Talk:Water fluoridation/Archive 2

Archive 1

Archive 2

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Archive 5

Effectiveness vs Cost-Effectiveness

This exchange was cut from ImperfectlyInformed's talk page. Please post article issues to the article talk page.

Hi II, I agree that an older study should not replace a newer one. However, I am concerned that the negative bits are picked out of the mostly positive information in these studies in order to cast doubt on the subject of water fluoridation. The phrase you replaced needs a little more explanation, in my opinion, about how it is refering to the fact that most people are exposed to more sources of fluoride than just water and that this hasn't been studied sufficiently. The article seems terribly biased against water fluoridation in general. --—CynRN ^(Talk) 14:59, 6 October 2008 (UTC)

The statement is regarding the cost-effectiveness of fluoridation rather than just the effectiveness. Anyway, the article, when done well, should be fairly critical of fluoridation because the most reliable estimates, such as the University of York review, are critical. I agree that the history section is dependent upon an unreliable website, incidentally. II | (t - c) 17:29, 6 October 2008 (UTC)

the article, like all Wikipedia articles, should not be "fairly critical" of fluoridation, highly critical, or uncritical -- or take any other position at all. It's not our place to render scientific or economic judgments. The article, i hope, will present the sources, and leave the reader to evaluate them. It is necessary to be careful to be fully representative, and not cherry-pick the studies which support ones point of view. You can give the dates, but not say that something supersedes unless there is a truly authoritative source to quote for that. DGG (talk) 03:58, 9 October 2008 (UTC)

If the best sources are fairly critical, then the article will be fairly critical. Who said it was my judgment? It was the judgment of the University of York's systematic review, published in the British Medical Journal. Per WP:MEDRS, that source is better than the CDC, which is tertiary, and truly is the authoritative source. Similarly, National Academy scientists were rather critical of the practice in the 2006 book on the subject. II | (t - c) 07:57, 9 October 2008 (UTC)

Tags at top of article

I saw the {{globalize}} and {{POV}} tags at the top of this article, came to the talk page to find discussion about them, and basically came up dry. I just now read the article for the first time and don't see significant problems in either area. For now I've removed the tags. Anyway, tags are not supposed to reflect a long-ago objection by an editor: they're supposed to reflect a continuing process to improve the article. Eubulides (talk) 20:09, 7 November 2008 (UTC)

Major restructuring

To be blunt, this article was written like a conspiracy-theorist's newsletter: disconnected paragraphs of irrelevant details full of weasel words and unnecessary opinions from individuals and advocacy groups. I've made an attempt to reduce that problem, but more work needs to be done (hence the cleanup tag). Opinions should be summarized on their own page.

I moved the summaries of mid-20th-century research to a special subsection of "History," put them in chronological order, and cleaned up some out-of-place advocacy. I was tempted to delete these paragraphs altogether, as they're probably irrelevant, but I didn't want to make that decision alone. If anyone else agrees, I'd encourage you to follow through. I also consolidated fluorosis into the section on health effects, since it has its own article.

There are a lot of ppm numbers thrown around, perhaps too many. The single most important one is absent: what concentration of fluoride is actually used in fluoridated water? If it's significantly and consistently far lower than that at which side effects occur, then much of this material doesn't belong here since it doesn't involve intentional fluoridation of water.

P.S. I didn't notice that I wasn't signed in when I edited the article itself, so the changes are attributed to an IP address. Sorry. Epistaxis (talk) 01:34, 10 November 2008 (UTC)

You may want to try that again, minus the vague allegations and rhetoric. Expert opinions from toxicology and dentistry researchers who have taken a long look at the scientific literature certainly belong on this page. And it is clear that you didn't read very carefully (or know much about the subject) if you didn't get the number which water is fluoridated at, which was stated clearly. II | (t - c) 09:59, 10 November 2008 (UTC)

The edits of these wise self-styled "experts" and guardians of Wikipedia´s "quality standards" make it obvious again that contributing to this article is a waste of time. Tren (talk) 20:56, 10 November 2008 (UTC)

I made these changes with the intention of improving the article and making it more encyclopedic. Please review my comments carefully. And in case that's still not clear: this article includes a lot of detail that, even if factual, is not informative about the issue. This includes a history of research studies performed in the mid-20th century. Few studies are noteworthy for being studies. What is noteworthy is the result of a study, as it pertains to the topic, and surely there are is a more recent study, or even a survey of studies, that could be cited instead.

Also, upon another close inspection of the article, the standard amount of fluoridation is still not there. Here is a list of the fluoride concentrations mentioned in the article:

• 2 to 13.7 ppm: contamination in Colorado, 1931
• 2.8 - 3.9 ppm: Amarillo 1936-7 (Wichita Falls is missing)
• 1 mg per day / 1 ppm: 1942 optimal fluoride
• 0.7 ppm to 1.2 ppm: present (?) CDC recommendation
• 1 ppm: 12.5% of people have aesthetic concerns about fluorosis (possibly the same number for decrease in cavities and decay, but this is not made clear and that number may be omitted)
• 0.7 – 1.2 mg/L: "above the commonly recommended dosage," causing side effects (or is this stated unclearly?)
• 1 – 3 mg/day: intake calculated by a Wikipedia author (?) based on recommended water consumption
• 4 mg/L: EPA maximum contaminant level, recommended by NRC to be lowered
• 1.4 – 2.4 mg/L: EPA MCL before 1985
• 1.5 mg/L: WHO caution
• 10 ppm: bone damage
• 0.07 – 1.2: optimal (WHO again?)
• 2 mg/L: NRC bone risk unknown
• 1 mg/L to 4 mg/L: differential known to increase risk
• 12 mg/day: expected to cause kidney side effects
• 4 mg/L: can possibly lead to the above intake
• 23 mg/day: some studies suggest negative liver effects
• 0.36 ± 0.15 mg/L (range 0.18-0.76 mg/L), 2.47 ± 0.79 mg/L (range 0.57-4.50 mg/L): areas compared for IQ in unpublished (?) studies

Not one of these is clearly stated as a typical fluoridation level introduced into a public water supply. And in an encyclopedia, as opposed to a medical reference book, I think most of these facts could be explained without having to specify the exact numbers; truly curious readers can follow the citations. Epistaxis (talk) 06:10, 11 November 2008 (UTC)

Epistaxis, I'm sorry if this sounds rude, but look at all those values you cited. Do you really think the fluoride level found naturally in 1931 Colorado water is the amount used? Now zero in on the present CDC recommendation, which differs "depending upon air temperature". Do you think that might mean something? It is stated in the second sentence on the cost-benefits section. In the possible health effects section, the section which you eliminated, it is stated again in the first sentence: "Negative health effects are generally associated with fluoride intake levels above the commonly recommended dosage, which is accomplished by fluoridating the water at 0.7 – 1.2 mg/L (0.7 for hot climates, 1.2 in cool climates)". So we have clear evidence that you didn't even read that section! I'm sorry if this sounds rude, but read before you make a big fuss! II | (t - c) 19:58, 11 November 2008 (UTC)

I'm pretty sure that the 0.7-1.2 ppm (mg/L) level is the general standard for municipal water supplies with added fluoride. The devil enters with the details: studies of natural water supply in excess of this level are included, in many cases with no 3rd-party comment on their methodological rigour; there is a valid argument that variation in daily water consumption (among water enthusiasts or low body-weight individuals, for example) could result in excessive fluoride intake, and this can be compounded by dietary intake. The current US regulation permits up to 4ppm I think, and this is a bone of controversy - even though no municipal facility is known to fluoridate to that level, it's within standard, so is (apparently) a legitimate target for commentary. Additionally, anytime there's a big tank of fluoride compounds hooked up to a water pipe, there's a risk that the entire tank can empty into the pipe, with toxic effect - again, a legitimate target of criticism.

Inclusion of the studies showing toxic effects at extremely high doses probably don't belong here, as we do have a separate article to describe the toxic effects. The studies which are not subject to 3rd-party commentary (review article or meta-study) are particularly on the edge. Here's a thought though - would it be possible to re-sort these data (maybe in a table) along a gradient of the fluoride level? Then the reported effects could be viewed by increasing dosage, and the "standard" and "maximum US allowable" dosage levels could be shown in-line. Franamax (talk) 06:50, 11 November 2008 (UTC)

Intake	Fluoride	Fluoride	Reported effects	Refs
mg/day	@1L/day	@3L/day
0.5	0.5mg/L	.167mg/L	none reported
2.0	2.0mg/L	.67mg/L	Elevated dental flourosis in children	[1]
4.0	4.0mg/L	1.33mg/L	kidneys are toast	[2]
20.0	20mg/L	6.7mg/L	so long baby!	[3]

Something like the above, only far, far less lame... Franamax (talk) 07:09, 11 November 2008 (UTC)

That would be an improvement over sprinkling these data throughout the text, but I still question whether the article should contain so many numbers at all. This isn't a medical reference; to treat it like one is at best irrelevant and at worst physically harmful. Maybe it should just state the recommended dosage and refer to "elevated" concentrations for the health effects etc. Curious medical scholars ought to follow the links to the primary sources anyway. --Epistaxis (talk) 08:24, 11 November 2008 (UTC)

First, there are 4 experts on fluoride and toxicology who say that some of the effects occurring at 2 – 4 ppm are relevant to municipal water fluoridation at 0.7 to 1.2. That's why some of this stuff is in here. The dosage is uncontrolled. Plus, it is nice to put a summary of the research up so that people know. In some cases it should qualm fears, since liver damage doesn't seem to happen until you get 23 mg/day (although the actual studies of that are slim). The osteosarcoma link occurs at the CDC's recommended levels, by the way. Also, the EPA standard on what can occur in drinking water (4 ppm) is also relevant, since natural fluoride is used as a substitute for added fluoride. II | (t - c) 19:58, 11 November 2008 (UTC)

What about this: "The CDC recommends fluoridation between 0.7 and 1.2 ppm, though the EPA allows higher levels for naturally occurring fluoride." "Typical fluoridation levels are between X and Y ppm" (still no source for this). "Higher levels of fluoridation can increase the incidence of fluorosis." "Extreme levels may lead to liver damage." "Osteosarcoma may result even at the recommended levels." This way, only the two most relevant figures are given, but all the important information is still there. If a physician really wants specific data or a survey of the latest literature, she probably isn't coming to Wikipedia for that information, and we have links to the sources for those kinds of details anyway. As I said before, for anyone other than an expert, such esoteric content is at best unencyclopedic, and at worst dangerously out of context. --Epistaxis (talk) 08:09, 12 November 2008 (UTC)

Let's hear what a few other people have to say on the issue. I don't think it is dangerous to summarize the conclusions of the National Research Council in this article. There's a lot of misinformation floating around, and this is not it. I also don't think it is amiss to cite conclusions of the NAS toxicology researchers arrived at after reviewing the evidence, although 2 of them aren't really that relevant. John Dull and Kathleen Thiessen's comments are the most relevant. Also, I certainly don't agree with you that fairly accurate summaries of the toxicological literature regarding fluoridation are "esoteric content" which are "at best unencyclopedic". Wikipedia is not dumbed down. We give people the dirty details and the numbers, especially when those numbers are simple and easy to understand. Take a look at the mathematics articles sometime. II | (t - c) 06:00, 20 November 2008 (UTC)

I agree with Epistaxis that there is waaaay too much detail about individual research studies, both in Water fluoridation #Early studies and in Water fluoridation #Possible adverse health effects. And as per WP:MEDRS and WP:RS we should be citing secondary reviews, not primary studies directly. This article certainly should not be citing ancient primary studies like Dean 1934 (!), nor should we be citing marginal speculative studies like Coplan et al. 2007. Stuff like that should be moved into a more detailed article on water fluoridation research, or perhaps into the opposition article. Eubulides (talk) 06:16, 20 November 2008 (UTC)

Change to lead overemphasized prevalence

This change to the lead has a couple of problems:

• It emphasizes the prevalence of water fluoridation all out of proportion to its weight in the body. The topic is only a small part of the body, and should not consume half the lead. A brief statistic of worldwide use should suffice.
• The cited source does not support the phrase "since the 1950s".
• I made this further change to try to improve the lead further.

Eubulides (talk) 09:15, 19 November 2008 (UTC)

The geographical prevalence is fundamental to providing a broad overview of the topic. Per WP:LEAD: "The lead should be able to stand alone as a concise overview of the article. It should establish context, explain why the subject is interesting or notable, and summarize the most important points—including any notable controversies that may exist." If you're going to mention that the United States routinely does, you're obligated to mention the fact that other developed nations do not in order to avoid misleading the reader. I hate to assume bad faith, but it seems as if you're trying to mislead the reader, especially since a common misconception in the United States is that water fluoridation is standard practice among developed nations. Let's hear what other people have to say. I may start a thread over at WP:NPOV/N and WP:MED to see if we can get an audience. II | (t - c) 09:23, 19 November 2008 (UTC)

Saying that 5.7% of the world's population drinks fluoridated water makes it pretty obvious that it's not that common worldwide, no? If you prefer a different concise wording to establish the contrast, please suggest it; but detailed statistics about this country and that region are out of place in the lead, due to the weight problem mentioned above. Eubulides (talk) 09:31, 19 November 2008 (UTC)

Well, no. Call me pessimistic, but I think a lot of American readers who consider themselves educated could take away from that statement that "oh, the US and the rest of the developed world fluoridates water, and the developing world doesn't". I don't think most people have a ballpark understanding of world population numbers. I still think the lead could be added to, especially in terms of evidence. And the CDC is a poor source, considering that its been promoting fluoridation for decades. The cost-benefits / efficacy section should give start with the York review. I may do that tomorrow. II | (t - c) 09:38, 19 November 2008 (UTC)

"Wikipedia is not dumbed down". And even if it were dumbed down, I doubt whether lots of American readers would be so dumb that they would think the developed world constitutes only 5.7% of world population. The revised wording still spent waaaaayy too much weight on prevalance compared to its weight in the body. I made this change to try to bring it back into balance. Eubulides (talk) 06:29, 20 November 2008 (UTC)

Having watched the edit wars for several years...
Would it not be more encyclopaedic to have the first paragraph explain that we are talking about a subject that should fall into the Category:Policy, for that it all it is (and all it can be) until the missing scientific research is conducted.
As it is now (starting with bold assertions) makes it sound like the benefits (or harms) are set in scientific concrete and is thus ensures the edit war continues. I blame med schools for instilling un-realistic view of how health polices come about and why and what is involved in their formulation – (but that's another matter). Having a separate article for the 'controversy' also guaranties polarisation, rather than the coming together and laying out of the known with the unknown.
Whilst some editors are left free to confuse the processes of agreeing policy and the process of scientific evaluation (or systematic review) in their minds, so the article will reflect that confusion don't you think? By always viewing it as just another policy however, it will then be a little easier to create text that explains simply why some countries change their water treatment policies from time to time -without another editor flagging it as POV in respect of one dogma or the other. The amount of 'weight' to give each aspect might also be a little easier to judge. I have seen a lot of editors generate acres of text over this article over the time I have been watching it and much time seems to be spent going back and forth and round and round. Maybe this different approach might help to anchor it.--Aspro (talk) 12:23, 20 November 2008 (UTC)

Major copyright infringement

This edit by 67.135.62.118 (talk · contribs · WHOIS) was a massive copyright infringement from here. I reverted it. Please don't do that. Eubulides (talk) 22:19, 30 November 2008 (UTC)

Evidence-basis changes

This set of edits has some problems:

1. It summarizes the York review as saying "there are no clear adverse effects aside from fluorosis". However, the earlier sentence that summarizes fluorosis talks about more-severe cases caused by too much fluoridation. A naive reader would easily conclude that typical fluoridation would cause these more-severe symptoms.
2. The York study doesn't merely say there are no clear adverse effects. For the most important and well-studied effects (cancers, bone fracture) it says that the best available evidence shows no association.
3. At this point, it would be better to cite Yeung 2008 (PMID 18584000) rather than the York review, done in 2000 (PMID 11021861). The reviews' conclusions are the same, from the point of view of the lead, but Yeung has more-recent data.
4. The set of edits alters the lead to say that WF has been "contentious" and that this is "generating an opposition to water fluoridation". But the contentiousness is not generating the opposition: it's the other way aroudn. The contentiousness is the result of proponents and and opponents arguing.
5. It alters the lead to cite an older source (McNeil 1985) that is not cited in the body. I don't see any reason to cite this older source in the lead; the claim was already well-sourced by a higher-quality and more up-to-date source (Cheng et al. 2007, PMID 17916854). Certainly the lead should not be citing sources that the body does not cite.
6. The set of edits alters Water fluoridation #Evidence basis so that it starts off with a criticism of the quality of the research. However, reliable sources don't start off that way. For example, Yeung's summary of findings (Table 3) starts off "Existing evidence strongly suggests water fluoridation is beneficial at reducing dental caries." We should lead with the primary results, and talk about quality of data later.
7. For sources that are relatively supportive of water fluoridation (the CDC), it gives in-text attribution ("the CDC has attributed"). For sources that are relatively critical of water fluoridation (the York review), it merely states their conclusions without attribution. This gives greater weight to critics of fluoridation, which is a POV presentation.
8. It give great weight and considerable to the York review's statement that it found no cost-effectiveness evidence that met its standards, and it removed the CDC's statement that fluoridation is cost-effective.
9. It removed the mention about the equitability of water fluoridation.
10. It presents the CDC's conclusions and then immediately argues with then ("but this has been disputed by others"). It does not do the same for the York conclusions.

I have attempted to work around some of these problems with this edit and with this edit. Eubulides (talk) 21:44, 21 December 2008 (UTC)

Numbered bullets for easier discussion.

