Transcript Slide 1

Community
Water Fluoridation
Acknowledgements to the New York State
Department of Health, Bureau of Dental Health for
parts of this presentation.
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Tooth Decay
D e n ta l ca rie s (to o th d e ca y ) is th e
sin g le m o st co m m o n ch ro n ic
ch ild h o o d d ise a se
Infection
Extreme pain
Difficulty in chewing
Poor weight gain
Difficulty concentrating
Crooked teeth
Missed school hours
Predictor of caries in later life
Costly treatment
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Why Fluoridation?
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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 socioeconomic status
Benefits children and adults
Benefits last a lifetime
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An Example from New
York State ….
Then there are the dental costs: A singlesurface 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
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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 General’s 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)
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Fluoride Standards in Public Drinking
Water Systems in the US
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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.
EPA’s 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 0.71.2 mg/L –
*In places where fluoride is artificially added to
water, the fluoride concentration is kept at a safe level
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between 0.7 and 1.2 mg/L.
Claims
Opponents of community water fluoridation have
made claims that optimally fluoridated water can
cause an array of health problems including:
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Not needed, doesn’t work, small effect, there are
alternatives
Cancer
Increased bone fractures
Lower IQ in children
Increases lead uptake
Down's syndrome
Allergies
AIDS
Alzheimer’s disease
Reproductive problems
Effects on renal, gastrointestinal, and immune systems
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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.
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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
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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 (con’t)
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 EPA’s Standards March 2006.
“Because fluoride is well known for its use in the
prevention of dental caries, it is important to make the
distinction here that EPA’s 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, EPA’s guidelines are maximum allowable
concentrations in drinking water intended to prevent
toxic or other adverse effects that could result from
exposure to fluoride.”
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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.
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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.
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Osteosarcoma
Claim: “The Bassin study proves fluoridation causes
osteosarcoma.”
FACT:
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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.
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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.”
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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/engineering/wfadditives.htm
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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
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Fluoride Levels in Breast Milk
Claims: “Infants (< 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.
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There is a theoretical risk for fluorosis if a child
predominantly consumes formula mixed with fluoridated
water for a prolonged period of time.
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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.
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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
fluoride’s bone and teeth-damaging effects.”
FACT: "The NKF has no position on fluoridation of
water."
http://www.kidney.org/
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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
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Fluoridation Status
(con’t)
In Maine, about 520,000 people in 133
communities receive fluoridated water:
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About 84% of Maine people with public water supplies
have fluoridated water
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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
Fluoride in Other Countries
Claim: “European countries don’t 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
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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 make
to the oral health of
its children and to
future generations.”
– Dr. C. Everett Koop
United States Surgeon General
1981-1989
Who Says Fluoridation Works?
“Fluoridation remains an ideal
public health measure based
on the scientific evidence in
preventing dental decay and
its impressive costeffectiveness.”
– David Satcher, MD, PhD
Assistant Secretary for Health
U.S. Surgeon General
More Resources
More information (websites):
Maine Oral Health Program:
www.maine.gov/dhhs/bohdcfh/odh/water-fluoridation.shtml
 Maine CDC’s 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.asp
 American Water Works Association
http://www.drinktap.org/consumerdnn/Default.aspx?tabid=184
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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.
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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