1. LEARNING OBJECTIVES Understand the biologic mechanism of fluoridation Understand the biologic mechanism of fluoridation Understand the benefits, possible adverse effects and fluoride dosing Understand the benefits, possible adverse effects and fluoride dosing Understand the community and well water fluoride content issues in SC Understand the community and well water fluoride content issues in SC

2. COMMUNITY WATER FLUORIDATION Single most effective public health measure to prevent tooth decay Single most effective public health measure to prevent tooth decay CDC has proclaimed fluoridation as one of the ten great public health achievements of the 20 th century CDC has proclaimed fluoridation as one of the ten great public health achievements of the 20 th century Fluoridation is a powerful strategy in efforts to eliminate health disparities among populations Fluoridation is a powerful strategy in efforts to eliminate health disparities among populations

3. COMMUNITY WATER FLUORIDATION Fluoridated water is accessible to the entire community Fluoridated water is accessible to the entire community Individuals do not need to change their behavior to obtain the benefits Individuals do not need to change their behavior to obtain the benefits Frequent exposure to small amounts of Fl over time makes Fluoridation effective throughout the life span Frequent exposure to small amounts of Fl over time makes Fluoridation effective throughout the life span

4. Community Water Fluoridation Community public health measure that is cost effective and saves $ Community public health measure that is cost effective and saves $ The cost of drinking fluoridated water for a lifetime is about the same as the cost of one dental filling The cost of drinking fluoridated water for a lifetime is about the same as the cost of one dental filling For every $1 invested in water fluoridation, $38 is saved in dental treatment costs For every $1 invested in water fluoridation, $38 is saved in dental treatment costs

5. Water Fluoridation Reduces decay by 20-40% EVEN in conjunction with Fl from other sources (e.g. toothpaste) Reduces decay by 20-40% EVEN in conjunction with Fl from other sources (e.g. toothpaste) 26% fewer cavities in 12 y/o children living in a state with >50% community water fluoridation 26% fewer cavities in 12 y/o children living in a state with >50% community water fluoridation Healthy People 2010 objective is for 75% public fluoridation; currently @70% Healthy People 2010 objective is for 75% public fluoridation; currently @70%

6. Public Water Fluoridation Stats United States as a whole –72.4% South Carolina –94.4% Rank –9 th best !!! www.cdc.gov/fluoridation/statistics/2008stats

7. Caries Prevention and Fluoride- mechanism of action Benefit results from (a) uptake of systemic Fl by enamel crystallites during pre-eruptive tooth development & (b) uptake of topical Fl through repetitive demineralization and remineralization cycles in the oral cavity after tooth eruption Benefit results from (a) uptake of systemic Fl by enamel crystallites during pre-eruptive tooth development & (b) uptake of topical Fl through repetitive demineralization and remineralization cycles in the oral cavity after tooth eruption Fl uptake allows formation of fluorohydroxyapatite (FHA) Fl uptake allows formation of fluorohydroxyapatite (FHA) FHA less susceptible to acid attack than Hydroxyapatite in normal tooth enamel FHA less susceptible to acid attack than Hydroxyapatite in normal tooth enamel

8. Dental Fluorosis Caused by excess Fl intake; @ risk 0-8y/o; highest risk boys 15-34 mos; girls 21-30 mos Caused by excess Fl intake; @ risk 0-8y/o; highest risk boys 15-34 mos; girls 21-30 mos No significant dental risk > 8y/o No significant dental risk > 8y/o MILD: chalk-like lacy marking across enamel surface; not readily apparent to casual observer MILD: chalk-like lacy marking across enamel surface; not readily apparent to casual observer MODERATE: >50% of enamel surface is opaque white MODERATE: >50% of enamel surface is opaque white SEVERE: enamel is pitted and brittle and may develop areas of brown staining (think of Dr. McKay and Colorado Brown Stain) SEVERE: enamel is pitted and brittle and may develop areas of brown staining (think of Dr. McKay and Colorado Brown Stain)

9. Frequency of U. S. A. Pediatric Fluorosis Age 6-11: 40% Age 6-11: 40% Age 12-15: 49% Age 12-15: 49% Age 16-19: 42% Age 16-19: 42%

10. RDA for Fl 0-6 mos: 0.01mg 0-6 mos: 0.01mg 7-12 mos: 0.5mg 7-12 mos: 0.5mg 1-3 yrs: 0.7mg 1-3 yrs: 0.7mg 4-8 yrs: 1.0mg 4-8 yrs: 1.0mg 9-13 yrs: 2.0mg 9-13 yrs: 2.0mg 14-18 yrs: 3.0mg 14-18 yrs: 3.0mg

11. Fluoride dosing that should not result in more than mild Fluorosis Birth to 6 months: 0.01 mg/day Birth to 6 months: 0.01 mg/day 7-12 months: 0.05 mg/kg/day 7-12 months: 0.05 mg/kg/day 12 months to 8 years: 0.1 mg/kg/day 12 months to 8 years: 0.1 mg/kg/day 1mg=1ppm 1mg=1ppm 0.7 ppm is 2011 current target water fluoridation dose 0.7 ppm is 2011 current target water fluoridation dose Community water systems are allowed to provide water up to 4.0 ppm (MCLG; Maximum Contaminant Level Goal) without taking corrective action Community water systems are allowed to provide water up to 4.0 ppm (MCLG; Maximum Contaminant Level Goal) without taking corrective action

12. Fluorosis True risk not clear re the variables of duration, timing, dose, biologic variability, cumulative dosing of fluoride from non- water sources (toothpaste, food, therapeutic Fl treatments, etc) True risk not clear re the variables of duration, timing, dose, biologic variability, cumulative dosing of fluoride from non- water sources (toothpaste, food, therapeutic Fl treatments, etc)

