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September 17, 20071 California Children ’ s Dental Disease Prevention Program September 17, 2007 Double Tree Hotel, Sacramento, CA Current Science on Community.

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Presentation on theme: "September 17, 20071 California Children ’ s Dental Disease Prevention Program September 17, 2007 Double Tree Hotel, Sacramento, CA Current Science on Community."— Presentation transcript:

1 September 17, California Children ’ s Dental Disease Prevention Program September 17, 2007 Double Tree Hotel, Sacramento, CA Current Science on Community Water Fluoridation Howard Pollick, BDS, MPH Health Sciences Clinical Professor School of Dentistry University of California San Francisco Howard Pollick, BDS, MPH Health Sciences Clinical Professor School of Dentistry University of California San Francisco

2 September 17, Community Water Fluoridation  Safety  Benefits  Safety  Benefits

3 September 17, Safety of Fluoride: all sources The main safety issue is chronic fluoride intake from all sources during tooth development years (less than 8 years of age) and enamel fluorosis Recommendations  refine fluoridated toothpaste to lower the risk of fluorosis without significantly reducing its effectiveness in caries prevention.  encourage commencement of toothpaste use in the 19- to 30- month age period  use of 400- to 550-ppm fluoridated toothpaste when toothpaste use starts  encourage spitting after brushing  prevent an eating/licking toothpaste habit in young children. The main safety issue is chronic fluoride intake from all sources during tooth development years (less than 8 years of age) and enamel fluorosis Recommendations  refine fluoridated toothpaste to lower the risk of fluorosis without significantly reducing its effectiveness in caries prevention.  encourage commencement of toothpaste use in the 19- to 30- month age period  use of 400- to 550-ppm fluoridated toothpaste when toothpaste use starts  encourage spitting after brushing  prevent an eating/licking toothpaste habit in young children. Do LG, Spencer AJ Risk-Benefit Balance in the Use of Fluoride among Young Children. J Dent Res Aug;86(8):723-8.

4 September 17, Safety of Water Fluoridation National Fluoridation Symposium July, 2005 Celebrating 60 Years of Water Fluoridation Hosted by the American Dental Association and U.S. Centers for Disease Control and Prevention Chicago National Fluoridation Symposium July, 2005 Celebrating 60 Years of Water Fluoridation Hosted by the American Dental Association and U.S. Centers for Disease Control and Prevention Chicago

5 September 17, Safety of Water Fluoridation Implementation Production and delivery of the chemical compounds Engineering safeguards and regulations Actions taken in the event of equipment malfunctions and human error Continuous Quality Improvement (CQI) National guidelines on safety minimum basis for each State’s regulations applied to each local community, water district and water wholesaler Implementation Production and delivery of the chemical compounds Engineering safeguards and regulations Actions taken in the event of equipment malfunctions and human error Continuous Quality Improvement (CQI) National guidelines on safety minimum basis for each State’s regulations applied to each local community, water district and water wholesaler ISSUES

6 September 17, Safety of Water Fluoridation Assurance of periodic review and updating of compliance with new guidelines and regulations Appropriate funding The community shares the benefits of CWF Cost per person receiving fluoridated water is very small Governmental and voluntary agencies must regularly cooperate and review the science, guidelines and regulations of the safety of CWF. Assurance of periodic review and updating of compliance with new guidelines and regulations Appropriate funding The community shares the benefits of CWF Cost per person receiving fluoridated water is very small Governmental and voluntary agencies must regularly cooperate and review the science, guidelines and regulations of the safety of CWF. ISSUES

7 September 17, Safety of Water Fluoridation Definition of Safety  The state of being certain that adverse effects will not be caused by some agent under defined conditions  Water is safe to drink if it meets regulatory standards Definition of Safety  The state of being certain that adverse effects will not be caused by some agent under defined conditions  Water is safe to drink if it meets regulatory standards

8 September 17, Safety of Water Fluoridation Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake ISSUES

9 September 17, Safety of Water Fluoridation Fluoridation Chemicals meet standards Trace contaminants, such as heavy metals Must not exceed the Maximum Allowable Level (MAL) one-tenth of the EPA ’ s regulated MCL when added to drinking water at its Maximum Use Level No detectable arsenic or lead in the majority of more than 100 samples of water fluoridated with fluorosilicic acid, tested by NSF International from 1992 to 2000 The average concentration of arsenic and lead from all samples was less than 0.1 ppb (parts per billion) Action Level Lead 15 ppb; MCL arsenic 10 ppb (January 2006) Fluoridation Chemicals meet standards Trace contaminants, such as heavy metals Must not exceed the Maximum Allowable Level (MAL) one-tenth of the EPA ’ s regulated MCL when added to drinking water at its Maximum Use Level No detectable arsenic or lead in the majority of more than 100 samples of water fluoridated with fluorosilicic acid, tested by NSF International from 1992 to 2000 The average concentration of arsenic and lead from all samples was less than 0.1 ppb (parts per billion) Action Level Lead 15 ppb; MCL arsenic 10 ppb (January 2006) Regulatory Standards

10 September 17, Safety of Water Fluoridation No credible evidence of increased Lead  Concerns have been raised about arsenic and lead in fluorosilicic acid- treated water (Masters and Coplan)  However there is no credible evidence to show that this is of concern (Urbansky and Schock) No credible evidence of increased Lead  Concerns have been raised about arsenic and lead in fluorosilicic acid- treated water (Masters and Coplan)  However there is no credible evidence to show that this is of concern (Urbansky and Schock) Regulatory Standards  Masters RD, Coplan MJ, Hone BT, Dykes JE. Association of silicofluoride treated water with elevated blood lead. Neurotoxicology Dec;21(6):  Masters RD and Coplan M. Water Treatment with Silicofluorides and Lead Toxicity. Intern. J. Environmental Studies 1999:56,  Urbansky ET and Schock MR. Can Fluoridation Affect Lead(II) in Potable Water? Hexafluorosilicate and Fluoride Equilibria in Aqueous Solution. International Journal of Environmental Studies (B), 2000:57:

