Community Water Fluoridation 1 Acknowledgements to the New York State Department of Health, Bureau of Dental Health for parts of this presentation.

Tooth Decay 2 Infection Extreme pain Difficulty in chewing Poor weight gain Difficulty concentrating Crooked teeth Missed school hours Predictor of caries in later life Costly treatment Root cavity

Why Fluoridation?  Fluoridated communities have 20%- 40% less tooth decay  Single most effective intervention  Saves money: every dollar spent on water fluoridation avoids on average $38 - $42 in dental care  Benefits all consumers across socio- economic status  Benefits children and adults  Benefits last a lifetime 3

Then there are the dental costs: A single- surface filling can costs nearly $100 nowadays. For that reason alone – because the county pays part of its Medicaid patients’ dental bills – Schenectady County should encourage the city to keep fluoridating its water 4 An Example from New York State ….

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) 5

Fluoride Standards in Public Drinking Water Systems in the US  MCL 4 mg/L - around 200,000 people in the US have naturally occurring fluoride concentrations at or exceeding 4 mg/L (the maximum concentration allowed under U.S. Environmental Protection Agency (EPA) standards)  SMCL 2.0 mg/L Another 1.4 million live in areas where F level in water is between 2.0 and 3.9 mg/L. 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 mg/L – *In places where fluoride is artificially added to water, the fluoride concentration is kept at a safe level between 0.7 and 1.2 mg/L. 6

Claims Opponents of community water fluoridation have made claims that optimally fluoridated water can cause an array of health problems including: 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 7

Fluoridation Improves Dental Health Claim: “Fluoridation does not work. A National Survey in 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. 8 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.

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 9

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) 10

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.

12 “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.”

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. 13 MMWR. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis – United States, and August 26, 2005/Vol 54/No. SS-3.

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). 14 Singh et al., 2003; Singh and Spencer, 2004.

Osteosarcoma Claim: “The Bassin study proves fluoridation causes osteosarcoma.” FACT:  A Harvard study has identified a larger sample of subjects with the disease (osteosarcoma) and followed them in time, has taken bone samples and measured fluoride in the bone. It appears that this follow-up study has failed to replicate the findings.  The Bassin study is an explorative study and has limitations. “When this study (Douglass et al.) is published, it should be considered in context with the existng body of evidence to help determine what follow-up studies are needed.” – NRC, 2006  The York Review in 2000 showed "no clear association between water fluoridation and the incidence or mortality of bone cancers, thyroid cancers or all cancers was found." 15 A Systematic Review of Public Water Fluoridation Marian McDonagh et al., 2000.

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.” 16

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) 17

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. 18

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.  There is a theoretical risk for fluorosis if a child predominantly consumes formula mixed with fluoridated water for a prolonged period of time.  Vitamin D is added to milk because mother's milk lacks sufficient amounts. The National Academy of Sciences and the American Academy of Pediatrics recommends that all infants, including those who are exclusively breastfed, have a minimum intake of 200 IU of vitamin D per day beginning during the first 2 months of life. 19 New Guidelines for Vitamin D Intake, Pediatrics Vol. 111 No 4 April 2003.

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." 20

Fluoridation Status Claim: “Communities are putting an end to fluoridation..” FACT: Large Cities/Counties Approving or Implementing Fluoridation ( ) 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 21 Data Source: 2006 CDC Fluoridation Census

Fluoridation Status (con’t) In Maine, about 520,000 people in 133 communities receive fluoridated water:  About 84% of Maine people with public water supplies have fluoridated water  Because 50-55% of Mainers get their water from private wells, only about 38-40% of the total state population has access to this public health benefit

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. 23

Public Policy on Fluoridation Endorsed by key scientific and professional organizations:  American Dental Association  U.S. Public Health Service  American Medical Association  World Health Organization  American Water Works Association And virtually every leading scientific and professional organization in the public health field concerned with oral health 24

What is the alternative? 25

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

Who Says Fluoridation Works? “Fluoridation remains an ideal public health measure based on the scientific evidence in preventing dental decay and its impressive cost- effectiveness.” – David Satcher, MD, PhD Assistant Secretary for Health U.S. Surgeon General

More Resources More information (websites): Maine Oral Health Program:  Maine CDC’s fluoride webpage Maine CDC’s fluoride webpage  US CDC, Division of Oral Health US CDC, Division of Oral Health  American Dental Association American Dental Association  28  American Water Works Association Water Works Association

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