A Tennessee Perspective on Community Water Fluoridation David E. Brumley, DDS, MPH South Central Region November 16, 2006

Community Water Fluoridation Centers for Disease Control and Prevention Community water fluoridation is one of ten great public health achievements of the 20 th century. MMWR April 2, 1999, Vol. 48 (12)

Community Water Fluoridation What is water fluoridation? Small amounts of fluoride are present naturally in all water sources.Small amounts of fluoride are present naturally in all water sources. Water fluoridation is the precise adjustment of the natural fluoride concentration in a public water supply up to the level recommended for preventing tooth decay.Water fluoridation is the precise adjustment of the natural fluoride concentration in a public water supply up to the level recommended for preventing tooth decay. The USPHS has established the optimal concentration for fluoride in water supplies in a range of 0.7 to 1.2 parts per million.The USPHS has established the optimal concentration for fluoride in water supplies in a range of 0.7 to 1.2 parts per million.

At the turn of the 20 th century, Dr. Fredrick S. McKay moved from Philadelphia to Colorado Springs, Colorado and opened a dental practice.At the turn of the 20 th century, Dr. Fredrick S. McKay moved from Philadelphia to Colorado Springs, Colorado and opened a dental practice. He noticed that many of his patients exhibited a peculiar condition referred to along the Continental Divide as Colorado Brown Stain.He noticed that many of his patients exhibited a peculiar condition referred to along the Continental Divide as Colorado Brown Stain. In 1908, he initiated a study and found that this condition was prevalent among long-term residents who were born in the area. It was also endemic to other communities along the Continental Divide.In 1908, he initiated a study and found that this condition was prevalent among long-term residents who were born in the area. It was also endemic to other communities along the Continental Divide. Dr. McKay and Dr. G.V. Black wrote the first detailed clinical description of mottled enamel which is now termed fluorosis.Dr. McKay and Dr. G.V. Black wrote the first detailed clinical description of mottled enamel which is now termed fluorosis. Historical Perspective

In 1928, Dr. McKay discovered the agent in the drinking water that caused mottled enamel also inhibited dental caries.In 1928, Dr. McKay discovered the agent in the drinking water that caused mottled enamel also inhibited dental caries. In 1931, Dr. McKay sent samples of this water to an Alcoa chemist named H.V. Churchill who identified the causative agent as fluoride.In 1931, Dr. McKay sent samples of this water to an Alcoa chemist named H.V. Churchill who identified the causative agent as fluoride. In the 1930s, Dr. McKay and Dr. H. Trendley Dean of the USPHS collaborated to explore the possibility of adjusting the level of fluoride in drinking water to reduce dental caries.In the 1930s, Dr. McKay and Dr. H. Trendley Dean of the USPHS collaborated to explore the possibility of adjusting the level of fluoride in drinking water to reduce dental caries. In the 1940s, four classic studies were begun which proved the benefits of adding fluoride to community water supplies.In the 1940s, four classic studies were begun which proved the benefits of adding fluoride to community water supplies. Grand Rapids, MI – Muskegon, MI Grand Rapids, MI – Muskegon, MI Newburgh, NY – Kingston, NY Newburgh, NY – Kingston, NY Evanston, IL – Oak Park, IL Evanston, IL – Oak Park, IL Brantford, Ontario – Sarnia, Ontario Brantford, Ontario – Sarnia, Ontario Historical Perspective

When Fluoridation is Discontinued

BristolCrossvilleCookevilleClevelandChattanoogaCowanLawrenceburgNashvilleParis

Milan, Tennessee In March 1951, Milan became the first city in Tennessee and the second city in the Southeast to adjust the level of fluoride in its community water supply for the prevention of dental caries.In March 1951, Milan became the first city in Tennessee and the second city in the Southeast to adjust the level of fluoride in its community water supply for the prevention of dental caries. As a result, five years later in 1956, the six-year-old Milan children had a 57 percent reduction in dental caries in their permanent teeth compared to the 1951 same-age cohort.As a result, five years later in 1956, the six-year-old Milan children had a 57 percent reduction in dental caries in their permanent teeth compared to the 1951 same-age cohort. In addition, when compared to their counterparts in Humboldt and Trenton – two neighboring nonfluoridated cities – the 1956 Milan six-year-olds had a 62 percent and 70 percent reduction in dental caries, respectively.In addition, when compared to their counterparts in Humboldt and Trenton – two neighboring nonfluoridated cities – the 1956 Milan six-year-olds had a 62 percent and 70 percent reduction in dental caries, respectively.