11 September 17, Safety of Water Fluoridation Criticism of studies by Masters and Coplan Urbansky and Schock conclude: Criticism of studies by Masters and Coplan Urbansky and Schock conclude: Urbansky ET and Schock MR. Can Fluoridation Affect Lead(II) in Potable Water? Hexafluorosilicate and Fluoride Equilibria in Aqueous Solution. International Journal of Environmental Studies (B), 2000:57:  “ the highly-promoted studies asserting enhanced lead uptake from drinking water and increased neurotoxicity still provide no credible evidence to suggest that the common practice of fluoridating drinking water has any untoward health impacts via effects on lead when done properly under established guidelines so as to maintain total water quality.  Our conclusion supports current EPA and PHS/CDC policies on water fluoridation. ”

12 September 17, Safety of Water Fluoridation Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake

13 September 17, Safety of Water Fluoridation  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)  University of York, U.K. (2000)  Institute of Medicine, U.S.A. (1999)  Locker: Health Canada (1999)  City of Calgary,Calgary Regional Health Authority (1998)  U.S. Public Health Service (1991)  Kaminsky et al. New York State Dept. of Health (1990)  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)  University of York, U.K. (2000)  Institute of Medicine, U.S.A. (1999)  Locker: Health Canada (1999)  City of Calgary,Calgary Regional Health Authority (1998)  U.S. Public Health Service (1991)  Kaminsky et al. New York State Dept. of Health (1990) Scientific Reviews

14 September 17, Safety of Water Fluoridation  A subcommittee of the National Research Council's (NRC) Committee on Toxicology (COT) reviewed toxicologic, epidemiologic, and clinical data, particularly data published since 1993, and exposure data on orally ingested fluoride from drinking water and other sources (e.g., food, toothpaste, dental rinses).  The purpose of this report is to provide recommendations to the Environmental Protection Agency (EPA) on whether the current maximum contaminant level goal (MCLG) of 4 mg/L protects children and others from adverse health effects.  The NRC committee did not examine health risks or benefits of water at the levels recommended for fluoridation of water to prevent tooth decay.  The current range for water fluoridation of community water systems is 0.7 to 1.2 ppm (equivalent to mg/L).  Water that has fluoride at these levels is safe and effective for preventing tooth decay.  A subcommittee of the National Research Council's (NRC) Committee on Toxicology (COT) reviewed toxicologic, epidemiologic, and clinical data, particularly data published since 1993, and exposure data on orally ingested fluoride from drinking water and other sources (e.g., food, toothpaste, dental rinses).  The purpose of this report is to provide recommendations to the Environmental Protection Agency (EPA) on whether the current maximum contaminant level goal (MCLG) of 4 mg/L protects children and others from adverse health effects.  The NRC committee did not examine health risks or benefits of water at the levels recommended for fluoridation of water to prevent tooth decay.  The current range for water fluoridation of community water systems is 0.7 to 1.2 ppm (equivalent to mg/L).  Water that has fluoride at these levels is safe and effective for preventing tooth decay. National Research Council, U.S.A. (2006) Fluoride in Drinking Water: A Scientific Review of EPA ’ s Standard

15 September 17, Safety of Water Fluoridation  The NRC Committee evaluated many health effects that have the potential to be associated with fluoride in drinking water.  The NRC concluded that only three adverse health effects warranted consideration in developing regulatory standards for high levels of fluoride in drinking water  severe enamel fluorosis from exposure to these high levels between birth to 8 years of age, and  the potential risk for  bone fractures and  the more severe forms of skeletal fluorosis after lifetime exposure. Severe skeletal fluorosis is a rare condition in the United States.  The NRC Committee evaluated many health effects that have the potential to be associated with fluoride in drinking water.  The NRC concluded that only three adverse health effects warranted consideration in developing regulatory standards for high levels of fluoride in drinking water  severe enamel fluorosis from exposure to these high levels between birth to 8 years of age, and  the potential risk for  bone fractures and  the more severe forms of skeletal fluorosis after lifetime exposure. Severe skeletal fluorosis is a rare condition in the United States. National Research Council, U.S.A. (2006) Fluoride in Drinking Water: A Scientific Review of EPA ’ s Standard

16 September 17, Safety of Water Fluoridation  Important for people living in areas with natural fluoride greater than 2 ppm (mg/L).  about 0.5% of the U.S. population (1.5 million)  About 220,000 Americans receive water from public water systems with fluoride levels that are equal to or exceed 4 mg/L.  People who consume water with ≥4 mg/L fluoride over a lifetime, when compared to people consuming water with 1 mg/L, are likely to be at increased risk for bone fractures.  Water at ≥2 mg/L fluoride may put children 8 years old and younger at increased risk for severe enamel fluorosis, a condition that causes staining and pitting of the enamel  Where fluoride levels are greater than 2 mg/L, CDC recommends that parents and caregivers of children 8 years and younger should provide children with drinking water from an alternative water source.  At levels less than 2 mg/L, the committee found that the prevalence of severe enamel fluorosis was very low (near zero).  Important for people living in areas with natural fluoride greater than 2 ppm (mg/L).  about 0.5% of the U.S. population (1.5 million)  About 220,000 Americans receive water from public water systems with fluoride levels that are equal to or exceed 4 mg/L.  People who consume water with ≥4 mg/L fluoride over a lifetime, when compared to people consuming water with 1 mg/L, are likely to be at increased risk for bone fractures.  Water at ≥2 mg/L fluoride may put children 8 years old and younger at increased risk for severe enamel fluorosis, a condition that causes staining and pitting of the enamel  Where fluoride levels are greater than 2 mg/L, CDC recommends that parents and caregivers of children 8 years and younger should provide children with drinking water from an alternative water source.  At levels less than 2 mg/L, the committee found that the prevalence of severe enamel fluorosis was very low (near zero). National Research Council, U.S.A. (2006) Fluoride in Drinking Water: A Scientific Review of EPA ’ s Standard

17 September 17, Safety of Water Fluoridation CDC Statement on the 2006 National Research Council (NRC) Report on Fluoride in Drinking Water  The findings of the NRC report are consistent with CDC ’ s assessment that water is safe and healthy at the levels used for water fluoridation ( mg/L). CDC reviews the latest scientific literature on an ongoing basis and maintains an active national community water fluoridation quality assurance program. CDC promotes research on the topic of fluoride and its effect on the public ’ s health. CDC ’ s recommendation remains the same; that community water fluoridation is safe and effective for preventing tooth decay.  Water fluoridation should be continued in communities currently fluoridating and extended to those without fluoridation.

