System breakdown: when water fluoridation proves unreliable


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water fluoridation system breakdown
Dubbo dentist Dr Afaq Babi says if dentists can be kept in the loop about fluoridation problems, they can deal with the consequences and inform patients. Photography:  THARINDU JAY – LOGAN PHOTOGRAPHY

Fluoridation complications in two regional NSW towns have highlighted the importance of governments, councils and local dentists working hand in hand to ensure that community dental health is not compromised. By Cameron Cooper

Dubbo dentist Dr Afaq Babi admits to being dumbfounded when a news reporter called him in August this year asking for his view on the city’s lack of water fluoridation.

He had no idea that this important dental health service was offline in the central NSW hub.

“I actually found out from the ABC about what had been happening with the water supply. I wasn’t aware about that at all,” says Dr Babi, principal dentist at Crescent Dental in Dubbo and nearby Narromine.

Dubbo Regional Council has admitted responsibility (see panel) for the ongoing absence of fluoride in the city’s water supply after first being alerted in 2019 to a failure of infrastructure at the John Gilbert Water Treatment Plant. Council CEO Murray Wood, who took on the role last year, was made aware of the circumstances in April this year and the Public Works Advisory has been engaged to scope the body of work required to build infrastructure that meets council’s legislative and regulatory obligations under the Fluoridation of Public Water Supplies Act 1957. The aim is for the corrective works to be undertaken in the 2022-23 financial year.

While Dubbo Council and NSW Health are liaising over the fluoridation mix-up, the scenario nevertheless highlights the importance of better communication between governments, councils and local health practitioners to safeguard community health.

“In such situations we at least need some sort of memorandum, or information to keep us in the loop so we can inform our patients,” Dr Babi says. “At this stage it’s a surprise for everyone and especially the dental community. We’re the ones who are left to deal with the consequences every day.”

Proven health advantages 

The oral health benefits of water fluoridation are undeniable, with research showing that it reduces decay by 26 per cent to 44 per cent in children and adolescents, and about 27 per cent in adults.

This reality underlines concerns that Dubbo and another NSW town, Coonabarabran, have gone without water fluoridation for years. In Coonabarabran’s case, residents of the town and the wider Warrumbungle Shire still have no fluoride in the town’s drinking water because of design faults with the fluoride dosing system that emerged in 2015. Nearby towns such as Baradine, Binnaway, Coolah and Mendooran have also missed out on water fluoridation for varying periods.

Despite governments having systems, regulations and infrastructure in place to ensure fluoridation works, these cases show that it can all go awry. 

For its part, NSW Health has distanced itself from responsibility for any fluoridation failures. “NSW Health supports fluoridation of drinking water as a safe and effective way to help prevent tooth decay and encourages communities to support this important public health program,” a spokesperson says. 

“Local water utilities are responsible for maintaining and monitoring the fluoridation of their water supplies under the Fluoridation of Public Water Supplies Act 1957 to ensure community oral health is not compromised. Those responsibilities include effective system operation, ongoing maintenance and complying with legislative requirements and codes of practice. NSW Health supports water utilities to meet these responsibilities through training, financial support, expert advice and guidance, compliance monitoring and follow-up, and advice when responding to incidents.”

Regulatory requirement

While a minority of Australian towns have opposed water fluoridation in the belief that the naturally occurring chemical can contribute to health problems, there are regulatory requirements to provide the health service.

Leeanne Ryan, director, Environment and Development Services at Warrumbungle Shire Council, which oversees Coonabarabran, acknowledges that the benefits of fluoridation to the community could include “a reduction in cavities, fillings and loss of teeth”. However, she adds that there has not been universal support for the move in her shire.

“The community provided mixed responses to the addition of fluoride as not everyone agrees with the use of fluoride. NSW Health, however, feels that it is imperative to be provided,” Ryan says.

Upgrades to water fluoridation plants across Warrumbungle Shire are continuing, as resolved by council, with support from NSW Health. “Designs for fluoride upgrades are being worked through,” Ryan says.

“While designs for dosing equipment were initially approved by NSW Health, the Department of Planning and Environment was also required to approve the designs, so we are now working through this process. Council is seeking formal funding deeds from NSW Health to formalise the funding being provided. There is no firm timeframe for completion at this stage.”

The community provided mixed responses to the addition of fluoride as not everyone agrees with the use of fluoride. NSW Health, however, feels that it is imperative to be provided.