97 percent of tooth enamel is composed of hydroxyapatite.97 percent of tooth enamel is composed of hydroxyapatite. When fluoridated water is ingested, the fluoride ion (F - ) readily replaces the hydroxyl ion (OH - ) during enamel formation of the tooth.When fluoridated water is ingested, the fluoride ion (F - ) readily replaces the hydroxyl ion (OH - ) during enamel formation of the tooth. Hydroxyapatite Ca 5 (PO 4 ) 5 OH then becomes a compound called fluorapatite Ca 5 (PO 4 ) 3 F.Hydroxyapatite Ca 5 (PO 4 ) 5 OH then becomes a compound called fluorapatite Ca 5 (PO 4 ) 3 F. Fluorapatite at the enamel surface is less soluble and more resistant to acids produced by cariogenic bacteria.Fluorapatite at the enamel surface is less soluble and more resistant to acids produced by cariogenic bacteria. Systemic Effect of Drinking Fluoridated Water

Community Water Systems >50 water treatment chemicals used for: DisinfectionDisinfection AbsorptionAbsorption DechlorinationDechlorination Algae controlAlgae control OxidationOxidation Metal coagulationMetal coagulation Water softeningWater softening Filtration pH control Iron control Coagulation Corrosion control Decolorization Fluoridation

Water Fluoridation Chemicals Sodium Fluoride (NaF)Sodium Fluoride (NaF) –Crystalline powder –Relatively constant (low) solubility –pH 7.6 –Saturator Systems Sodium Fluorosilicate (Na 2 SiF 6 )Sodium Fluorosilicate (Na 2 SiF 6 ) –Crystalline powder –Solubility varies with water temperature –pH 3.5 –Dry-feed Systems Fluorosilicic Acid (H 2 SiF 6 )Fluorosilicic Acid (H 2 SiF 6 ) –Liquid –Infinite solubility –pH 1.2 –Venturi Systems

Community Water Fluoridation Is it safe? Acute fatal poisoning (CLD) in adults requires the ingestion of grams of fluoride in a hour time frame.Acute fatal poisoning (CLD) in adults requires the ingestion of grams of fluoride in a hour time frame. In drinking fluoridated water at 1.0 ppm, an adult would have to drink 660 gallons in hours to reach the lower limit of a fatal dose.In drinking fluoridated water at 1.0 ppm, an adult would have to drink 660 gallons in hours to reach the lower limit of a fatal dose. A 10kg child ( months of age) would have to drink 85 gallons of fluoridated water (1.0 ppm) in hours to reach the lower limit of a fatal dose.A 10kg child ( months of age) would have to drink 85 gallons of fluoridated water (1.0 ppm) in hours to reach the lower limit of a fatal dose.

Community Water Fluoridation What are the costs? $0.50 per person Average annual cost of water fluoridation in the U.S. Systems serving 2,000 or less = $ $1.16 per person per year Systems serving 2, ,000 = $ $0.95 per person per year Systems serving 100,000 = $ $0.21 per person per year In most communities, every $1 invested in fluoridation saves $38 to $80 in dental treatment costs.

Healthy People 2010 Goal 75% States Currently Meeting Goal = 24 States range from: 2.3% (Utah) to 100% (Kentucky, Rhode Island, South Dakota, & the District of Columbia) CDC Fluoridation Status, 2002 Community Water Fluoridation Status

10 states, Puerto Rico, and the District of Columbia mandate statewide fluoridation through legislation.10 states, Puerto Rico, and the District of Columbia mandate statewide fluoridation through legislation. –California, Connecticut, Delaware, Georgia, Illinois, Minnesota, Nebraska, Nevada, Ohio, South Dakota Kentucky mandates statewide fluoridation through administrative regulation.Kentucky mandates statewide fluoridation through administrative regulation. Tennessee has a voluntary process with an emphasis on education rather than legislative mandate.Tennessee has a voluntary process with an emphasis on education rather than legislative mandate.

Tennessee(2005) United States (2002) Percentage of total population receiving fluoridated water 89.7%60.5% Percentage of population on public water system receiving fluoridated water 96.0%67.3% Community Water Fluoridation Status Healthy People 2010 Goal 75.0%

Public Water System Source:

Total Population Source:

Tennessees Water Systems 532 Approved Systems 214 Fluoridating Systems 118 Consecutive Systems 332 Fluoridated Systems

Tennessees 50-Year Fluoridated Cities MilanCookevilleNashvilleKingsport BrownsvilleCowanMurfreesboroLinden ClevelandLawrenceburgWoodburyLebanon GermantownCrossvilleLewisburgRipley Bristol Union City SpringfieldHartsville Chattanooga Oak Ridge Shelbyville ParisWinchesterDresden

Tennessees Largest Non-Fluoridating Systems SystemCountyPopulation South Blount Blount30,725 Lincoln County #1 Lincoln16,643 Poplar Grove Tipton16,043 OcoeeBradley13,313 Pleasant View Cheatham11,846 Watts Bar Rhea9,001 First Utility District Tipton8,479 County Wide Crockett8,258 First Utility District Carter6,951 Mount Pleasant Maury6,220

East Tennessee Dental Health Survey 15 ETR counties 62 communities 65 schools 17,256 children