18 Prevalence of severe enamel fluorosis and water fluoride concentration MCLG SMCL Guideline Value WHO, Canada, EU Fluoridation

19 September 17, Safety of Water Fluoridation Trace elements in human nutrition and health. W.H.O  An expert consultation of the WHO on trace elements in human nutrition and health categorized fluoride among "potentially toxic elements, some of which may nevertheless have some essential functions at low levels."  Fluoride was regarded as "essential," since the consultation "considered resistance to dental caries to be a physiologically important function."  The consultation indicated that total intakes at 1, 2 and 3 years of age "should, if possible, be limited to 0.5, 1.0 and 1.5 mg/day, respectively," with not more than 75% coming in the form of soluble fluorides from drinking- water.  It was also noted that "adult intakes exceeding 5 mg of fluoride per day from all sources probably pose a significant risk of skeletal fluorosis."

20 September 17, Safety of Water Fluoridation Evidence to date suggests that fluoride has no effect on hip fractures There is currently no firm evidence linking water fluoridation to cancer in general, or to specific cancers The group considered suggestions that fluoride may be implicated in various other health effects and concluded that there was no evidence for these suggestions Evidence to date suggests that fluoride has no effect on hip fractures There is currently no firm evidence linking water fluoridation to cancer in general, or to specific cancers The group considered suggestions that fluoride may be implicated in various other health effects and concluded that there was no evidence for these suggestions Scientific Reviews Medical Research Council (U.K.) working group report: Water fluoridation and health. 2002

21 September 17, Total Fluoride Intake Tolerable Upper Intake levels 0.1 mg/kg/day for children (birth - 8 years) 10 mg/day for children over 8 years and adults LOAEL (lowest-observed-adverse-effect level) Based on moderate enamel fluorosis for young children Based on skeletal fluorosis for older children and adults Tolerable Upper Intake levels 0.1 mg/kg/day for children (birth - 8 years) 10 mg/day for children over 8 years and adults LOAEL (lowest-observed-adverse-effect level) Based on moderate enamel fluorosis for young children Based on skeletal fluorosis for older children and adults Scientific Reviews Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press, 1999.

22 September 17, Safety of Water Fluoridation  Regulatory Standards  Scientific Reviews  Health concerns  Cosmetic concerns  Environmental concerns  Total intake  Regulatory Standards  Scientific Reviews  Health concerns  Cosmetic concerns  Environmental concerns  Total intake

23 September 17, Safety of Water Fluoridation Erickson (1978)  Residents of 24 cities with fluoridation and 22 cities without  Death rates were similar  after adjustment for differences in age, sex, race, education and population density  1,123.9 per 100,000 person-years (fluoridated)  1,137.1 per 100,000 person-years (non-fluoridated) Erickson (1978)  Residents of 24 cities with fluoridation and 22 cities without  Death rates were similar  after adjustment for differences in age, sex, race, education and population density  1,123.9 per 100,000 person-years (fluoridated)  1,137.1 per 100,000 person-years (non-fluoridated) Health concerns No effect on Mortality Agency for Toxic Substances and Disease Registry, U.S. Public Health Service (2003)

24 September 17, Safety of Water Fluoridation Seven studies of osteosarcoma, presenting 12 analyses were included Of these, the direction of association between water fluoridation and osteosarcoma incidence or mortality was found to be:  positive (fewer cancers) in seven,  negative (more cancers) in three and  no association (two found no relationship) Of the six studies that presented variance data  Only one (Cohn 1992) found a statistically significant association between fluoridation and increased prevalence of osteosarcoma in males. This study however, also had the lowest validity score, 2.5 out of 8. Importance of not establishing or changing public policy based on a single study Seven studies of osteosarcoma, presenting 12 analyses were included Of these, the direction of association between water fluoridation and osteosarcoma incidence or mortality was found to be:  positive (fewer cancers) in seven,  negative (more cancers) in three and  no association (two found no relationship) Of the six studies that presented variance data  Only one (Cohn 1992) found a statistically significant association between fluoridation and increased prevalence of osteosarcoma in males. This study however, also had the lowest validity score, 2.5 out of 8. Importance of not establishing or changing public policy based on a single study Health concerns No evidence of Bone Cancer or Osteosarcoma York Review* *NHS Centre for Reviews and Dissemination, University of York. U.K. A Systematic Review of Public Water Fluoridation

