Transcript 03-08-2010 ODonaghue City Council Brief

Operational (Observational) Science: a systematic approach to
understanding that uses observable, testable, and repeatable
experimentation to understand how nature commonly behaves.
Operational Science gives us data which the scientist then interprets
and draws a conclusion.
“There are three kinds of lies: lies, damned lies, and statistics.” Benjamin
Disraeli, 1st Earl of Beaconsfield and popularized by Mark Twain.
The semi-ironic statement refers to the persuasive power of numbers, and
succinctly describes how even accurate statistics can be used to bolster
inaccurate arguments.
F- is effective as a topical application to teeth for the prevention of
dental decay. This will not be addressed in this presentation.
CDC on Benefits: 1999 “Fluoridation is
one of 10 great public health
achievements
of the 20th century. . .
(http://www.ada.org/prof/resources/positions/statements/fluoride_community_effective.asp)
. . . fluoride prevents dental caries
predominately after eruption of the tooth
into the mouth, and its actions primarily
are topical for both adults and
children…”
CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of
Drinking Water to Prevent Dental Caries. MMWR, 48(41); 933-940, October 22.
CDC 2001 Also Stated:
The laboratory and epidemiological research . . . Indicates
that fluoride’s predominant effect is post-eruptive and
topical . . .
“The concentration of fluoride in ductal saliva as secreted
is 0.016 ppm in fluoridated areas and 0.006 ppm in nonfluoridated areas. (27)
Not likely to effect cariogenic activity.”
The CDC: MMWR Report August 17, 2001/Vol 50/No. RR-14
Fluoride’s anticaries effects are
NOT systemic
•SJ Fomon, ed., Fluoride Nutrition of Normal Infants pp. 299-310. Philadelphia: Mosby 1993
•Journal of the American Dental Association 7/2000
•USDA www.nal.usda.gov/fnic/
“Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans,
1995 to the Secretary of Health and Human Services and Secretary of Agriculture.”
Tooth Decay Trends for 12 Year Olds: Fluoridated Vs. Unfluoridated
Countries. Data from World Health Organization. (Graph by Chris Neurath).
http://www.fluoridealert.org/health/teeth/caries/who-dmft.html
100
40
0
Utah
Hawaii
Oregon
Montana
New Jersey
California
New Hampshire
Wyoming
Vermont
Idaho
Mississippi
Alaska
Louisiana
Maine
Pennsylvania
Washington
Arizona
Arkansas
North Carolina
Nebraska
Massachusetts
Kansas
Wisconsin
Florida
New Mexico
Michigan
Delaware
Texas
South Dakota
Nevada
Colorado
Alabama
New York
West Virginia
Oklahoma
Connecticut
Missouri
Virginia
Indiana
South Carolina
North Dakota
Minnesota
Iowa
Ohio
Georgia
Maryland
Rhode Island
Kentucky
Illinois
Tennessee
Dist. of Col.
Percentage
Children's oral health
(HRSA, parental survey)
80
60
Kathleen M. Thiessen, Ph.D.
SENES Oak Ridge, Inc., Center for Risk Analysis
102 Donner Drive, Oak Ridge, TN 37830 USA
E-mail: [email protected]
20
% whole population, fluoridated
% of children with excellent or very good teeth
% of Residents with Water Fluoridation
Residentswith
with
Water
Fluoridation
%%ofof
Residents
Water
Fluoridation
Lo Income with Very Good/Excellent Teeth
Lo Income with Very Good/Excellent Teeth
120
Hi Income Very Good/Excellent Teeth
120
120
100
100
AK = 57.3%
#16
Percent
100
80
80
80
60
60
60
40
40
40
20
20
0
0
1 3 5 7 9 11
11 13
13 15
15 17
17 19
19 21
21 23
23 25
25 27
27 29
29 31
31 33
33 35
3537
37 39
39 41
41 43
4345
4547
4749
49
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49
50 USA States and DC
http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm National Survey of Children's Health.
