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Board Paper 21st January 2009

  1. Introduction

The implementation of water fluoridation schemes to adjust to the optimal level of fluoride in the water supplies of 1ppm (parts per million) has been inconsistent across the country and in the East Midlands.
The Department of Health issued guidance on the consultation on water fluoridation, as Best Practice Guidance (Gateway Reference No. 9361, February 2008). This sets out the legislative framework and the roles of PCTs and SHAs in the process of conducting the consultation.
Whilst there are various ways to deliver fluoride as a public health measure – water, milk, salt, topical fluoride supplements and toothpaste programmes - this paper will be concerned with processes to consider the introduction of new or extensions to existing water fluoridation schemes. It provides a summary for dental health and fluoridation and recommendations regarding a feasibility study.

  1. Existing East Midlands Fluoridation Schemes

Water companies and water distribution systems are not coterminous with PCT and other administrative boundaries. There are two main water suppliers in the East Midlands, Severn Trent Water and Anglian Water. Severn Trent Water serves most of Derbyshire. In addition South Staffordshire Water Company serves a small area of South Derbyshire district with fluoridated water and North West Water serves a small area in High Peak.
All water supplies naturally contain a small amount of fluoride. Details of local authorities in Derbyshire part of which receive a water supply with fluoride levels adjusted to 1ppm are in Table 1: -
Table 1. Current water fluoridation schemes in Derbyshire

Water Company

Local Authority

Year established

South Staffordshire Water Company.

Part of South Derbyshire


Severn Trent Water

Part of Bolsover District and small areas of North East Derbyshire

Early 1970s

  1. Oral Health Needs Assessment

The effect of fluoride in disease terms is on dental caries (decay) so the prime dental measure is the decay rates measured as dmft (decayed missing and filled teeth in deciduous and permanent dentitions, respectively). Water fluoridation can be an effective solution to reducing the prevalence of dental decay and reducing inequalities in oral health.
The current position for 5 year-olds, across the East Midlands, is summarised in Figure 1 which clearly illustrates the wide variations in child dental health across the East Midlands by new PCT area. The position is noticeably worse in the inner city areas of Nottingham and Leicester, and to a lesser extent Derby, although the worrying picture in Central Derby is diluted by the merging of data from the former Greater Derby PCT area. Dental caries is a multi-factorial disease, with socio-economic, geographic and cultural differences influencing the extent of the problem and there are variations in dental health within all PCTs.
Figure 1. dmft levels in 5 year-olds 2005/06 – East Midlands

Despite the fact that some areas of the East Midlands compare favourably with the national and Regional averages, there is clearly still much to do to improve oral health when one considers the proportion of children affected by this preventable disease by the age of five. Figure 2 shows that in Derbyshire County 30% of 5 year-old children are affected compared with 32% on average across the East Midlands. As with most diseases, the children with most tooth decay and the greatest need for dental care are those in the lowest socio-economic groups, which paradoxically make the least use of services.

Figure 2. Proportion of 5 year-olds affected by decay – 2005/06 East Midlands

The variations in caries levels in older children and the benefits to the permanent dentition is broadly the same as the deciduous dentition.

  1. Benefits and harms of water fluoridation

To clarify the issue of scientific evidence, the Department of Health commissioned York University’s NHS Centre for Reviews and Dissemination to undertake a systematic review of the evidence on fluoridation of water and this was reported in 2000. It considered 3,000 research papers spanning over 50 years of evidence. The review looked specifically at the effects on dental decay, social inequalities and any harmful effects. The York Review found that many of the studies were undertaken to different standards from today, and were excluded from the results. However the report said that from the evidence it considered that fluoride at the level suggested (1ppm) did reduce dental decay, by on average over 2 teeth per child with the percentage of caries free children increasing by 15%, and that there was no evidence of any harmful effects. It also noted that the reduction is greatest in those areas with the highest caries levels. This beneficial effect comes at the expense of an increase in the prevalence of dental fluorosis. No association between water fluorides and other adverse effects, such as cancer, bone fracture and Down’s syndrome was found. However the review team felt that not enough was known because the quality of evidence was poor.
The Department of Health commissioned further research from the Medical Research Council (MRC) to address outstanding issues and advise on any further priorities for water fluoridation. The MRC’s key findings and recommendations included:

  • Support for the findings of the York Review that fluoridating water may have a beneficial effect on reducing tooth decay.

  • That the majority of research indicated that water fluoridation reduced inequality in dental decay between high and low social economic groups.

  • Additional information about fluoridation was needed by the public in order to allow them to make an informed decision particularly on the prevalence of forms of dental fluorosis.

  • The evidence did not support claims that fluoridated water affected the immune system, reproductive system, child development the kidneys, or the gastro-intestinal tract. The MRC Report (2002) recommended routine monitoring of the factors such as cancer as a matter of good practice. (Regulations now require the SHAs to monitor health in fluoridated areas on a 4 yearly cycle)

  • Comparison to be made between the amounts of fluoride the body absorbs from water supply in which it occurs naturally and those to which it has been added artificially.

