Water fluoridation schemes have operated for nearly 50 years in England and over 50 years internationally. In that time no evidence has arisen demonstrating that there is harm to general health from these schemes. Furthermore there are communities in England who have consumed fluoride in their water supply for generations at levels close those achieved by water fluoridation schemes. It is reasonable to judge that, after the passage of so many years of public health surveillance, if there was any harm to general health from water fluoridation then this would be apparent.

The authors of the York review of water fluoridation have stated that they found a benefit in the form of reduction in caries, balanced against an increase in

fluorosis and that no clear evidence of other potential negative effects was found. In 2002, the Medical Research Council made recommendations regarding surveillance and research priorities. The National Institute for Health Research welcomes funding applications for research into any aspect of human health, including water fluoridation. These applications are subject to peer review and judged in open competition, with awards being made on the basis of the scientific quality of the proposals made. Any new evidence emerging regarding water fluoridation will be assessed by Public Health England (PHE). PHE is currently working towards publishing a first report on the health effects of fluoridation by the end of March 2014, as required by legislation. This will be a publicly available document. Further reports will follow within four-yearly time periods in accordance with the timetable prescribed in legislation.

Given the degree of scrutiny that has been applied to the links between water fluoridation and general health, the government is satisfied that water fluoridation is a safe and effective public health measure. What is very apparent is the harm caused by dental caries which is still a common cause of children to be admitted to hospital and affects those children from deprived communities the most.

The study by McGrady et al used novel technologies and photographing teeth in order to facilitate a highly standardised and reliable assessment of mottling (fluorosis), reducing potential examiner bias—a key recommendation of the York Review. Fluorosis is primarily a cosmetic issue affecting the appearance of the teeth and therefore, when attempting to assess whether there is a greater level of mottling in populations which may be caused by fluorosis, it is useful to distinguish mottling which is likely to be of aesthetic concern.

Whilst this study by McGrady et al is a cross-sectional study, it is the largest and most recent study to be undertaken on a domestic population since the York Review and addresses methodological concerns raised by that review. The study supports previous work and adds to the evidence base, providing further assurance that water fluoridation reduces oral health inequalities. The aforementioned report by PHE will also review the available information on tooth decay levels in fluoridated communities.

The maxillary central incisors are usually the most visible teeth in the mouth when smiling and speaking and will therefore contribute the most to the aesthetic appearance of the dentition. The use of maxillary central incisors in this study was partly to facilitate the use of a standardised photographic methodology and partly to reflect that the appearance of the two largest upper front teeth will be a key part of an individual’s perception of the appearance of their dentition as a whole. Fluoride absorption during tooth development will potentially affect all developing teeth so examination of the maxillary central incisors should provide a good representation of the teeth as a whole. Furthermore, the enamel of these teeth will be fully visible at the age of 11. Therefore this research methodology appears appropriate for the purpose of providing an accurate estimate of clinical fluorosis levels in a population and

has advantages over visual examination and scoring as factors such as differences in incident light can affect the appearance of teeth quite markedly.

Water fluoridation schemes have operated for nearly 50 years in England and over 50 years internationally. In that time no evidence has arisen demonstrating that there is harm to general health from these schemes. Furthermore there are communities in England who have consumed fluoride in their water supply for generations at levels close those achieved by water fluoridation schemes. It is reasonable to judge that, after the passage of so many years of public health surveillance, if there was any harm to general health from water fluoridation then this would be apparent.

The authors of the York review of water fluoridation have stated that they found a benefit in the form of reduction in caries, balanced against an increase in

fluorosis and that no clear evidence of other potential negative effects was found. In 2002, the Medical Research Council made recommendations regarding surveillance and research priorities. The National Institute for Health Research welcomes funding applications for research into any aspect of human health, including water fluoridation. These applications are subject to peer review and judged in open competition, with awards being made on the basis of the scientific quality of the proposals made. Any new evidence emerging regarding water fluoridation will be assessed by Public Health England (PHE). PHE is currently working towards publishing a first report on the health effects of fluoridation by the end of March 2014, as required by legislation. This will be a publicly available document. Further reports will follow within four-yearly time periods in accordance with the timetable prescribed in legislation.

Given the degree of scrutiny that has been applied to the links between water fluoridation and general health, the government is satisfied that water fluoridation is a safe and effective public health measure. What is very apparent is the harm caused by dental caries which is still a common cause of children to be admitted to hospital and affects those children from deprived communities the most.