U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
The National Survey of Children's Health 2003. Rockville, Maryland: U.S. Department of Health and Human Services, 2005
http://www.cdc.gov/oralhealth/waterfluoridation/fact_sheets/states_stats2002.htm
Although ecological studies are considered weak, certainly the number of cohorts and states is significant.
ADA Positions & Statements
“Studies prove water fluoridation continues to be
effective in reducing tooth decay by 20-40%”
http://www.ada.org/prof/resources/positions/statements/fluoride_community_effective.asp
Newbrun E. Effectiveness of water fluoridation. J Public Health Dent
7/13/06
1989;49(5):279-89
Brunelle JA, Carlos JP. Recent trends in dental caries in US children and the effect of water fluoridation. J Dent Res
;69(Spec
1990
Iss 723-7
“The major anticaries benefit of fluoride is topical
and not systemic”
NRC 2006 p 13
1. A number of recent cessation studies show that stopping
fluoridation does literally nothing to increase overall dental
decay. Komarek et al, A Bayesian analysis of multivariate doubly-interval-censored dental data,
Biostatistics 2005 6 pp 145-155 Copy Available.
2. Modern studies find difficulty in measuring the benefits of
fluoridation (no difference between fluoridated and nonfluoridated communities) Studies by: Brunelle, Angelilo, Clark, Ismail,
Slade, Kumar and in Australia by Armfield JM. Spencer AJ 2004, a very large study
found No difference in dental decay in permanent teeth.
3. Not taking into account delayed tooth eruption makes early
fluoridation studies “over-estimates of the benefits”....
Fluoride added to drinking water may have simply
delayed caries in the past. Hardy Limeback DMD, PhD
Even those flawed studies found 0.6 ppm F better than 1.0ppm. Edward & Strickler
“Effectiveness”
Population Fluoridated
Decay % 6-8 yr. olds
Any Permanent Teeth Extracted
Very Good/Excellent Teeth
Low Income Children
Oregon
19%
57%*
60%****
58%***
Confounding Factors
Median Income
$42,593
Bachelor’s Degree
25.1%
English Spoken
88%
Race Similar
+1% Hispanic
Preventive Dental Visit
45%
(within 12 mo Low income)
Delay in tooth eruption
Fluoride Supplements
???
Washington
59%
59%**
63%
51%
$48,185
27.7%
88%
+1% Black
60%
10-20%
???
***National Survey of Children's Health. http://mchb.hrsa.gov/oralhealth/portrait/1cct.htm
U.S. Department of Health and Human Services,
http://www.cdc.gov/oralhealth/waterfluoridation/fact_sheets/states_stats2002.htm
BRFSS 2002 http://www.dhs.state.or.us/dhs/ph/chs/brfs/02/orahea/dentvisi.shtml
****http://apps.nccd.cdc.gov/brfss/display.asp?state=WA&cat=OH&yr=2004&qkey=6610&grp=0&SUBMIT4=Go Sample size OR 3509
and WA 12,926 2004 data
**http://www.doh.wa.gov/cfh/Oral_Health/Documents/SmileSurvey2005FullReport.pdf
*http://www.oregon.gov/DHS/ph/oralhealth/docs/databook.pdf#search='Oregon%20Decay%20experience‘
http://quickfacts.census.gov/qfd/states/41000.html
http://www.cdc.gov/fluoridation/fact_sheets/states_stats2002.htm
http://www.fluoridationcenter.org/papers/2002/cdcmmwr022102.htm
ADA awarded Kentucky with “50 Year Award”
for
(100%) fluoridation 2003
42% were edentulous, #1 in USA (2002 Mortality Weekly Report)
“With 1.6 to 4ppm fluoride in the water,
50% or more past age 24 have false teeth
because of fluoride damage.” JADA 1944
Connecticut (87.5% water fluoridated)
Detroit
Boston
all report a crisis with decay and all have water fluoridation.
http://www.fortwayne.com/mld/newssentinel/7521679.htm?template=contentModules/printstory.jsp
http://www.enquirer.com/editions/2002/10/06/loc_special_report.html
http://www.fluoridealert.org/f-boston.htm
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=13678102&query_hl=
1
http://www.nhregister.com/site/news.cfm?newsid=14472801&BRD=1281&PAG=461&dept_id=517515&rfi=8&xb=kasan
Brunelle and Carlos (1990)





This was the largest dental survey in US. By the NIDR,
39,000 children.
