Community

1
Community Water Fluoridation
Acknowledgements to the New York State Department
of Health, Bureau of Dental Health for parts of
this presentation.
2
Tooth Decay
Infection Extreme pain Difficulty in
chewing Poor weight gain Difficulty concentrating
Crooked teeth Missed school hours Predictor of
caries in later life Costly treatment
Root cavity
3
Why Fluoridation?

• Fluoridated communities have 20-40 less tooth
  decay
• Single most effective intervention
• Saves money every dollar spent on water
  fluoridation avoids on average 38 - 42 in
  dental care
• Benefits all consumers across socio-economic
  status
• Benefits children and adults
• Benefits last a lifetime

4
An Example from New York State .
Then there are the dental costs A single-
surface filling can costs nearly 100 nowadays.
For that reason alone because the county pays
part of its Medicaid patients dental bills
Schenectady County should encourage the city to
keep fluoridating its water
5
Reviews Benefits Safety(Expert committees
systematic reviews) Health Canada Report on
Fluoride and Human Health (2008) National Health
and Medical Research Council, Australian
Government (2007) National Research Council,
U.S.A. (1993, 2006) World Health Organization
(1994, 1996, 2006) Agency for Toxic Substances
and Disease Registry, U.S. Public Health Service
(2003) International Programme on Chemical
Safety, W.H.O. (2002) Forum on Fluoridation,
Ireland (2002) Medical Research Council, U.K.
(2002) U.S. Guide to Community Preventive
Services (2002) U.S. Surgeon Generals Report
(2000) University of York, U.K. (2000) Institute
of Medicine, U.S.A. (1999) U.S. Public Health
Service (1991) New York State Department of
Health (1990)
6
Fluoride Standards in Public Drinking Water
Systems in the US

• MCL 4 mg/L - around 200,000 people in the US have
  naturally occurring fluoride concentrations at or
  exceeding 4 mg/L (the maximum concentration
  allowed under U.S. Environmental Protection
  Agency (EPA) standards)
• SMCL 2.0 mg/L Another 1.4 million live in areas
  where F level in water is between 2.0 and 3.9
  mg/L.
• EPAs level ? prevent moderate-severe dental
  fluorosis
• Strong evidence exists that the prevalence
  of severe enamel fluorosis is nearly zero at
  water fluoride concentrations below 2 mg/L.
• Optimal Level of fluoride to prevent tooth decay
  is 0.7- 1.2 mg/L
• In places where fluoride is artificially
  added to water, the fluoride concentration is
  kept at a safe level between 0.7 and 1.2 mg/L.

7
Claims

• Opponents of community water fluoridation have
  made claims that optimally fluoridated water can
  cause an array of health problems including
• Not needed, doesnt work, small effect, there are
  alternatives
• Cancer
• Increased bone fractures
• Lower IQ in children
• Increases lead uptake
• Down's syndrome
• Allergies
• AIDS
• Alzheimers disease
• Reproductive problems
• Effects on renal, gastrointestinal, and immune
  systems

8
Fluoridation Improves Dental Health

• Claim Fluoridation does not work. A National
  Survey in 1986-87 showed the difference in tooth
  decay between fluoridated and non-fluoridated
  areas of only 0.6 teeth on average.
• FACT 0.6 teeth is a tremendous reduction in
  tooth decay, amounting to millions of teeth
  saved. Several recent and authoritative reviews
  conducted in the US, Australia, the UK, and
  Ireland provide evidence of the effectiveness of
  water fluoridation under modern conditions.

A Systematic Review of Public Water
Fluoridation Marian McDonagh et al., 2000
Government of Ireland, 2002 Truman et al., 2002
National Health and Medical Research Council,
2007.
9
National Research Council
Report issued in March 2006 Involved 3 ½ year
review Opponents and proponents of fluoridation
on committee Focused on naturally occurring high
levels of fluoride in drinking water
Reviewed studies Effects of Fluoride on
Teeth Musculoskeletal Effects Reproductive and
Developmental Effects Neurotoxicity and
Neurobehavioral Effects Effects on the Endocrine
System Effects on the Gastrointestinal, Renal,
Hepatic, and Immune Systems Genotoxicity and
Carcinogenicity
States with high levels of fluoride occurring
naturally Colorado 11.2 mg/L Oklahoma 12.0
mg/L New Mexico 13.0 mg/L Idaho 15.9
mg/L Virginia 6.3 mg/L Texas 8.8 mg/L S.
Carolina 5.9 mg/L
10
NRC 2006 Report

• Claim The National Research Council (part of
  the National Academy of Sciences), released in
  March 2006, cites evidence of harm to a great
  number of people 
• FACT The report concluded that MCLG of 4 mg/L
  fluoride (from natural sources that 200,000
  people in the US are exposed to) is not
  protective against
• Severe dental fluorosis
• Bone fractures (Not unanimous)

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NRC 2006 Report (cont)

• The National Academy of Sciences, the umbrella
  organization that includes the National Research
  Council, clarified that point in a report titled
  Drinking Water, Understanding the Science and
  Policy behind a Critical Resource by stating "In
  places where fluoride is artificially added to
  water, the fluoride concentration is kept at a
  safe level between 0.7 and 1.2 mg/L."