The study by McGrady et al used novel technologies and photographing teeth in order to facilitate a highly standardised and reliable assessment of mottling (fluorosis), reducing potential examiner bias—a key recommendation of the York Review. Fluorosis is primarily a cosmetic issue affecting the appearance of the teeth and therefore, when attempting to assess whether there is a greater level of mottling in populations which may be caused by fluorosis, it is useful to distinguish mottling which is likely to be of aesthetic concern.

Whilst this study by McGrady et al is a cross-sectional study, it is the largest and most recent study to be undertaken on a domestic population since the York Review and addresses methodological concerns raised by that review. The study supports previous work and adds to the evidence base, providing further assurance that water fluoridation reduces oral health inequalities. The aforementioned report by PHE will also review the available information on tooth decay levels in fluoridated communities.

The maxillary central incisors are usually the most visible teeth in the mouth when smiling and speaking and will therefore contribute the most to the aesthetic appearance of the dentition. The use of maxillary central incisors in this study was partly to facilitate the use of a standardised photographic methodology and partly to reflect that the appearance of the two largest upper front teeth will be a key part of an individual’s perception of the appearance of their dentition as a whole. Fluoride absorption during tooth development will potentially affect all developing teeth so examination of the maxillary central incisors should provide a good representation of the teeth as a whole. Furthermore, the enamel of these teeth will be fully visible at the age of 11. Therefore this research methodology appears appropriate for the purpose of providing an accurate estimate of clinical fluorosis levels in a population and

has advantages over visual examination and scoring as factors such as differences in incident light can affect the appearance of teeth quite markedly.

Water fluoridation schemes have operated for nearly 50 years in England and over 50 years internationally. In that time no evidence has arisen demonstrating that there is harm to general health from these schemes. Furthermore there are communities in England who have consumed fluoride in their water supply for generations at levels close those achieved by water fluoridation schemes. It is reasonable to judge that, after the passage of so many years of public health surveillance, if there was any harm to general health from water fluoridation then this would be apparent.

The authors of the York review of water fluoridation have stated that they found a benefit in the form of reduction in caries, balanced against an increase in

fluorosis and that no clear evidence of other potential negative effects was found. In 2002, the Medical Research Council made recommendations regarding surveillance and research priorities. The National Institute for Health Research welcomes funding applications for research into any aspect of human health, including water fluoridation. These applications are subject to peer review and judged in open competition, with awards being made on the basis of the scientific quality of the proposals made. Any new evidence emerging regarding water fluoridation will be assessed by Public Health England (PHE). PHE is currently working towards publishing a first report on the health effects of fluoridation by the end of March 2014, as required by legislation. This will be a publicly available document. Further reports will follow within four-yearly time periods in accordance with the timetable prescribed in legislation.

Given the degree of scrutiny that has been applied to the links between water fluoridation and general health, the government is satisfied that water fluoridation is a safe and effective public health measure. What is very apparent is the harm caused by dental caries which is still a common cause of children to be admitted to hospital and affects those children from deprived communities the most.

The study by McGrady et al used novel technologies and photographing teeth in order to facilitate a highly standardised and reliable assessment of mottling (fluorosis), reducing potential examiner bias—a key recommendation of the York Review. Fluorosis is primarily a cosmetic issue affecting the appearance of the teeth and therefore, when attempting to assess whether there is a greater level of mottling in populations which may be caused by fluorosis, it is useful to distinguish mottling which is likely to be of aesthetic concern.

Whilst this study by McGrady et al is a cross-sectional study, it is the largest and most recent study to be undertaken on a domestic population since the York Review and addresses methodological concerns raised by that review. The study supports previous work and adds to the evidence base, providing further assurance that water fluoridation reduces oral health inequalities. The aforementioned report by PHE will also review the available information on tooth decay levels in fluoridated communities.

The maxillary central incisors are usually the most visible teeth in the mouth when smiling and speaking and will therefore contribute the most to the aesthetic appearance of the dentition. The use of maxillary central incisors in this study was partly to facilitate the use of a standardised photographic methodology and partly to reflect that the appearance of the two largest upper front teeth will be a key part of an individual’s perception of the appearance of their dentition as a whole. Fluoride absorption during tooth development will potentially affect all developing teeth so examination of the maxillary central incisors should provide a good representation of the teeth as a whole. Furthermore, the enamel of these teeth will be fully visible at the age of 11. Therefore this research methodology appears appropriate for the purpose of providing an accurate estimate of clinical fluorosis levels in a population and

has advantages over visual examination and scoring as factors such as differences in incident light can affect the appearance of teeth quite markedly.