1. I don't mind saying most of fluorosis is mild in order to avoid confusing the reader. It may be better to just use numbers in the body: 48% are expected to have fluorosis, with 12.5% having it at the aesthetic concern level. You may also want to mention the precautions that Australia has taken. I can't recall what Yeung said about how effective that was.
2. It is important to note that distinction. It is also important to note that the York review's conclusion on negative effects aside from bone fracture and osteosarcoma is that the studies "provide insufficient evidence on any particular outcome to permit confident conclusions" (14). The lead should specifically note where the high-quality evidence has been directed.
3. In general, we're trying to cover all the angles of information in the interests of being comprehensive. The Yeung review includes only study more than the York review, so while it is more up to date, its benefits over York should not be exaggerated. Yeung itself says that it largely depended upon the York review. If the Yeung review doesn't cover an angle covered by the York review, we cite the York review. If the two disagree, we note their disagreements. Let me know what your thoughts on this approach are. Since the Yeung review avoids discussing evidence quality and does not contradict the York's reviews conclusions, the York review should be cited.
4. Isn't this like what came first, the chicken or the egg? It seems obvious that the opposition movement would come after certain people contended that fluoridation has not been proven to be justified. Please restore.
5. OK.
6. If we're starting off a section on evidence basis, starting with a summary of the quality seems reasonable. Yeung avoids discussing quality, so the York review was used. I disagree with your conclusions here. We should lead with the quality and the results, since the results are informed by the quality. Anyway, I don't mind how it looks now.
7. The York review is obviously more reliable than the CDC, as it is independent. The CDC has been promoting fluoridation for 50 years and is defensive if someone says the evidence isn't as good as they've been saying. Thus, this is appropriate. However, if you want to attribute the York review's claims, feel free to do so.
8. Again, conflict of interest and reliability. The CDC not only has a conflict of interest, it is also unpublished and thus not subject to peer review. Stating that the reduction in caries in the US can be attributed to water fluoridation could probably not pass peer review. The CDC's cost-effectiveness is based on an unpublished workshop in 1989 which found little high-quality evidence, even before the York's critical review (which changed the dialogue from 50% reduction to 15%). The CDC source here is dated and unreliable.
9. I'm not seeing where I removed it. Anyway, the York review was only able to find C level evidence on the equitability. It's more up to date and more independent. Its conclusions (which are not that there's no evidence) are on page 14. Cite those before the CDC.
10. 5 European nations with neither water nor salt fluoridation have lower DMFTs in 12-year olds than the US. Overall, 10 European countries with no water fluoridation have lower DMFTs than the US. The WHO data is here. Fluoride Action Network has put in a graph her, along with snippets from various reviews. Cheng correctly points out that attributing the reduced cavities to water fluoridation cannot be justified, regardless of what the CDC says. Please put back the fact that this is disputed.

Looking through the changes, I don't have that big of a problem with them, but I don't like the way you've obfuscated how the research has gone. We should actually be getting a bit more specific by mentioning that most of the evidence is before and after studies, which is why the York review criticized it so much. There are no RCTs, even though RCTs are theoretically possible. Describing particular studies, when there have been a few key studies, is good, and you've eliminated that. The York review needs to be given more weight than the CDC in terms of equitability and cited when Yeung cannot be. The lead of effectiveness, that "water fluoridation most effective and socially equitable way to achieve wide exposure to fluoride's cavity-prevention effects" is untenable. It doesn't matter whether Yeung says it, it is just far too questionable and disputed to state so matter-of-factly. The York review had a different interpretation of the same evidence, so its interpretation needs to be included. The fact that the CDC's attribution of lower cavities to water fluoridation is highly questionable needs to be included. I don't understand why or how you can, in good faith, justify removing Cheng and Diesendorf's dispute of the claim. If we can't agree on these things, then we'll have to do some dispute resolution.

1. Yes, it might make sense to give the York numbers for fluorosis in the body of the article.
2. It's not clear that the lead needs to go into details about the difference between no-association and not-enough-evidence, simply because the York review makes that distinction. That sort of detail seems more appropriate for the body. At the level of abstraction appropriate for the lead, almost all major dental and health organizations either have found no association with adverse health effects or support water fluoridation. The lead shouldn't imply anything different, and shouldn't go into a lot of detail that makes it sound like there might be something different.
3. I don't know of any material area where the Yeung review disagrees with the York review. However, the Yeung review is more up to date, covers more material, and comes to more conclusions than the York review does. The Yeung review largely defers to the York review for the effectiveness of water fluoridation, but it also notes the issue of the halo effect, and for dental fluorosis it also relies on Griffen et al. 2001 as well as 11 other additional studies (not covered by the York review). I don't see any reason to omit results from the Yeung review in these areas.
4. If we can't show that contention led to opposition, we shouldn't assert that in the lead. (Just as we shouldn't assert the chicken came before the egg....)
5. OK.
6. If you don't mind how it looks now, let's move on to the more-important matters.
7. It is not at all clear that the difference (if any) in reliability between the York review and the CDC source requires in-text attribution for the CDC but not for York. The CDC has not existed for 50 years, so it can hardly be said to have been promoting anything for 50 years. The CDC is generally recognized as a reliable source on public-health issues, and we shouldn't be inserting text to undermine or dispute its results unless there is a conflict among reliable sources on what we are summarizing here, which there doesn't appear to be.
8. Claims that the CDC have a conflict of interest in this area are fringe claims, and the article should not be based on them. That sort of argument belongs in Opposition to water fluoridation, not here. There is no controversy among reliable sources for any claims in Water fluoridation that are currently sourced by the CDC, so there's no need to have in-text attribution for any of those claims.
9. The point about equitability is now sourced by Yeung 2008, not by the CDC.
10. The point about European results being different is addressed in the body, and is sourced by Burt & Tomar 2007, not by the CDC. I don't see anywhere that Cheng et al. 2007 (PMID 17916854) says anything like "attributing the reduced cavities to water fluoridation cannot be justified, regardless of what the CDC says"; perhaps you could supply an exact quote?

The followup remarks seem to be arguing against the CDC's conclusion that water fluoridation is associated with fewer cavities. But the York and Yeung reviews come to the same conclusions. I don't see why the article should be arguing against this point: it's the mainstream opinion. As per WP:NPOV we should base most of the coverage on the mainstream opinion, not on the fringe opinion that fluoridation does not help against tooth decay. Diesendorf 1986 (PMID 3523258) is way, way, dated; we should not be relying on 20-year-old sources for medical facts and figures, especially when up-to-date sources are available. Cheng et al. 2007 (PMID 17916854) is cited six times in the article; I'm not sure what removal is being talked about here. Eubulides (talk) 08:37, 22 December 2008 (UTC)

Please try not to mischaracterize my remarks. I've never edited to take out statements that water fluoridation reduces cavities, and I said just a second ago that I'm fine with the intro in the Evidence Basis section. What I do oppose is turning the effectiveness section into a fluffy, shallow promotional section. The York review stated that there is not limited evidence on the equitability or the cost-effectiveness. There is some evidence, yes, but it stated that it should be viewed with caution. Clearly, then, McDonagh seems to disagree with Yeung. Or maybe there is no disagreement, and the other public health measures have even less evidence, which allows Yeung to use that superlative. Either way, the evidence quality needs to be presented. Yeung includes only 1 relevant extra study (though categorized as Level IV), which actually found that caries did not increase after fluoridation was discontinued, so there's not a major reason to shut out York's differing interpretation of the evidence. Discussion of the quality of the efficacy should also not be ignored or relegated to a vague statement. In any other medical article, you would certainly be arguing that the quality of the evidence should be taken into consideration when discussing effects. Here's a pop question for you: how many of these before and after studies looked at confounding effects at all (toothpaste use, mouthwash, ect.)? I'll save you time: none. There's a reason the York review was critical and stated that it was "unable to discover any reliable good-quality evidence in the fluoridation literature world-wide".

Burt & Tomar 2007 speculate, without any sources, that better access to dentists for children in Europe explains the decline in cavities. That is just speculation and opinion if there are no sources using data to back it up. Cheng et al write that "[a decline in caries] has occurred regardless of the concentration of fluoride in water or the use of fluoridated salt, and it probably reflects use of fluoridated toothpastes and other factors, including perhaps aspects of nutrition". Similarly, Aoba et al 2002, states that "the dramatic decline in dental caries which we have witnessed in many different parts of the world has occurred without the dental profession being fully able to explain the relative role of fluoride in this intriguing process". II | (t - c) 01:29, 23 December 2008 (UTC)

• Sorry, I don't know what is meant by "mischaracterize my remarks". I don't recall claiming that you "edited to take out statements that water fluoridation reduces cavities", or anything like that.
• There was nothing fluffy or promotional about the effectiveness section. It accurately summarized recent, reliable reviews in the area.
• The York review does not disagree with Yeung on any substantial point. It certainly does not disagree on the issues of equitability and cost-effectiveness. The York review itself (McDonagh et al. 2000, PMID 11021861) never mentions equitability, cost-effectiveness, or caution. The full York report (which is not peer reviewed) says that they briefly researched studies of equitability only in England (not worldwide), and says that cost-effectiveness was outside the bounds of the review. No doubt this explains why issues of equitability and cost-effectiveness were not addressed in the York review itself.
• Water fluoridation gives detailed statistics from the York review, including ranges; surely this should suffice for "quality of the efficacy". It's certainly not vague.
• I don't see how York has a "differing interpretation of the evidence" from Yeung. On points where they both have interpretations, these interpretations substantially agree.
• Certainly the body should talk about the relatively low quality of the evidence. But it does that. What more is needed there?
• Burt & Tomar 2007 are a reliable source, and are giving the mainstream opinion about why the experience in Europe has been different. It substantially agrees with what Cheng is saying. Aoba & Fejerskov write that "Water fluoridation is by far the most cost-effective public health measure in caries prevention", and this does not disagree with their other statement (which you mention) that we can't fully explain how fluoride works.
• For more, please see #Effectiveness, motivation, biological mechanism, etc. below.

Eubulides (talk) 21:23, 27 December 2008 (UTC)

You said that "followup remarks seem to be arguing against the CDC's conclusion that water fluoridation is associated with fewer cavities". There was nothing in my remarks which argued that. What I do object to is the misleading implication that water fluoridation is necessary for low cavities rates, and that the evidence is incontrovertible. That's what you have been pushing, and that is not supported by any reviews. All the comments which are made to qualify the results, you pull out, even though they are highly pertinent. These include the York review's statements that it was unable to find high-quality evidence, the Yeung review's qualification that no studies controlled for topical fluorides, Pizzo's observation that caries have declined significantly in Europe, ect. Since none of this is mentioned, we can't say that these reviews are being accurately summarized. II | (t - c) 21:25, 30 December 2008 (UTC)

• I don't see anything in the article claiming, or implying, that "water fluoridation is necessary for low cavities rates", much less that the evidence is incontrovertible for that. Obviously the article should not say or imply that; if it does, we should fix it.
• Water fluoridation #Evidence basis says "the quality of the research on fluoridation has been generally low" and Water fluoridation #Effectiveness says "little high-quality research has been done on the cost-effectiveness and solid data are scarce". So the point is already being made, prominently, that high-quality evidence is lacking. We should emphasize this point roughly as much as high-quality reviews do, not more.
• Diving into each review, and pulling out just the negative parts of it, is not the right way to summarize what it says. We need to summarize the whole review, accurately, giving the big picture of what it says. For the big picture, it is quite reasonable to mention that evidence is lacking (which is what the article already says); it is not so reasonable to go into an enormous amount of detail as to which evidence is lacking and why, as that will bring on WP:WEIGHT problems, obscuring the big picture that there's widespread consensus among all reliable sources that fluoridation prevents cavities.

Eubulides (talk) 22:23, 30 December 2008 (UTC)

Politics

Following up on the discussion about the unsourced part of the lead in #Evidence-basis changes above, I found a recent reliable source on the politics of fluoridation, Armfield 2007 (PMID 18067684), and used it to source the following rewritten version that unsourced part: "and considerable opposition to water fluoridation exists despite its support by public health organizations". I also used the new source to improve Water fluoridation #Politics considerably, and moved the "top 10" point to Effectiveness, where it belongs better. The new version of Water fluoridation #Politics gives considerably more text to opponents of fluoridation than to proponents, but it does so from the mainstream point of view, so I hope that's OK. Eubulides (talk) 21:51, 22 December 2008 (UTC)

The section looks OK, but it could use a bit of balance. Armfield takes the relatively strong position that all scientific opponents are basically quacks, cites the York review selectively, and cites as one of his most authoritative sources that there is no scientific controversy the 1978 issue of Consumer Reports. It's not accurate to portray the opposition like that, when it includes notable and credentialed researchers such as Hardy Limeback and several other members of the recent NAS panel. Incidentally, even though the contentious -> opposition thing is over, I still don't understand how you can say that opposition can exist without contention. I'm guessing that you regard the contentions of mere citizens to be illegitimate? I'm surprised that you didn't notice the spot where Burt & Tomar mention that research scientists were among the early opponents. They note Sutton's methodological critique in 1959. II | (t - c) 01:29, 23 December 2008 (UTC)

I'm wondering if you'd mind answering my question here? II | (t - c) 21:25, 30 December 2008 (UTC)

By "my question" I assume you mean "I'm guessing that you regard the contentions of mere citizens to be illegitimate?". My answer is "no". I thought it was a rhetorical question and therefore did not require answer; my apologies if you intended it to be a serious question. Eubulides (talk) 22:23, 30 December 2008 (UTC)

Effectiveness, motivation, biological mechanism, etc.

This series of edits has several problems:

• It changed the section header Motivation to Motivation and biological mechanism and added a discussion of the history of fluoride's presumed biological mechanism. As the ungainly title suggests, this is mixing topics. Also, it is better to put historical stuff in the History section; this will allow us to keep the rest of the article up-to-date. I don't see the relevance of a detailed coverage of the dispute over fluoridation's mechanism into this article; this topic may be relevant to Fluoride therapy, but is only marginally relevant here, and it's certainly not relevant to Motivation, as the motivation for water fluoridation is almost entirely independent of how it works.
• It introduced distracting numeric details into the introductory paragraph of Evidence basis, using the following wording "At 1 mg/L 48% of the population is expected to have fluorosis, 12.5% of which is of aesthetic concern." These detailed numbers were introduced only into the part of that paragraph that is negative, which beefed it up and introduced WP:NPOV problems. There is no need for that level of detail in the brief summary; it should be put into the detailed section.
• Furthermore, the numbers are not correct: they understate the amount of fluorosis of aesthetic concern by more than a factor of two.
• Yeung 2008 (PMID 18584000) summarized those numbers in a different way, which is more useful: it gave the number needed to harm (NNH) for fluoridation versus no fluoridation. (This way was also used in the York review.)
• It removed the lead sentence of Effectiveness, thus making the section harder to follow.
• It adds prominence to the York review, mentioning it by name while not mentioning any other reviews by name. In its discussion of the York review it repeats the review's conclusions, which are already discussed; this overemphasis adds NPOV concerns. There is no need to emphasize the York review to this degree: it is not a revolutionary review nor (due to its age) is it the best and most reliable review right now. Any direct mention of it in the text should be in the History section.
• There is no need to give details like "26 studies met its inclusion criteria, all but 3 of which were 'before and after' studies" for the York review, when details like that are not given for other reviews.
• It relegates the more-recent Yeung review to a mere update of the York review. This is an inaccurate summary of the Yeung review. Yeung based its work on effectiveness on the York review's method, but it covered areas that the York review did not, and it refers to many more studies than jsut "one additional relevant study".
• It introduced discussion of that one study, without citing it. There is no good reason to single out that one study and discuss it in detail here; as per WP:MEDRS we should be summarizing reviews, not individual studies. If we do discuss it, we should cite it.
• It inaccurately summarizes the mainstream opinion about why the water fluoridation experience has been different in Europe. The mainstream opinion is that this is because of the other use of fluorides there, even if we don't fully understand how fluoridation works.
• It inserts text like "some believe" and "is believed to" in text supportive of fluoridation, while omitting qualifiers like that in front of text that is critical. This is clearly a POV problem.
• There's no reason, except perhaps in the History section, to talk about the obsolete theory that fluoride operates primarily preeruptively.
• The paragraph starting "Worldwide, a decline in tooth decay has been observed regardless of water or salt fluoridation" contains a string of claims that omit important caveats in the underlying sources and, together, presents a misleading summary of what is known about fluoridation. For example, the very first word in that paragraph, "Worldwide", is completely inaccurate: Box 1 (pp. 699 and 700) of the cited source (Cheng et al. 2007, PMID 17916854) is clearly talking only about EU countries, not about fluoridation worldwide.
• The statement "Water fluoridation has been regarded as extremely cost-effective for the past fifty years" understates the source, Pizzo et al. 2007 (PMID 17333303), which says that water fluoridation has been considered "the most cost-effective measure for the control of caries at the community level".
• The statement "Fluoridation is also believed to increase the equitability of caries prevention" is not supported by the cited source (Pizzo et al.) which says nothing about belief.
• The statement "The dental profession has not been able to fully explain this decline through the use of fluorides" is a inaccurate summary of the cited source, Aoba & Fejerskov 2002, which says that the dramatic decline in dental caries "has occurred without the dental profession being fully able to explain the relative role of fluoride in this intriguing process". That is, Aoba & Fejerskov imply that fluoride can entirely explain the dramatic decline in dental caries, even if we don't understand its mechanism fully; but the statement in Water fluoridation makes it sound like the decline in caries has occurred for reasons unknown, and we can't explain it with fluoridation (an implication that Aoba & Fejerskov do not make).

To help address these problems, along with some more-recently added changes alleging involvement by nefarious industries and Nazis, I have just now installed a series of edits, the most substantial was this one for Water fluoridation #Effectiveness. The result is by no means flawless, but I hope it is an improvement. Eubulides (talk) 21:23, 27 December 2008 (UTC)

Is there a reason that you don't like numbered bullets? It makes it less easy to reference your points. I changed it before, but since you're adopting that, I want to know why before I change it again.