National Academy of Sciences. Fluoride in
Drinking Water, A Scientific Review of EPAs
Standards March 2006.
12
Because fluoride is well known for its use in
the prevention of dental caries, it is important
to make the distinction here that EPAs
drinking-water guidelines are not recommendations
about adding fluoride to drinking water to
protect the public from dental caries. Guidelines
for that purpose (0.7 to 1.2 mg/L) were
established by the U.S. Public Health Service
more than 40 years ago. Instead, EPAs guidelines
are maximum allowable concentrations in drinking
water intended to prevent toxic or other adverse
effects that could result from exposure to
fluoride.
13
Dental Fluorosis

• Claim We should discontinue fluoridation
  because 1/3 of children age 6-19 in the US have
  dental fluorosis.
• FACT
• Dental fluorosis in fluoridated areas is barely
  noticeable.
• The vast majority of dental fluorosis in the
  United States can be prevented by limiting the
  ingestion of topical fluoride products (such as
  toothpaste) and by the appropriate use of dietary
  fluoride supplements. Milder forms of dental
  fluorosis have no clinical significance.

MMWR. Surveillance for dental caries, dental
sealants, tooth retention, edentulism, and enamel
fluorosis United States, 1988-1994 and
1999-2002. August 26, 2005/Vol 54/No. SS-3.
14
Fluoride Action

• Claim Fluoride works primarily topically, not
  systemically.
• FACT Studies show fluoride works both topically
  and systemically. There still is a pre-eruptive
  caries preventive effect and continuous exposure
  to small amounts of fluoride is the best for
  remineralization of tooth enamel (benefits both
  adults and children).

Singh et al., 2003 Singh and Spencer, 2004.
15
Osteosarcoma

• Claim The Bassin study proves fluoridation
  causes osteosarcoma. 
• FACT
• A Harvard study has identified a larger sample of
  subjects with the disease (osteosarcoma) and
  followed them in time, has taken bone samples and
  measured fluoride in the bone. It appears that
  this follow-up study has failed to replicate the
  findings.
• The Bassin study is an explorative study and has
  limitations.
• When this study (Douglass et al.) is published,
  it should be considered in context with the
  existng body of evidence to help determine what
  follow-up studies are needed. NRC, 2006
• The York Review in 2000 showed "no clear
  association between water fluoridation and the
  incidence or mortality of bone cancers, thyroid
  cancers or all cancers was found."

A Systematic Review of Public Water
Fluoridation Marian McDonagh et al., 2000.
16
Decrease in IQ

• Claim Fluoridation causes a decrease in IQ.
• FACT No credible evidence of IQ effect
• In our appraisals we found that the study
  design and methods used by many of the
  researchers had serious limitations. The lack of
  a thorough consideration of confounding as a
  source of bias means that, from these studies
  alone, it is uncertain how far fluoride is
  responsible for any impairment in intellectual
  development seen.
• Bazian. Independent critical appraisal of
  selected studies reporting an association between
  fluoride in drinking water and IQ. A report for
  South Central Strategic Health Authority.
  February 2009.

17
Fluoride Additive

• Claim FSA is not acceptable because it adds
  dangerous impurities like arsenic and lead to
  water supply.
• FACT
• To ensure the public's safety, all additives used
  at a water treatment facility must meet strict
  quality standards. American Water Works
  Association (AWWA) and the NSF/ANSI (National
  Sanitation Foundation/American National Standards
  Institute) measure levels of impurities.
• The average concentration of arsenic and lead
  from all samples of water fluoridated with FSA,
  tested by NSF International from 1992 to 2000 was
  less than 0.1 ppb (parts per billion)

http//www.cdc.gov/fluoridation/fact_sheets/engine
ering/wfadditives.htm
18
Infant Formula and Fluoride

• Claim The ADA warns parents not to add
  fluoridated water to infant formula because of
  its harmful effects.
• FACT The occurrence of advanced forms of enamel
  fluorosis is extremely rare in fluoridated
  communities even though some water systems have
  been fluoridating for over 50 years. Milder forms
  of enamel fluorosis are not noticeable.
• The critical period for permanent tooth
  development when enamel fluorosis is most likely
  to occur is later in life when children are less
  likely to be using infant formula as their
  primary source of nutrition.

http//www.nyhealth.gov/prevention/dental/fluoride
_guidance_during_infancy.htm
19
Fluoride Levels in Breast Milk

• Claims Infants (lt 1 yr) should not consume
  fluoridated water. "Fluoridated water contains
  250x more fluoride than mother's milk."
• FACTS
• There is no known adverse health effect for
  infants.
• There is a theoretical risk for fluorosis if a
  child predominantly consumes formula mixed with
  fluoridated water for a prolonged period of time.
  
