Eastern Ontario Health Unit Community Water Fluoridation April 25, 2016

Overview of presentation Mayor & Council have received Letter with: Scientific references from 2000 to 2016, Ontario Dental Association Information booklet on CWF, American Fluoridation Society rebuttal of April 11, 2016 presentation. Signed petition by local dentists Discussion for this presentation will relate to international fluoride studies but also to Canadian and local data

We are talking about HEALTH Oral Health and Overall General Health Dental disease is: The #1 chronic disease in children & adolescents; (U.S. Surgeon General’s Report, May 2000) http://profiles.nlm.nih.gov/ps/access/NNBBJT.pdf Five (5) times more common than asthma; One of the main reasons preschool children receive a general anaesthetic; 47% of Canadians have had dental disease by six (6) years of age. 96% have had it in their lifetime; http://www.fptdwg.ca/English/e-documents.html Oral health is linked to a number of systemic diseases

Health Canada *Dr.Hoskins’ letter Ministerial Statement - Oral Health Month - April 2016 Don't overlook your oral health. Regular check-ups with an oral health professional, daily brushing and flossing, not smoking, reducing daily intake of sugars, and drinking fluoridated water will lower the risk of oral health problems and improve overall health. Simple daily routines, like brushing with your kids at bedtime, can make oral health care fun. *Dr.Hoskins’ letter

Ontario Medical Association Water Fluoridation “In October 2010, Ontario’s doctors examined concerns that have been raised about possible negative health effects resulting from the fluoridation of water systems in Ontario. The OMA found no reason for health concern and approved a policy that supports the addition of fluoride to drinking water. In order to ease the concerns of some patients, we engaged in an effort to publicly address the misconceptions surrounding the safety of fluoride in drinking water with a press release and opinion article written by the OMA President.” https://www.oma.org/HEALTHPROMOTION/Pages/Fluoridation.aspx

Percentage of People with Dental Insurance in Canada http://www.fptdwg.ca/English/e-documents.html

Percentage of People with Root Caries http://www.fptdwg.ca/English/e-documents.html

Current Status in Canada $12.8B spent annually on oral health. In 2013, LIHN data demonstrated that there were 879 hospital emergency room visits for oral health at the Cornwall Community Hospital, at an estimated cost of $450, 927. The visits ranged from emergency/life threatening to urgent and less urgent. 1 out of 3 Canadians have a dental need, and 1 out of 6 say they cannot address this need because of financial reasons. * Yet dental decay is almost 100% preventable. * Canadian Health Measures Survey 2010: http://hc-sc.gc.ca/ahc-asc/branch-dirgen/fnihb-dgspni/ocdo-bdc/project-eng.php#a1

Questions from recent discussions: What happens if fluoridation is stopped? Dorval, Quebec: Removed 2003-Reinstated 2008* *Levy, update on water fluoridation in Quebec; Quebec Public Health Meeting, June 2007. *CJAD- Dorval Kids’ teeth in better shape than anywhere else on Island (02/14/2016) McGill study. Dryden, Ontario: Removed 2001.** Caries rates of 5 year old 2001-2008 ↑ by 26%. **Water fluoridation in Toronto. Staff report March 2011. NorthWestern Health Unit, Dryden, Ontario Windsor, Ontario: Removed 2013*** The % of children that required urgent dental care increased by 10% 2011-2015. A two fold increase in the proportion of children eligible for topical fluorides. ***http://www.cbc.ca/news/canada/windsor/windsor-tooth-decay-fluoride-1.3546919

Windsor Star, February 2016

Questions from recent discussions: (cont’d) Calgary, Alberta: Removed 2011, Publication February 2016.* “Trends observed for primary teeth consistent with adverse effect of fluoridation cessation.” *Community Dentistry and Oral Epidemiology, McLaren et Al, February 2016. NOTE: Dr. Sheldon’s concerns (U.K.) Dr. Perrott’s concerns regarding Dr. Sheldon’s issues (N.Z.) Survey : 2 out of 3 Calgarians want it back

What is the situation in Cornwall regarding decay and fluorosis? Decay rates in EOHU area: We use a sentinel age group (5 year old) in our index group We use the index on average number of decayed, missing, filled teeth. (dmft) In 2014-2015, 5 year olds dmft 1.23 29% of children show decay very high (4.24) Fluorosis: 2008-2009 8% in 7 year olds was very mild/mild Trends: children with decay in Cornwall have a higher average than our health unit area (4.47 vs 4.24) numbers needing urgent care in EOHU 2011, 571 (1137 services) and in 2015, 593 (1244 services) numbers needing preventive services in EOHU up by 66%

Cornwall is in Good Company Organizations supporting water fluoridation World Health Organization Canadian Dental Association Ontario Dental Association Canadian Pediatric Society Ontario Associations of Local Public Health Agencies Health Canada Public Health Agency of Canada Health Ministers of Canada/Ontario