• Motivation and mechanism are inextricably linked, and therefore there's a decent reason to discuss them together. Clearly fluoride's use is motivated by its mechanism? They can be separated if it's a big deal for you, but originally water fluoridation was believed to work almost entirely preeruptively and thus only in children, as the FWRG notes. This is a major fact related to mechanism, and deserves to be noted in that section. If we can't agree to include some historical context in the Mechanism section, we'll have to do mediation or I'll have to open a RfC.
• The Yeung review was a broad review of fluoridation. For efficacy, it relied basically entirely upon the York review, although it did find 1 additional study, which I described and which did not support water fluoridation. Since the Effectiveness section is focused on water fluoridation rather than other types, York is clearly superior to Yeung on water fluoridation's effectiveness. Yeung can be viewed as a collection of reviews, whereas York is a much more focused review of water fluoridation's effectiveness. This can be seen on page 33 of the report, where Yeung writes "[o]nly one additional relevant original study was identified in the current review and this did not change the conclusion of the existing systematic review [York]". For water fluoridation, it cites only two reviews that additional study -- and it says over and over that the York review was the superior one.
• Burt & Tomar do not cite data (or anything) for their assertion. Thus, it should not be stated as fact, as it is now. If something is supported by a careful, focused review of data, as the York review's conclusions are, and cited indisputably, then I'm fine with writing it as fact. It's not POV, and I don't see why we need to start throwing around accusations.
• One can interpret Aoba either way, but clearly if one can't explain fluoride's role in the decline, it's premature to assert conclusively that fluoride does explain the role. In any case, my version did cite Cheng in saying that the decline is largely attributed to fluorides, but mainly topical ones, and was more accurate in that it noted that the research isn't conclusive. If it isn't conclusive, or it's arguable, then we shouldn't put it in the article as if it is conclusive. That's the general problem with your approach to the Effectiveness section.

Should I just go ahead and try to do mediation or a RfC, or can we reach a happy medium on this Effectiveness section which notes the basic qualifications about the evidence raised by York's review, or even by Yeung's review (that the studies did not control for topical fluorides)? Relying largely on the Yeung review when the York review is indisputably the highest-quality review of water fluoridation's effectiveness seems like suffers from WP:RECENTISM bias. We know how up to date the York review is because Yeung did a literature search with its criteria, and found only 1 additional study, which was poor and did not support water fluoridation. Whether the York review is revolutionary or not, no substantive critique has appeared in 8 years; in fact there has been the exact opposite response. II | (t - c) 21:25, 30 December 2008 (UTC)

• In the past, I've found that numbered bullets don't work well on talk pages: people insert text between the numbers and then the numbers go haywire. Anyway, the numbers don't help all that much. It's no big deal either way; please feel free to use numbers in your comments.
• Motivation is "inextricably linked" only in the sense that it's related to fluoridation, and fluoridation is linked to its mechanism. Motivation is equally "inextricably linked" to history, and to the evidence basis, and to politics, and to all the other sections of Water fluoridation. Overall it's better to put historical matters in the History section, to avoid cluttering up the other sections with obsolete stuff. It is certainly better to avoid cluttering up the Motivation section with arguments about why part of long-ago arguments supporting fluoridation were incorrect.
• York is not at all "clearly superior" to Yeung on effectiveness. Yeung is more recent and has better data. Yeung covers every study that York does, and then some. It's rare for high-quality public-health reviews to be significantly worse than reviews done 8 years before, and Yeung is not an exception to this general rrule.
• Burt & Tomar are expert opinion on this subject, and no reliable source disagree with them. There is no reason to insist on Cochrane Collaboration quality reviews for every point in this article: we should be reporting the mainstream consensus, which we are doing in this case.
• There is a difference between not being able to explain every detail of how fluoride actually works (which we can't), and being able to show that fluoride prevents tooth decay (which we can). It's similar to autism: we don't know the exact mechanism for autism, but we do know (because we've done the science) that autism is highly heritable. This is not a question of interpreting Aoba either way: it is a question of whether mainstream scientific opinion is that fluoride prevents tooth decay, which is what the opinion clearly is.
• As mentioned above, the claim in the older version that "Worldwide, a decline in tooth decay has been observed regardless of water or salt fluoridation, and this decline usually attributed to the use of topical fluorides and perhaps nutrition." (citing Cheng et al. 2007, PMID 17916854) is incorrect. Cheng et al. say nothing about a "worldwide" decline: their claim is only about the EU. Cheng et al. do not attribute the decline to "topical fluorides" in general, but instead said that it was probably "fluoridated toothpastes and other factors".
• I'm not sure what "noted that the research isn't conclusive" refers to. The current version notes that fluoridation research is of low quality. That point needs to be made clearly, but it doesn't need to be repeated over and over.
• I agree that the Wikipedia article should not take sides when reliable sources disagree. But there isn't much disagreement here, among reliable sources.
• I don't know what is meant by "Yeung's review (that the studies did not control for topical fluorides)". I don't see anything to that effect in Yeung's review. Can you supply a page number and/or quote from the published review?
• Obviously further changes can be made in this area: Water fluoridation is by no means perfect. But we need to follow the main outline of what the reliable sources say: we should not be emphasizing just the negative parts (or just the positive parts, for that matter).
• I suggest that you propose further changes to address the concerns you raise, in the light of the above comments. I don't think an RfC or mediation is called for at this point, as I think we're still making progress in improving this article.

Eubulides (talk) 22:23, 30 December 2008 (UTC)

Moderate quality etc.

This edit added the sentence 'The evidence was of moderate quality, and none of the analyses controlled for other sources of fluoride.', with the edit summary 'Page 37 of Yeung's full report: "it should be noted that the analyses did not take into account the use of other sources of fluoride".' There are several problems with this edit:

• The cited source is the York review (PMID 11021861), not Yeung 2008 (PMID 18584000), so this text is incorrectly sourced.
• The comment on page 37 of the Yeung full report does not apply to the results of the York review. It applies only to Table 12 (page 38) of the Yeung full report. Pulling that comment out of the Yeung full report and placing it here, out of context, makes it appear that Yeung's comment applies to all of the York study, which it does not.
• The comment on page 37 of the Yeung full report says nothing about "moderate quality", so that part of the text does not seem to be sourced.
• Water fluoridation should not be reach down into the full Yeung report (which was not published in a refereed journal) to emphasize details that Yeung himself did not feel worth emphasizing in the published peer-reviewed article that Water fluoridation is citing. As per WP:MEDRS, the article should rely on peer-reviewed review articles in refereed journals for information about weight.

Eubulides (talk) 01:11, 31 December 2008 (UTC)

Neither the CDC nor Burt & Tomar are published in peer-reviewed articles, so it seems a bit like wikilawyering to say that a government agency report, similar to the CDC's reports, should not be cited. You really want to stick with that argument? I put the Yeung comment in there to answer your question, but I was also aware that the York review supported the statement I put in. The York review states the following:

The most serious defect of the studies of possible ben­eficial effects of water fluoridation was the lack of appropriate design and analysis. Many studies did not present an analysis at all, while others did not attempt to control for potentially confounding factors. Age, sex, social class, ethnicity, country, tooth type (primary or permanent), mean daily regional temperature, use of fluoride, total fluoride consumption, method of measurement (clinical exam or radiographs, or both), and training of examiners are all possible confound­ing factors in the assessment of development of dental caries.

Although I can't find it off the top of my head, I know that the only confounding factors controlled by any of the studies were age and possibly one other thing (not fluorides). I'll switch the statement to be closer to York's review, though. Yeung does relate York's statement that the evidence is of B quality (moderate quality, moderate bias). Use your PDF find function for any of the prior words. Also, Yeung does appear to be referring to all the York review's studies when he says none controlled for topical fluorides, contrary to your statement. II | (t - c) 01:36, 31 December 2008 (UTC)

• Yes, we should prefer high-quality review articles, as per WP:MEDRS. However, the CDC report in question (PMID 11521913) is a special case: it is published in Morbidity and Mortality Weekly Report, which, although not formally peer-reviewed, has a reputation higher than many peer-reviewed medical journals. For example, Olmsted et al. 2006 (PMID 17161735) lists MMWR as the equal of the best peer-reviewed journals as a source of information about infection control: it says, "Among nonpeer-reviewed periodicals, most infection control coordinators hold the CDC's MMWR in high regard. It is unique because the content contains science-based public health information and must meet rigorous criteria for publication (such as originality, quality, and timeliness)." WP:MEDRS already lists MMWR in an approving context, and it is the equal of peer-reviewed medical journals for most Wikipedia purposes.
• Burt & Tomar 2007 are published in a high-quality book Silent Victories: The History and Practice of Public Health in Twentieth-Century America (ISBN 0195150694), published by a respected university press (Oxford) and written and edited by prominent mainstream scientists and historians. While not strictly a peer-reviewed review, it's clearly a high-quality source as per WP:RS and WP:MEDRS. If we find a peer-reviewed review in a journal article, that would be better, but Burt & Tomar will do fine for now.
• Thanks for switching the statement to be closer to what the York review says, by replacing ", and none of the analyses controlled for other sources of fluoride" with ". Many studies did not appropriately control for observer bias and confounding factors, and many failed to use appropriate statistical techniques". I checked the York review (PMID 11021861), and found:

• It talked about "reducing potential observer bias" (p. 859) rather than controlling for observer bias.
• It did not mention "failed to use appropriate statistical techniques", or anything close to that that I could see.
• It said (p. 858) "The most serious defect of the studies of possible beneficial effects of water fluoridation was the lack of appropriate design and analysis. Many studies did not present an analysis at all, while others did not attempt to control for potentially confounding factors." When discussing flaws in the studies, we should be emphasizing this defect. The current wording mentions controlling for confounding factors, which is appropriate, but it does not mention design and analysis.

• I used my PDF find function on Yeung 2008 (PMID 18584000) and could not find anything about controlling for topical fluorides. Could you please give an exact quote and/or a page number? Thanks.

Eubulides (talk) 09:23, 31 December 2008 (UTC)

Asking for a third opinion. 01:47, 31 December 2008 (UTC)

Sorry, what exactly is that 3rd opinion being asked about? WP:3O#Active disagreements says "Disagreement as to whether to include critical statements made by a 2000 review, which were less stridently repeated by a 2008 review which largely depended upon the 2000 review." but I don't know which specific critical statements it is referring to. Eubulides (talk) 09:23, 31 December 2008 (UTC)

If we can agree on how it looks now, then I'll take down the 30 request. But generally I think an outside opinion on the entire situation wouldn't hurt. II | (t - c) 01:07, 1 January 2009 (UTC)

I agree that an outside opinion would help; still, it's not clear right now what the outside editor is being asked to look at. Eubulides (talk) 08:05, 1 January 2009 (UTC)

Caries decline etc.

This series of edits introduces some more problems:

• It introduces the claim "The tooth decay decline in industrialized nations is generally attributed to the use of topical fluorides", citing Pizzo et al. 2007 (PMID 17333303). But Pizzo et al. place an important qualifier on this claim: they are talking only about the decline in caries since the 1970s, not the decline before that.
• A nit: most non-expert readers won't know what a "topical fluoride" is; it needs to be explained.
• It uses the word "but" to oppose Pizzo et al.'s claim to the CDC's claim that the decline in tooth decay in the U.S. since water fluoridation began has been attributed largely to the fluoridation. These claims are not mutually exclusive, and the reliable sources are not opposing them, so we should not oppose them either.
• It inserts the claim "Diminishing returns to fluoride introductions have been observed as topical fluorides became more common, with early studies showing declines of around 50-60 percent and more recent studies in the range of 18-40 percent.", citing the FRWG, but the FRWG does not use the phrase "diminishing returns" and what they do say has nothing to do with with the common meaning of the term "diminishing return" as explained in Diminishing return.
• It inserts the claim "In Europe, many countries have experienced substantial declines in caries without the use of water fluoridation, leading some researchers to speculate that water fluoridation may be unnecessary in industrialized nations.", citing Pizzo et al. But Pizzo et al. do not say "some researchers" or anything like that. This needs to be reworded to avoid saying things that the source does not say. Also, the source says "most European countries", not "many European countries".
• It introduced duplicate citations to Pizzo et al.

I made this further change to attempt to address the above problems. Eubulides (talk) 08:05, 1 January 2009 (UTC)

Your edit looks pretty good. Some comments:

• Clearly there is tension between the CDC's statement that the decline in the US since the 1950s is largely attributed to water fluoridation and Pizzo's statement that the decline since the 1970s is attributed to topical fluorides. But I suppose it's fine the way it is.
• I beg to differ that average readers won't understand that term, but what you added certainly is more precise.
• I can't understand how that could be interpreted as anything but diminishing returns. Please explain how what Pizzo calls a "diminishing benefit" (citing that very same CDC source as well another) caused by the application of more and more of one product on a fixed surface (fluoride) is not a diminishing return. Using the exact same words that the source uses can introduce plagiarism problems. Summarizing with synonyms or well-known conceptual terms such as diminishing returns should not a problem.
• Pizzo et al are researchers, and they are speculating. I think you know that. Could you please explain how this was confusing to you? Certainly it's nothing like original research. Citing the more speculative conclusions of a few researchers with "some researchers" preface is pretty common, and there's nothing wrong with it except that it's awkward stylistically.
• Oh yeah, I meant to do that. Please reintroduce those duplicate citations.

II | (t - c) 09:22, 1 January 2009 (UTC)

• Diminishing returns are when each additional unit of variable input yields less and less output. When applied to water fluoridation, it would mean (I suppose) that each additional mg/mL of water fluoridation would yield less and less reduction in dental caries. But that's not what is being discussed here: the topic is that, in locales where toothpaste fluoridation works better, water fluoridation has less benefits than in locales where toothpaste fluoridation does not work as well. This is a different phenomenon; it is not diminishing returns.
• For Water fluoridation to say that Pizzo et al. are researchers, and that they are speculating, we would need a reliable source saying that they are researchers, and that they are speculating. We don't have such a source, and in the absence of such a source we shouldn't put material like that into the article.
• Even if we had a source for that claim, we shouldn't include it. People read Water fluoridation to find out about water fluoridation, not to find out about Giuseppe Pizzo. More generally, the main text of articles should not mention the identity of sources, as this clutters things up unnecessarily. There are exceptions for notable and/or controversial research, but nothing in Water fluoridation rises to that level.

Eubulides (talk) 19:39, 1 January 2009 (UTC)

• In the context of fluoride, it means that if you use brush your teeth with fluoridated toothpaste every day, drink fluoridated water, and use a fluoridated rinse or varnish, each one has a weaker and weaker effect because you're trying to add more fluoride when fluoride is already there and doing its thing. That's what Pizzo is referring to as a "diminishing benefit". And that is what's being discussed here: water fluoridation has less benefits in areas where toothpastes work better not for a mysterious reason, but simply because toothpastes are more commonly used and applied in areas where it "works better". The article doesn't need to be changed, but I'm surprised you're pushing back so hard against this basic, ubiquitous phenomenon. II | (t - c) 20:57, 1 January 2009 (UTC)

But that's now how fluoride works. It's not a question of adding more and more fluoride, and getting less and less benefit for each addition. On the contrary, it's a question of obtaining an optimal level; for some locations you need to remove fluoride, not add it. So it's not a case of diminishing returns in the classic sense (as described in Diminishing returns). Mentioning the phrase "diminishing returns" here might give the inexpert reader the misimpression that more fluoride is always better. Eubulides (talk) 00:09, 2 January 2009 (UTC)

"Oh yeah, I meant to do that. Please reintroduce those duplicate citations." By "duplicate citations" I meant that this version of the References section contains two copies of the citation to Pizzo et al. 2007 (PMID 17333303), once as reference [14] and once as reference [18] (the latter cited twice). In this edit I coalesced those two copies into a single copy; in the current version of References it is reference [14], cited three times. The total number of citations in the article did not change; it is only the number of copies in References has been reduced from 2 to 1. Eubulides (talk) 20:30, 1 January 2009 (UTC)

I know, I was joking. I forgot to add the / when referencing Pizzo and the bot added the full cite. Could we try to stick to things that matter rather than careless mistakes? Your focus on the above mistake makes you seem a bit robotic. I'm not sensitive about it, and I'll try to make less in the future, but it's not worth raising on the talk page. II | (t - c) 20:57, 1 January 2009 (UTC)

Borrow foundation sources

This edit was reverted by Trendley (talk · contribs) without comment on this talk page, the change log being "Milk fluoridation topic has been subject of discussion already!" I just now searched this talk page and its archives looking for discussion of "milk" and "Borrow" (for the Borrow foundation), and came up dry: I don't see anything relevant to the change.

The edit did four things:

• For less-reliable sources (self-published web pages by the Borrow Foundation) it substituted more-reliable ones (medical journal articles).
• It mentioned that fluoridated milk has been aimed at children, not adults.
• It mentioned that a Cochrane Collaboration review found insufficient evidence to support the practice.
• It removed detailed discussion of a dated example from Beijing.

All these changes seem to be improvements to me. None of these changes, as far as I can see, have been discussed on this talk page before now. On the theory that it's the dated example whose removal was being objected to, I reinstalled the change with one further improvement: an addition that mentions as an example the fluoridation of milk powder in rural Chile. I hope this suffices to remove the objection, whatever it is. Eubulides (talk) 18:45, 3 January 2009 (UTC)

Mechanism

I might have not spotted previous discussions on this, but I think this section is too short. This paper [1] gives a good synopsis of the biological mechanisms. Fluoride alters the tooth enamel and makes it less susceptible to attack by acid produced by bacterial metabolism, but equally importantly, it has a direct anti-bacterial action in that it inhibits bacterial enzymes inside their cells, (enolases I think). Graham Colm ^Talk 10:58, 11 January 2009 (UTC)

Unfortunately that paper (Featherstone 2000, PMID 10916327), although a reasonable one for its time, is somewhat obsolete.