25 September 17, Fluoridation: Bassin Study “Our exploratory analysis found an association between fluoride exposure in drinking water during childhood and the incidence of osteosarcoma among males but not consistently among females. Further research is required to confirm or refute this observation.” Bassin EB, Wypij D, Davis RB, Mittleman MA. Age-specific fluoride exposure in drinking water and osteosarcoma (United States). Cancer Causes Control May;17(4): “…preliminary findings from the overall analysis of the second set of cases ( ) do not appear to replicate the overall findings from the first part of the study. Our findings currently being prepared for publication, do not suggest an overall association between fluoride and osteosarcoma.” Douglass CW, Joshipura K. Caution needed in fluoride and osteosarcoma study. Cancer Causes Control May;17(4): “Our exploratory analysis found an association between fluoride exposure in drinking water during childhood and the incidence of osteosarcoma among males but not consistently among females. Further research is required to confirm or refute this observation.” Bassin EB, Wypij D, Davis RB, Mittleman MA. Age-specific fluoride exposure in drinking water and osteosarcoma (United States). Cancer Causes Control May;17(4): “…preliminary findings from the overall analysis of the second set of cases ( ) do not appear to replicate the overall findings from the first part of the study. Our findings currently being prepared for publication, do not suggest an overall association between fluoride and osteosarcoma.” Douglass CW, Joshipura K. Caution needed in fluoride and osteosarcoma study. Cancer Causes Control May;17(4): Safety: New Study Cancer Causes & Control: Editorial Board at Harvard, Boston, MA

26 September 17, Fluoridation: Bassin Study After reviewing a recently published paper on a possible association between fluoride in water and osteosarcoma (a rare form of bone cancer), the ADA remains confident that community water fluoridation is a safe, effective public health measure for preventing tooth decay. The ADA agrees with the paper’s authors that their work constitutes an exploratory analysis that will require scientific confirmation to confirm or refute the findings. The data in this paper is simply one piece of a much more comprehensive 15-year study by the Harvard School of Dental Medicine scheduled for publication later this summer. The data in this paper is simply one piece of a much more comprehensive 15-year study by the Harvard School of Dental Medicine scheduled for publication later this summer. The principal investigator of the larger Harvard study has advised against drawing conclusions before seeing the full study, which will not suggest an overall association between fluoride and osteosarcoma, he states. Further, an association found in one, limited study, falls far below any scientific standard needed to establish a cause-and-effect relationship. In fact, after more than 60 years of rigorous scientific study of water fluoridation, the overwhelming weight of scientific evidences does not show an association with osteosarcoma. After reviewing a recently published paper on a possible association between fluoride in water and osteosarcoma (a rare form of bone cancer), the ADA remains confident that community water fluoridation is a safe, effective public health measure for preventing tooth decay. The ADA agrees with the paper’s authors that their work constitutes an exploratory analysis that will require scientific confirmation to confirm or refute the findings. The data in this paper is simply one piece of a much more comprehensive 15-year study by the Harvard School of Dental Medicine scheduled for publication later this summer. The data in this paper is simply one piece of a much more comprehensive 15-year study by the Harvard School of Dental Medicine scheduled for publication later this summer. The principal investigator of the larger Harvard study has advised against drawing conclusions before seeing the full study, which will not suggest an overall association between fluoride and osteosarcoma, he states. Further, an association found in one, limited study, falls far below any scientific standard needed to establish a cause-and-effect relationship. In fact, after more than 60 years of rigorous scientific study of water fluoridation, the overwhelming weight of scientific evidences does not show an association with osteosarcoma. Safety: New Study ADA Reaffirms Support of Water Fluoridation Chicago, April 7, 2006

27 September 17, Fluorine is the most electronegative and reactive of all elements; fluoride is the ionic form of fluorine. Fluorine is the most electronegative and reactive of all elements; fluoride is the ionic form of fluorine.

28 September 17, Safety of Water Fluoridation  Regulatory Standards  Scientific Reviews  Health concerns  Cosmetic concerns  Environmental concerns  Total intake  Regulatory Standards  Scientific Reviews  Health concerns  Cosmetic concerns  Environmental concerns  Total intake

29 September 17, Safety of Water Fluoridation  Extensive epidemiological research conducted in the United States during the 1930s and 1940s (Dean, 1942) established, with a high degree of certainty  Chronic fluoride intake of less than 0.10 mg/kg/day by children at risk of enamel fluorosis (under 8 years of age) associated with a low prevalence (approximately 10%) of the milder forms of the condition  Institute of Medicine 1999  Extensive epidemiological research conducted in the United States during the 1930s and 1940s (Dean, 1942) established, with a high degree of certainty  Chronic fluoride intake of less than 0.10 mg/kg/day by children at risk of enamel fluorosis (under 8 years of age) associated with a low prevalence (approximately 10%) of the milder forms of the condition  Institute of Medicine 1999 Cosmetic Concerns Enamel fluorosis

30 September 17, Fluoride in water: Caries and Fluorosis Pre-1945 data; year-olds 21 US cities; hundreds of children Caries Experience Number of decayed, missing and filled teeth per child (DMFT) Enamel Fluorosis Dean ’ s index: normal, questionable, very mild, mild, moderate, severe Community Fluorosis Index Public Health Significance Minimum Caries/ Minimum Fluorosis 1 ppm Fluoride in water

31 September 17, Dean’s Classification of Fluorosis Photographs from Forum on Water Fluoridation in Ireland, 2002

32 September 17, Moderate and Severe Fluorosis and ‘Moderate/Severe’ Caries Photographs from Forum on Water Fluoridation in Ireland, 2002 “Moderate/Severe Caries”

33 September 17, Safety of Water Fluoridation  Regulatory Standards  Scientific Reviews  Health concerns  Cosmetic concerns  Environmental concerns  Total intake  Regulatory Standards  Scientific Reviews  Health concerns  Cosmetic concerns  Environmental concerns  Total intake

34 September 17, Safety of Water Fluoridation  Environmental concerns have been investigated in literature reviews  Tacoma Pierce County Health Department, Washington State (August 2002)  City of Port Angeles, Washington State (October 2003)  no negative impact of water fluoridation on the environment has been established Pollick HF. Water fluoridation and the environment: current perspective in the United States. Int J Occup Environ Health Jul-Sep;10(3):  Environmental concerns have been investigated in literature reviews  Tacoma Pierce County Health Department, Washington State (August 2002)  City of Port Angeles, Washington State (October 2003)  no negative impact of water fluoridation on the environment has been established Pollick HF. Water fluoridation and the environment: current perspective in the United States. Int J Occup Environ Health Jul-Sep;10(3): Environmental concerns Fluoridation is safe for the environment