The average difference in tooth decay, aged 5 –17
years, was
0.6 of one tooth surface out of 88 to 128 tooth
surfaces.
This difference was not shown to be statistically
significant.
Did not consider delay in tooth eruption caused by
Fluoride.
Spencer et al (1996 AUS) found benefits of 0.12 - 0.3
tooth surfaces.

de Liefde (1998 NZ) “clinically meaningless.”
From Scientific American, Jan. 2008 pg. 78
Fluorosis of Teeth
Permanent discoloration of the tooth,
develops during tooth
formation. Birth to 8th yr. NRC 2006
white spots or brown spots (endemic).
80% of US Children suffer from some
degree of dental fluorosis. NRC 1993
Normal Dentin
Mild Fluorosis Moderate Fluorosis
ScienceDirect - Journal of Dentistry Caries susceptibility of human fluorosed
enamel and dentine - "Fluoride bombs" explained? Peter Kearney
3. Is it ethical to fluoridate public water?
EPA Scientists say
“NO” to Fluoridation
"In summary, we hold that fluoridation is an
unreasonable risk. That is, the toxicity of fluoride is
so great and the purported benefits associated with it
are so small - if there are any at all – that requiring
every man, woman and child in America to ingest
it borders on criminal behavior on the part of
governments."
-Dr. J. William Hirzy, Senior Vice-President, Headquarters Union,
-US Environmental Protection Agency, March 26, 2001
May 1, 1999
WHY EPA'S HEADQUARTERS UNION OF
SCIENTISTS OPPOSES FLUORIDATION
Despite dental pressure, 90+% of European Governments and
Dental Associations have rejected, banned, or stopped fluoridation
due to environmental, health, legal, or ethical concerns
Austria
Belgium
Finland
REJECTED: "toxic fluorides" NOT added
REJECTED: encourages self-determination – those who want fluoride should get it themselves.
STOPPED: "...do not favor or recommend fluoridation of drinking water. There are better ways of providing the
fluoride our teeth need." A recent
study found ..."no indication of an increasing trend of
caries....“
Germany STOPPED: A recent study found no evidence of an increasing trend of caries
Denmark REJECTED: "...toxic fluorides have never been added to the public water supplies in Denmark.“
Norway
REJECTED: "...drinking water should not be fluoridated“
Sweden
BANNED: "not allowed". No safety data available!
Netherlands REJECTED: Inevitably, whenever there is a court decision against fluoridation, the dental lobby
Hungary
Japan
fluoride,
Israel
“The
China
France
Ireland
UK
pushes to have the judgment overturned on a technicality or they try to get the laws changed to legalize
it. Their tactics didn't work in the vast majority of Europe.
STOPPED: for technical reasons in the '60s. However, despite technological advances, Hungary
remains unfluoridated.
REJECTED: "...may cause health problems...." The 0.8 -1.5 mg regulated level is for calciumnot the hazardous waste by-product which is added with artificial fluoridation.
SUSPENDED mandatory fluoridation until the issue is reexamined from all aspects.: June 21, 2006
labor, welfare and health Knesset committee”
BANNED: "not allowed“
40-50% fluoridated Salt
74% Fluoridated
9% Fluoridated
Most European Dental Associations no longer recommend fluoride supplements
Zimmer 2003
Shame: A Major Reason Why Most Medical Doctors Don't Change
Their Views
By Frank Davidoff
In the 1960s the results of a large randomized controlled study by the University Group Diabetes Program showed
that tolbutamide, virtually the only blood sugar lowering agent available at the time in pill form, was associated
with a significant increase in mortality in patients who developed myocardial infarction.