• Soon after it was published, van Loveren 2001 (PMID 11359062) questioned whether fluoride's antimicrobial activity was of practical importance in preventing cavities.
• A couple of years later Marquis et al. 2003 (PMID 12586392) reviewed the area, and concluded "Any inhibitory effects fluoride may have on growth of plaque bacteria are not very pertinent to its anticaries action." The review also said that the antimicrobial-anticaries effects seemingly have to do with the acid tolerance of glycolysis by intact bacteria, not by any direct antibacterial effect.
• More-recent reliable sources state that the major action of fluoride is to inhibit demineralization and to encourage remineralization, and the bacteriostatic action of fluoride is no longer considered to be that well-supported. Here are three examples:

• Selwitz et al. 2007 (PMID 17208642), a recent and reliable review of dental caries, mentions only the demineralization/remineralization effects of fluoride.
• García-Godoy & Hicks 2008 (PMID 18460677), a recent, reliable (and freely-available) source, talks at length about the demineralization/remineralization effects of fluoride, but doesn't mention its antimicrobial effects. On the contrary, when it talks about eliminating bacteria, it limits itself to discussion of pro-biotic and molecular genetic techniques.
• Koo 2008 (PMID 18694872) is a bit more generous about the bacteriostatic theory, writing "Fluoride exerts its major effect by reducing demineralization and enhancing remineralization of early caries lesions (Dawes and ten Cate, 1990). However, there is a plethora of evidence which shows that fluoride, even at low concentrations, can affect the physiology of microbial cells, including cariogenic streptococci (as reviewed by Hamilton, 1990; van Loveren, 2001; Marquis et al., 2003)." That is, Koo isn't saying that fluoride has a significant and beneficial antibacterial action; all Koo says is that fluoride affects bacteria (which is indisputable, but of unknown significance).

Given what recent reliable sources say, Water fluoridation shouldn't be mentioning the obsolescent antibacterial theory, except perhaps in Fluoride #History. Eubulides (talk) 09:27, 12 January 2009 (UTC)

On second thought, perhaps it would be helpful to mention it briefly, if only to say that it's not like fluoride kills bacteria or anything. I added the text "Demineralization and remineralization is how fluoride exerts its major effect. Fluoride also affects the physiology of dental bacteria, although its effect on bacterial growth does not seem to be relevant to cavity prevention." to Water fluoridation #Mechanism. Thanks for the suggestion. Eubulides (talk) 09:54, 12 January 2009 (UTC)

This is the fullest, most lucid and interesting answer to a talk page question I have ever received. Thanks. Graham Colm ^Talk 18:58, 12 January 2009 (UTC)

Good overview

Here is a Canadian governmental paper form 1999 on the benefits and risks of fluoridation. http://www.health.gov.on.ca/english/public/pub/ministry_reports/fluoridation/fluor.pdf

--Doc James (talk · contribs · email) 18:19, 11 January 2009 (UTC)

And another from Quebec in 2007. http://www.inspq.qc.ca/pdf/publications/705-WaterFluoration.pdf

--Doc James (talk · contribs · email) 18:21, 11 January 2009 (UTC)

• The 1999 paper may well have been a good one, but it is outdated and is not published in a peer-reviewed journal. Is there any point that it makes that we can't support with an up-to-date source?
• The 2007 paper is much more up-to-date, but it is not peer-reviewed either. If we can cite a peer-reviewed source on a point, it'd be better to do that than to use this non-peer-reviewed source. That being said, the 2007 paper is of good quality, and is certainly a reliable source for the state of water fluoridation in Québec, as well as for advice about WP:WEIGHT issues. You mention below that it talks about health impacts and about fish. For health effects I think sources like Yeung 2008 (PMID 18584000) are better; for fish perhaps the 2007 paper could be referred to (see #Aquatic life below).

Eubulides (talk) 09:27, 12 January 2009 (UTC)

These are both government papers and well referenced. --Doc James (talk · contribs · email) 16:05, 12 January 2009 (UTC)

True on both counts. But this does not disagree with my comments. Eubulides (talk) 17:29, 12 January 2009 (UTC)

Mechanism and worldwide view

The content of the English article is different from the content of articles about the same topic in other languages. For example, the article on the German Wikipedia mentions that fluoridation works through digestion of fluoride, which is then carried through blood to the teeth, while the English article says it works through fluoride reacting with saliva and plaque. Also, the German article is less favorable concerning water fluoridation than the English article, highlighting the effectiveness of other forms of fluoridation. It also quotes Canadian dentist Hardy Limeback who initially was a strong supporter of water fluoridation and now vehemently opposes it. It thus seems that this article does not represent a worldwide view. This is also supported by the misquote (now corrected) of a WHO paper as supporting water fluoridation, while the paper in effect does not take any position on the issue.

Another argument against water fluoridation is that usually less than 2% of public water supply is used as drinking water, and more and more households avoid tap water completely, relying on bottled water. Treating 100% of tap water with fluoride can thus be considered a waste of money, with decreasing effectiveness as bottled water use increases.--Mschiffler (talk) 03:04, 12 January 2009 (UTC)

• The German Wikipedia article is reporting an obsolete theory about fluoride's mechanism, involving the systemic action of fluoride ("blood to the teeth"). This theory is no longer supported by reliable sources, so the German article needs to be updated. It is now known that the effects of fluoride are primarily topical. This change to our understanding of fluoride's mechanism is briefly mentioned at the end of Water fluoridation #History.
• Hardy Limeback's work is cited several times in Pizzo et al. 2007 (PMID 17333303), a critical review of fluoridation that is cited multiple times in Water fluoridation. As per WP:MEDRS, we should prefer secondary reviews like Pizzo et al. to primary sources like the papers of Limeback.
• The main sources cited in Water fluoridation do reflect a worldwide view. Here is a list of every source that's cited 3 or more times:

• Australia:

• Yeung 2008 (PMID 18584000). This is the most-cited report in Water fluoridation: it is cited 7 times.
• Armfield 2007 (PMID 18067684), cited 4 times.

• Finland:

• Lamberg et al. 1997 (PMID 9332806), cited 3 times.

• Italy:

• Pizzo et al. 2007 (PMID 17333303), cited 3 times.

• UK:

• McDonagh et al. 2000 (PMID 11021861), cited 4 times.
• Cheng et al. 2007 (PMID 17916854), cited 5 times.
• British Fluoridation Society et al. 2004, cited 3 times.
• Jones et al. 2005 (PMID 16211158), cited 3 times. This has 2 UK, 1 Swiss, and 1 U.S. author.

• U.S.:

• CDC 2001 (PMID 11521913), cited 6 times.
• Reeves 1986, cited 4 times.
• Bailey et al. 2008 (PMID 18614991), cited 3 times.
• Burt & Tomar 2007 (in ISBN 0195150694), cited 3 times.

Roughly 1/3 of these citations are to U.S. sources. Given that the U.S. originated community water fluoridation, and that about half of the world's people who receive fluoridated water live in the U.S., this if anything is underweighted for the U.S.

• The WHO supports both fluoridation in general and water fluoridation in particular. The cited WHO source (Petersen 2008, PMID 18630105) said that the WHO recommends that "particular emphasis should be laid on" several elements, one of which is "Establishment of national plans for use of fluoride, based on appropriate programmes for automatic administration of fluoride through drinking-water, salt, or milk, or topical use of fluoride such as affordable fluoride toothpaste." It is true that the WHO does not support water fluoridation over and above other forms of fluoridation, but Water fluoridation never said otherwise. Water fluoridation did not quote the WHO at all, so I'm not sure what is being referred to by the "misquote (now corrected)". However, to help clarify the issue, I'll adjust the mention of the WHO to also cite the WHO report by Petersen & Lennon 2004 (PMID 15341615), which says "Water fluoridation, where technically feasible and culturally acceptable, has substantial advantages" compared to other fluoridation techniques.
• The cost argument against fluoridation is not supported by reliable sources. One occasionally runs into the cost argument among the antifluoridation fringe, and so it'd be reasonable to discuss it in Opposition to water fluoridation, but not here. Newbrun 1996 (PMID 9034969) mentions the argument briefly, saying "Opponents have argued that since only a very small fraction (less than 0.1%) of public water supplies is actually drunk, most being used for other purposes such as washing, watering gardens, and flushing toilets, water fluoridation is inherently wasteful. Of course, the same logic also would stop water chlorination as wasteful." Newbrun then goes on to give the standard discussion of how fluoridation is cost-effective even though most public water is not ingested.
• Water fluoridation #Implementation already covers the use of bottled water (filtered water too).
• This edit inserted a couple of instances of "U.S." in the phrases "Almost all major U.S. health and dental organizations support water fluoridation" and "Despite support by public health organizations and authorities in the U.S.", but the cited source (which is Australian) is talking in general, and is not limiting its comments to the U.S. I therefore removed these instances of "U.S.".
• The same edit, with the comment "Corrected inaccurate quote of World Health Assembly 2007 document", inserted text saying that the WHO "does not have a position on water fluoridation". As mentioned above, this is not correct: the WHO favors several forms of fluoridation, one of them being water fluoridation. I made this edit to try to clarify the situation, by citing another source on the topic.

Eubulides (talk) 09:27, 12 January 2009 (UTC)

This paper at its end gives a list of all the organizations that support fluoridation. It list over a hundred. Well most are American many are international. http://www.inspq.qc.ca/pdf/publications/705-WaterFluoration.pdf --Doc James (talk · contribs · email) 16:18, 12 January 2009 (UTC)

There is a similar list (oriented for the UK instead of for Canada) in Support for water fluoridation (PDF). But do we really need detailed lists like that here? Surely this would be better to put into a subarticle about the controversy. At the high level, the important thing is that mainstream medical support is nearly universal, and we have a reliable source to that effect. Eubulides (talk) 17:29, 12 January 2009 (UTC)

Faced with the evidence, I rest my case. Those who worked on the article have clearly done a lot of thorough research with impressive results. I was not familiar with Wikipedia:MEDRS and I am impressed by the high standards applied to sources, which even discard peer-reviewed primary research. The only thing I would suggest for the process of improving this article further is to keep in mind, as always, that many readers will not be nearly as familiar as you are with the topic. Therefore it may make sense to write a section to dispel some views that apparently are basic misconceptions, such as the transmission of fluoride to teeth through blood. As ridiculous as some of these views may sound to experts, this seemed plausible to me. The article itself did not convince me until I saw your reaction to my comment.--Mschiffler (talk) 01:29, 13 January 2009 (UTC)

Fluoride Action Network

Without wanting to take any position on this controversial issues, it seems that the article could benefit from adding the views of opponents to fluoridation beyond just the conspiracy theorists of the Cold War. For example, in the case of the U.S., some information from http://www.fluoridealert.org/ could be added. It seems that the activities of FAN are notable. It also seems that they raise issues not raised in the article, such as health impacts of fluoride compounds and the impact of fluoride on fish (not sure how valid they are, though).--Mschiffler (talk) 03:24, 12 January 2009 (UTC)

The above two Canadian paper touch on these points.--Doc James (talk · contribs · email) 04:43, 12 January 2009 (UTC)

The Fluoride Action Network is not a reliable source for information about water fluoridation. As per WP:MEDRS, Water fluoridation should not rely on web sites like that. Newspapers like the New York Times are more reliable than the Fluoride Action Network, but WP:MEDRS says the article should not rely on them for medical facts and figures either. As per WP:MEDRS, the article should not even be relying on primary studies published in peer-reviewed medical journals. Instead, Water fluoridation should use the highest quality secondary reviews published by reliable, peer-reviewed medical and scientific journals. Eubulides (talk) 09:27, 12 January 2009 (UTC)

Point well taken. I saw now that they are mentioned in Opposition to water fluoridation, where their positions belong.--Mschiffler (talk) 01:33, 13 January 2009 (UTC)

Population ≠ water systems

This edit replaced "two-thirds of the U.S. population on public water systems" with "two-thirds of U.S. public water systems". That is not at all the same thing, as most U.S. public water systems are small and have few users, and smaller water systems are less likely to be fluoridated. Also, that change removed the phrase "U.S. researchers discovered that"; but this phrase summarizes a big chunk of Water fluoridation #History, and without it that entire section would not be represented in the lead. I attempted this fix of the problem. Eubulides (talk) 09:27, 12 January 2009 (UTC)

Thanks for the headsup on my talkpage. The article now reads fluoridation prevents cavities, and it is now used by two-thirds of the U.S. population on public water systems. This could be ambiguous. Are two thirds of the US population on public systems or do two thirds of public systems use it. I guess the second is intended but this then begs the question as to how many have flouridated water. I'll leave it to others to fix. Happy to leave the plug for the US.Mccready (talk) 10:37, 12 January 2009 (UTC)

Thanks for the comment. I changed the wording to read "fluoridation prevents cavities, and it is now used by 61.5% of the U.S. population"; that's much simpler and corresponds better to the following "5.7% of people worldwide". Eubulides (talk) 10:52, 12 January 2009 (UTC)

Needs a section on ethics

Part of the controversy is about can we as a government / medical organization administer medication (fluoride) to people without their consent.

http://www.cda-adc.ca/jcda/vol-67/issue-10/578.pdf

This is dealt with on the page about opposition to water fluoridation, which should be changed to controversy around water fluoridation. The only people we are allowed to lock up for medication reason are those that are a risk to themselves or others. We are not allowed to force treatment on adults even if lack of such results in their death. But than we add iodine to salt and vitamins to flour so why not fluoride to water? The section on ethics is a little short.

--Doc James (talk · contribs · email) 16:27, 12 January 2009 (UTC)

It's true that the discussion of ethics is brief. But that is because it's written in summary style, with the main article about ethical concerns being elsewhere. It's not at all clear that ethics requires a whole section to itself in this article; that would raise WP:WEIGHT and WP:NPOV issues. It wouldn't hurt to add another sentence or two about ethics to Politics, though. Eubulides (talk) 17:29, 12 January 2009 (UTC)

Does require a section under controversies I think... --Doc James (talk · contribs · email) 20:18, 12 January 2009 (UTC)

OK, I added an attempt at a section, citing the source mentioned above, along with 3 other relevant sources. Eubulides (talk) 23:13, 12 January 2009 (UTC)

Other review

I have looked at some of the literature. There are reviews that support fluoride in water and there are reviews that do not. The following does not. Oganessian E, Lencová E, Broukal Z (2007). "Is systemic fluoride supplementation for dental caries prevention in children still justifiable?". Prague Med Rep. 108 (4): 306–14. PMID 18780642.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Verses this review which says it is still a good idea. Kumar JV (2008). "Is water fluoridation still necessary?". Adv. Dent. Res. 20 (1): 8–12. PMID 18694870.

I have some concern with the POV of this article. Most supporting info is in the main article well non supporting info has been move to the article on opposition to fluoride. I know for a controversial article these two are hard to combine. But I think for this to reach good article status it should combine the two. What is becoming obvious is that the US supports fluoride. Canada is sort of in the middle and much of Europe does not. Why this is so is not really addressed.

--Doc James (talk · contribs · email) 16:41, 12 January 2009 (UTC)

I am aware of both reviews but do not currently have access to either. I am quite leery of citing works that no editors have read. If we can find reliable sources about why the U.S. supports fluoride and Europe does not, then we can cite them; but I am skeptical that reliable sources exist in this area, and it is not reasonable to require a Wikipedia article to answer questions that reliable sources do not answer. Eubulides (talk) 17:29, 12 January 2009 (UTC)

Have access to both if you are interested. Limiting research to only that which is freely available is a bit restrictive. --Doc James (talk · contribs · email) 20:10, 12 January 2009 (UTC)

Yes, I am interested. I agree that we should use the best sources, even if they are not freely available. What's the next step? Can you summarize what they say? Most important, what would they add to the article that is not there already? Eubulides (talk) 23:13, 12 January 2009 (UTC)

The goal, by the way, is to describe fairly what reliable sources say about water fluoridation, according to the principles of WP:NPOV and WP:WEIGHT. Most of the negative material discussed in Opposition to water fluoridation is supported only by unreliable sources; it may be suitable for an article about politics but it is out of place here. Eubulides (talk) 23:13, 12 January 2009 (UTC)

Florosis

Saying that florosis in not a concern is a bit presumptuous and dated. --Doc James (talk · contribs · email) 16:43, 12 January 2009 (UTC)

Water fluoridation does not say that fluorosis is not a concern. It says only that the fluorosis caused by water fluoridation is mostly not considered to be of aesthetic concern. This is the mainstream consensus; the source for that claim is Yeung 2008 (PMID 18584000), which is certainly not dated. I know of no reliable source that disputes the claim, and can easily cite other reliable sources that agree. Eubulides (talk) 17:29, 12 January 2009 (UTC)

This lines looses me a bit: "At the commonly recommended dosage, the only clear adverse effect is dental fluorosis, most of which is mild and not considered to be of aesthetic concern. Compared to unfluoridated water, fluoridation to 1 mg/L is estimated to cause fluorosis in one of every 6 people, and to cause fluorosis of aesthetic concern in one of every 22 people"

Is it saying that mild dental flourosis is not a concern? Or that all flurosis is not a concern? It is than followed by a statement that 1 in 22 causes is an aesthetic concern? Sorry it makes my head spin.  :-) --Doc James (talk · contribs · email) 20:16, 12 January 2009 (UTC)

It is saying that most of the fluorosis is both (a) mild and (b) not of aesthetic concern. (It is not saying that all fluorosis is not a concern; severe fluorosis would be.) It is saying that fluoridation causes 1/6 (16.7%) of people to have fluorosis, and 1/22 (4.5%) of them to have fluorosis of aesthetic concern; by simple subtraction this would mean fluoridation causes 4/33 (12.1%) of people to have fluorosis that is not of aesthetic concern. With all this in mind, can you suggest a way to rephrase the sentence to make it clearer? Eubulides (talk) 23:13, 12 January 2009 (UTC)

Aquatic life

This edit added the following text to Water fluoridation #Safety:

Relatively little is known about fluoride's toxicity to aquatic life, and as of 2003 safe levels for aquatic life had not yet been determined. Discharges of municipal fluoridated water significantly increase the fluoride concentration in recipient rivers to about five times the natural background level, and fluoride can adversely affect invertebrates and fish at about 0.5 mg/L. The most sensitive animals are net-spinning caddisfly larvae and upstream-migrating adult salmon.[citing Camargo 2003, PMID 12656244] However, one 1990 study concluded that water fluoridation was likely to increase total river fluoride concentrations by only 0.001-0.002 mg/L.[citing Osterman 1990, PMID 2400035]

Camargo 2003 is not a reliable source on water fluoridation or on fluorides in the environment. In p. 85 of the chapter "Effects of inorganic fluorides on animals" of the book Fluorides in the Environment (ISBN 0851996833, dated 2004), Weinstein & Davidson write:

"Finally, in a review, Camargo (2003) suggested than in soft waters with low ionic concentrations the safe level should be below 0.5 mg F/l. Apart from the fact that effects at such levels have not been confirmed by sufficient authors and that a very limited range of species and genotypes has been investigated, there has been insufficient research into the effects of cations like aluminium. Nor have there been any long-term field studies at the community level. It is dangerous to extrapolate from simple, acute laboratory tests to recommending a limit that is unattainable."