13. Fluorosis The most critical ages of susceptibility are from 0-6 y/o with the highest risk in boys from 15-24 mos and girls from 21-30 months. After age 7-8, fluorosis does not occur because the permanent teeth are fully developed although not erupted The most critical ages of susceptibility are from 0-6 y/o with the highest risk in boys from 15-24 mos and girls from 21-30 months. After age 7-8, fluorosis does not occur because the permanent teeth are fully developed although not erupted

14. Mild Fluorosis Mild Fluorosis

15. Moderate Fluorosis Moderate Fluorosis

16. Severe Fluorosis

17. Fl in formula Product/mean ppm +/- 1SD Powdered mild base/0.12 +/- 0.08 Powdered soy/0.16 +/-0.09 Liquid concentrate milk base: 0.27 +/- 0.18 Liquid concentrate soy base: 0.50 +/-0.08 Ready to feed milk base: 0.15 +/- 0.06 Ready to feed soy base: 0.21 +/- 0.01

18. Fl in Formula Most infants exceed the upper tolerable limit of Fl if formula prepared with 1ppm water @ 0-12 months of age Most infants exceed the upper tolerable limit of Fl if formula prepared with 1ppm water @ 0-12 months of age 6-12 month infants unlikely to reach adequate Fl intake if fed ready to feed, powdered, or liquid concentrate reconstituted with <0.4 ppm water 6-12 month infants unlikely to reach adequate Fl intake if fed ready to feed, powdered, or liquid concentrate reconstituted with <0.4 ppm water No ready to feed formula will exceed the 0.1 mg/kg/day RDA upper tolerable limit No ready to feed formula will exceed the 0.1 mg/kg/day RDA upper tolerable limit True risk of fluorosis not clear re “brief” exposure to formula before switching to regular milk @ 1y True risk of fluorosis not clear re “brief” exposure to formula before switching to regular milk @ 1y What impact does Fl in solid food have on this Fl dose? What impact does Fl in solid food have on this Fl dose?

19. Fluoride Content Toothpaste: 0.15% Fl ion (1.5 gm/L); Toothpaste: 0.15% Fl ion (1.5 gm/L); 0.243% NaFl (2.43 mg/L) 0.243% NaFl (2.43 mg/L) 5% Dental Fluoride Varnish: 50 gm/L NaFl or 2.26% Fl ion (22.6 gm/L); available in 0.4ml and 0.25 ml volumes in disposable kit form; 9.0 mg of Fl ion in 0.4 ml dish or 5.6 mg Fl ion in 0.25 ml dish 5% Dental Fluoride Varnish: 50 gm/L NaFl or 2.26% Fl ion (22.6 gm/L); available in 0.4ml and 0.25 ml volumes in disposable kit form; 9.0 mg of Fl ion in 0.4 ml dish or 5.6 mg Fl ion in 0.25 ml dish

20. Other selected fluoride sources Bottled water not required to label Fl content; assume sub-optimal content unless fluoride content labeled; the distributor can tell the customer on request Bottled water not required to label Fl content; assume sub-optimal content unless fluoride content labeled; the distributor can tell the customer on request Seafood: likely high content Seafood: likely high content Foods/Beverages frequently prepared by manufacturer with community water; may not be included in label Foods/Beverages frequently prepared by manufacturer with community water; may not be included in label Breast milk: very little fluoride Breast milk: very little fluoride

21. Fluoride content of selected foods ppm 2% milk = 0.04 2% milk = 0.04 Wheaties = 0.4 Wheaties = 0.4 Cherrios = 0.9 Cherrios = 0.9 Minute Maid OJ = 0.39 Minute Maid OJ = 0.39 Tea = 0.1-0.6 Tea = 0.1-0.6 Chicken = 0.06-0.1 Chicken = 0.06-0.1 Hunt’s Tomato Paste = 0.27 Hunt’s Tomato Paste = 0.27 Sardines = 0.2-0.4 Sardines = 0.2-0.4

22. COMMON WATER FILTERS Include carafe filters, faucet filters, under the sink filters, and whole house filters Include carafe filters, faucet filters, under the sink filters, and whole house filters In general, the amount of Fl filtered depends on the type of filter, age of filter, working condition, and presence of activated alumina (up to 80% removal) or carbon in filter (generally little removal) In general, the amount of Fl filtered depends on the type of filter, age of filter, working condition, and presence of activated alumina (up to 80% removal) or carbon in filter (generally little removal) Each type of filter needs to be assessed individually Each type of filter needs to be assessed individually

23. WATER FILTRATION Reverse osmosis filters remove 65-95% of Fl Reverse osmosis filters remove 65-95% of Fl Steam distillation units remove 100% of Fl Steam distillation units remove 100% of Fl Water softeners do not remove significant amounts of Fl Water softeners do not remove significant amounts of Fl Consumers using home water treatment systems should have their water tested at least annually Consumers using home water treatment systems should have their water tested at least annually

24. WELL WATER SAMPLES 1/18/10-6/22/11 1/18/10-6/22/11 339 bottles released 339 bottles released 170 bottles returned 170 bottles returned

25. WELL WATER SAMPLES ppm 1/18/10-6/22/11 1/18/10-6/22/11 0 to 0.69 = 129--76% 0 to 0.69 = 129--76% 0.7 to 1.20 = 13--8% 0.7 to 1.20 = 13--8% 1.21 to 2.01 = 17--10% 1.21 to 2.01 = 17--10% 2.01 to 3.0 = 9--5% 2.01 to 3.0 = 9--5% 3.1 to 4.0 = 1--<1% 3.1 to 4.0 = 1--<1% >4.0 = 1-- 4.0 = 1--<1%