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Water Fluoridation in Ireland—a Success Story

Dental School, Trinity College, Dublin, Ireland;

^* corresponding author, jclarkson{at}dental.tcd.ie

KEY WORDS: water fluoridation • implementation • evaluation • dental fluorosis

	BACKGROUND

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The publication of a major report on water fluoridation in Ireland (Forum on Fluoridation, 2002) prompted the authors to reflect on the implementation of fluoridation and the impact it has had on oral health in Ireland.

As early as the 1940s, the severity and extent of dental caries as a public health problem were claiming increased attention in Ireland. In 1952, the Minister for Health requested the Medical Research Council to carry out a survey "to ascertain whether there are significant differences in dental conditions amongst school children living in different areas of the country, and whether such differences, if they exist, could be related to differences in the dietary intake of the children". The results of the ensuing epidemiological survey showed that dental caries experience among schoolchildren was high in all the survey areas, and that the prevalence and severity of the condition were independent of the environmental or domestic circumstances and dietary habits of the children (Medical Research Council, 1952). The seminal factor in the eventual fluoridation of the public water supplies in Ireland, however, was the visit of Dr. Trendley Dean to Dublin, also in 1952 (MacNeill, 1972). He spoke at a meeting in the Royal College of Surgeons about the evidence of the relationship between dental caries experience and the fluoride content of drinking water. He also met the Minister for Health, Dr. James Ryan, who was very impressed by Dean’s commitment to fluoridation.

Subsequently, in 1956, the Minister for Health appointed what was called the Fluorine Consultative Council to reflect on the advantages and disadvantages of an ‘increased intake of fluorine’. Two years later, the Council (Fluorine Consultative Council, 1958) advised that:

• ‘An increased intake of fluorine will reduce the incidence of dental caries and that it is desirable to provide for such an increased intake;
  
• The increased intake of fluorine can best be provided by the fluoridation of public water supplies to a maximum level of 1ppm of fluorine...’
  

	LEGISLATION

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By December, 1956, the Minister for Health had decided that it was necessary to make water fluoridation mandatory in Ireland. He had three reasons for adopting a mandatory approach. First, the prevalence and extent of dental caries were high throughout the country. Second, if the decision was to be left to the discretion of each local authority in Ireland, all the members of such bodies would need to familiarize themselves with the mass of scientific literature on the subject before coming to a conclusion. Members would be open to the propaganda of anti-fluoridationists, who could undermine their consciences and profit from their ignorance. Third, more than 80 separate water authorities would be involved, many of them supplying piped water to two or more areas. A chaotic situation could arise if some areas elected to have fluoridated water and some others rejected it (O’Hickey, 1976).

In December, 1960, the Fluoridation Act became part of Irish law. However, the constitutionality of the fluoride legislation in Ireland was challenged, and a case to decide this issue was heard in the High Court in 1963 and in the Supreme Court, on appeal, in 1964. In July of 1964, the decision of the Supreme Court was delivered, which was in favour of the constitutionality of the Fluoridation Act. The High Court case was the longest case in Irish legal history at that time, and is a landmark case in legislation on fluoridation and is quoted extensively (Kenny, 1972).

	IMPLEMENTATION

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Almost immediately after the court’s final decision had been handed down, the physical process of fluoridation went into operation. Once all the public water supplies of the large urban areas had been covered, progress was inevitably slower, since public piped water schemes did not extend to the more remote rural households. As new regional water schemes were provided, a fluoridation plant was installed as part of each scheme. The present position is that about 73% of the State’s inhabitants live in areas served by fluoridated water supplies (Forum on Fluoridation, 2002).

	PROGRESS & DEVELOPMENT

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The actual process of supplementing the fluoride content of the public piped water supplies is performed by the local sanitary authorities—that is, county councils and city corporations act as agents for the regional health authorities. The fluoride compounds used must comply with specifications, samples of the water must be tested daily to ascertain their fluoride content, and tests by public laboratories must be made every month. The concentration of fluoride must be kept between 0.8 and 1.0 parts per million. Originally, fluoride in powder form was used, but later, liquid hydrofluorosilicic acid was and continues to be used.

Over the years, some difficulties of a technical nature were encountered with fluoridation plants. Most of these difficulties related to the problems associated with maintaining a constant concentration of the fluoride ion in the water and the continuity of supply of the fluoride additive. Most of these difficulties related to smaller water treatment plants, and these issues have now been overcome (Hobdell and O’Hickey, 1989).

It is highly improbable that it will ever be possible to provide fluoridated public piped water supplies to the whole population, because some people will continue to live in the more remote rural areas. For schoolchildren who live in some of these areas, there have been schemes for providing them with fluoride by other methods—for example, fluoride mouthrinsing (O’Hickey, 1972). In addition, of course, fluoride toothpastes have been available since the early 1970s, and the vast majority of toothpastes sold in Ireland are fluoridated.