Given the dubious quality of Camargo's review, and the fact that the review is not about water fluoridation but is about fluoride toxicity, we should not be citing it here, on both WP:RS and WP:OR grounds. Water fluoridation's existing text briefly talks about "no adverse effects" on "downstream rivers", and this is a high-quality summary of what reliable mainstream sources say; adding relatively-extensive discussion of a fringe theory fails on WP:WEIGHT and WP:FRINGE grounds. I therefore removed the text based on this source. Eubulides (talk) 09:27, 12 January 2009 (UTC)

One offhand critique does not suddenly make a PubMed-indexed, relatively recent review from an environmental researcher who has published over a couple dozen articles on the topic or closely related topics suddenly fringe and unreliable. A 2001 Canadian research report on the topic concluded that 0.12 mg/L was an appropriate interim standard, so clearly 0.5 mg/L is not that unreasonable. In fact, Pollick says that 0.5 mg/L is difficult to reach, and also says it 0.5 is dangerous to salmon. So Weinstein and Davison don't seem to be very up on their facts. By the way, I forgot to add that Camargo says the natural background level of a typical river is about 0.05 mg/L. 5 times that is 0.25 mg/L - he cites two studies for his statement that fluoridated water discharge increases levels by 5 times. Anyway, let's hear what other people have to say. You're certainly jumping to conclusions when you say Camargo is fringe and unreliable because Weinstein & Davison say his adverse effect level is overly cautious. I'm sure that many industry-supported scientists would say that, since he said that aluminum and phosphate industries increase the fluoride levels of water the most (10 and 100 times background levels, IIRC). If I felt like jumping to conclusions as quickly as you, I could flip it and say that since Camargo has more experience in environmental research, he should be given more weight than Pollick, who is not an environmental researcher but rather a fluoridation proponent. But I'm not going to do that. II | (t - c) 01:24, 13 January 2009 (UTC)

Weinstein & Davidson are not an "offhand critique"; they are reflecting mainstream opinion. Nor is Camargo's piece a secondary source (in the sense of WP:RS) of the topic of the effect of water fluoridation on the environment, as Camargo is reviewing his own work in that area. If Camargo had reported something of real interest with respect to water fluoridation, we would have expected to see other serious researchers build on his work. We have not; instead, what we've seen is unusually strong skepticism. Eubulides (talk) 18:55, 13 January 2009 (UTC)

WP:lead

This article is really very good. One thing that need to be address however is WP:lead before it can be promoted to GA. --Doc James (talk · contribs · email) 19:11, 13 January 2009 (UTC)

• Thanks for the comment. I modified the lead to try to address these concerns.
• One other thing: this recently-installed change to Water fluoridation #Ethics and politics has some WP:OR and WP:NPOV problems, but I haven't yet had time to review it carefully.

Eubulides (talk) 21:28, 13 January 2009 (UTC)

The only place I could see a possible WP:OR problem is mentioning the York review's critical statement, although that general statement is highlighted by Cheng and has served as a bit of a rallying point for opponents. Although the scientists are a minority, they should not be unduly marginalized as uninformed peasants. I'm not saying you've done this -- you've done a very good job -- but Armfield does marginalize them while other sources, including Burt and Tomar, describe them fairly neutrally. If you can find a reliable source which neutrally discusses the dissenting scientists in a more critical manner, feel free to add it. Also, although most sources on here won't mention it, the Dutch Supreme Court did rule fluoridation illegal in Denmark according to Denmark biologist Kim Bruning. He provided the source there. There's little reason to think that Arvid Carlsson is lying when he says that Sweden ruled similarly. II | (t - c) 20:51, 14 January 2009 (UTC)

I wonder whether it is worth mentioning that the York review was mentioned favourably by Ben Goldacre, a science journalist who is scathing about quackery and pseudoscience. He gave it as an example of the kind evidence-based medicine that journalists ignore or misinterpret because they are looking for an either/or story when the reality is more complex. On a related point, the abstract of the York review that we link to gives the confidence intervals for the proportions affected by fluorosis, and they are very wide. The full report presumably also has the confidence intervals. Although it will be more difficult to find a fluent wording accessible to lay readers, it would be better to give the confidence intervals instead of the means and/or medians. Itsmejudith (talk) 21:34, 14 January 2009 (UTC)

Thanks for the comment and suggestion. The Ben Goldacre remark might be suited for the controversy subarticle, but it'd be a bit out of place here, as this article focuses on fluoridation (not on the fluoridation controversy) and shouldn't be advocating its own sources. I added the 95% CI ranges to the text. Eubulides (talk) 21:48, 14 January 2009 (UTC)

Thank you for doing that, and good point. Itsmejudith (talk) 21:52, 14 January 2009 (UTC)

Given that the York reviewers were worried that the review was being misrepresented and said so in 2003, I don't think it is WP:OR to include their critical comments in the politics section. II | (t - c) 23:23, 14 January 2009 (UTC)

Neutrality of the evidence basis section.

I am concerned that the section "Evidence Basis" is at times presenting the evidence in favor of fluoridation as if the quality of the research on fluoridation very strong despite the first paragraph mentioning "the quality of the research on fluoridation has been generally low.". When statement "The introduction of fluoride toothpaste in the early 1970s has been the main reason for the decline in tooth decay since then in industrialized countries." seems to the imply that there is unanimous acceptance of fluoride toothpaste effect in reducing tooth decay when as I understand it there are competing theories for the reduction. One way to improve the section is the attribute the claims in favor of fluoride to the studies and meta-analysis that support them rather using language that implies the claims are undisputed by anyone. While it's true that the supporters outnumber the critics, the number of critics is still significant enough to warrant mention of their view on the flaws in the current research within the section.

--Cab88 (talk) 08:09, 14 January 2009 (UTC)

• If the article explicitly states "the quality of the research has been generally low", then what wording, specifically, is giving the impression that the quality is very strong?
• What "competing theories for the reduction" are there? If that claim about fluoride toothpaste is disputed by reliable sources, then presenting both sets of sources would be helpful; but I'm not aware of any such dispute.

Eubulides (talk) 08:19, 14 January 2009 (UTC)

IQ, hazmat fees, etc.

• This set of edits by 71.174.189.146 (talk · contribs · WHOIS) inserts several claims:

• There is a correlation between water fluoridation and mental retardation (or reduced IQ). The cited source is fluoridealert.org, an unreliable source for water fluoridation. And the source itself [2] does not claim that there is a correlation between water fluoridation and anything. Furthermore, the studies it mentions are not about water fluoridation: they are about naturally fluoridated water above the recommended levels. So this claim is not only not reliably sourced, it's original research to say that the (unreliable) source is about water fluoridation.
• Fluoridation is motivated by polluters wanting to get rid of toxic products they'd otherwise have to pay haszmat fees for. No reliable source is given.

• Also, insertion of phrases like "widely claimed" and "stated" (in front of "goal") and "Until recently" were made, without any support for these phrases among the cited sources.
• Because of these problems with the core Wikipedia policies of WP:V and WP:OR, I reverted the changes. If we can find reliable sources (not published in fringe web sites etc.) that support the claims, we can revisit the issue.

Eubulides (talk) 10:06, 14 January 2009 (UTC)

GA

Well done with all the changes. This page now fulfills wiki GA criteria and has been tagged as such. Congratulations.

--Doc James (talk · contribs · email) 16:02, 15 January 2009 (UTC)

Politics improvement

Water fluoridation #Ethics and politics had some problems. One paragraph talked about the arguments involved, which is fine, but the next rehearsed some old arguments against fluoridation and mentioned some individual fluoridation opponents. This section shouldn't be arguing against fluoridation, nor should it focus on individual opponents; that sort of detail is best left for Opposition to water fluoridation. However, it does make sense to discuss the nature of the opposition in general, using recent reliable sources and focusing on the overall movement rather than on individuals, so I rewrote the second paragraph to do that, in this change. I kept the reliable sources that talked about politics, while omitting articles that talked about efficacy, or were individual statements by opponents (this is too much detail). Eubulides (talk) 21:38, 15 January 2009 (UTC)

Should we semiprotect?

Water fluoridation was featured on Coast to Coast AM last night. Coast-to-Coast is a nightly conspiracy theory talk show. The show discusses several fringe theories that have been brought up in the discussion page (see the 1/14/09 edits above this post). I'd expect this particular page to be a vandal/fringe magnet for the next couple of days. Cheers. Murphy2010 (talk) 01:42, 15 January 2009 (UTC)

Darn. User Eublides beat me to it. Murphy2010 (talk) 01:43, 15 January 2009 (UTC)

It's getting pretty bad. I just now asked for page protection. Eubulides (talk) 19:58, 16 January 2009 (UTC)

I have semi-protected the article for three days and I will extend this if needed. Congratulations on the GA b.t.w. Graham. Graham Colm ^Talk 22:53, 16 January 2009 (UTC)

Fluoridation and adults

This edit changed "Fluoridation prevents cavities in both children and adults." to "Fluoride prevents cavities in both children and adults." with the comment "The article referenced in footnote 7 does not specifically address water fluoridation but rather fluoride when applied professionally, etc..". The comment is incorrect. It is true that the referenced article, Griffin et al. 2007 (PMID 17452559) also covers self- and professionally applied fluoride; but Griffin et al. separately and specifically covers water fluoridation, and says:

"How Effective is Community Water Fluoridation in Preventing Caries? The combined results of the 9 studies (7853 participants) examining the effectiveness of water fluoridation were significant at p < 0.001 (Table 2). Among the 7 studies including only lifelong residents of control or fluoridated-water communities (5409 participants; Appendix Table 8 and Appendix Fig. 2), the summary relative risk ratio was 0.654 (95% confidence interval [CI]: 0.490–0.874); this is equivalent to a prevented fraction of 34.6% (95%CI: 12.6%–51.0%). Heterogeneity was present. Heterogeneity was not an issue when we pooled the 5 fluoridation studies published after 1979 (2530 participants); the summary-prevented fraction was 27.2% (95%CI: 19.4%–34.3%)."

To help make this clearer I replaced "Fluoride" with "Water fluoridation", and in the next paragraph replaced "Fluoridation" with "Water fluoridation". Eubulides (talk) 07:48, 24 January 2009 (UTC)

Cumulative toxin, etc.

This edit has some good points, but also has several problems:

• It inserts the claim "fluoride is a cumulative toxin" into the lead, but this claim's source is an unreliable web site, and the claim does not summarize anything in the body. Please see WP:MEDRS for what constitutes a reliable source for medical facts and figures, and WP:LEAD for why the lead should summarize the body. The phrases "water fluoridation" and "cumulative toxin" appear often in WP:FRINGE sources, but hardly ever in reliable sources; Water fluoridation should not be emphasizing the fringe claim.
• It inserts the text "It is currently believed that" in front of a claim that the optimal level of fluoridation is 0.6 to 1.1 mg/L. Good point about the "optimal"; that word isn't in the cited source (Yeung 2008, PMID 18584000) and should be removed here. However, Yeung does not say "it is currently believed that"; it says "It is recommended ... that water be fluoridated in the target range of 0.6–1.1 mg/l...". Better to say "recommended" than "believed" here.
• It replaces "Fluoridation prevents cavities" with "Fluoridation is believed to increase resistance to cavities", but the cited sources (Yeung 2008; and Griffin et al. 2007, PMID 17452559), which are reliable, do not say "believed" or "increase resistance to", they simply say "prevents".
• It adds the word "Unfortunately,", which is WP:POV, and is not in the cited source (Yeung 2008).
• It removes the text "Fluoridation is not associated with other adverse effects." which is supported by a reliable source (McDonagh et al. 2000, PMID 11021861).
• When talking about fluorosis, it replaces the well-sourced text "most of this is mild and usually not considered to be of aesthetic concern" with the unsourced text "though this may be mild". The source for the original text is Yeung 2008. Let's stick with what the source says.
• It replaces "the quality of the research has been generally low" with "The quality of the research into the ill effects of fluoride has been generally low". The cited source uses phrases like "potential adverse effects" or "possible adverse effects"; it never says "ill effects". Good catch, though, as the source says that safety studies (not effectiveness studies) are almost all of low quality; the text needed to be revised to say this.
• It adds the text "there are many hypothesis of ill effects caused by fluoride, including cancer, hypothyroidism, and even increased risk of tooth decay" to the lead. These hypotheses are not supported by mainstream sources, are briefly and properly discussed in the Water fluoridation #Safety (with reliable sources cited there), and as per WP:WEIGHT should not be emphasized in in the lead; nor should an unreliable source be used in the lead.
• It inserts the text "Some argue that" in front of the claim "Fluoridation may be more justified in the U.S. for reasons that include lack of access to dental care" but the cited source (Burt & Tomar 2007, in ISBN 0-19-515069-4) doesn't say "some argue", and inserting the "some argue" here is clearly an editorial attempt to deprecate a reliable source. The "may" (which is in the source) is enough qualification here.
• It removes the point that tooth decay is a chronic disease. This point is well-sourced to Selwitz et al. 2007 (PMID 17208642).
• It removes the point that tooth decay's burdens fall particularly on children and the poor, also well-sourced to Selwitz et al.
• It replaces "Almost all" with "Most" in front of the phrase "major public health and dental organizations support water fluoridation", but the cited source (Armfield 2007, PMID 18067684) says "almost all", not "most".
• It moves the mention of salt, milk, and toothpaste fluoridation up a paragraph, next to the discussion of bottled water, but it's more logical to mention alternate fluoridation techniques next to the mention of Europe, which uses them.
• In the lead sentence. It replaces "to reduce" with "for the purpose of reducing". Lead sentences are supposed to be short and to the point; this extra verbiage gains readers nothing.
• It replaces "Fluoridation's goal" with "The goal of fluoridation"; again, isn't shorter wording better in the lead?

As per WP:RS, WP:MEDRS, and WP:WEIGHT, Water fluoridation should use reliable sources (preferably high-quality medical reviews) and should reflect mainstream opinion in proportion to its weight. It's not our job to argue with the experts, even if we disagree with them. I made this edit to try to fix the problems noted in the above remarks. Much of this is reversion to the previous version, when I couldn't glean any improvements out of the changes; but in some cases (noted above) there were good ideas in the changes and I tried to keep all these. Eubulides (talk) 06:04, 20 January 2009 (UTC)

The York review says in section 12.9, their overall conclusion, that the quality of the research is generally low. They do seem to be referring to research in general. I don't mind your changing it to refer to only adverse effects studies since moderate quality effectiveness studies do exist. I'm guessing that they passed up a lot of lower quality effectiveness studies. II | (t - c) 18:10, 20 January 2009 (UTC)

Thanks for mentioning this, since I didn't summarize York quite right in my previous change. Please see #York review's summary of research quality below. Eubulides (talk) 19:08, 20 January 2009 (UTC)

York review summary of research quality

Section 12.9 is of the York review is in their full report, which wasn't published in a peer-reviewed journal. The peer-reviewed paper (PMID 11021861) uses slightly-more-cautious wording and is more appropriate here. Its abstract says "The quality of studies was low to moderate." The discussion says that all effectiveness studies used "were of evidence level B (moderate)", that all fluorosis studies "were of evidence level C (lowest quality), except one level B study", of cancer studies "Eighteen of these studies were of evidence level C and eight of level B", of other possible adverse effects "quality of these studies was low; all studies were of evidence level C", and in conclusion "little high quality research has been undertaken". When I wrote the above-mentioned followup patch and talked about effectiveness studies, I mistakenly read only about the fluorosis studies, which were almost all of low quality; it would be more accurate to summarize all sets of studies (in the body) and to use the "little high quality research has been undertaken" idea in the lead. I made this change to try to reword the text to match the source better. Eubulides (talk) 19:08, 20 January 2009 (UTC)

Response to Above

Hi! It was my edit that you've paved over. I'm very concerned with the neutrality of this article, which was my motivation for my scope-widening edit. This article currently reads as though there are virtually no differing opinions which is, of course, quite incorrect. Rather the article should cleanly reflect that there exists differing opinions and leave the reader to decide for themselves. Also, I noted that you mentioned one of the websites I cited as "unreliable", however I must say that this article is full of website sources of questionable reliablity. While certainly the website citation in question was also of a low caliber, selectively filtering web sources is a dubious practice. In the end, I this article could be made significantly better by openly addressing concerns and letting the reader consider all things together.

Finally, I think there should be some care with the quotes. The article can not be a collection of quotes concatenated together. It has to be readible and as such should have good transitions. If you object to my changes then by all means find another way to make the article coherient in a way you feel is more representative of the sources. Selevercin (talk) 15:24, 31 January 2009 (UTC)

• Among reliable sources on water fluoridation, the opinions don't differ all that much, and the article currently reflects this. There are WP:FRINGE opinions that the article also mentions, but as per WP:WEIGHT the article should not emphasize them, or give them "equal time".
• The criteria used to determine which sources are reliable are given in WP:MEDRS. Generally speaking, the best sources are secondary sources published in reliable, peer-reviewed medical journals. Self-published web sites are very low on the reliability scale, and should be avoided when discussing medical facts and figures. I'm not aware of any such source in the current article, but if there is one, please mention it here.
• There aren't any quotes in Water fluoridation, so I'm not sure what the comment "care with the quotes" is referring to. Which transitions in particular are the problem? Certainly the article's prose could be improved, but I don't see much transition-improving in the edit in question.