Water fluoridation schemes have operated for nearly 50 years in England and over 50 years internationally. In that time no evidence has arisen demonstrating that there is harm to general health from these schemes. Furthermore there are communities in England who have consumed fluoride in their water supply for generations at levels close those achieved by water fluoridation schemes. It is reasonable to judge that, after the passage of so many years of public health surveillance, if there was any harm to general health from water fluoridation then this would be apparent.

The authors of the York review of water fluoridation have stated that they found a benefit in the form of reduction in caries, balanced against an increase in

fluorosis and that no clear evidence of other potential negative effects was found. In 2002, the Medical Research Council made recommendations regarding surveillance and research priorities. The National Institute for Health Research welcomes funding applications for research into any aspect of human health, including water fluoridation. These applications are subject to peer review and judged in open competition, with awards being made on the basis of the scientific quality of the proposals made. Any new evidence emerging regarding water fluoridation will be assessed by Public Health England (PHE). PHE is currently working towards publishing a first report on the health effects of fluoridation by the end of March 2014, as required by legislation. This will be a publicly available document. Further reports will follow within four-yearly time periods in accordance with the timetable prescribed in legislation.

Given the degree of scrutiny that has been applied to the links between water fluoridation and general health, the government is satisfied that water fluoridation is a safe and effective public health measure. What is very apparent is the harm caused by dental caries which is still a common cause of children to be admitted to hospital and affects those children from deprived communities the most.

The study by McGrady et al used novel technologies and photographing teeth in order to facilitate a highly standardised and reliable assessment of mottling (fluorosis), reducing potential examiner bias—a key recommendation of the York Review. Fluorosis is primarily a cosmetic issue affecting the appearance of the teeth and therefore, when attempting to assess whether there is a greater level of mottling in populations which may be caused by fluorosis, it is useful to distinguish mottling which is likely to be of aesthetic concern.

Whilst this study by McGrady et al is a cross-sectional study, it is the largest and most recent study to be undertaken on a domestic population since the York Review and addresses methodological concerns raised by that review. The study supports previous work and adds to the evidence base, providing further assurance that water fluoridation reduces oral health inequalities. The aforementioned report by PHE will also review the available information on tooth decay levels in fluoridated communities.

The maxillary central incisors are usually the most visible teeth in the mouth when smiling and speaking and will therefore contribute the most to the aesthetic appearance of the dentition. The use of maxillary central incisors in this study was partly to facilitate the use of a standardised photographic methodology and partly to reflect that the appearance of the two largest upper front teeth will be a key part of an individual’s perception of the appearance of their dentition as a whole. Fluoride absorption during tooth development will potentially affect all developing teeth so examination of the maxillary central incisors should provide a good representation of the teeth as a whole. Furthermore, the enamel of these teeth will be fully visible at the age of 11. Therefore this research methodology appears appropriate for the purpose of providing an accurate estimate of clinical fluorosis levels in a population and

has advantages over visual examination and scoring as factors such as differences in incident light can affect the appearance of teeth quite markedly.

Public Health England is currently working towards publishing a first report on the health effects of fluoridation by mid-March 2014, as required by legislation. This will be a publicly available document. Further reports will follow within four-yearly time periods in accordance with the timetable prescribed in legislation. This report will analyse the overall incidence of cancer, including specifically that of osteosarcoma, in relation to residence within a fluoridated area, taking into account confounding variables.

The Department's National Institute for Health Research welcomes funding applications for research into any aspect of human health, including water fluoridation. These applications are subject to peer review and judged in open competition, with awards being made on the basis of the scientific quality of the proposals made.

The NHS Choices website section on fluoride is due for review in January 2014 and we have asked Public Health England (PHE) to review the information and make recommendations by 15 December. This will include ensuring that the information for the public is clear and based on evidence.

Pending that review, we are advised by PHE that there is no credible scientific evidence that water fluoridation at 1 part per million, the target level for water fluoridation schemes in England, or fluoridated toothpaste, used as such, is a cause of general ill health.

Regarding dental fluorosis, we are advised by PHE of a recent research by McGrady and co-workers, published in BMC Public Health 2012, comparing levels of dental fluorosis in fluoridated Newcastle and unfluoridated Manchester which showed that 0.1% of children in Newcastle had severe fluorosis compared with 0.2% in Manchester; the prevalence of moderate fluorosis was 1% in Newcastle compared to 0% in Manchester, these being far lower levels than those suggested by the York review.