	EVALUATION OF WATER FLUORIDATION

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A series of epidemiological studies was carried out immediately prior to and in the years since the commencement of water fluoridation in 1964. The pre-fluoridation national study which was required under the legislation was carried out in 1961–63. In this study, more than 96,000 children, adolescents, and young adults (from 3 to 18 yrs old) were examined in all of the 26 counties. These data provided a benchmark against which caries levels in children have since been monitored (Minister for Health, 1965). Dental caries levels were high throughout the country: For example, in 12-year-olds, the mean DMFT value ranged from 4.2 to 5.4.

In 1984, encouraged by David Barmes and Ingolf Möller from the WHO, another national survey of the oral health status of children and adolescents was carried out by the Oral Health Services Research Centre at University College, Cork. The results of this survey demonstrated that water fluoridation was effective in reducing dental caries levels (O’Mullane et al., 1986). The mean DMFT for 12-year-olds in Ireland fell from 4.7 in the pre-fluoridation survey of 1961–63 to 2.6 in 1984.

Local surveys were undertaken in different regions in Ireland during the 1990s. All demonstrated a continuing fall in dental caries levels in children and adolescents. For example, the mean DMFT values in 12-year-olds for the greater Dublin area, which is fluoridated, are shown in the Fig. A DMFT value of 1.1, compared with 5.2 in 1961, clearly shows the vast improvement since fluoridation was introduced in Dublin (Whelton et al., 1998b).

View larger version (56K): [in this window] [in a new window]   Figure. Mean DMFT of 12-year-old children in Eastern Health Board region (greater Dublin area), 1961–1997.

It is obviously important to consider how Ireland has fared compared with similar regions/countries. Studies of the health behavior of children in the Republic of Ireland, Northern Ireland, and Scotland demonstrate very similar poor dietary and toothbrushing behavior (Health Behaviour in School-aged Children, 2000). Based on these criteria, caries levels should be similar. In non-fluoridated Northern Ireland, the mean DMFT for 12-year-olds fell from 5.5 to 4.4 during the period 1961–1984, compared with the reduction to 2.6 DMFT in the fluoridated part of the Republic of Ireland in the same period. It is interesting to note that the difference between Northern Ireland and the Republic is still apparent in a recent study of 12-year-olds in adjacent geographic areas of the Republic of Ireland and Northern Ireland. The mean DMFT values were 1.6 in the fluoridated area of the Republic of Ireland and 2.5 in the non-fluoridated adjacent area in Northern Ireland (Whelton et al., 2001).

A comparison of dental caries levels in the cities of Dublin (fluoridated) and Glasgow (non-fluoridated) in Scotland was carried out in 1992 (Blinkhorn et al., 1992). The mean DMFT values were 1.5 in Dublin and 2.7 in Glasgow, while the mean DMFS values were 2.7 in Dublin and 4.9 in Glasgow, showing significant differences between countries with similar dietary patterns.

From the data presented, it can be clearly seen that water fluoridation has been very effective in improving oral health in Ireland.

	GENERAL HEALTH AND DENTAL RISKS

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The use of any health measure, including water fluoridation, requires an assessment of risks and benefits. In Ireland, the public health authorities have relied on studies and reviews from other countries and from international agencies to monitor health effects. Public health officials in Ireland have kept abreast of international research in this area and have accepted the view that, at the level of fluoride used in water fluoridation, there is no evidence of any detrimental effects on general health.

Dental fluorosis has always been accepted as a side-effect of the ingestion of fluoride, and in Ireland the fluoridation of water was expected to result in an increase in the prevalence of dental fluorosis. The baseline studies carried out prior to fluoridation did not include any measurement of fluorosis. In the 1980s, a strong interest in the study of dental fluorosis in Ireland was developed by Clarkson and O’Mullane. In particular, they studied the indices used to measure fluorosis. The role of the Developmental Defects of Enamel Index (DDE) was studied in collaboration with researchers in England, Denmark, New Zealand, and the United States, and as a result, a modified index was produced and piloted in Ireland (Clarkson and O’Mullane, 1989). Since that time, all of the national and local studies on fluoridation in Ireland have included this modified index for measuring enamel defects and Dean’s Index for measuring fluorosis. A summary of some recent studies of fluorosis in the greater Dublin area can be found in the Table. It can be seen that the prevalence and severity of fluorosis are increasing; however, most are of the milder forms, which are primarily of minor cosmetic importance only (Whelton et al., 1998a).

	RECENT DEVELOPMENTS—FORUM ON FLUORIDATION

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A panel of 18 people with a wide range of appropriate knowledge and experience was selected to form the Forum. The Forum held 14 plenary sessions, during which every effort was made to obtain the views of individuals and groups, both those in favor of and those opposed to water fluoridation. In addition, an extensive program of consultation with members of the public took place. The Report makes interesting reading, since it covers the scientific, technical, and ethical issues relating to fluoridation and has an extensive list of references (Forum on Fluoridation, 2002).