Eubulides (talk) 15:49, 31 January 2009 (UTC)

Health Dangers

From the EPA...

http://www.epa.gov/safewater/contaminants/index.html#inorganic

"Potential Health Effects from Ingestion of Water / Sources of Contaminant in Drinking Water: Bone disease (pain and tenderness of the bones); Children may get mottled teeth; Water additive which promotes strong teeth / erosion of natural deposits; discharge from fertilizer and aluminum factories"

From the CDC...

http://www.cdc.gov/Fluoridation/safety.htm

http://www.cdc.gov/FLUORIDATION/safety/infant_formula.htm —Preceding unsigned comment added by 98.219.52.189 (talk) 21:38, 30 January 2009 (UTC)

Thanks for mentioning these sources. I made three changes to mention the points raised by the sources:

• This edit talks about the recent increases in prevalance of dental fluorosis in industrialized countries.
• This edit covers fluorosis and infant formulas.
• This edit cites the 2006 NRC report and mentions the consequences of higher levels of fluoridation.

Eubulides (talk) 06:36, 1 February 2009 (UTC)

Recent edits strayed from sources

The recently-installed set of changes has a series of problems. Generally speaking, the changes appear to have been made without references to what the cited sources say, and cause the text to diverge from the sources in material ways. For each change, I'll list the affected text, with inserted text in italics and removed text struck out.

• "Drinking fluoridated water creates low levels of fluoride in throughout the body including the saliva". The cited source, Pizzo et al. 2007 (PMID 17333303) do not support the revised claim: they don't talk about "throughout the body".
• "Water fluoridation prevents cavities in both children and some adults.". The cited source, Griffin et al. 2007 (PMID 17452559) doesn't say "some adults". Its results talk about all the adults studied. It says "The combined results of the 9 studies (7853 participants) examining the effectiveness of water fluoridation were significant at p < 0.001 (Table 2)." Table 2 says "Water fluoridation, all adults, coronal caries (9 studies; 7853 participants; Eklund < 0.001 et al., 1987; Englander and Wallace, 1962; Grembowski et al., 1992; Hunt et al., 1989; Morgan et al., 1992; Murray, 1971; Stamm et al., 1990; Thomas and Kassab, 1992; Wiktorsson et al., 1992)" with a combined p-value <0.001.
• "Fluoridation is not possibly associated with other adverse effects". The cited source, McDonagh et al. 2000 (PMID 11021861), doesn't say "possibly"; it says there was "no clear evidence of other potential adverse effects." We should probably use wording closer to the source here, but the "possibly" is further from the source, not closer.
• "Existing evidence strongly suggests that water fluoridation may prevents tooth decay." The cited source, Yeung 2008 (PMID 18584000) says "strongly" and does not say "may"; it says "Is intentional water fluoridation more effective than no water fluoridation in prevention of dental caries? Existing evidence strongly suggests water fluoridation is beneficial at reducing dental caries." We should say "reduce" rather than "prevent" though.
• "The best available evidence shows no is unconclusive association with other adverse effects." The cited source, McDonagh et al. 2000, doesn't say "inconclusive" or anything like that. However, in rereading the sources it appears that this "best available evidence" phraseology comes from the full report rather than from the peer-reviewed summary, and the text should be reworded to match that of the peer-reviewed summary.
• "research into other potential adverse effects has been almost all of low quality" This statement was well-sourced: the cited source, McDonagh 2000, under "Other possible adverse effects", says "The quality of these studies was low".
• "Water fluoridation is the most an effective and socially equitable way to achieve wide exposure to fluoride's cavity-prevention effects." This change strays from the cited source, Yeung 2008, which says "Fluoridation of drinking water remains the most effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride." (my emphasis)
• "and has contributed to the dental health of children and adults worldwide" The cited source, CDC 2001 (PMID 11521913), says "adults also benefit from fluoride, rather than only children, as was previously assumed."
• "A 2000 systematic review found that fluoridation was possibly associated with a decreased proportion of children with cavities" The cited source, McDonagh 2000, does not say "possibly"; it says "Water fluoridation was associated with an increased proportion of children without caries and a reduction in the number of teeth affected by caries."
• "Fluoridation also prevents cavities in adults of all ages though at a much lesser rate as adult teeth are already hardened" The cited source, Yeung 2007 (PMID 17891121) does not support the new text; it doesn't talk at all about hardened text, and the percentage of averted caries for adults (estimated 27%) is less than the percentage for children (about 40%), but the cited source doesn't say "much lesser rate". The 27% figure is already mentioned in the text, and it would help to also mention the 40% figure, without saying "much lesser" (which would be WP:OR).
• "(9575% confidence interval [CI] 19–34%)" The cited source, Griffin et al. 2007 (PMID 17452559) talks about the standard 95% CI, not a 75% CI.
• "The decline in tooth decay in the U.S. since water fluoridation began in the 1950s has been attributed largely to the fluoridation" The cited source, Bailey et al. 2008 (PMID 18614991), says "largely"; it says "The decline in the prevalence and severity of dental caries (tooth decay) in the United States during the past 60 years has been attributed largely to the increased use of fluoride". However, now I see it's talking about fluoride, not fluoridation, so that should get fixed.
• "The introduction of fluoride toothpaste in the early 1970s has been may be the main reason for the decline in tooth decay since then in industrialized countries though no high-quality studies support such a claim." The cited source, Pizzo et al. 2007, say "The main reason for the decline in the caries prevalence in industrialized countries is recognized to be the introduction of fluoridated toothpaste in the early 1970s". It cites 5 studies. It does not say anything about "no high-quality studies".

To fix the above problems I reverted the edits in question, and then installed the following fixes:

• Reword the summary of the York Review to match more closely what the peer-reviewed version said, namely, that there is no clear evidence of other adverse effects.
• Remove claim that the decline in tooth decay in the U.S. since 1950 is attributed largely due to water fluoridation. It's attributed to fluoride in general, not to water fluoridation in particular.
• Say that fluoridation reduces rather than prevents tooth decay, when summarizing Yeung 2008.
• Mention the 40% reduction of cavities in children.
• Say "Fluoride" rather than "Fluoridation" when summarizing Yeung 2007.
• Say "Water fluoridation" rather than plain "fluoridation" when it's not clear that we're talking specifically about water fluoridation.

Eubulides (talk) 06:39, 8 February 2009 (UTC)

Problems with recent edits about Europe

This recently installed edit has some good points, but some problems (noted below) as well. In each quote below, italics marks inserted text and strikeouts deleted text.

• "It is controversial, and opposition to water fluoridation has been based on ethical, legal, safety, and efficacy grounds." The substance of this change is fine, but the wording is a bit odd, as the pronoun "it" comes before the nounphrase that it designates, and it's not clear (unless one already knows) whether the "it" refers to the fluoridation or to the opposition to fluoridation. To fix this, I replaced the above text with:

"It is controversial, and opposition to it has been based on ethical, legal, safety, and efficacy grounds."

• "... conversely, in Europe, most industrialized countries have experienced substantial declines in tooth decay by using fluoride toothpaste and other products instead without its use.<ref name=Pizzo/> Fluoridation may be more justified in the U.S. for reasons that include lack of access to dental care and less exposure to topical fluorides.<ref name=Burt/>"

• That "industrialized" isn't supported by the the cited source (Pizzo et al. 2007, PMID 17333303), which says that "most European countries" (not "most industrialized European countries") have experienced a substantial decline.
• The new phrase "less exposure to topical fluorides" is not supported by the cited source (Burt & Tomar 2007, in ISBN 0-19-515069-4). Their discussion (pp. 315 and 316) doesn't mention topical fluorides in particular; instead, it talks about two things, namely lack of access to dental treatment (in particular, "professional fluoride attention") and reducing "dental health disparities that exist between socioeconomic groups".
• Pizzo et al. talk about topical fluorides, but strongly emphasize toothpaste. They write "The main reason for the decline in the caries prevalence in industrialized countries is recognized to be the introduction of fluoridated toothpaste in the early 1970s [6, 9, 11, 26, 29]. The diminishing benefit from CWF has been also attributed to the large use of the other fluoride-containing products, including mouthrinse, dietary supplements, and professionally applied or prescribed gel, foam, or varnish [6, 26]." This emphasize the role of fluoridated toothpaste; other fluorides (which are not necessarily topical) are clearly secondary.

To try to fix the above problems, I replaced the above-quoted text with:

"conversely, in Europe, most countries have experienced substantial declines without its use, primarily due to fluoride toothpaste.<ref name=Pizzo/> Fluoridation may be more justified in the U.S. because of lack of access to dental care and of socioeconomic inequalities in dental health.<ref name=Burt/>"

Eubulides (talk) 07:03, 14 February 2009 (UTC)

Disputing the factual accuracy and neutrality of the Yeung study PMID 18584000

Here's the beef:

• The study is published in a journal not listed in JCR 2007: Evidence-Based Dentistry, despite being published by NPG, is rather obscure journal, not even in top 50 of dentistry journals! (Because of this I also don't have access to it)
• The sentence sourced from that journal is the 1st one used in the Effectiveness section giving it WP:UNDUE weight given the issue above
• The sentence, which is a copy&paste job from the abstract is a rather meaningless PC-drivel: "Water fluoridation is the most effective and socially equitable way to achieve community-wide exposure to fluoride's cavity-prevention effects".
  • Most effective it isn't; see the CDC 2007 study, PMID 17452559, where it's below average.
  • So, it's probably the only "socially equitable way" to give people fluoride. What did Yeung compare it with to come to this conclusion? Giving free toothbrushes and toothpaste? I'm asking this seriously. Someone with access to the paper please explain how he came to this conclusion. My honest conclusion from the face of it is this is not science, but a social agenda or more simply a justification for the gov't program that sponsored his research.
  • Also, see this metaanalysis (same journal; but this one is old enough that access is free) that comes to somewhat different conclusion: "At the moment one should not rely on water fluoridation as the only means of bringing about equality in dental heath." (Yes, I realize that it's not the exact same question, but relevant nonetheless.)

Xasodfuih (talk) 02:31, 17 February 2009 (UTC)

The claim that Yeung 2008 (PMID 18584000) "is not science, but a social agenda or more simply a justification for the gov't program that sponsored his research" is an unsupported opinion that does not withstand serious scrutiny. Addressing the comments one by one:

• "rather obscure journal"

• Evidence-based Dentistry began as a supplement of the British Dental Journal and became independent in 2000. Being newer, it understandably has a lower impact factor. However, it is quite a respectable dental journal in its area, namely, evidence-based medicine as applied to dentistry. As noted, one of the two sources cited in the above comment (namely Hausen 2002, doi:10.1038/sj.ebd.6400102) was published in Evidence-based Dentistry, which undermines the argument that EBD is an low-quality venue.

• No it doesn't; just because a somewhat contradictory result was published in the same venue, it doesn't make the venue anymore reputable. You have clearly committed a logical fallacy here. Xasodfuih (talk) 13:42, 17 February 2009 (UTC)

• My comment was not a purely logical argument: arguments about reputation are rarely pure matters of logic. This does not mean that my comment had no force. Evidence-based Dentistry is a respectable venue, perhaps the most respectable journal in the world on its titular topic. Eubulides (talk) 18:55, 17 February 2009 (UTC)

• The study in question, Yeung 2008 (PMID 18584000), is a reliable source by any reasonable standard. Its author has published several papers in the area of dentistry in general and fluoridation in particular. For example, Yeung is the lead author on the Cochrane Library review of fluoridated milk for preventing tooth decay (Yeung et al. 2005, PMID 16034911).

The Cochrane argument may not be strong. Unfortunately Cochrane teams, for example in acupuncture, have been unduly influenced by those with an agenda. Kevin McCready (talk) 14:00, 17 February 2009 (UTC)

• If even Cochrane is not good enough, then what is? Should we erase all of Water fluoridation{'}s sources and throw the article away? After all, none of its sources are published in venues better than Cochrane. I don't see evidence of an undue agenda in any of the Cochrane reviews that Yeung has helped coauthor; these are Yeung et al. 2005 (PMID 16034911) on fluoridated milk; Hayashi & Yeung 2003 (PMID 12535474) on ceramic inlays, and Nadin et al. 2003 (PMID 12535462) on pulp treatment. Again, no evidence has been presented to support the claim that Yeung 2008 (PMID 18584000) is an unreliable source, much less that Yeung "is not science". Eubulides (talk) 18:55, 17 February 2009 (UTC)

• Yeung 2008 is currently the highest-quality review available on water fluoridation. The other two of the top three are McDonagh et al. 2000 (PMID 11021861) and Truman et al. 2002 (PMID 12091093). All three reviews are cited in Water fluoridation, but Yeung 2008 naturally is cited the most often as it reviews more-recent studies than either McDonagh et al. and Truman et al., and covers more water-fluoridation-related issues than either of the earlier two reviews do.

• I strongly disagree that it's the "the highest-quality review"; this is your very subjective assessment. I agree however that McDonagh's (aka York report) is highly respected, and widely discussed, much more so than Yeung's. Xasodfuih (talk) 13:46, 17 February 2009 (UTC)

• It's correct that it's my own assessment, as is your assessment that McDonagh et al. is better. I agree the York review is respected, and has been discussed much more than Yeung has. Also, the York review is older, which on the plus side contributes to its citation count, and on the minus side means it's relatively dated. The Yeung review has the advantage of starting from the York review (which it largely defers to, on the issue of effectiveness) and then covering more material. For example, Yeung also covers the issue of the halo effect, and for dental fluorosis it also relies on Griffin et al. 2001 (PMID 11300171) as well as 11 other additional studies not covered by the York review. There is no good reason to omit these results here. Eubulides (talk) 18:55, 17 February 2009 (UTC)

• The cited conclusions of Yeung 2008 do not disagree with the conclusions of either of the other two major reviews on water fluoridation. There is obviously some controversy among reliable sources about water fluoridation, but it's in other areas, not here.

• "giving it WP:UNDUE weight" The topic in question comes up as the first sentence of the Recommendations section of the abstract of Yeung 2008, so it's clearly a weighty issue to Yeung. It is not for us to second-guess the weight given by reliable sources, unless of course we can find other equally-reliable sources disputing the weight in question. I doubt whether we'll be able to find that: the issue of equitable access comes up quite a bit in this area.
• "meaningless PC drivel" The phrase is summarizing what a reliable source says on an important topic. It neither meaningless, nor politically-correct, nor drivel.
• "Most effective it isn't; see the CDC 2007 study, PMID 17452559" The CDC study does not disagree with Yeung's claim. The CDC study says that community water fluoridation is about as effective for adults as fluoride from any source, e.g., fluoride toothpaste when the adults brush teeth properly. Yeung's claim is about community-wide exposure to fluoride, a different topic which also covers the case when adults (or children) don't properly brush their teeth.
• "What did Yeung compare it with" Yeung does not explicitly state what he compared community water fluoridation to. His paper and the corresponding full report (the latter is also cited in Water fluoridation, and is freely readable) cite many sources on various forms of fluoridation, which presumably formed the basis for his statement.
• "this is not science, but a social agenda or more simply a justification for the gov't program that sponsored his research." I see no evidence to support this claim of bad faith, and I am extremely skeptical of the claim. Using this sort of unsupported argument, one could just as easily reject every source that Water fluoridation currently uses, which would not be reasonable.
• "At the moment one should not rely on water fluoridation as the only means of bringing about equality" That quote from Hausen 2002 (doi:10.1038/sj.ebd.6400102) does not contradict Yeung's statement. Furthermore, Hansen's commentary cites no studies dated after 2000, and significant work published since then exists in the area of water fluoridation and social equity. See, for example, Armfield 2005 (PMID 16255452), which Yeung's full paper cites.

Eubulides (talk) 08:52, 17 February 2009 (UTC)

• That's a cross-sectional study. It is not different in any significant way, except perhaps sample size, from other studies of this nature that have been done before. Xasodfuih (talk) 14:58, 17 February 2009 (UTC)

• Sorry, I've lost content; I don't know which study the previous "cross-sectional study" comment refers to. Eubulides (talk) 18:55, 17 February 2009 (UTC)

(undent) Other methods of applying fluoride are indeed far more effective for individuals. So perhaps any misunderstanding by a reader who may not focus on the qualification of "community-wide exposure" needs to be headed off. Kevin McCready (talk) 14:00, 17 February 2009 (UTC)

Indeed, this is what the "clarify me" tag was for. I think a FA-level article should explain this better. Unfortunately some long term editors here appear to be in constant "battle mode" and just reject any changes/objections; somewhat understandable given how Opposition to water fluoridation reads (i.e. POV fork). Xasodfuih (talk) 14:23, 17 February 2009 (UTC)

To summarize my concern: water fluoridation is "the most effective" in narrowly defined circumstances, probably so narrowly defined that nothing else qualifies as a competitive intervention ("community-wide exposure"). The BMJ editorial that introduced the York metaanalysis makes the following observations wrt. varying effectiveness [3]: Xasodfuih (talk) 14:59, 17 February 2009 (UTC)

“ In terms of benefits, the only aim of community water fluoridation is to prevent dental caries. A recent review of the effectiveness of water fluoridation in the United States shows that previous reductions in mean caries scores of one half to two thirds are no longer attainable because other methods of providing fluoride and the availability of products containing fluoride have reduced the prevalence of caries, thus diluting this measurement of effectiveness.(PMID 9034970) Similar findings have been reported from the United Kingdom.(PMID 8634899) The reduction in the relative effect of fluoridation, which is also seen in the systematic review by McDonagh et al has generally not been big enough to call into question the justification for fluoridating water.(cites York)

However, a much larger reduction occurred between 1973 and 1982 among 13-15 year olds in Finland: in 1973 the score of decayed and filled teeth was 43% lower in a fluoridated area than in a low fluoride area, whereas in 1982 there was no difference.(PMID 3861658) In Finland preventive dental care is provided free to all children, and this reduction shows that the relative effect of fluoridation can vary strongly depending on different circumstances.

”

I have looked at the lengthy original report and see no support for "the most effective and socially equitable way" statement. It did not appear amongst the numerous question subject of the systematic review. Just like the York review, the NHMRC review compared water fluoridation to no water fluoridation, and often relied on the York review for evidence e.g.:

“ Research question: Is intentional water fluoridation more efficacious than no water fluoridation in the prevention of dental caries?