Leeanne Ryan, director, Warrumbungle Shire Council

Ryan says council will start implementation of water fluoridation “as soon as designs are finalised and funding deeds executed”. She notes that council is committed to addressing the issue of fluoridation and points out that it is a regulatory requirement.

“NSW Health have been somewhat slow to act,” Ryan says. “However, since this has been driven by council to effect the change required, they are responding in a timely manner. The measures are already in place for the management and delivery of fluoride and they are heavily regulated by legislation and codes of practice that must be adhered to.”

Dr Sarah Raphael, Advisory Services manager, Engagement & Advocacy Executive at the Australian Dental Association NSW, notes that fluoridation of public water supplies has been named by the US Centers of Disease Control and Prevention as “one of 10 great public health achievements of the 20th century and supported by more than 150 international peak health organisations.

“Why? Because it is one of the most equitable, cost-effective, efficacious and safe public health initiatives,” Dr Raphael says. “Fluoridation of community water supplies is an effective way to deliver fluoride to all members of the community, regardless of age, individual motivation or socio-economic status.”

She adds that it is widely accepted that poor oral health over a lifespan has significant impacts on general health, including increased risk of diabetes, cardiovascular disease and adverse pregnancy outcomes. 

The Dubbo case highlights the issue of poorer access to many services that people living in our rural and remote communities experience, according to Dr Raphael, who notes that it is critical to achieve the right dosages of fluoridation.

“There are exceptionally good safety protocols around water fluoridation—and the levels are monitored continually to ensure that the correct amount of fluoride is in the water (0.6-1.1ppm),” she says. 

“Once there are issues with regard to equipment and suitably qualified personnel to ensure the safety of water fluoridation, there can be disruptions in the provision of fluoridation. NSW Health supports the local councils to operate water fluoridation. Good communication channels between local councils and NSW Health assist in avoiding disruptions, but at the end of the day we need to have good incentives in place to ensure that our rural and remote communities are well-serviced.”

Crucial role for dentists

In communities that do not have fluoridation, local dentists often have to deal with the fallout. 

Dr Raphael says that in areas without community water fluoridation, or natural fluoride levels below 0.6ppm, the active prevention of dental disease has to be increased. 

“It gets back to the basics—brushing twice daily with fluoride toothpaste, flossing and visiting your dentist regularly. Where there is no water fluoridation, children should start brushing with fluoride toothpaste from when the teeth first erupt and use adult-strength toothpaste rather than child-strength from 18 months of age. Adults who have a moderate to high decay risk can also use high-strength fluoride toothpaste that you can buy at a pharmacy. This offers more protection against decay.”

While Dr Babi is encouraged that efforts are being made to fix the issue in Dubbo, he is concerned that any resolution will not be finalised until at least the early stages of 2023. “So, it’s still a fair way off.”

In the meantime, he will monitor patients for tooth decay and recommend the use of a fluoridated toothpaste that is left on teeth for a period after brushing. 

“That’s the primary go-to,” Dr Babi says. “I go on a case-by-case basis and if there’s any higher index for decay, obviously adjunct means of fluoridation and remineralisation of teeth with other substances— primarily tooth mousse—will help.”

He also urges patients to be rigorous about having their six-monthly check-ups and cleans.

“That way we can pick up on any type of decay that is occurring,” Dr Babi says. “If we can address it early, we can alert the patient to it and they can take steps towards prevention, rather than relying on a cure.” 

In this Q&A, Luke Ryan, Dubbo Regional Council’s director, Infrastructure, responds to questions from Bite about the city’s fluoride issues.  

Q. What is the update from Dubbo Council on the fluoridation issue?

“Dubbo Regional Council takes full responsibility for this failure in service delivery, recognising the community relies on the council to ensure their responsibilities are upheld. Undertaking works to reinstate storage facilities at John Gilbert Water Treatment Plant is now being addressed as a priority.”

Q. What feedback are you getting from the community in terms of the importance of getting fluoride protection as part of better dental-care outcomes?

“The community has been quite understanding and appreciative that council is now being open and transparent about the future plans to reinstate the fluoride dosing. Noting that the situation is not ideal, however, we are taking steps to rectify the issue as promptly as possible.” 

Q. What can be done to ensure there is not a repeat of such service issues for Dubbo or other towns in NSW?

“Dubbo Regional Council’s relevant operational staff completed all the required reporting processes to the appropriate agencies from the beginning. However, we would have liked to have been more transparent and up-front with our community from the beginning. Moving forward, a more rigorous review of infrastructure assets and a proactive renewal program will help to prevent equipment failure in the future.” 

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