The health secretary's promise of £14m a year over the next three years for water fluoridation schemes has reignited the debate. Strategic health authorities and primary care trusts must persuade local communities to agree to it, but opponents protest that fluoridation is mass medication to benefit the few and point to negative effects such as teeth discoloration (fluorosis).

The local data needed to untangle these complex issues is often missing - some PCTs have not done child dental surveys in recent years. However, the North West dental observatory's child dental surveys ( reveal huge local inequalities. It shows children in the poorest areas have 3.2 times more decayed, missing and filled teeth than those in the most affluent areas (see charts below).

Assuming the above applies across the country, the heavily fluoridated West Midlands has half the level of decayed, missing and filled teeth than predicted from its level of deprivation (middle chart). The East Midlands and East of England, which have some natural or artificial water fluoridation, also have lower than predicted levels. But fluoridation does not yet appear effective in the North East, where figures are at deprivation-predicted levels.

The fluoridation debate comes amid growing media coverage of lack of access to NHS dentists and the prohibitive costs of private care. This could be widening health inequalities. Recent Information Centre data shows that people in regions with highest dental health need, in the North, tend to see NHS dentists more and get more NHS treatment than people living in the South (bottom chart). But without data from private dentistry, it is not possible to determine the real amount of dental treatment across the country.

Nationally, work is going on to improve local data. The dental epidemiology programme for England aims to provide robust intelligence on the dental health of adults and children, geographic relationships with deprivation, lifestyle factors, fluoridation (including adverse effects) and treatment (NHS and private). The North West public health observatory and North West dental observatory now have responsibility for collating this data and ensuring that it informs the debate.

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