The NHS Choices website section on fluoride is due for review in January 2014 and we have asked Public Health England (PHE) to review the information and make recommendations by 15 December. This will include ensuring that the information for the public is clear and based on evidence.

Pending that review, we are advised by PHE that there is no credible scientific evidence that water fluoridation at 1 part per million, the target level for water fluoridation schemes in England, or fluoridated toothpaste, used as such, is a cause of general ill health.

Regarding dental fluorosis, we are advised by PHE of a recent research by McGrady and co-workers, published in BMC Public Health 2012, comparing levels of dental fluorosis in fluoridated Newcastle and unfluoridated Manchester which showed that 0.1% of children in Newcastle had severe fluorosis compared with 0.2% in Manchester; the prevalence of moderate fluorosis was 1% in Newcastle compared to 0% in Manchester, these being far lower levels than those suggested by the York review.

The NHS Choices website section on fluoride is due for review in January 2014 and we have asked Public Health England (PHE) to review the information and make recommendations by 15 December. This will include ensuring that the information for the public is clear and based on evidence.

Pending that review, we are advised by PHE that there is no credible scientific evidence that water fluoridation at 1 part per million, the target level for water fluoridation schemes in England, or fluoridated toothpaste, used as such, is a cause of general ill health.

Regarding dental fluorosis, we are advised by PHE of a recent research by McGrady and co-workers, published in BMC Public Health 2012, comparing levels of dental fluorosis in fluoridated Newcastle and unfluoridated Manchester which showed that 0.1% of children in Newcastle had severe fluorosis compared with 0.2% in Manchester; the prevalence of moderate fluorosis was 1% in Newcastle compared to 0% in Manchester, these being far lower levels than those suggested by the York review.

The NHS Choices website section on fluoride is due for review in January 2014 and we have asked Public Health England (PHE) to review the information and make recommendations by 15 December. This will include ensuring that the information for the public is clear and based on evidence.

Pending that review, we are advised by PHE that there is no credible scientific evidence that water fluoridation at 1 part per million, the target level for water fluoridation schemes in England, or fluoridated toothpaste, used as such, is a cause of general ill health.

Regarding dental fluorosis, we are advised by PHE of a recent research by McGrady and co-workers, published in BMC Public Health 2012, comparing levels of dental fluorosis in fluoridated Newcastle and unfluoridated Manchester which showed that 0.1% of children in Newcastle had severe fluorosis compared with 0.2% in Manchester; the prevalence of moderate fluorosis was 1% in Newcastle compared to 0% in Manchester, these being far lower levels than those suggested by the York review.

The NHS Choices website section on fluoride is due for review in January 2014 and we have asked Public Health England (PHE) to review the information and make recommendations by 15 December. This will include ensuring that the information for the public is clear and based on evidence.

Pending that review, we are advised by PHE that there is no credible scientific evidence that water fluoridation at 1 part per million, the target level for water fluoridation schemes in England, or fluoridated toothpaste, used as such, is a cause of general ill health.

Regarding dental fluorosis, we are advised by PHE of a recent research by McGrady and co-workers, published in BMC Public Health 2012, comparing levels of dental fluorosis in fluoridated Newcastle and unfluoridated Manchester which showed that 0.1% of children in Newcastle had severe fluorosis compared with 0.2% in Manchester; the prevalence of moderate fluorosis was 1% in Newcastle compared to 0% in Manchester, these being far lower levels than those suggested by the York review.

Prior to April 2013 South Central Strategic Health Authority assessed the potential benefit to health if fluoride were to be added to the drinking water in Southampton and South West Hampshire, and whether it was feasible to do so.

Public Health England is continuing to review the matter.

No agreement was signed between South Central Strategic Health Authority, prior to its abolition, and Southern Water to add fluoride to the water supply in Southampton and the South West Hampshire area. The position, as at the end of March 2013, was that the strategic health authority was in discussions with Southern Water in relation to agreeing the terms of the agreement.

By virtue of amendments made to the relevant legislation by the Health and Social Care Act 2012, the statutory functions of strategic health authorities in relation to fluoridation have transferred to the Secretary of State.