35 September 17, Safety of Water Fluoridation  There is no negative effect on the health of plants, animals, or humans  There is no effect on corrosion of pipes.  There is no measurable increase in lead and arsenic.  There are no emissions of fluoride into the air outside the well houses.  There is no release of toxic or hazardous substances.  There is no noise production.  There is no measurable increase in the fluoride concentrations in rivers downstream of the discharges due to adding fluoride to the water supply system.  There is no concentration of fluoride in groundwater.  There is no negative effect on the health of plants, animals, or humans  There is no effect on corrosion of pipes.  There is no measurable increase in lead and arsenic.  There are no emissions of fluoride into the air outside the well houses.  There is no release of toxic or hazardous substances.  There is no noise production.  There is no measurable increase in the fluoride concentrations in rivers downstream of the discharges due to adding fluoride to the water supply system.  There is no concentration of fluoride in groundwater. Environmental concerns Fluoridation is safe for the environment Pollick HF. Water fluoridation and the environment: current perspective in the United States. Int J Occup Environ Health Jul-Sep;10(3):343-50

36 September 17, Safety of Water Fluoridation  Regulatory Standards  Scientific Reviews  Health concerns  Cosmetic concerns  Environmental concerns  Total intake  Regulatory Standards  Scientific Reviews  Health concerns  Cosmetic concerns  Environmental concerns  Total intake

37 September 17, Safety of Water Fluoridation  Extensive reviews of the scientific literature revealed no adverse effects unless fluoride intakes were greater than 10 mg/day for 10 or more years (Kaminsky et al., 1990; NRC, 1993; USPHS, 1991).  At these high, chronic intake levels, the risk of skeletal changes consistent with preclinical or stage 1 skeletal fluorosis increases.  Institute of Medicine 1999  Extensive reviews of the scientific literature revealed no adverse effects unless fluoride intakes were greater than 10 mg/day for 10 or more years (Kaminsky et al., 1990; NRC, 1993; USPHS, 1991).  At these high, chronic intake levels, the risk of skeletal changes consistent with preclinical or stage 1 skeletal fluorosis increases.  Institute of Medicine 1999 Total Intake Fluoride Intake and Skeletal Fluorosis

38 September 17, Safety of Water Fluoridation  The Tolerable Upper Intake Level for children under 8 years of age (0.1 mg/kg/day) is exceeded by approximately 1 in 100 children in areas where the water fluoride concentration is 1.0 mg/liter or slightly higher  In the 1930s and 1940s, no moderate or severe cases of enamel fluorosis were recorded in these areas  Fluoride intake from water and the diet appears not to have increased since that time  Additional intake by children at risk of enamel fluorosis almost certainly derives from the use of fluoride-containing dental products (toothpaste, prescription supplements)  Institute of Medicine 1999  The Tolerable Upper Intake Level for children under 8 years of age (0.1 mg/kg/day) is exceeded by approximately 1 in 100 children in areas where the water fluoride concentration is 1.0 mg/liter or slightly higher  In the 1930s and 1940s, no moderate or severe cases of enamel fluorosis were recorded in these areas  Fluoride intake from water and the diet appears not to have increased since that time  Additional intake by children at risk of enamel fluorosis almost certainly derives from the use of fluoride-containing dental products (toothpaste, prescription supplements)  Institute of Medicine 1999 Total Intake Total Intake and Enamel Fluorosis

39 September 17, Safety of Water Fluoridation  On November 9, 2006, the ADA issued interim guidance on fluoride intake for infants and young children. Sound science was the driving force behind the release of the guidance. It was issued so parents, caregivers and health care professionals, who may be concerned about a possible increased risk of fluorosis, have some simple and effective advice on ways to reduce fluoride intake from reconstituted infant formula.  For infants who get most of their nutrition from formula during their first 12 months, ready-to-feed formula is preferred to help ensure that they do not exceed the optimal amount of fluoride intake.  If liquid concentrate or powdered infant formula is the primary source of nutrition, it can be mixed with water that is fluoride free or contains low levels of fluoride to reduce the risk of fluorosis. Examples are water that is labeled purified, demineralized, deionized, distilled or reverse osmosis filtered water. Many grocery stores sell these types of drinking water for less than $1 per gallon.  Breast milk is widely acknowledged as the most complete form of nutrition for infants. The American Academy of Pediatrics recommends human milk for all infants (except for the few for whom breastfeeding is determined to be harmful).   On November 9, 2006, the ADA issued interim guidance on fluoride intake for infants and young children. Sound science was the driving force behind the release of the guidance. It was issued so parents, caregivers and health care professionals, who may be concerned about a possible increased risk of fluorosis, have some simple and effective advice on ways to reduce fluoride intake from reconstituted infant formula.  For infants who get most of their nutrition from formula during their first 12 months, ready-to-feed formula is preferred to help ensure that they do not exceed the optimal amount of fluoride intake.  If liquid concentrate or powdered infant formula is the primary source of nutrition, it can be mixed with water that is fluoride free or contains low levels of fluoride to reduce the risk of fluorosis. Examples are water that is labeled purified, demineralized, deionized, distilled or reverse osmosis filtered water. Many grocery stores sell these types of drinking water for less than $1 per gallon.  Breast milk is widely acknowledged as the most complete form of nutrition for infants. The American Academy of Pediatrics recommends human milk for all infants (except for the few for whom breastfeeding is determined to be harmful).  Total Intake Infant Formula and Enamel Fluorosis - ADA

