Talk:Water fluoridation/GA1

GA Review

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I have reviewed the article. It is well written however I find it is still too limited to the United States. It seems to start with positive evidence, than neutral evidence, than negative evidence.

The history section only discusses the US.

It states dental fluorosis is "not considered to be of aesthetic concern". Not a concern to whom is the question? And from what period in history is this from? Here is a good paper from Canada on the topic. http://www.health.gov.on.ca/english/public/pub/ministry_reports/fluoridation/fluor.pdf People are a lot more concerns about looks now than ever before.

The section on effectiveness begins by saying that fluoride "has contributed to dental health worldwide" follows this with "evidence was of moderate quality: many studies did not attempt to reduce observer bias, control for confounding factors" and finished with "water fluoridation may be unnecessary in industrialized countries".

Why does Europe and many areas of Canada not fluoridate their water? These questions need to be addressed. From the previous article "The report did not address whether or not water fluoridation produces appreciable benefits in the modern context when caries rates in children are low and fluoride is obtained from many other sources."

If we are getting most of our water from bottles than is their any benefit in showering in fluoridated water? Unfortunately the literature on this topic is old and often doesn't address the issue in the modern age.

From the above report again "These two studies provide some of the better evidence that water fluoridation is beneficial in terms of reductions in dental caries. However, they indicate that the effect is more pronounced in the deciduous than the permanent dentition, that declines in caries are relatively small in absolute terms, particularly in permanent teeth, and that water fluoridation explains very little of the variation in caries experience in either the deciduous or permanent dentition."

Discussion lacking about groups getting to much "In Canada, actual intakes are larger than recommended intakes for formula-fed infants and those living in fluoridated communities. Efforts are required to reduce intakes among the most vulnerable age group, children aged 7 months to 4 years. Children of this age who are consuming the maximum dose are at risk of moderate levels of dental fluorosis."

What should be the level in water is debated by the scientific community. Some more discussion of this should occur.

Still think the topic is a bit limited...

--Doc James (talk · contribs · email) 18:17, 11 January 2009 (UTC)

It says there is little data on cost benefit analysis. This report from 2007 has some: http://www.inspq.qc.ca/pdf/publications/705-WaterFluoration.pdf It also talks about any other issues like rates of fluoridation in Ontario and Quebec. And it has a great section of references.

This is a difficult topic as some interpretations of the research say it is beneficial and some interpretations say it has little benefit. And this is even before the quacks and conspiratory theorists jump in.

--Doc James (talk · contribs · email) 18:32, 11 January 2009 (UTC)

A few things in wiki formatting. WP:lead says it should be 4 paragraphs. --Doc James (talk · contribs · email) 18:36, 11 January 2009 (UTC)

I think this page would be better served with a section about controversy over water fluoridation rather then one about opposition to water fluoridation. Opposition would be appropriate if 99% of the developed world add fl and 1% did not. But if much of the developed world does not add fl than what we have is more of a controversy. Some studies say there is a financial benefit, some say the benefit in the modern world in not significant. --Doc James (talk · contribs · email) 18:54, 11 January 2009 (UTC)

Thanks for the review. A flurry of edits were made to the article right after it was put up for GA status (not too surprising in such a controversial area) and I have attempted to address them. I will wait for a bit, to see how well that works out, and then turn to your review. With luck, some of the points you raise will be answered on the talk page, or fixed in the article, before I go through the review in detail. Eubulides (talk) 09:31, 12 January 2009 (UTC)

Opposition vs controversy

'"I think this page would be better served with a section about controversy over water fluoridation rather then one about opposition to water fluoridation."' The title of the section is Ethics and politics, which is relatively neutral. I suspect that your eye was caught by the {{main}} template pointing to Opposition to water fluoridation. I changed that to point to Water fluoridation controversy, a more-neutral-sounding alias. Eubulides (talk) 09:53, 15 January 2009 (UTC)

Worldwide perspective

• "I find it is still too limited to the United States". Currently, the United States is actually underweighted in terms of often-cited sources; see Talk:Water fluoridation #Mechanism and worldwide view. No doubt there is still some U.S. centric stuff there, though, and I'll try to fix specific examples as they are pointed out. However, given that the U.S. originated the practice and represents about half of worldwide use, we should expect to see heavy U.S. representation in the article.
• "The history section only discusses the US." Thanks, I have introduced discussion of some history in England, Brazil, and Finland with this edit. I was unable to obtain a reliable secondary source on the worldwide history of fluoridation, so I used bits and pieces of various sources, trying hard to avoid WP:OR.