The existing body of evidence strongly suggests that water fluoridation is beneficial at reducing dental caries. After adjustment for potential confounding variables, McDonagh et al (2000a) showed in their systematic review [...]

Research question: Is the use of topical fluoride supplementation more efficacious than no topical fluoride supplementation in the prevention of dental caries? There is consistent Level I evidence from existing systematic reviews and a review of additional original studies that topical fluoride agents reduce caries in children, when compared to no topical fluoride supplementation.

Research question: Is a combination of topical fluoride supplementation products more efficacious than a single topical fluoride supplementation product in the prevention of dental caries? There is Level I evidence that some combinations of topical agents may be more effective at preventing/reducing caries than single agents.

”

There is no comparison between various delivery methods. Finding the "the most effective" delivery method was not a a "research question". Ergo, the conclusion from the Yeung summary paper is his editorial opinion, and should be presented as such not as a bare fact. Xasodfuih (talk) 18:01, 17 February 2009 (UTC)

Thanks for all that work! To try to address the problem, I rewrote the claim to attribute it to the Yeung review in-text, and deemphasized it by putting it at the end of the paragraph rather than the start. Eubulides (talk) 18:55, 17 February 2009 (UTC)

Changes early on 2009-02-17

The changes made early on 2009-02-17 UTC were mostly fine, but had three problems:

• Adding the {{dubious}} and {{Clarifyme}} templates isn't called for; this is discussed further in [[#Disputing the factual accuracy and neutrality of the Yeung study PMID 18584000|the previous talk-page section]]. Yeung 2008 (PMID 18584000), the cited source, is a reliable one. I'll leave the tags there for a bit to give the editor who installed the tags time to respond.
  • I have replaced them with more appropriate tags (see explanation in the section above). Xasodfuih (talk) 13:53, 17 February 2009 (UTC)
• A placeholder {{see also}} to Skeletal fluorosis and Fluoride poisoning was inserted at the start of the Safety section, with a comment "these would be better introduced in this section by saying that they don't happen at normal concentration". However, that section's 3rd paragraph already covers that issue, and wikilinks to both Skeletal fluorosis and Fluoride poisoning. Perhaps the 3rd paragraph was overlooked?
  • Indeed I had overlooked that; apologies. Xasodfuih (talk) 13:53, 17 February 2009 (UTC)
• Adding the illustration Image:FluorosisFromNIH.jpg is inappropriate for the Safety section. Using this image would convey to the casual reader the incorrect impression that water fluoridation causes severe enamel fluorosis. It would be greatly misleading to scare readers in this way.

Eubulides (talk) 08:52, 17 February 2009 (UTC)

• A similar picture (of better quality, equal severity, but copyrighted) appears in connection with water fluoridation in the source cited in the caption. If you find the factually correct caption misleading to a casual reader please adjust that instead. Or find a suitable picture of milder dental fluorosis— this was the only one available on commons. A FA should be well illustrated, and given that dental fluorosis is an aesthetic issue, a picture is very necessary. Xasodfuih (talk) 13:53, 17 February 2009 (UTC)

• I share your desire for better illustrations. I have looked hard for pictures, and have found none that are both free and appropriate here. As an aside, it is really amazing how poorly this stuff is documented on U.S. government [i.e., free] web sites.
• I would like pictures of teeth with no fluorosis at all, with fluorosis that is not of aesthetic concern, and fluorosis that is mild but is not of aesthetic concern, as these are the realistic images that one should have in an article about water fluoridation. Scary images of severe fluorosis are not appropriate here. It is better to have no picture than to have a highly misleading picture.

Eubulides (talk) 18:55, 17 February 2009 (UTC)

• I don't agree. The wiki has this in the 3rd paragraph of the Safety section (not added by me): "Fluoride can occur naturally in water in concentrations well above recommended levels, which can have several adverse effects, including severe dental fluorosis, skeletal fluorosis, and weakened bones. In 2006 the U.S. National Research Council recommended lowering the Maximum Contaminant Level Goal for fluoride, or known safe level independent of cost and feasibility, from its current value of 4 mg/L.[44]" This is exactly what was illustrated with that picture; a better quality picture, but showing a similarly severe dental fluorosis was given in the summary for the source [4]. Apparently the authors did not consider it misleading. Xasodfuih (talk) 19:36, 17 February 2009 (UTC)

• The coverage of fluoride well above recommended is somewhat tangential to Water fluoridation. It is present in the Safety section only to make it clear that we're not talking about increasing fluoride to levels so high as to cause fluorosis at the higher levels of severity.
• It would be heavily misleading if that section were illustrated by a picture of moderate or high levels of fluorosis, as the casual reader would see just the picture, and would think that it is a common or significant consequence of water fluoridation. It is not. The source cited in the previous comment is not about water fluoridation; it is about the consequences of fluoride well above recommended levels. It would be quite misleading to use its image here.
• It may well be that the current wording doesn't make the above points clearly enough, namely that the effects of fluoride well above recommended levels are not that relevant to the safety of water fluoridation. If so, we should improve the wording.

Eubulides (talk) 20:44, 17 February 2009 (UTC)

• Before I waste my time with Photoshop, do you find the left image from here acceptable? Xasodfuih (talk) 20:01, 17 February 2009 (UTC)

That's such a poor quality picture, it is hard to tell what is camera noise (which often shows as yellow splodges) and what is fluorosis. I'm not keen on trusting some dentist's home-made before/after pics either. This is an article on the artificial addition of fluoride to the water supply. So the effects of natural levels above those recommended aren't relevant. I wouldn't support the sort of pic from the paper Xasodfuih cites, which is clearly not the result of water fluoridation. This isn't an article on dental fluorosis in general. I'd be uncomfortable with any fluorosis pic in this article unless its source indicated this was typical of that produced by water fluoridation alone, and Eubulides' suggestion of a set of pics would be ideal (and avoid WEIGHT issues). But I don't think such a pic is required for FA and the article has ample appropriate pics for the topic. Colin°^Talk 20:37, 17 February 2009 (UTC)

I agree with Colin. The image on the left in Image:Fluorosisb&a.jpg has real problems. First, most of what the casual reader would see in that image is stain, not fluorosis. Second, we don't know how its fluorosis severity corresponds to the fluorisis of concern with water fluoridation. Much better would be the images in The Vermont Dept. of Health's page on fluoridated water, but alas, these are copyrighted. Eubulides (talk) 20:44, 17 February 2009 (UTC)

Section title for "Safety"

Shouldn't this be better called "side effects" since the main adverse effect is an aesthetic one, thus not a safety concern? Xasodfuih (talk) 15:19, 17 February 2009 (UTC)

I'd need further convincing. The section is broader than side-effects in that it covers bone-fracture risk and skeletal fluorosis. Kevin McCready (talk) 15:25, 17 February 2009 (UTC)

You have a point, but "safety" alone is too narrow of a title methinks. Call it "Adverse effects and safety" (or the other way around) then? Xasodfuih (talk) 15:42, 17 February 2009 (UTC)

I'm not fussed either way but I think safety alone covers it and has the advantage of simplicity. Kevin McCready (talk) 16:51, 17 February 2009 (UTC)

I don't have a strong opinion, but also mildly prefer the shorter title Safety. Eubulides (talk) 18:55, 17 February 2009 (UTC)

The research done on water fluoridation's safety is such that the high-quality assessments from the York review and the National Academy of Sciences don't conclude "water fluoridation is safe". That's stated in the section to some degree, although it could be made clearer, and it is in contrast to the opinions of public health agencies in fluoridating countries and the US, which have considered fluoridation safe since their inception. In science, you only find what you're looking for (what you've collected data on). Since we haven't really looked closely for many adverse affects, they won't show up on the radar. Even among the things that have been looked for, there's been a few positive, statistically significant osteosarcoma studies and other cancer relationships. II | (t - c) 18:41, 17 February 2009 (UTC)

Suggestions for specific wording changes to help clarify this would be helpful. Eubulides (talk) 18:55, 17 February 2009 (UTC)

Nothing is absolutely safe. But the York and later NHMRC report do answer specific questions. Letters to the BMJ editor following the York report did point out that other questions have not been answered, e.g. the possibility of adverse effects of fluoride on the thyroid gland. McDonagh's reply ends with this: "Our review of water fluoridation is specific and appropriately narrow in focus. It is not the answer to the question of whether or not to fluoridate. Our review found a benefit in the form of reduction in caries, balanced against a dose related increase in fluorosis. We said that no clear evidence of other potential negative effects was found. We have been assiduous in our paper, our full report, and our contacts with the media, not to convey a message of no evidence of harm. We suggest caution against overinterpretation of our results and emphasise again that the quality of these data on benefit and harm is only low to moderate." I'm not sure that more cautionary statements are needed in this article though. YMMV. Xasodfuih (talk) 19:18, 17 February 2009 (UTC)

US maps somewhat misleading

The 2007 NHMRC report has a map (p. 19) showing that the Western US has a natural level of water fluoridation above 1.5mg/L. This should be at least said in the text, but preferably a map showing this natural level should also be presented. Xasodfuih (talk) 16:25, 17 February 2009 (UTC)

Might want to replace the southern Arizona map. Come to think of it it's pretty US focused. Kevin McCready (talk) 16:54, 17 February 2009 (UTC)

The NHMRC world map would be great, much better than the Arizona map as it has worldwide scope; but it's copyrighted, and in the meantime the Arizona map is the best free map I've found on the topic. The NHMRC map does not say that the entire Western U.S. has a fluoride above 1.5 mg/L; it merely says that higher-fluoride water is associated with the Western U.S. As can be seen from the Arizone map, a good-sized chunk of southern Arizona has water less than 2 mg/L (and I assume also less than 1.5 mg/L). I will look into adding text to the effect of what that world map says; that should be easy. Copying the map would raise copyright issues. Eubulides (talk) 18:55, 17 February 2009 (UTC)

Requesting source verification for a Pizzo statement

"The introduction of fluoride toothpaste in the early 1970s has been the main reason for the decline in tooth decay in industrialized countries.[PMID 17333303]" It does not appear in the freely available 1st page on Springer, and I'm not having much luck with dentistry journals (this one is not so obscure, it's in top 20 or so for dentistry). Xasodfuih (talk) 23:22, 17 February 2009 (UTC)

It checks out (thanks to User:ImperfectlyInformed). Having read this paper I came to the (rather sad) conclusion that starting from the same studies (as other recent reviews) Pizzo et al. spin the spin ever so subtly towards the conclusion they prefer. The "which is the best delivery route for fluoride" question so far has been answered only by expert/narrative reviews rather than anything more systematic. And the conclusions differ in a rather predictable way. So this is how it should be presented. Xasodfuih (talk) 03:13, 18 February 2009 (UTC)

2009-02-17 changes

This recent set of edits had some problems:

• It added a {{pn}} tag after the claim "which is roughly equivalent to preventing 40% of cavities." A simple text search for "40%" in that source (Yeung 2007, PMID 17891121) will find the claim on the source's first page, which says: "The findings of the York review showed that there was a median change of 14.6% in the proportion of caries-free children, roughly equivalent to a prevented fraction of 40%." It is surely unnecessary to record a page number in a source that has only two pages.
• It changed the URL for the York final report from http://www.york.ac.uk/inst/crd/pdf/fluorid.pdf (which is the report itself) to http://www.york.ac.uk/inst/crd/fluorid.htm (which is a web page about the report) without changing the rest of the citation to match the new URL.
• It added the text "Adverse effects other than fluorosis, bone fracture, and cancer lack sufficient evidence to reach a confident conclusion.", citing the York Review. The York Review does not say this, or anything like this. It says that there is no clear evidence of any potential adverse effects other than dental fluorosis. I see nothing in the review about "confident conclusion", and nothing about "Adverse effects other than fluorosis, bone fracture, and cancer". Anyway, this sentence isn't needed here once we undo the change described in the next bullet.
• It removed the text "Some adverse effects lack sufficient evidence to reach a scientific conclusion.", citing Yeung 2008. This claim is hardly controversial, and serves as a useful introduction to the containing paragraph.
• It added the text "In contrast, reactions to fluoride have been reported in case studies and a 1974 double-blind study which found a gastrointestinal reaction to water fluoridated at 1 mg/L.", citing the NRC 2006 report. But the NRC 2006 report is specifically not about water fluoridation, and we should not be suggesting conclusions about water fluoridation based on that study. Furthermore the 1974 report is an old primary study on a subject that was reviewed by all the more-recent reviews on the subject that we already cite; as per WP:MEDRS, we should definitely not be using older primary studies to argue positions not taken by newer reliable reviews on this subject. Recent reviews are unanimous in saying there's no clear evidence of adverse effects other than dental fluorosis, and we should not be implying the contrary.
• More generally, this edit is building on the idea that the NRC 2006 report is important to the issue of water fluoridation. The study itself says that it is not. As the study is on a relatively marginal and local issue (should some advisory maximum level in the U.S. be changed? but water fluoridation goes nowhere near that level), it would be better to drop the study entirely, briefly mention the WHO suggestions in this not-that-relevant area, and move on. This will fit better into the Wikipedia aim of having a worldwide view.Eubulides (talk) 09:16, 18 February 2009 (UTC)

Responses:

• I got Yeung 2007 confused with Yeung 2008. Sorry.
• This is another thing which was pointless to point out, but thanks for changing the template.
• The York reviewers later commentary in the British Dental Journal clearly states that adverse effects other than those I noted don't have enough evidence to reach a conclusion. So does Yeung's full report. On the other hand, I'm looking at the published Yeung 2008 and he doesn't seem to say anything about these things. The sentence is too vague. Ironically, correcting the vagueness supports your POV, since it implies that confident conclusions can be made about cancer and bone fracture.
• The NRC 2006 report is the most focused review of the toxicology of chronic fluoride exposure. It has some conclusions which are clearly relevant to fluoridation, and these can be used -- especially if we have misleading text which directly contradicts what they've found, like the current citation to a single primary source which doesn't agree with the rest of the literature. Your argument sounds like wikilawyering, and this is an area where I won't budge. Should I raise it at WP:RS/N?
• It's not building on that idea at all. If the NRC comments on effects of fluoride exposure at the level used in fluoridation, these comments can be noted. I hadn't planned on citing it for other effects, but I won't let a biased and misleading summary of the literature remain in this article.
• The NRC report has gathered a lot of attention. It suggests that the margin of safety has been underestimated, it motivated concerns about excess exposure in children, and it's a source which opponents cite. Further, its chairman and 3 of its (12) members criticized fluoridation after it was published in a recent Scientific American article. Removing it makes the article seem biased. II | (t - c) 18:24, 18 February 2009 (UTC)

• "The York reviewers later commentary in the British Dental Journal clearly states that adverse effects other than those I noted don't have enough evidence to reach a conclusion." Thanks, I hadn't see that. I'll undo that change.
• "The NRC 2006 report ... has some conclusions which are clearly relevant to fluoridation". That report clearly states, multiple times, that it does not evaluate or make conclusions about the practice of water fluoridation. Its page 16, for example, says "As noted earlier, this report does not evaluate nor make judgments about the benefits, safety, or efficacy of artificial water fluoridation." We should not be second-guessing the authors of the report in order to say or imply that their conclusions are indeed about the safety of water fluoridation.
• "the current citation to a single primary source which doesn't agree with the rest of the literature" Which citation is that? Sorry, I've lost context.
• "The NRC report has gathered a lot of attention." That's quite true, but that does not mean it needs to be cited here, nor that its results are relevant. It focuses on whether the U.S. should remove more fluoride from water that is naturally fluoridated well above recommended levels. It can be cited on that question, but that is a different question, and is not a central issue to the safety of water fluoridation. We should not cite it in a misleading way, to imply that its results were intended to be about water fluoridation.
• The current text of Water fluoridation gives the lower WHO guideline of 1.5 mg/L, which makes the NRC report (which asks "should we lower some nonbinding U.S. advisory goal from 4 to 2 mg/L?") sort of a tempest in a teapot. It's about a question that is not that relevant to water fluoridation, and it's a local matter where we already have a global guideline, which is more conservative anyway.