40 September 17, Safety of Water Fluoridation  Recent studies have raised the possibility that mixing infant formula with fluoridated water, particularly for infants exclusively on a formula diet during the first year of life, may play a more important role in enamel fluorosis development than was previously understood.  Ready to feed (no-mix) infant formula typically has little fluoride and may be preferred for use at least some of the time.  For decades, parents have been mixing infant formula with optimally fluoridated tap water (a level determined by the U.S. Public Health Service between 0.7 mg/L fluoride and 1.2 mg/L fluoride and maintained by your water utility to maximize decay prevention and limit fluorosis potential) and no association has been observed between infant formula use and an increased risk for moderate or severe fluorosis.   Recent studies have raised the possibility that mixing infant formula with fluoridated water, particularly for infants exclusively on a formula diet during the first year of life, may play a more important role in enamel fluorosis development than was previously understood.  Ready to feed (no-mix) infant formula typically has little fluoride and may be preferred for use at least some of the time.  For decades, parents have been mixing infant formula with optimally fluoridated tap water (a level determined by the U.S. Public Health Service between 0.7 mg/L fluoride and 1.2 mg/L fluoride and maintained by your water utility to maximize decay prevention and limit fluorosis potential) and no association has been observed between infant formula use and an increased risk for moderate or severe fluorosis.  Total Intake Infant Formula and Enamel Fluorosis - CDC

41 September 17, Safety of Water Fluoridation  where concentration is 1.0 ppm F in water  range from 1.4 to 3.4 mg fluoride per day  where concentration is less than 0.3 ppm F  range from 0.3 to 1.0 mg/day  Institute of Medicine 1999  where concentration is 1.0 ppm F in water  range from 1.4 to 3.4 mg fluoride per day  where concentration is less than 0.3 ppm F  range from 0.3 to 1.0 mg/day  Institute of Medicine 1999 Total Intake Dietary fluoride intakes by adults from food, water and beverages

42 September 17, Total Fluoride Intake Institute of Medicine, 1999 Table from - Dietary Reference Intakes for Fluoride

43 September 17, Safety of Water Fluoridation Regulatory StandardsMeets the standards Scientific Reviews15 reviews in past 17 years Health concernsNo health concerns Cosmetic concerns Cosmetic benefit Caries / Enamel fluorosis * Environmental concernsNo negative effect Total intakeWater fluoridation: OK * *Concerns with compliance with Rx F Supplements, Toothpaste supervision for children under 8 years of age, mixing infant formula

44 September 17, Community Water Fluoridation  Safety  Benefits  Safety  Benefits

45 September 17,  Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries  A Report on Recommendations of the Task Force on Community Preventive Services  Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries  A Report on Recommendations of the Task Force on Community Preventive Services CDC’s MMWR Recommendations and Reports (RR-21) November 30, 2001

46 September 17, Recommendations Preventing dental caries  Community water fluoridation (strongly recommended)  School-based sealant programs (strongly recommended) Preventing dental caries  Community water fluoridation (strongly recommended)  School-based sealant programs (strongly recommended)

47 September 17, Community Water Fluoridation  21 studies (good to fair quality)  Median decrease in dental caries:  29.1% (before-and-after measures)  50.7% (after measures only)  Children (4-17 years) of varying levels of baseline caries and socioeconomic status  Evidence of effectiveness: strong  21 studies (good to fair quality)  Median decrease in dental caries:  29.1% (before-and-after measures)  50.7% (after measures only)  Children (4-17 years) of varying levels of baseline caries and socioeconomic status  Evidence of effectiveness: strong

48 September 17, Fluoride in water: Caries and Fluorosis: Pre-1945 data The Scientific Foundation for fluoridation Historical Background year-olds Midwest US 21 cities Dean,H.T. in Dental caries and Fluorine, Washington, American Association Advancement Science, pp. 5-31, 1946

49 September 17, CDC: Fluoridation protects teeth in two ways  When delivered through the water supply to children during the tooth forming years.  Through direct contact with teeth throughout life.  When delivered through the water supply to children during the tooth forming years.  Through direct contact with teeth throughout life.

50 September 17, Systemic and Topical Effects: or pre- and post-eruptive effects of fluoridation on caries prevention

51 September 17, Experiment to determine topical and systemic effects of fluoride on caries prevention Effect of fluoride administered by stomach tube or orally (5 ppm) on smooth surface & sulcal (fissure) caries in rat molars Experiment to determine topical and systemic effects of fluoride on caries prevention Effect of fluoride administered by stomach tube or orally (5 ppm) on smooth surface & sulcal (fissure) caries in rat molars Group Number of animals All Molars: Mean number of carious areas SmoothSulcal Control - No F F - Stomach Tube *23.1 F - orally (water) * 10.6 * Larson RH, Mellberg JR, Senning R. Experiments on local and systemic action of fluoride in caries inhibition in the rat. Archives of Oral Biology. 1977;22(7):437-9 * p <0.01

52 September 17, Experiment to determine pre- and post-eruptive effects of fluoride on caries prevention Effect of fluoride administered by stomach tube or orally on smooth surface & sulcal (fissure) caries in rat: 3 rd molars only (>2 weeks pre-eruptive effect) Experiment to determine pre- and post-eruptive effects of fluoride on caries prevention Effect of fluoride administered by stomach tube or orally on smooth surface & sulcal (fissure) caries in rat: 3 rd molars only (>2 weeks pre-eruptive effect) Group Caries score Smooth surfaces % Reduction Caries score Sulcal surfaces % Reduction Control: no F F - stomach tube 0.5 * 93 % 1.6 *30 % F - orally (water) 0.0 *100 % 0.8 *65 % Larson RH, Mellberg JR, Senning R. Experiments on local and systemic action of fluoride in caries inhibition in the rat. Archives of Oral Biology. 1977;22(7):437-9 * p <0.01

53 September 17, Tiel-Culemborg Netherlands  Cross-sectional study of dentinal caries based on standardized bite-wing x-rays of permanent teeth  Tiel, Netherlands, began fluoridating water at 1 ppm in 1953 and stopped Dec 1973 under court order. Culemborg served as non-fluoridated control  Data collected in 1961, 1973, and  In all categories of surfaces (proximal, smooth, pit & fissure) the use of fluoridated water only post-eruptively shows less effect than the use only pre-eruptively.  “In order to obtain maximal reduction in all surfaces the use of fluoridated water must be started at onset of calcification of a tooth.” Groeneveld A, Van Eck AA, Backer Dirks O. Fluoride in caries prevention: is the effect pre- or post-eruptive? J Dent Res Feb;69 Spec No:751-5; discussion 820-3

