Developmental Fluoride Neurotoxicity: Clinical Importance versus Statistical Significance
Siamak Sabour, Zahra Ghorbani
School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran, E-mail: email@example.com
Environ Health Perspect 121:a70–a70 (2013). http://dx.doi.org/10.1289/ehp.1206192 [Online 1 March 2013]
The author declares they have no actual or potential competing financial interests.
We were interested to read the article by Choi et al. (2012), who investigated the effects of increased fluoride exposure and delayed neurobehavioral development by reviewing published studies and performing a meta-analysis. Of the 39 studies identified, the authors considered 27 to be eligible. Choi et al. reported a mean difference in IQ (intelligence quotient) score between exposed and reference populations of –0.4 (95% confidence interval: –0.5, –0.3) using a random-effects model. Thus, children in high-fluoride areas had significantly lower IQ scores than those who lived in low-fluoride areas.
Even if we ignore the weaknesses of the study (Choi et al. 2012), including a lack of individual-level information and the high probability of confounding because the authors did not adjust for covariates, a difference of 0.4 in mean IQ is clinically negligible (Jeckel et al. 2007; Rothman et al. 2008; Szklo and Nieto 2007) even though it was statistically significant. In general, clinical importance takes priority over statistical significance. The p-value can easily change from significant to nonsignificant because of sample size or the mean difference and standard deviation of the variable in the study population (Jeckel et al. 2007; Rothman et al. 2008; Szklo and Nieto 2007). As Choi et al. (2012) pointed out in their conclusion, there is a “possibility of an adverse effect of high fluoride exposure on children’s neurodevelopment.” Such a conclusion can be considered an ecological fallacy, which can easily lead to misinterpretation of the results. It is important to know that statistics cannot provide a simple substitute for clinical judgment (Jeckel et al. 2007; Rothman et al. 2008; Szklo and Nieto 2007).
Choi AL, Sun G, Zhang Y, Grandjean P. 2012. Developmental fluoride neurotoxicity: a systematic review and meta-analysis. Environ Health Perspect 120:1362–1368.
Jeckel JF, Katz DL, Elmore JG, Wild DMG. 2007. Epidemiology, Biostatistics, and Preventive Medicine. 3rd ed. Philadelphia:Saunders/Elsevier.
Rothman JK, Greenland S, Lash TL. 2008. Modern Epidemiology. 3rd ed. Philadelphia:Wolters Kluwer/Lippincott Williams & Wilkins.
Szklo M, Nieto FJ. 2007. Epidemiology; Beyond the Basics. 2nd ed. Sudbury, MA:Jones and Bartlett.
CEHN December 2014 Article of the Month
“The Navigation Guide—Evidence-Based Medicine Meets Environmental Health: Integration of Animal and Human Evidence for PFOA Effects on Fetal Growth” (Environ Health Perspect; DOI:10.1289/ehp.1307923) has been selected by the Children’s Environmental Health Network (CEHN) as its December 2014 Article of the Month. These CEHN summaries discuss the potential policy implications of current children’s environmental health research.
Introducing Children’s Health Collection 2014
EHP’s fifth annual Children’s Health Collection is now available. The collection comprises abstracts of all relevant articles published in EHP from October 2013 through September 2014: peer-reviewed research articles, news features, Science Selections, and editorials.
ISEE 2014 Abstracts Now Available
EHP is pleased to present the abstracts for the 26th annual conference of the International Society for Environmental Epidemiology (ISEE), From Local to Global: Advancing Science for Policy in Environmental Health, held 24–28 August 2014 in Seattle, Washington.
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