A further Systematic Review of the efficacy and safety of fluoridation by the Australian National Health and Medical Research Council was reported in 2007. The conclusion was that “Fluoridation of drinking water remains the most widely effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride.” In relation to dental fluorosis this review commented that water fluoridation does result in the development of dental fluorosis but most of it is “mild and not to be considered of aesthetic concern”. The Review concluded that there was “little effect on fracture risk, either protective or deleterious” and no clear association between water fluoridation and overall cancer incidence or mortality (for “all cause” cancer, and, specifically for bone cancer and osteosarcoma). [Reported in Evidence –Based Dentistry Vol 9 No. 2 2008 pp39-43 or full report at]

  1. Legal and Human Rights

There has been controversy on the legal and human rights aspects of water fluoridation. Recent opinion was to South Central SHA by their legal representative which was that this has been tested in cases at the European Court of Justice and water fluoridation has not been judged to contravene human rights legislation.

  1. Funding for Water Fluoridation in England

The funding position is set out in the February 2008 Guidance in paragraphs 34-36.

“34. If the SHA receives a request from a PCT to explore the possibility of fluoridation and it decides to take the matter further, it will have to reach agreement with the PCTs on how the feasibility study required of the water undertaker and any subsequent consultation should be funded.

35. Should, following public consultation, an SHA decide to proceed with a fluoridation scheme, then under section 87(6) of the 1991 Act the fluoridation agreement with the water company must include terms requiring the SHA to meet the reasonable capital and operating costs incurred by the water undertaker in giving effect to the arrangements. Subject to the availability of funding, the Department will pay the capital costs of new schemes or the replacement of plant required to maintain existing schemes. SHAs should note that the fluoridation plant becomes an asset of the water company and is therefore excluded from the NHS capital charges arrangements.
36. If the scheme is implemented, the PCTs will have to reimburse the SHA for the recurring costs of the fluoridation scheme. PCTs may use funds allocated to them for primary care dental services to meet these costs. As the SHA is the legally responsible NHS body and holds the legal agreement with the water undertaker, the expenditure will need to be shown in its accounts.”

  1. Feasibility Study

The Act that covers water fluoridation is the 1991 Water Act and the specific 2003 Amendment. The legislation gives SHAs the executive role for water fluoridation because water distribution systems are generally larger than the area covered by a single PCT. SHAs are therefore responsible for the conduct of consultations and making arrangements with water undertakers. However, PCTs also contribute because they are responsible for assessing the oral health needs of their population, and commissioning the services required to meet these needs.
If the PCT concludes that fluoridation of water could be appropriate to reduce the prevalence of dental disease and reducing inequalities in oral health it may then approach the SHA in order to discuss the commissioning of a study from the water company to assess the technical feasibility and cost of a fluoridation scheme. It is important that, from that stage on, the PCT(s) concerned and the SHA work very closely together. Within the East Midlands this has happened via the Regional Directors of Public Health Group.
Before an SHA decides to proceed with exploring the benefits of fluoridation, and before deciding whether to carry out a public consultation under section 89(1) of the 1991 Act, it is required to consult the water undertaker in question on whether the fluoridation arrangements would be operable and efficient. SHAs are encouraged to work with PCTs on the commissioning of a feasibility study from the relevant water undertaker(s). As these discussions are likely to attract local interest, including that of the media, it may be appropriate for the SHA to work with PCTs on preparing a communication plan before first approaching the water undertaker.
During all the discussions described above, it is essential that all parties understand and make clear to the public that those discussions are an aid to understanding whether or not a fluoridation scheme may be technically viable and affordable. They are therefore an essential pre-requisite to making a decision subsequently as to whether or not the SHA should undertake a formal (statutory) public consultation as required by the legislation.
It is proposed, therefore, that there should be a collaborative approach in the design of the feasibility study and an assurance of economies of scale for the NHS. The feasibility studies will need to include the technical aspects, the cost of a fluoridation scheme and the impact on disease levels.

  1. The PCT is asked to approve the commissioning of a feasibility study and associated cost benefit / disbenefit analysis through and in close collaboration with Nottingham City PCT which is leading for East Midlands PCTs and SHA.

  2. The Board are asked to recommend the most appropriate process for reaching a decision on the PCT position regarding water fluoridation.

  3. Establish a local Fluoridation Group to oversee the feasibility study and develop recommendations to the PCT regarding its position on water fluoridation, including that due process is followed.

  4. Ensure that the local Fluoridation Group coordinates with the Regional Dental Public Health Network or similar Regional group established to coordinate work at a regional level, including consideration of a communications plan.


Ken Wragg - Consultant in Dental Public Health

Derbyshire County PCT

January 2009

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