The obvious response from the medical profession should have been gratitude: here was an important way to
improve the safety of clinical practice. But in fact the response was doubt, outrage, even legal proceedings against
the investigators; the controversy went on for years.
Why?
An important clue surfaced at the annual meeting of the American Diabetes Association soon after the study was
published. During the discussion a practitioner stood up and said he simply could not, and would not, accept the
findings, because admitting to his patients that he had been using an unsafe treatment would shame him in their
eyes. Other examples of such reactions to improvement efforts are not hard to find.
Indeed, it is arguable that shame is the universal dark side of improvement.
After all, improvement means that, however good your performance has been, it is not as good as it could be. As
such, the experience of shame helps to explain why improvement, which ought to be a "no brainer", is generally
such a slow and difficult process.
What is it about shame that makes it so hard to deal with? Along with embarrassment and guilt, shame is one of
the emotions that motivate moral behavior. Current thinking suggests that shame is so devastating because it goes
right to the core of a person's identity, making them feel exposed, inferior, degraded; it leads to avoidance, to
silence.
The enormous power of shame is apparent in the adoption of shaming by many human rights organizations as their
principal lever for social change; on the flip side lies the obvious social corrosiveness of "shameless" behavior.
Despite its potential importance in medical life, shame has received little attention in the medical literature:
a search on the term shame in Medline in November 2001 yielded only 947 references out of the millions indexed.
In a sense, shame is the "elephant in the room": something so big and disturbing that we don't even see it, despite
the fact that we keep bumping into it.
An important exception to this blindness to medical shame is a paper published in 1987 by the psychiatrist Aaron
Lazare which reminded us that patients commonly see their diseases as defects, inadequacies, or shortcomings,
and that visits to doctors' surgeries and hospitals involve potentially humiliating physical and psychological
exposure.
Patients respond by avoiding the healthcare system, withholding information, complaining, and suing. Doctors too
can feel shamed in medical encounters, which Lazare suggests contributes to dissatisfaction with clinical practice.
Indeed, much of the extreme distress of doctors who are sued for malpractice appears to be attributable to the
shame rather than to the financial losses. Also, who can doubt that a major concern underlying the controversy
currently raging over mandatory reporting of medical errors is the fear of being shamed?
Doctors may, in fact, be particularly vulnerable to shame, since they are self-selected for perfectionism when they
choose to enter the profession.
Moreover, the use of shaming as punishment for shortcomings and "moral errors" committed by medical students
and trainees such as lack of sufficient dedication, hard work, and a proper reverence for role obligations probably
contributes further to the extreme sensitivity of doctors to shaming.
What are the lessons here for those working to improve the quality and safety of medical care?
Firstly, we should recognize that shame is a powerful force in slowing or preventing improvement and that unless it
is confronted and dealt with progress in improvement will be slow. Secondly, we should also recognize that shame is
a fundamental human emotion and not about to go away. Once these ideas are understood, the work of mitigating
and managing shame can flourish.
This work has, of course, been under way for some time. The move away from "cutting off the tail of the
performance curve" that is, getting rid of bad apples towards "shifting the whole curve" as the basic strategy in
quality improvement and the recognition that medical error results as much from malfunctioning systems as from
incompetent practitioners are important developments in this regard.
They have helped to minimize challenges to the integrity of healthcare workers and support the transformation of
medicine from a culture of blame to a culture of safety.
But quality improvement has another powerful tool for managing shame. Bringing issues of quality and safety out of
the shadows can, by itself, remove some of the sting associated with improvement. After all, how shameful can
these issues be if they are being widely shared and openly discussed?
Here is where reports by public bodies and journals like Quality and Safety in Health Care come in. More
specifically, such a journal supports three major elements autonomy, mastery, and connectedness that motivate
people to learn and improve, bolstering their competence and their sense of self worth, and thus serving as
antidotes to shame.
British Medical Journal 2002;324:623-624 March 16, 2002