In 2006, Health Canada initiated a review of fluoride In 2006, Health Canada initiated a review of fluoride. This process included: -3 external experts drafted technical reports on toxicology/intake of fluoride/risks & benefits -External peer-review of technical reports by 3 experts (2006). -Expert Panel Meeting with 6 experts & stakeholders (2007). -Findings & Recommendations of Expert Panel Meeting (2008). http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluorure/index-eng.php -Guideline Technical consultation document prepared -2 month national public consultation undertaken (2009) http://www.hc-sc.gc.ca/ewh-semt/consult/_2009/fluoride-fluorure/index-eng.php -Approval on the updated technical report received from 2 Federal-Provincial-Territorial Committees -Release of Guideline Technical Document (2010) http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2011-fluoride-fluorure/index-eng.php

Findings & Recommendations from Review Total Daily Intake: General decrease in recent years (Use of supplements has decreased and concentrations of fluoride in infant formulas have decreased); Dental Fluorosis: First 3 years of age is period of most significant concern; Point of concern should be moderate dental fluorosis (Dean’s Index); Other Health Effects: No conclusive evidence related to bone fracture, cancers, intelligence quotient, skeletal fluorosis, immunotoxicity, reproductive and developmental toxicity, genotoxicity and neurotoxicity based on a MAC of 1.5 mg/L. The MAC of 1.5 mg/L for fluoride in drinking water should be reaffirmed. To adopt a level of 0.7 mg/L as the optimal target concentration. http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluorure/index-eng.php

On Health Canada’s process: “Health Canada has established a comprehensive process for developing new guidelines and reviewing existing ones that require an update. The process is consultative, transparent, and based on risk and science.” Commissioner on Environment and Sustainable Development in his report tabled in September 2005. http://www.oag-bvg.ca/internet/English/parl_cesd_200509_e_14951.html#ch4hd4a

Does Fluoride in water cause fluorosis? Fluorosis → 6-12 years old Normal teeth Questionable* Very Mild Mild Moderate/Severe** 60% 24% 12% 4% <0.3% * ill defined and could be due to antibiotic usage, infection, severe fever, trauma etc. http://www.fptdwg.ca/English/e-coments.html Note: - Initial WHO central calibration Recalibration at mid-point of each site Recalibration before end ** Statistics Canada criteria for withholding reporting value: Highly unstable numbers (<10) Coefficient of variation >33.3% http://www.statcan.gc.ca/edu/power-pouvoir/ch12/5214876-eng.htm

Fluoride facts: Is drinking water safe with recommended fluoride levels? Yes!! Health Canada’s “Fluoride in Drinking Water Guidelines Technical Document” 2011. Australian National Health and Medical Research Council’s “A systematic review of the efficacy and safety of fluoridation” 2007. US National Research Council’s “Fluoride in Drinking Water: A Scientific Review of EPA’s Standards Committee on Fluoride in drinking water, Board on Environmental Studies and Toxicology” 2006. Examples of acute/chronic toxicity

HFSA- Hydrofluorosilicic Acid Is the form of Fluoride that is added to the water safe? Yes!! The European Unions’ Scientific Committee on Health and Environmental Risks (SCHER) “Critical reviews of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridating agents of drinking water” 2010. KEY: Hydrolysis is rapid and the release of fluoride is complete. NSF standard 60: impurities are below levels that could pose a risk to human health.

Question- If most of our water does not get consumed but goes to lawns and other uses, how could it save money? CDC study $1 saves $38 in care Review of 564 studies (Jan 1995- Nov 2013)* Per capital annual benefit $5.49 to $93.19 Benefit cost ratios 1.12:1 to 135:1 *American Journal of Preventive Medicine- Systematic Reviews: Economic Evaluation of Community Water Fluoridation- Ran Tao, Chattopadhyay SK., March 2016 (Similar advantages seen from Quebec’s Institut National de Santé Publique’s; “Water Fluoridation: An analysis of the health benefits and risks” 2007.)

Does Fluoride reduce children’s IQ? From 1940s to 1990s the average IQ scores of Americans improved 15 points.* From 1951 to 2012, fluoridation increased from 3.3% of the population to 67.1% ** (75% of those on community water systems) In the last 20 years of records in the US (1992-2012), those on community water systems drinking fluoridated water increased by 66M. * http://americanscientist.org/issues/non2/rising-scores-on-intelligence-tests/1 **US Centres for Disease Control and Prevention www.cdc.good/fluoridation/statistics/forgrowth.html

Conclusions Health organizations recognize the benefits of community water fluoridation and support it as a safe and effective method to prevent tooth decay Water fluoridation at the recommended fluoride levels is safe, and the existing evidence does not support it causing health problems. Municipalities have the legal authority to add fluoride to the water and safeguards are in place to ensure the recommended levels are maintained. Mayor and Council made the correct decision in 2013 and it is hoped this Mayor and Council will do the same.