54 September 17, Fluoride effect: Pre- and Post-eruptive SitePre-Post- Pit & Fissure66%33% Approximal50% Smooth surfaces25%75% Fluoride has an important pre-eruptive effect on subsequent caries experience; % reduction depends on site Groeneveld A, Van Eck AA, Backer Dirks O. Fluoride in caries prevention: is the effect pre- or post-eruptive? J Dent Res Feb;69 Spec No:751-5; discussion 820-3

55 September 17, Conclusions from recent Australian studies  Confirm earlier findings: higher pre- than post-eruptive exposure more beneficial for overall caries experience and for pit & fissure surfaces caries reduction  Children with optimum exposure to fluoridated water both pre- & post-eruption had lowest caries in all surface types  There was an exposure-response relationship between pre-eruptive exposure and caries.  Confirm earlier findings: higher pre- than post-eruptive exposure more beneficial for overall caries experience and for pit & fissure surfaces caries reduction  Children with optimum exposure to fluoridated water both pre- & post-eruption had lowest caries in all surface types  There was an exposure-response relationship between pre-eruptive exposure and caries.  Singh KA, Spencer AJ, Brennan DS. Effects of water fluoride exposure at crown completion and maturation on caries of permanent first molars.Caries Res. 2007;41(1):  Singh KA, Spencer AJ. Relative effects of pre- and post-eruption water fluoride on caries experience by surface type of permanent first molars.Community Dent Oral Epidemiol Dec;32(6):  Singh KA, Spencer AJ, Armfield JM. Relative effects of pre- and posteruption water fluoride on caries experience of permanent first molars.J Public Health Dent Winter;63(1):11-9.

56 September 17, Exposure to fluoridated water since birth produces the maximum benefit.  The strongest caries-preventive effect was produced by a high exposure to fluoridated water at crown completion  supplemented by a high exposure at  maturation and/or  post-eruption  but the latter two phases could not produce a significant caries- preventive effect on their own.  findings relate mainly to pit and fissure surfaces Singh KA, Spencer AJ, Brennan DS. Effects of water fluoride exposure at crown completion and maturation on caries of permanent first molars. Caries Res. 2007;41(1):34-42

57 September 17, Effectiveness of water fluoridation Difference in Caries Prevalence by U. S. Region according to % on fluoridated water. ( ) Children 5-17 year-olds Newbrun E. Current regulations and recommendations concerning water fluoridation, fluoride supplements, and topical fluoride agents. J Dent Res May;71(5): (data from: Brunelle JA, Carlos JP Recent Trends in Dental Caries in U.S. Children and the Effect of Water Fluoridation Journal of Dental Research Feb; 69 (Special Issue); Explained by Halo or diffusion effect The more fluoridation in a region, the less difference between fluoridated and non- fluoridated areas Explained by Halo or diffusion effect The more fluoridation in a region, the less difference between fluoridated and non- fluoridated areas

58 September 17, HALO (or diffusion) Effect 12-year-old children living in states where more than half of the communities have fluoridated water will have 26% fewer decayed tooth surfaces per year than 12- year-old children living in states where less than one- quarter of the communities are fluoridated. 12-year-old children living in states where more than half of the communities have fluoridated water will have 26% fewer decayed tooth surfaces per year than 12- year-old children living in states where less than one- quarter of the communities are fluoridated. A 12-year-old child who has lived in a non-fluoridated community in a highly fluoridated state would typically have one fewer cavity than a child in a low-fluoridated state Griffin SO, Gooch BF, Lockwood SA, Tomar SL. Quantifying the diffused benefit from water fluoridation in the United States. Community Dent Oral Epidemiol Apr;29(2):120-9.

59 September 17, The Percentage of the U.S. Population on Public Water Supply Systems Receiving Fluoridated Water is 67.3%, but varies from State to State California: 27.6%

60 September 17, Caries Status in California: Caries Status in California: High School Students in fluoridated areas have far fewer urgent treatment needs Pollick HF, Isman R, Fine JI, Wellman J, Kipnis P, Ellison J. Report of the California Oral Health Needs Assessment of Children, : Background, Methodology, Findings. The Dental Health Foundation, Oakland, California. 1999

61 September 17, Fluoride is cost-effective  Every dollar spent on community water fluoridation saves from $7 to $42 in treatment costs depending on the size of the community. Savings are greatest in large communities.  At least 60% of the U.S. population on public water systems has received fluoridated water since 1990, translating to savings in dental treatment costs of over $25.7 billion in the past decade.  Every dollar spent on community water fluoridation saves from $7 to $42 in treatment costs depending on the size of the community. Savings are greatest in large communities.  At least 60% of the U.S. population on public water systems has received fluoridated water since 1990, translating to savings in dental treatment costs of over $25.7 billion in the past decade.

62 September 17, Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. Journal Public Health Dentistry 2001;61(2):78-86 Annual per person cost savings resulting from fluoridation ranged from $15.95 in very small communities to $18.62 in large communities On the basis of the most current data available on the effectiveness and cost of fluoridation, caries increment, and the cost and longevity of dental restorations, we find that water fluoridation offers significant cost savings. Annual per person cost savings resulting from fluoridation ranged from $15.95 in very small communities to $18.62 in large communities On the basis of the most current data available on the effectiveness and cost of fluoridation, caries increment, and the cost and longevity of dental restorations, we find that water fluoridation offers significant cost savings.