Eubulides (talk) 00:42, 13 January 2009 (UTC)

Order of material

"It seems to start with positive evidence, than neutral evidence, than negative evidence." Sorry, I can't tell: is that a suggestion to make a change to the article? Anyway, Water fluoridation #Evidence basis attempts to summarize reliable sources roughly in proportion to the weight they give to various topics. It's organized by section, and within each section the main and most-important evidence is given first. I don't see any overall attempt there to put positive evidence first, except insofar that the mainstream opinion of water fluoridation is more positive than negative. Eubulides (talk) 00:42, 13 January 2009 (UTC)

"The section on effectiveness begins by saying that fluoride 'has contributed to dental health worldwide' follows this with 'evidence was of moderate quality: many studies did not attempt to reduce observer bias, control for confounding factors' and finished with 'water fluoridation may be unnecessary in industrialized countries'." Again, I'm not sure whether there is a suggestion for improvement here. All three statements are supported by reliable sources, and the statements do not contradict each other. Eubulides (talk) 08:56, 14 January 2009 (UTC)

Aesthetic concern

"It states dental fluorosis is 'not considered to be of aesthetic concern'. Not a concern to whom is the question?" Good question. I added the text "Here, 'aesthetic concern' is a term used in a standardized scale based on what adolescents would find unacceptable, as measured by a 1996 study of British 14-year-olds." and cited the York review. Eubulides (talk) 08:41, 14 January 2009 (UTC)

Oh, sorry, forgot to mention, I read the Locker 1999 paper you cited, and its page 36 cites that same 1996 study to support the claim "This work confirms and expands previous surveys which have shown that lay people can detect fluorosis and both professionals and lay people view the more severe forms as having negative consequences for children." Since the York review used a lay-people-based metric we should be OK here. Eubulides (talk) 08:51, 14 January 2009 (UTC)

Europe and Canada

"Why does Europe and many areas of Canada not fluoridate their water?" The lead now says "Fluoridation may be more justified in the U.S. for reasons that include lack of access to dental care.", and the body says "Fluoridation may be more justified in the U.S. because unlike most European countries, the U.S. does not have school-based dental care, many children do not attend a dentist regularly, and for many U.S. children water fluoridation is the prime source of exposure to fluoride." Both statements are sourced by Burt & Tomar 2007 (published in ISBN 0195150694). I don't know of any reliable source on this particular topic with respect to Canada, but I hope this suffices to explain why the U.S. might be different. (We can't speculate beyond what reliable sources say, obviously; I looked for other sources but didn't find anything else.) Eubulides (talk) 10:18, 14 January 2009 (UTC)

Bottled water

"If we are getting most of our water from bottles than is their any benefit in showering in fluoridated water? Unfortunately the literature on this topic is old and often doesn't address the issue in the modern age." Water fluoridation #Implementation cites Hobson et al. 2007 (PMID 17485621) on the subject of fluoridation, bottled and filtered water; it's not the greatest source but it's better than speculation. I assume your comment about "showering" is ironic. Eubulides (talk) 10:18, 14 January 2009 (UTC)

Two studies

"From the above report again 'These two studies provide some of the better evidence that water fluoridation is beneficial in terms of reductions in dental caries. However, they indicate that the effect is more pronounced in the deciduous than the permanent dentition, that declines in caries are relatively small in absolute terms, particularly in permanent teeth, and that water fluoridation explains very little of the variation in caries experience in either the deciduous or permanent dentition.'" The two studies in question are:

• Slade et al. 1995 (PMID 8551461) was excluded from Yeung 2008 (PMID 18584000), our most reliable and recent systematic review. The related paper Slade et al. 1996 (PMID 9117970) was also excluded, but the full report mentions it as being useful to the "reader with a special interest in Australian fluoride research". It later mentions it as "seminal work ... that compared the dental caries rates amongst children in fluoridated Townsville and unfluoridated Brisbane, illustrating that the children of Townsville had 32 to 55% fewer tooth surfaces affected with caries, when compared to the children of Brisbane". Both Slade papers were also excluded from the York review (PMID 11021861), another reliable (though not as recent) systematic review.
• Heller et al. 1997 (PMID 9383751) was also excluded from Yeung 2008. It is mentioned on p. 44 of the York review's full report, briefly, but not as a study of the effectiveness of water fluoridation! (instead, as a study of the safety fluoride drops etc.)

