Health effects of water fluoridation

Public consultation on the Draft Information Paper: Effects of Water Fluoridation on Dental and Other Health Outcomes (draft Information Paper) has now closed.

News Briefing

Health Effects of water fluoridation – NHMRC Draft Information Paper release

Background

Community water fluoridation, also known as artificial water fluoridation, is the addition of fluoride to drinking water with the aim of helping to reduce tooth decay. This practice is the process of adjusting the amount of fluoride in drinking water to reach a level that can help to reduce tooth decay in people of all ages. Good oral health is an integral part of good general health1, and allows people to eat, speak and socialise without discomfort or embarrassment. In Australia, dental health has improved since water fluoridation began in the 1950s and Australians born after 1970 (when the majority of water fluoridation programs commenced in Australia) have, on average, half the level of tooth decay of their parents’ generation2.

In 2006, NHMRC undertook a systematic review of the evidence for the efficacy and safety of fluoride interventions. This review focused on sources that could be used to deliver fluoride to the Australian community including drinking water, milk, salt and topical fluoride treatments. The review, titled “A Systematic Review of the Efficacy and Safety of Fluoridation” (the 2007 Systematic Review) considered possible benefits and harms of these different sources of fluoride.

As a result of the 2007 Systematic Review, NHMRC released the

(the 2007 Public Statement). This is NHMRC’s current position on water fluoridation and was reaffirmed by the Council of NHMRC (Council) in June 2013 prior to NHMRC undertaking the current review of evidence that is summarised in the draft Information Paper. This 2007 Public Statement recommends that water be fluoridated in the target range of 0.6 to 1.1 mg/L, depending on climate, to balance reduction of dental caries (tooth decay) and occurrence of dental fluorosis (mottling of teeth). It also states that fluoridation of drinking water is an effective way to ensure people across the community are exposed to fluoride and can benefit from its preventative role in tooth decay, regardless of age, gender or socioeconomic status.

At its meeting in November 2012, Council advised that NHMRC consider options for investigating new evidence on the health effects of fluoridation. In response, on 20 June 2013, NHMRC hosted a meeting of experts in the field and state and territory government health representatives to consider NHMRC’s advice on water fluoridation. The main outcome of this meeting was that an update of the 2007 Systematic Review should be undertaken, subject to the availability of funding.

Following this meeting, Council reaffirmed its position on the 2007 Public Statement, and recommended that NHMRC update the body of evidence to include more recent studies and assess their relevance in the Australian context. 

Current evaluation of the evidence on the health effects of water fluoridation

The 2016 NHMRC Evidence Evaluation is now complete and the final Information Paper (which summarises and assesses how these research findings are relevant to Australia and Australians) will be released later in 2017.

NHMRC’s 2016 Evidence Evaluation included the following activities:

  1. A comprehensive evaluation of the dental effects of water fluoridation, which consisted of:
    1. an overview of systematic reviews on the effects of water fluoridation on dental caries
    2. a systematic review of recent primary studies on the effects of water fluoridation on dental caries not identified in the reviews included in the overview
    3. a critical appraisal of the evidence on tooth decay and dental fluorosis reviewed by the Cochrane Collaboration (Iheozor-Ejiofor et al  published on 18 June 20153)
  2. A systematic review of other possible health effects of water fluoridation.

The NHMRC appointed a team from the University of Sydney to undertake this evaluation. In seeking a Contractor to undertake this work, NHMRC sought quotes from panellists on its Health Evidence Panel (HEP). The responses were evaluated and the preferred panellist, the University of Sydney, was selected as providing the best value for money. The HEP was established in June 2013 through an open market activity. The HEP is a continuing offer over three years for suppliers to provide services relating to the development and presentation of evidence based health advice, at agreed prices, terms and conditions. Panel arrangements are established to increase efficiency, reduce administration costs and reduce risk. The names of suppliers on the HEP are available on the AusTender website.

Fluoride Reference Group

In May 2014, NHMRC established the Fluoride Reference Group to guide the evaluation of the evidence on the health effects of water fluoridation. The Fluoride Reference Group considered the outcomes of the evidence evaluation and advised on how relevant these findings are for Australia, given that concerns regarding water fluoridation vary across international and geographic regions. The group also used the findings to provide advice on a draft Information Paper, which provides a summary of the evidence evaluation and its key findings.

Public call for evidence

The Australian community was invited to submit published studies to be evaluated as part of the systematic review on the possible health effects (excluding dental effects) of water fluoridation from 23 July until 22 August 2014. Literature that met the scope of the systematic review was provided to the evidence review team at the University of Sydney. They evaluated studies identified by the community in exactly the same way that they evaluated studies found using their own systematic searches.

Public consultation on the draft Information Paper

The Australian community was given a second opportunity to be involved in NHMRC’s work on water fluoridation. The draft Information Paper was available for comment via NHMRC’s public consultation portal from 14 September to 13 October 2016. As part of this process the community could submit published studies on the dental and other human health effects of water fluoridation. To be considered by NHMRC, this literature had to meet the advertised scope of public consultation.

Next steps

NHMRC is currently revising its 2007 Public Statement to reflect the latest evidence reviewed by NHMRC, and ensure it is suitable for the general public. A draft will be released for public consultation later in 2017.

Key milestones

Public call for evidence 23 July – 22 August 2014
Evidence evaluation completed Early 2016
Public consultation on draft Information Paper 14 September - 13 October 2016
Expert review of the Information Paper 7 February – 7 March 2017
Final Information Paper issued Mid 2017
Public consultation on draft Public Statement Mid 2017
Final Public Statement issued Late 2017

Relevant resources

NHMRC’s current position on water fluoridation

2016 NHMRC Evidence Evaluation

Please note: These documents are not open for public consultation.

2007 NHMRC Review

Further information

For further information please contact NHMRC at fluoride@nhmrc.gov.au.

References

1 Australian Institute of Health and Welfare 2012. Australia’s health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra: AIHW

2 Australian Institute of Health and Welfare 2012. Australia’s Health 2012: in brief. Cat. no. AUS 157. Canberra: AIHW

3 Iheozor-Ejiofor Z,Worthington HV, Walsh T, O’Malley L, Clarkson JE, Macey R, AlamR, Tugwell P, Welch V, Glenny AM. Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD010856. DOI: 10.1002/14651858.CD010856.pub2