63 September 17, Fluoridation: Recent Evidence Mean number of teeth affected by dental caries Fluoridated Republic of Ireland; Non-fluoridated Northern Ireland Mean number of teeth affected by dental caries Fluoridated Republic of Ireland; Non-fluoridated Northern Ireland 5-year-olds15-year-olds Fluoridated Non-Fluoridated Australia Subjects with a lifetime exposure to fluoridated drinking water had a lower level of caries experience than those with no exposure to fluoridated drinking water, and this was more noticeable in approximal surfaces than occlusal surfaces. Hopcraft MS, Morgan MV. Pattern of dental caries experience on tooth surfaces in an adult population. Community Dent Oral Epidemiol Jun;34(3): Whelton H, Crowley E, O'Mullane D, Donaldson M, Cronin M, Kelleher V. Dental caries and enamel fluorosis among the fluoridated population in the Republic of Ireland and non fluoridated population in Northern Ireland in Community Dent Health Mar;23(1):37-43 Benefits - New Studies

64 September 17, Water fluoridation and Sealants  Prospective (mean 2 years) cohort study of children in Australia  789 children (mean age = 10.5 years) with one sealed permanent first molar at baseline, while the paired surface was diagnosed as sound.  The caries incidence of the fissure sealed occlusal surfaces was 5.6% compared to 11.1% for sound surfaces (p < 0.001); a 50% reduction in caries incidence for sealed vs non-sealed surfaces.  Prospective (mean 2 years) cohort study of children in Australia  789 children (mean age = 10.5 years) with one sealed permanent first molar at baseline, while the paired surface was diagnosed as sound.  The caries incidence of the fissure sealed occlusal surfaces was 5.6% compared to 11.1% for sound surfaces (p < 0.001); a 50% reduction in caries incidence for sealed vs non-sealed surfaces.  The reduction in caries increment attributable to sealants increased across fluoridated water exposure categories  36.4% reduction was found for children with 0% exposure (p > 0.05)  55.0% reduction for children with intermediate exposure (p < 0.01)  82.4% reduction for children with 100% lifetime exposure to fluoridated water (p < 0.001). Armfield JM, Spencer AJ. Community effectiveness of fissure sealants and the effect of fluoridated water consumption. Community Dent Health Mar;24(1):4-11

65 September 17, Water fluoridation and Sealants Conclusion The effectiveness of fissure sealants in community-based programs may be further improved when coupled with increased lifetime exposure to optimally fluoridated water. Armfield JM, Spencer AJ. Community effectiveness of fissure sealants and the effect of fluoridated water consumption. Community Dent Health Mar;24(1):4-11

66 September 17, Annual incremental benefit of water fluoridation  An annual incremental benefit of fluoridation of 0.19 tooth surfaces (range 0.04 to 0.34).  This equates to 1.9 tooth surfaces every decade, or  9.5 tooth surfaces over 50 years. Griffin SO, Jones K, Tomar SL. Economic Evaluation of Community Water Fluoridation. J Publ Health Dent 2001;61(2):78-86  An annual incremental benefit of fluoridation of 0.19 tooth surfaces (range 0.04 to 0.34).  This equates to 1.9 tooth surfaces every decade, or  9.5 tooth surfaces over 50 years. Griffin SO, Jones K, Tomar SL. Economic Evaluation of Community Water Fluoridation. J Publ Health Dent 2001;61(2):78-86 Difference in mean Decayed, Missing due to caries and Filled Permanent Tooth Surfaces (DMFS) between children with continuous exposure to water fluoridation and those with no such exposure. Data from Table 6 of Brunelle & Carlos. Brunelle JA, Carlos JP. Recent trends in dental caries in U.S. children and the effect of water fluoridation. J Dent Res. 1990;69 Spec No:723-7; discussion Pollick HF. Scientific evidence continues to support fluoridation of public water supplies. Int J Occup Environ Health Jul-Sep;11(3):322-6.

67 September 17, Benefit for adults from water fluoridation  Review of adult studies after 1980  Any fluoride, whether self-applied, professionally applied or water fluoridation, or combination  averted 0.29 (95%CI: ) carious coronal tooth surfaces per year  and averted 0.22 (95%CI: ) carious root surfaces per year.  Total averted 0.51 carious surfaces /year Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5):  Review of adult studies after 1980  Any fluoride, whether self-applied, professionally applied or water fluoridation, or combination  averted 0.29 (95%CI: ) carious coronal tooth surfaces per year  and averted 0.22 (95%CI: ) carious root surfaces per year.  Total averted 0.51 carious surfaces /year Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5):  The prevented fraction for water fluoridation was 27% (95%CI: 19%-34%)  Prevents 0.14 carious surfaces / year  Slightly less than 0.19 for all ages from the 2001 review

68 September 17, Benefit for adults from water fluoridation  Water fluoridation, all adults, coronal caries  Including only lifelong residents of control or fluoridated-water communities  7 studies  5409 participants Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5):  Water fluoridation, all adults, coronal caries  Including only lifelong residents of control or fluoridated-water communities  7 studies  5409 participants Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5):  equivalent to a prevented fraction of 34.6% (95%CI: 12.6%-51.0%).  Prevents 0.18 carious surfaces / year  Slightly less than 0.19 for all ages from the 2001 review

69 September 17, A lthough adults are as likely to experience new caries as children, certain segments of the U.S. adult population - those with low incomes and the elderly - may have little or no access to restorative or preventive clinical care. A t present, approximately 15% of state Medicaid programs provide no adult dental benefits at all, and approximately 45% cover only tooth extraction and emergency services (Oral Health America, 2003). Routine dental care is one of the few health areas not covered by Medicare. L imited access to restorative care increases the need for effective prevention; complications and pain and suffering are more likely if caries remains untreated. T he proportion of the U.S. population comprised of older adults is increasing, most of these persons are likely to be dentate and at risk for dental caries, and many lower-income adults lack access to timely restorative care. O ur finding that fluoride is effective among all adults supports the development and implementation of fluoride programs to serve this population. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5): CONCLUSION

70 September 17, Questions?


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