What I can conclude from this is that later systematic reviews don't agree with the Locker paper you cited that the two studies are important evidence to support (or refute) water fluoridation's effectiveness or safety. These reviews are much more reliable (they are systematic reviews, published in peer-reviewed journals, review more and more-recent data, etc.) and by comparison Locker 1999 does not seem to be nearly as reliable a source. Certainly I'd rather see a newer review than Locker's; even the York review is pretty dated, and is included in Water fluoridation only because it has by far the best reputation of any skeptical review. Eubulides (talk) 10:18, 14 January 2009 (UTC)

The York review also did the legwork for Yeung, and Yeung could only find 1 study which met the strict inclusion criteria adopted from York by Yeung (and that study did not support fluoridation) -- so isn't it a bit misleading to say York is pretty dated? Its coverage of the effectiveness data is fairly current. II | (t - c) 00:36, 15 January 2009 (UTC)

Any review of an actively researched medical topic that's older than around 5 years old is getting dated, yes. The York review (2000) is no exception. It was a fine review for its time, significantly better than what came before, but Yeung 2008 is newer and contains newer data, and I don't know of any way in which the 2000 York review is significantly better Yeung 2008.Eubulides (talk) 00:43, 15 January 2009 (UTC)

I'm surprised you would say that. The York review had 10 authors. The Yeung review had 1, Yeung. That's probably because, as I said, York did the legwork, and Yeung assembled reviews. Yeung himself would probably have been hard-pressed to do the work done by the CRD himself. Yet Yeung strangely did not relay the concerns expressed by his main source. I've seen criticisms of Yeung already, although I haven't been able to find them recently. It would not be surprising if the CRD attacked Yeung sometime in the future, considering their 2003 statement. Anyway, this is a tangent. Assuming that some of the stuff which I have added recently remains in the article, I think it's a good article. II | (t - c) 00:57, 15 January 2009 (UTC)

• OK, I will grant you that: the York review had more authors. Are there any significant technical reason that the older York review is better than the newer Yeung review? Certainly the Yeung review has the advantage of more-recent data. But anyway, I agree this is a tangent: the two reviews do not disagree on any important point.
• I'm afraid that some of the stuff you added recently has real problems, but I have not had time to review it yet, as I have been busy responding to the GA review.

Eubulides (talk) 03:27, 15 January 2009 (UTC)

A few more points

Excellent on all the changes. A few more point.

1. The lead: The lead says "The optimal level of fluoridation is about 1 mg/L" However the Canadian review says optimal fluoridation levels are 0.5-0.8 because of other sources of fluid from dental care, etc. So optimal depends on other sources in your environment and what is optimal in the US may not be optimal elsewhere. As does this one http://www.city.waterloo.on.ca/Portals/57ad7180-c5e7-49f5-b282-c6475cdb7ee7/PWS_UTILITIES_documents/RegionalFluorideInformation.pdf
2. Bottle waters is said to have unknown fluoride levels. However this ref from uptodate says "Most bottled water contains less than 0.30 mg/L of fluoride, although the content varies. In one study the fluoride concentration in bottled water ranged from <0.1 to 0.9 mg/L [54].PMID 10728111 Only six of the 57 brands tested contained more than 0.30 mg/L of fluoride (show table 3). The United States Food and Drug Administration (USFDA) does not require bottled waters to list fluoride content on the label unless the bottler adds fluoride during processing [53]." Really it should say bottles water contains low levels of fluoride usually less then 0.3
3. It says "a process that costs about $0.72 per person per year". It is presented as a worldwide value when we Canadian are able to do it for less $0.60 Canadian. http://www.city.waterloo.on.ca/Portals/57ad7180-c5e7-49f5-b282-c6475cdb7ee7/PWS_UTILITIES_documents/RegionalFluorideInformation.pdf
4. Units used are mg/L but much of the world uses PPM even though they are the same I think this should be stated.
5. WP:lead recommends four paragraphs
6. Motivation: "iodized salt for the prevention of mental retardation and goiter" Most people associate iodine with goiter not mental retardation. Mental retardation is also a term not longer used frequently. I think it might be clearer if it just says goiter rather then both.
7. Implementaion: Not sure if this really belong in this section "Minority children have higher rates of untreated cavities, and poor children have less dental care, especially dental sealants.[5]"
8. Safty: "cancer, deaths due to cancer, bone cancer, or osteosarcoma." The last two are types of cancer and therefore not need. All one needs to say is cancer and death due to cancer.
9. The list of three things under safety is a little awkward and would be better in prose.
10. Under the list of organization that support it are 3 US and the WHO maybe one from the rest of the world. I know many Canadian and Australian organizations support aswell. http://www.cda-adc.ca/_files/position_statements/fluorides.pdf
11. History section looks good.