Eubulides (talk) 00:01, 19 February 2009 (UTC)

Xaso's changes

This further set of recent edits made several improvements (thanks!) but had some problems:

• It inserts the text "In countries where caries prevalence has declined, the single common factor appears to be flouride toothpaste." which is a direct quote of the cited source without quote marks. The article generally does not use the word "caries", preferring the common terms "tooth decay" or "cavities"; we can rewrite it using these terms. Also, the "single common factor" text duplicates some of the next sentence; some rewriting can trim that. (Also, the "Thus" is not directly supported by the cited source, and should go.)
  • For minor adjustments like that you should just go ahead and do them; there's no need to post lengthy justifications here. Most likely nobody is going to object, and it will take less time for everyone involved (you writing, me reading). Xasodfuih (talk) 15:03, 18 February 2009 (UTC)
• It inserted the text "Due to the paucity of studies in adults, this metaanalysis included studies without blind outcome assessment and cross-sectional studies of water fluoridation." which is, I'm afraid, going to be gobbledygook to our readers. And it's unnecessary gobbledygook for this article, really.
  • Feel free to say the sources were of lower quality than those in children studies if technical term (not gratuitous jargon in this case) are an issue. Xasodfuih (talk) 15:03, 18 February 2009 (UTC)
    • I see you already addressed this; thanks. Eubulides (talk) 00:01, 19 February 2009 (UTC)
• It introduced a 70-word rebuttal (sourced to Pizzo et al.) to a 23-word claim (sourced to Yeung), which hardly seems balanced. The rebuttal contains words like "however" that introduce POV and are not directly supported by the cited source. Also, the rebuttal had problems with coherency (at least, I couldn't follow it). In the water fluoridation review world, a better balance for Pizzo et al. 2007 is Kumar 2008, so we can use that.
  • Feel free to adjust, but Yeung's opinion needs balancing because there obviously are experts, publishing in mainstream journals, who don't agree with Yeung. In the mean time I have also read his paper, and there is nothing in it that's not in the full report. Xasodfuih (talk) 15:03, 18 February 2009 (UTC)
    • Thanks, I tried to do that with this edit. Eubulides (talk) 00:01, 19 February 2009 (UTC)
• It introduced a relatively long discussion about Finland, citing an old primary study, Parviainen et al. 1985 (PMID 3861658), and saying preventive care is free in Finland, citing Hausen 2000 (PMID 11021844). As per WP:MEDRS, we should not be directly citing primary sources like this, particularly older primary sources, when there are perfectly good recent reviews on the topic that make the connections for us. The newly introduced point, that the European system costs more, can be addressed by citing a review. Perhaps I'm missing the point here, but I didn't see much else that was added by the Finnish material that is not already addressed in the article.
  • The point here is: it needs some details on a non-US country (given the emphasis on US in the opening); it's also one of the few studies that compared costs of water flouridation to alternative deliveries. It's also one of the few studies that evaluated the subsitution of one prevention with another. Finally, it's one of the few (primary) studies cited in the BMJ editorial that accompanied the York report. Ergo, it stands out. It also ties in nicely with the following paragraphs about cost-effectiveness in general. Xasodfuih (talk) 15:03, 18 February 2009 (UTC)
    • You've replaced that with yet another study about the US :( Xasodfuih (talk) 15:10, 18 February 2009 (UTC)

• "it needs some details on a non-US country (given the emphasis on US in the opening)" As shown in Talk:Water fluoridation/Archive 2 #Mechanism and worldwide view, the article already relies heavily on non-U.S. sources, compared to the amount of research that has been published in the area. This is particularly true in the Effectiveness section. I don't think it's way out of balance, but if any balancing is to be done it should be to focus more on U.S. sources.
• "it's also one of the few studies that compared costs of water flouridation to alternative deliveries" That may well be, but this topic has been thoroughly reviewed by subsequent secondary sources, such as CDC 2001 (PMID 11521913); there really is no need for us to be bypassing their conclusions and directly citing primary sources in this area.
• "Finally, it's one of the few (primary) studies cited in the BMJ editorial that accompanied the York report." That BMJ editorial, Hausen 2000 (PMID 11021844), contains a paragraph citing several high-quality reviews giving the mainstream consensus that fluoride still reduces cavities, even in the modern world where people use use fluoride toothpaste; it then goes on give one sentence saying that there's an old study in Finland showing there's no difference. That context and weight was lost in the the change inserting the Finland study, which emphasized the Finnish results way out of proportion to what the Hausen said. Furthermore, our best sources are not Hausen, but the systematic reviews on the topic, namely the York review 2000 (PMID 11021861), Truman et al. 2002 (PMID 12091093), and Yeung 2008 (PMID 18584000); we should be following their lead on this topic, not Hausen's, and we should not be citing that old primary source ourselves.
• "You've replaced that with yet another study about the US" It was replaced with a citation to a review (Kumar 2008, PMID 18694870). It is better to cite recent high-quality reviews than old primary studies; whether the reviews are U.S. or non-U.S. is not that important. Also, is this really that controversial an issue? I don't know of any reliable source disagreeing with the claim that fluoridation is cheaper than toothpaste.

Eubulides (talk) 00:01, 19 February 2009 (UTC)

I made this series of further changes to try to address the above problems. Eubulides (talk) 09:16, 18 February 2009 (UTC)

Cleanup-combine tag

More disturbingly, the Alternative methods section preempts the discussion from the Effectivenss section proper. This should be a subsection of effectiveness that discusses the relative effectiveness and cost-effectiveness of fluoride delivery methods. Xasodfuih (talk) 15:59, 18 February 2009 (UTC)

Here's my proposal for dealing with this:

1. Move the Alternative methods section after Mechanism because at that point the reader should suspect that other delivery methods exist based on how fluoride works for preventing caries.
2. Keep Alternative methods descriptive; avoid comparisons of effectiveness (this may be easier said than done), relegating comparisons to the proper Effectiveness section, which in this proposed layout follows shortly, so the reader doesn't need to recall stuff said far back.

Thoughts? Xasodfuih (talk) 20:25, 18 February 2009 (UTC)

That proposal sounds fine. Another idea, which would be much simpler to implement, is to move Alternative methods to after Evidence basis; this should require only relatively-minor changes other than the move. The idea is that readers have just waded through Evidence basis and have the topic fresh on their minds, so when the topic is revisited in Alternative methods it's not jarring. Logically, the topic of the effectiveness of alternative methods can be covered either under Effectiveness or under Alternative methods; since Effectiveness is already rather long, it may make more sense to discuss the topic in Alternative methods (perhaps with a brief pointer from Effectiveness to Alternative methods). Eubulides (talk) 00:01, 19 February 2009 (UTC)

This works as well. I'm rather tired at this point (in the day) for FA-level prose. So, it's to you to do it today. I'll look over it tomorrow. Oh, and sorry I was bit irate on the FAC page. Xasodfuih (talk) 01:55, 19 February 2009 (UTC)

You call that irate? (But thanks.) Anyway, I gave it a shot. Eubulides (talk) 07:02, 19 February 2009 (UTC)

Placement of "Water fluoridation does not affect the appearance, taste, or smell of water."

I moved this from the mechanism section it was out of place there. But I'm not entirely happy where I put it in the lede, in part due to duplication with the caption of the "catchy" image. This sentence isn't much longer than "Human senses cannot detect whether the water is fluoridated", so perhaps it could replace it in the caption. Any other ideas how do deal with this? Xasodfuih (talk) 18:53, 18 February 2009 (UTC)

The lead should summarize the body, so if the lead says that fluoridation doesn't affect the appearance, the body should say that too. It would be fine to move the sentence from the lead to the caption, thus deleting the somewhat-awkwardly-worded "Human senses" sentence. By the way, that's the way the caption used to read; I changed it to the "Human senses" wording only because User:Chergles complained about captions sounding "like a public service message"[5]. Coming back to the issue now, I preferred the older, snappier wording of this particular caption, and don't think it sounds like a public-service message. Eubulides (talk) 00:01, 19 February 2009 (UTC)

I guess you can't please everyone. Ideally an issue like this should be mentioned in the body in a section dealing either with physicochemical properties of fluoridated water, or with the public acceptance of water fluoridation. But we don't quite have section like that (in Ethics and politics it would be rather odd). Perhaps move it to the implementation section, and prefix it with "At recommended dosage, fluoridation does not affect..."? I'll leave message to User:Chergles since he cares about this more than both of us it seems. Xasodfuih (talk) 01:37, 19 February 2009 (UTC)

Moving it to Implementation sounds fine. I'd rather avoid the "At recommended dosage," phrase, though. The phrase "water fluoridation" implies controlled addition of fluoride to recommended values, so there's no need to prepend "At recommended dosage" every time we write "water fluoridation". Also, prepending that phrase just here would imply that one can taste the fluoride at naturally occurring values above recommended dosage, which (as far as I know) isn't so. Eubulides (talk) 07:02, 19 February 2009 (UTC)

Fine your way. I was just trying to find some way to tie it in with the implementation stuff. Xasodfuih (talk) 13:13, 19 February 2009 (UTC)

Problem with general tone of article

Given that the York review says the quality of evidence is low, how come this article is so sure that water fluoridation reduces tooth decay? It seems like this article's purpose is just to promote water fluoridation. If Europe has reduced it's level of tooth decay without water fluoridation (so you could conclude that if it does have an effect, it is a little one); there are major ethical concerns about mass medication; there is massive cost involved - all these things - yet this article is massively imbalanced in favour of water fluoridation. Ridiculous. Tremello22 (talk) 22:30, 7 February 2009 (UTC)

• The York review does not say that the quality of evidence is low. It says that moderate-quality research exists as to water fluoridation's effectiveness. There is no doubt among reliable sources that fluoridation reduces tooth decay; the concerns expressed are that much of the evidence was gathered by studies that, by today's standards, are not of high quality. (I speculate that high quality studies are not being done partly because of their cost, partly due to ethical concerns in withholding fluoridation, and partly because nobody wants to spend the money to find out the same thing all over again; but this is just my speculation, and obviously as such does not belong in the article.)
• Most (but not all) of Europe has reduced its level of tooth decay by fluoridating salt and toothpaste and by having higher-quality dental care for everybody. This does not at all mean that water fluoridation has only a small effect; it means that water fluoridation is not the only way to reduce tooth decay. This latter is not a controversial point, and is discussed in Water fluoridation #Effectiveness.
• The ethical concerns about water fluoridation are discussed in Water fluoridation #Ethics and politics, at some length; they are also mentioned in the lead.
• The cost of water fluoridation is discussed in Water fluoridation #Implementation, and also mentioned in the lead. Water fluoridation is much cheaper than fluoridated toothpaste.
• Naturally, to someone who is strongly opposed to water fluoridation, the current article will seem imbalanced. The same is true for someone who is strongly supportive of water fluoridation. However, every statement in this recent version of the article (before some of today's edits, which I have not yet had time to review) is directly supported by a reliable source.

Eubulides (talk) 23:29, 7 February 2009 (UTC)

I do believe that a requirement of this Wikipedia post is to be impartial. This article on water fluoridation is not. There is a plenitude of scholarly research available that indicates that fluoride is a neurotoxin. When I wanted to include that edit into the article, supporting my work with scholarly research not of my own agenda, therefore not violating the rules, it was prohibited. Why? By not allowing me to post such information clearly shows a bias. If this is to be a reputable post, like any good informative and neutral presentation of fact (I teach English at a University), for there to be no agenda, both sides of an argument must be presented. For example, to make this post better, there should be a section showing the evidence that supports health risks of water fluoridation as well as the alleged benefits. This way, the reader has adequate representation of both sides. It is NOT the writers job to imply a position which this article, almost flamboyantly promulgates only pro-water fluoridation and is vehemently opposed to any conflicting statement that would oppose it's agenda. --which by the way, to iterate, reproaches the terms of posting. There clearly needs to be revisions made. Maybe someone more qualified than a Professor could help me with this? Here are some "reliable" sources to insert information into the post since I was not allowed to do so.

[6]

[7] Pan Gnosis (talk) 20:07, 19 February 2009 (UTC)

The edit you made was immediately reverted (not by me) because it made claims like "Fluoridated water has been scientifically noted to have zero health benefits" which are completely at variance with what reliable sources say. The sources given in that edit were WP:FRINGE sources, containing unscientific claims like the one that 10% of the cancer deaths in the U.S. are linked to fluoride.[8] As per WP:RS and WP:MEDRS, this article can't rely on sources like that; it needs high-quality secondary sources, such as what you'd find in a respectable peer-reviewed medical journal. Eubulides (talk) 15:51, 22 February 2009 (UTC)

Where are the 50-60% and 18–50% given in Truman? [9]

"Initial studies showed that water fluoridation led to reductions of 50–60% in childhood cavities; more recent estimates are lower (18–50%[37])" I don't see them giving either of these ranges, and I think the interpretation of their figures is quite wrong.

• First issue: they don't divide the studies by year. The have two groups of studies:
  • group A (before-and-after measurement with a control group)
  • group B (only-after measurement with a control group)
• Second issue: this is what the numbers actually are, and more importantly, what they mean (fig. 2-4 in paper, and table 3):
  • Starting fluoridation in group A: 29.1% median decrease in caries (range: 66.8% increase to 110.5% decrease)
    • [yes, some of these studies found an increase in cavities after starting fluoridation relative to the control group]
  • Stopping fluoridation in group A: 17.9% median increase in caries (range: 31.7% increase to 42.2% decrease)
    • [similarly, some of these studies found a decrease in cavities after stopping fluoridation relative to the control group]
  • Starting fluoridation in group B: 50.7% median decrease in caries (range: 22.3% decrease to 68.8% decrease)
  • Stopping fluoridation in group B: 59.9% median increase in caries (range: Not applicable)

Math:

• For group A, effects = ((Fpost - NoFpost) - (Fpre - NoFpre)) / NoFpre. [I've rearranged this a bit; see page 24 bottom]
• For group B, effects = (Fpost - NoFpost)/NoFpost.

• Fpre means dental caries prevalence in fluoridated community before fluoridation (or at first measurement during ongoing fluoridation)
• Fpost means dental caries prevalence in fluoridated community after fluoridation (or at second measurement during ongoing fluoridation)
• NoFpre means dental caries prevalence in nonfluoridated community before fluoridation (or at first measurement during ongoing fluoridation)
• NoFpost means dental caries prevalence in nonfluoridated community after fluoridation (or at second measurement during ongoing fluoridation).

I think what these numbers mean is too complicated to the average Wikipedia reader. If you have any idea on a simple, but non-misleading presentation, please let me know. I think the other studies (York, CDC) give enough numbers, even though they are split by children and adults.

On the other hand, Truman's numbers for dental sealant (fig. 5) are lot easier to explain: 60% median reduction in cavities. Xasodfuih (talk) 13:13, 19 February 2009 (UTC)

But their numbers are bit at odds with the other metaanalyses, which are easier to explain and have CIs, not just a median value (plus range) from a bunch of studies. Fairly big YMMV. Xasodfuih (talk) 13:17, 19 February 2009 (UTC)

Thanks for pointing out the problem. It exists because I tried to summarize two papers briefly in one sentence, and erred by smashing together incompatible numbers.

• First, the source cited for the entire sentence (CDC 2001, PMID 11521913) says, "Initial studies of community water fluoridation demonstrated that reductions in childhood dental caries attributable to fluoridation were approximately 50%–60% (94--97). More recent estimates are lower — 18%–40% (98,99)." Their (98) is Brunelle & Carlos 1990 (PMID 2312893), which gives the 18% (increasing to 25% if some of the background effect due to topical fluoride was controlled); their (99) is Newbrun et al. 1989 (PMID 2681730), which gives a range 13–35% for ages 13 and up, 20–40% for ages 8 to 12, and 30–60% for ages under 8.
• Second, the CDC 2001 source has been updated by Truman et al. 2002 (PMID 12091093), a later CDC publication. It says (p. 27), "Although we could not quantitatively combine effect measures from groups A and B, both seem to support the conclusion that community water fluoridation reduces dental caries by 30% to 50% of what could be expected for people not consuming fluoridated water. In addition, stopping CWF may lead to the median 17.9% increase in caries described above, in situations in which alternative sources of fluoride are inadequate."
• As you pointed out, I combined these two results inappropriately. I think Truman et al. is the latest published CDC consensus, but it's not reporting the same statistics. I made this change to try to fix things, by summarizing the Truman et al. results separately.

Eubulides (talk) 18:12, 19 February 2009 (UTC)

• The "30% to 50%" bit is a fairly loose presentation of two median results, which do not form a statistically valid range. The average Wikipedia reader will conclude that the "average" must be 40%, which is an overstatement compared to the <30% (25% for post 1979-studies) from more careful metaanalyses (Griffin etc.) Xasodfuih (talk) 21:38, 19 February 2009 (UTC)
• Truman also finds 60% median reduction by using dental sealants by using the same (non-pooled) methond. If his estimates for size effect are to be considered good, this number needs to be presented as well in (in the alternative methods section); it was one of the main findings of their study (fig. 5) Xasodfuih (talk) 21:38, 19 February 2009 (UTC)

• In context I don't see a big problem. Water fluoridation #Effectiveness says "A 2002 systematic review found data seeming to support the conclusion that starting fluoridation reduces tooth decay by 30–50% overall, and that stopping it leads to an 18% increase when other fluoride sources are inadequate." The immediate "18%" tells the reader that the actual average is not going to be 40%. The Griffin results are for adults, so they're not directly comparable.
• Good point about the "60%"; I added that.

Eubulides (talk) 15:51, 22 February 2009 (UTC)

Yeah, I'm nitpicking too much. It's fine. Xasodfuih (talk) 16:58, 22 February 2009 (UTC)

Dixon and Shackley

This edit removed material supported by Dixon & Shackley 1999 (PMID 10226722), saying "this is a poor contrast since the study cited in the previous sentence included the UK". I'm not sure how to interpret that comment, but let me try to explain why it's helpful to mention both studies. The two studies are Dixon and Shakley, based on a UK survey, and Griffin et al. 2008 (PMID 18333872), based on focus groups in 2003. Griffin et al. remark (p. 101), "Dixon and Shackley's finding of a majority of their UK sample being in favour of fluoridation seems at odds with the response of our UK focus groups. But this may be due to the majority of people not holding strong views about dental public health, or an artefact of the way questions are asked, and the ability of people to develop and explain their opinions within qualitative research, compared with the 'Yes'/'No' option originally presented by Dixon and Shackley." Given that Griffin et al. found the contrast notable, it seems worth reporting the contrast here. Eubulides (talk) 15:51, 22 February 2009 (UTC)

Both these studies are low quality as far as surveys go, and they used different designs, not to mention they are 4 years apart, so I'm not at all convinced there's anything to contrast. The focus groups from Griffin were like 8 people / country if I recall correctly; the overall results were significant, but I doubt that per country results are (hence a contrast with Dixon seems rather meaningles). Also, you're not giving the per country results from Griffin, so the reader can't guess what you're trying to contrast. Since water fluoridation is practised in the UK, from the presentation of Griffin's study one can easily conclude that the UK guys were in favor; at least I did when reading that passage (and looked only at the abstracts of the sources). Also, it's quite possible that the opinion in the UK changed in the 4 or so years in between. The contrast you're trying to make just doesn't connect.

From Dixon the interesting result is that the strong conviction of the opposes; I'm fine with adding that back, and perhaps also say how many held the wrong info. Too bad there aren't any better studies. Xasodfuih (talk) 16:30, 22 February 2009 (UTC)

Also, very important caveat, all participants in Dixon's study were from Sheffield, weren't they? From the US studies on opposition to fluoridation it's well known that local opinion varies widely. So, I'm not convinced that Sheffield is representative for UK as a whole in this matter. Xasodfuih (talk) 16:56, 22 February 2009 (UTC)

I have reworded it accordingly. Xasodfuih (talk) 11:48, 25 February 2009 (UTC)