The overall conclusions of the Report are that: (1) water fluoridation has been very effective in improving oral health in Ireland, (2) the best available and most reliable scientific evidence indicates that water fluoridation does not adversely affect human health, and (3) the prevalence of dental fluorosis is increasing in Ireland, although most of it is of a very mild nature.

The Report makes many recommendations on policy, technical, research, and educational issues relating to fluoridation, as well as on the use of other sources of fluoride and on controlling levels of dental fluorosis. The main policy recommendation is to reduce the optimal range of concentration of fluoride in drinking water in Ireland from the present level of 0.8–1.00 ppm to 0.6–0.8 ppm. The Forum was of the opinion that this lower level, combined with the appropriate use of fluoride toothpaste, will be sufficient to maintain the experience of dental caries at current low levels while reducing the occurrence of dental fluorosis. The Report of the Forum can also be seen at www.fluoridationforum.ie

	CONCLUSIONS

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There are several important conclusions that can be drawn from the experience of water fluoridation in Ireland over the past 40 years. Investment in dental care services in Ireland was limited until the past 15 years. In addition, the frequent consumption of snacks and foods with a high sugar content is common in Ireland. Despite these facts, the recent experience of dental caries in Ireland is low and similar to that of countries which have put major resources into dental care and have better dietary habits. It is also clear that the mandatory nature of the legislation for water fluoridation in Ireland has ensured that a relatively large proportion of the population has received the benefits of this preventive measure. In addition, it has been judged safe and constitutionally legal.

The success of water fluoridation in Ireland is due to numerous factors, some of which are outlined in this paper. It is also due to the role of many individuals over the years, such as political leaders, the officials in the Department of Health and Children and the Department of the Environment, staff in the regional health authorities, as well as academic staff in universities. Their commitment has ensured that a relatively simple public health preventive approach, through water fluoridation, has ensured an excellent oral health status for the population of Ireland.

Received December 19, 2002; Accepted January 16, 2003

	REFERENCES

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Blinkhorn AS, Attwood D, Gavin G, O’Hickey S (1992). Joint epidemiological survey on dental health of 12-year-old school children in Dublin and Glasgow. Community Dent Oral Epidemiol 20:307–308.[ISI][Medline]

Clarkson J, O’Mullane D (1989). A modified DDE Index for use in epidemiological studies of enamel defects. J Dent Res 68:445–450.[Abstract/Free Full Text]

Fluorine Consultative Council (1958). Report of Fluorine Consultative Council. Dublin: Stationery Office.

Forum on Fluoridation (2002). Dublin: Stationery Office.

Health Behaviour in School-aged Children (2000). A WHO Cross-National Study (HBSC) International Report. Currie C, Hurelmann K, Settertobulte W, Smith R, Todd J, editors. EUR/ICP/IVSP 06 03 05(a) UNICORN no. E67880.

Hobdell MH, O’Hickey S (1989). Public water fluoridation in Ireland: twenty-five years on. Br Dent J 167:36–38.[ISI][Medline]

Kenny J (1972). The legal issues in the fluoridation case. J Ir Dent Assoc 18:56–58.

MacNeill S (1972). The fluoridation case in Ireland—legal and scientific evaluations. J Ir Dent Assoc 18:59–67.

Medical Research Council (1952). Dental caries in Ireland. Dublin: Stationery Office.

Minister for Health (1965). Reports on the incidence of dental caries in school-children and on the analyses of public piped water supplies in the different counties (1961–1965). Dublin, Republic of Ireland: Stationery Office.

O’Hickey S (1972). The progress of fluoridation in Ireland. J Ir Dent Assoc 18:68–72.

O’Hickey S (1976). Water fluoridation and dental caries in Ireland; background, introduction and development. J Ir Dent Assoc 22:61–66.

O’Mullane DM, Whelton H (1992). Oral health of Irish adults 1989–90. Dublin: Stationery Office.

O’Mullane DM, Clarkson J, Holland T, O’Hickey S, Whelton H (1986). Children’s dental health in Ireland 1984. Dublin: Stationery Office.

Report of the Fluorine Consultative Council (1958). Dublin: Stationery Office.

Whelton H, Clarke D, Daly F, McDermott S, Murphy B, O’Nolan N, et al. (1998a). Dental fluorisis in the Eastern Health Board in the Republic of Ireland. Caries Res 32:267–317.

Whelton H, O’Mullane D, Cronin M (1998b). Children’s dental health in the Eastern Health Board Region 1997. Dublin: Department of Health.

Whelton H, O’Mullane D, Cronin M (2001). Children’s dental health in the North Western Health Board Region 1997. Dublin: Department of Health.

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