These few small corrections and I think this will pass. Cheers --Doc James (talk · contribs · email) 15:08, 14 January 2009 (UTC)

• "However the Canadian review says optimal fluoridation levels are 0.5-0.8 because of other sources of fluid from dental care, etc." Every jurisdiction seems to have its own value. The current expert Canadian recommendation is 0.7 mg/L as the optimal target, without any range (!). The U.S. says 0.7–1.2 mg/L, depending on climate. Our best and most-recent systematic review, for Australia, says 0.6–1.1 mg/L, depending on climate. Let's go with that; that includes the Canadian optimal target and is close enough to the U.S. recommendations that it's not worth talking about in the lead. I made this change to try to do that. Eubulides (talk) 21:33, 14 January 2009 (UTC)
• "Really it should say bottles water contains low levels of fluoride usually less then 0.3" I checked up on that bottled-water fluoride source, and found that it talked only about bottled water bought in Cleveland, with another source for Iowa. It's a bit much to extrapolate this to the U.S. I looked for a reliable source on fluoride in bottled water in the U.S., or worldwide, and found none. So, for lack of a better alternative, I made this edit which cited that source (Lalumandier & Ayers 2000, PMID 10728111), for Cleveland and Iowa, and another newer source (Grec et al. 2008, PMID 18200355) with quite different results for São Paulo. Eubulides (talk) 22:37, 14 January 2009 (UTC)
• "It is presented as a worldwide value when we Canadian are able to do it for less $0.60 Canadian." The cost varies, depending on chemicals used etc; see Talk:Water fluoridation #Implementation. I changed the lead to mention the range given by our source, which is $0.17–$7.62 in 1999 U.S. dollars. Eubulides (talk) 22:45, 14 January 2009 (UTC)
• "Units used are mg/L but much of the world uses PPM even though they are the same I think this should be stated." Water fluoridation #Implementation says "mg/L (milligrams per liter, equivalent to parts per million)". Is that enough, or should we also say that in the lead? I'd rather omit this measurement detail from the lead, but this is only a mild preference. Eubulides (talk) 22:48, 14 January 2009 (UTC)
• "WP:lead recommends four paragraphs" I just now checked, and WP:LEAD #Length recommends "three or four paragraphs" for articles of this size. Eubulides (talk) 22:50, 14 January 2009 (UTC)
• "Most people associate iodine with goiter not mental retardation. Mental retardation is also a term not longer used frequently. I think it might be clearer if it just says goiter rather then both." Historically goiter was the big deal, and our older readers might associate iodized salt with goiter; but these days, iodized salt is aimed primarily at preventing neurological disorders, and it's better if we stay up-to-date here. See, for example, Andersson et al. 2005 (PMID 16175826), which says:

"Conditions related to iodine deficiency include goitre, stillbirth and miscarriage, hypothyroidism and impaired growth. However, the most devastating toll is from the mental and neurological disorders resulting from brain damage; preventing these is the primary motivation behind the current worldwide drive to eliminate iodine deficiency. Although cretinism is the most extreme manifestation, the more subtle degrees of mental impairment leading to poor school performance, reduced intellectual ability and impaired work capacity are of considerably greater significance."

As for terminology, the source (Horowitz 2000, PMID 11014508) says "mental retardation", and all other things being equal it's better to stick with the source's terminology. For what it's worth (which is not much), currently, in Wikipedia, Mental retardation is the main page, and other common synonyms such as Intellectual disability, are redirects to that page. Eubulides (talk) 23:56, 14 January 2009 (UTC)

• "Not sure if this really belong in this section 'Minority children have higher rates of untreated cavities, and poor children have less dental care, especially dental sealants.[5]'" Thanks for catching that. I moved it to Water fluoridation #Motivation. Eubulides (talk) 00:05, 15 January 2009 (UTC)
• "'cancer, deaths due to cancer, bone cancer, or osteosarcoma.' The last two are types of cancer and therefore not need. All one needs to say is cancer and death due to cancer." The cited source (Yeung 2008, PMID 18584000) says, "The existing SR [McDonagh et al. 2008, PMID 11021861] concluded there is no clear association between water fluoridation and overall cancer incidence or mortality (for 'all cause' cancer, and specifically for bone cancer and osteosarcoma)." In epidemiology it is quite possible for there to be no significant statistical association between cancer and X, and yet for there to be a significant association between bone cancer and X, or between osteosarcoma and X, so we can't merely drop mention of bone cancer and osteosarcoma. However, the previous wording wasn't as clear as the source's wording, so I changed it to "cancer or deaths due to cancer, both for cancer in general and also specifically for bone cancer and osteosarcoma.". Eubulides (talk) 00:25, 15 January 2009 (UTC)
• "The list of three things under safety is a little awkward and would be better in prose." Done. Eubulides (talk) 00:43, 15 January 2009 (UTC)
• "Under the list of organization that support it are 3 US and the WHO maybe one from the rest of the world. I know many Canadian and Australian organizations support aswell." I added the Australian and the Canadian Dental Associations. Eubulides (talk) 09:44, 15 January 2009 (UTC)