Since Birmingham’s first water fluoridation scheme started in 1964, levels of dental decay have been consistently lower than in Manchester which has a similar socioeconomic profile, but does not have a fluoridation scheme. By way of illustration, the most recently readily available comparable statistics from child dental surveys conducted as part of the National Health Service Dental Epidemiology Programme (NHSDEP) show that in 2005-06, five year-old children in the area served by Birmingham City Council had an average of 1.36 decayed, missing or filled teeth (DMFT) compared to an average of 2.39 DMFT in the area of Manchester City Council. Evidence that the protective effect of water fluoridation is maintained during the development of permanent teeth may be seen from a later NHSDEP survey which showed that, in 2008-09, 12 year-old children in Birmingham had an average DMFT of 0.65 compared to an average of 1.12 DMFT for children in Manchester. Health profiles maintained by Public Health England show that there are no significant differences in the general health of the population of Manchester and Birmingham.

The studies reviewed by the Harvard School of Public Health, which included a measure of fluoride concentration in drinking water, had concentrations as high as 11 milligrams per litre. In fluoridation schemes in England the target concentration is one milligram of fluoride per litre with a maximum concentration permitted of 1.5 milligrams per litre. The study referred to contains data from different areas of China and the measurements are not presented in a standardised format. This makes it difficult to interpret or draw conclusions. We would need to see studies in which the fluoride concentrations and measurement of IQ were more closely standardised before reviewing the 1 milligram concentration on the grounds of a possible effect on children’s intelligence. A copy of the report of the review has been placed in the Library.

We have addressed this issue in the regulations we have laid on the public consultations that local authorities will have to undertake on fluoridation proposals. In response to representations we received to our consultation on the content of the regulations, we have decided that the overarching consideration should no longer be that, “the health arguments in favour of proceeding with the proposal outweigh all arguments against proceeding”. We consider a wider range of factors should be taken into account including the extent of the support for the proposals, the strength of any scientific evidence or ethical arguments advanced and any evidence of benefit to the health and wellbeing of individuals who would be affected by the proposal.

A combination of oral health promotion programmes and fluoridated water provide the best means of reducing tooth decay. Evidence that support and education alone may not achieve optimum results can be found from experience in Manchester. Here there has, over many years, been a range of programmes targeted at families with young children including the provision of free fluoride toothpaste, toothbrushes and trainer cups from the age of six months and supervised toothbrushing in nursery classes, children’s centres and nurseries. Training in the key dental health messages has also been provided for a wide range of personnel who meet parents of young children and healthy food policies have been implemented in primary schools and their attached nurseries. However, the results of the NHS Dental Epidemiology Programme five year-old child dental health survey of 2007-08

show that children in the Manchester local authority area had an average of 2.39 decayed missing or filled teeth (dmft) compared to a figure of 1.35 dmft in Birmingham where the water is fluoridated.

The studies reviewed by the Harvard School of Public Health, which included a measure of fluoride concentration in drinking water, had concentrations as high as 11 milligrams per litre. In fluoridation schemes in England the target concentration is one milligram of fluoride per litre with a maximum concentration permitted of 1.5 milligrams per litre. The study referred to contains data from different areas of China and the measurements are not presented in a standardised format. This makes it difficult to interpret or draw conclusions. We would need to see studies in which the fluoride concentrations and measurement of IQ were more closely standardised before reviewing the 1 milligram concentration on the grounds of a possible effect on children’s intelligence. A copy of the report of the review has been placed in the Library.

The Department of Health leads on policy on the fluoridation of drinking water. In our view, fluoridation offers the best option for reducing inequalities in oral health, but it has been the policy of successive Governments that decisions on fluoridation should be taken locally. We do not wish to impose fluoridation centrally but, through the Health and Social Care Act 2012, we have made arrangements for public consultations and decision on fluoridation to be undertaken by local authorities with effect from April 2013. There

have been water fluoridation schemes in operation in England for over 40 years, even longer in the United States of America, and the only risk to health that has been identified is dental fluorosis, a white flecking of the teeth, which is seldom found to be aesthetically unacceptable. However, we are not complacent and, in addition to monitoring relevant research, the Department is to publish reports on selected indicators of the health of the population of fluoridated areas.

The Department of Health leads on policy on the fluoridation of drinking water. In our view, fluoridation offers the best option for reducing inequalities in oral health, but it has been the policy of successive Governments that decisions on fluoridation should be taken locally. We do not wish to impose fluoridation centrally but, through the Health and Social Care Act 2012, we have made arrangements for public consultations and decision on fluoridation to be undertaken by local authorities with effect from April 2013. There

have been water fluoridation schemes in operation in England for over 40 years, even longer in the United States of America, and the only risk to health that has been identified is dental fluorosis, a white flecking of the teeth, which is seldom found to be aesthetically unacceptable. However, we are not complacent and, in addition to monitoring relevant research, the Department is to publish reports on selected indicators of the health of the population of fluoridated areas.