• Vitamin D is added to milk because mother's milk
  lacks sufficient amounts. The National Academy of
  Sciences and the American Academy of Pediatrics
  recommends that all infants, including those who
  are exclusively breastfed, have a minimum intake
  of 200 IU of vitamin D per day beginning during
  the first 2 months of life.

New Guidelines for Vitamin D Intake, Pediatrics
Vol. 111 No 4 April 2003.
20
National Kidney Foundation statement

• Claim The National Kidney Foundation withdrew
  its support of water fluoridation citing the 2006
  National Research Council (NRC) report indicating
  that kidney patients are more susceptible to
  fluorides bone and teeth-damaging effects.
• FACT "The NKF has no position on fluoridation of
  water."

http//www.kidney.org/
21
Fluoridation Status

• Claim Communities are putting
• an end to fluoridation.. 
• FACT Large Cities/Counties Approving or
  Implementing Fluoridation (1999-2008)
• Abilene, TX San
  Francisco PUC, CA
• Beaverton, OR Orange
  County, FL
• Davis County, UT Palm Beach
  County, FL
• Gilbert, AZ Pinellas
  County, FL
• Las Vegas, NV Salt Lake
  County, UT
• Los Angeles, CA San Antonio,
  TX
• Manchester, NH San Diego, CA
• Metropolitan Water District of Southern California

Data Source 2006 CDC Fluoridation Census
22
Fluoridation Status (cont)

• In Maine, about 520,000 people in 133 communities
  receive fluoridated water
• About 84 of Maine people with public water
  supplies have fluoridated water
• Because 50-55 of Mainers get their water from
  private wells, only about 38-40 of the total
  state population has access to this public health
  benefit

23
Fluoride in Other Countries

• Claim European countries dont allow use of
  fluoride. 
• FACT Over 30 countries use water fluoridation
• The addition of fluoride to food, practiced
  through addition of fluoride to drinking water
  (in the Irish Republic, UK, Spain), or salt
  (Austria, the Czech Republic, France, Germany,
  Hungary, Slovak Republic, Spain, S. America) or
  milk (various projects in several countries) is
  now authorized in the countries of the EU.

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Public Policy on Fluoridation

• Endorsed by key scientific and professional
  organizations
• American Dental Association
• U.S. Public Health Service
• American Medical Association
• World Health Organization
• American Water Works Association
• And virtually every leading scientific and
  professional organization in the public health
  field concerned with oral health

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What is the alternative?
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Who Says Fluoridation Works?
Fluoridation is the single most important
commitment a community can maketo the oral
health ofits children and tofuture generations.
Dr. C. Everett KoopUnited States Surgeon
General1981-1989
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Who Says Fluoridation Works?
Fluoridation remains an ideal public health
measure basedon the scientific evidence in
preventing dental decay and its impressive
cost-effectiveness.
David Satcher, MD, PhD Assistant Secretary for
Health U.S. Surgeon General
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More Resources

• More information (websites)
• Maine Oral Health Program
• www.maine.gov/dhhs/bohdcfh/odh/water-fluoridation.
  shtml
• Maine CDCs fluoride webpage http//www.maine.gov/
  dhhs/boh/fluoride.htm
• US CDC, Division of Oral Health
  http//www.cdc.gov/fluoridation/index.htm
• American Dental Association
• http//www.ada.org/public/topics/fluoride/index.as
  p

• American Water Works Association
  http//www.drinktap.org/consumerdnn/Default.aspx?t
  abid184

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US CDC Community water fluoridation prevents
tooth decay safely and effectively.  CDC
identifies it as one of 10 great public health
achievements of the 20th century.

• The Benefits page provides information on the
  oral health benefits of fluoride to individuals
  and communities.
• The Safety page provides references and other
  information about fluoride safety.
• The Statistics page provides access to data
  sources such as the National Oral Health
  Surveillance System.
• The Engineering and Operations page provides
  information on water fluoridation technical
  assistance resources to state programs.
• Other Fluoride Products describes forms of
  fluoride delivery other than water fluoridation.
• Guidelines and Recommendations offers technical
  information on programs, and Fact Sheets covers
  specific topics. See also Journal Articles,
  Related Links, and FAQs.

http//www.cdc.gov/fluoridation/index.htm