points to the fact the lower your socioeconomic status the more likely you are to get cavities.

http://scholar.google.ca/scholar?q=tooth+brushing+rates+socioeconomic+cl...

I am not willing to abdicate a proven public health measure for the most socio-economically deprived members of our society because of 600K. You haven't put forth a convincing argument as to why we should get rid of fluoride aside from the economic argument, which is highly disputable.

Do not throw away the conclusions of the Center for Disease Control so lightly. It is one of the most respected public health bodies in the world. If $1 invested in fluoridation saves anywhere near $38 in dental treatment costs then I am on board.

Great argument Duncan. I think I'm convinced.

From my own experience, I've was shocked to see the teeth of kids in one northern Alberta community that presumably doesn't have fluoridated water. Mouths full of metal.

I also have felt better ever since the city of Edmonton halved the amount of fluoride in our water last year (?).

Based on my favourite slide at the top of this page, I believe that Jane Brody is discounting the benefits of what she refers to as "the diffusion effect" - the benefit of adding fluoride to toothpastes. The 6 DMFT down to 1 of unfluoridated Germany versus 5.5 DMFT down to 1 of fluoridated Ireland is a 100% diminishment the benefit that can be attributed to fluoridated water supplies, not the 25-40% that Brody cites, so, I trust that Duncan and I are only debating whether Edmonton's poor are helped or hindered by the City's fluoridation practice, and that for anyone on socio-economic par with homo economicus, water fluoridation is redundant.

I accept Duncan's argument that owning toothbrushes and toothpaste are not enough. People also have to use them. And I will further accept from his references that I overestimated the prevalence of toothbrushing among the poor.

I do accept (based on the references in the silicofluoride/lead uptake section of the bibilography at http://www.slweb.org/bibliography.html#silicofluorides) the finding that children co-exposed to fluoridated water and old housing were the most likely to have venous blood lead > 10ug/dL.

I accept Epcor’s finding that 2,211 Edmonton homes of 1950’s vintage and older have lead service pipe. http://www.epcor.ca/SiteCollectionDocuments/Communities/Alberta/Initiati...

I believe that children living in older housing are probably poor.

I accept the New England Journal of Medicine’s findings that:
a. there is an inverse relationship between blood lead levels and IQ in children (ie. the more lead, the lower IQ)
b. exposure to lead in early childhood has an enduring effect of neuropsychological development throughout childhood
http://www.nejm.org/doi/full/10.1056/NEJM199210293271805

I infer from the NEJM’s findings that for each 1ug/dL increase in blood lead levels, $2,000 in gross social costs are incurred in clinical attention, remedial education, and lost productivity, and that poor households are less capable of providing any additional enrichment therapies.

I also conclude that part of the deficits incurred in early childhood exposure to lead will increase the probability that children of poor households will lead poor households later in life.
I submit that the number of Edmontonians who are arguably benefiting dentally from municipal fluoridation is small, and are also the people who are most at risk from the negative effects of fluoridation (rich people don’t have lead pipes) through the creation of long-term systemic problems.

I propose that it would be more beneficial to cease fluoridating the water of poor children, and contribute instead to ensuring topical fluoride treatments are provided to them.

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