1. Community Water Fluoridation Community Water Fluoridation Maintaining a Legacy of Healthy Teeth in Ontario Dr. Charles Gardner, Medical Officer of Health, CIHR Strategic Training Program in Public Health Policy Public Health Policy Rounds January 24, 2014

2. Acknowledgement Dr. Dick Ito, Dental Consultant for SMDHU, Assistant Professor at the University of Toronto, Faculty of Dentistry, and Past President for the Ontario Association of Public Health Dentistry

3. Declaration I am the Medical Officer of Health, Simcoe Muskoka District Health Unit We have had substantial challenges in maintaining community water fluoridation in Simcoe Muskoka (SM) Until 2012, 7% of the population in SM received community water fluoridation (CWF) Since October, three municipal councils for communities in SM have decided to discontinue CWF…

4. Presentation Position Provincial Leadership for Water Fluoridation NOW THEREFORE BE IT RESOLVED THAT the Province of Ontario should amend regulations of the Safe Drinking Water Act requiring community water fluoridation for all municipal water systems (when source-water levels are below the Health Canada-recommended level of 0.7 mg/L) to prevent dental caries; AND FURTHER THAT the Province should provide the funding and technical support to municipalities required for community water fluoridation.

5. Decay has a substantial burden of illness Tooth decay is the most common childhood health condition Recent Ontario study: there are more ER visits for non- traumatic dental problems than for diabetes and high blood pressure diseases 1 Dental and other infections – not only affect teeth and gums, but there’s potential for spread to other parts of mouth and face Studies have shown that poor oral health impacts children’s development: Limits food choices Impairs speech development Repeated absences from school Trouble concentrating or learning Loss of self-esteem (appearance and poor school performance) 1 Community Dentistry and Oral Epidemiology, August 2009 University of Toronto, Faculty of Dentistry. Water Fluoridation; Questions and Answers (April 2012).

6. The prevention of tooth decay Fluoridation makes a contribution Oral hygiene – including fluoridated toothpaste (precaution re excessive quantities and swallowing in young children) Healthy diet – reduced sugar content Dental care – pit and fissure sealants, scaling, fluoride applications Social determinants of health – income, demographics, dental insurance coverage Community water fluoridation

7. Reductions in Dental Decay Over Time

8. Source: Simcoe Muskoka District Health Unit Oral Health Report Focus on Health 2009 Local concern – a recent upward trend Data Sources: Dental Indices Survey, extracted August 2008 and SMDHU Screening Data (2009-2011) Results from the 1993-94 Ontario Dental Health Indices Survey. PHERO 1996:355-35. Ontario Association of Public Health Dentistry (OAPHD) Survey of Ontario Health Units, August 2008.

9. Fluoridation / Dental Caries in Ontario

10. Hospitalized Pediatric Dental Surgery Notes Quebec elected to not participate in this study. Analyses of ECC day surgery visits by neighbourhood attributes (rurality, MDI and size of the immigrant or Aboriginal population) exclude residents for whom these attributes could not be calculated. Rates were calculated by dividing the number of procedures found in the pooled two-year cohort by the sum of the combined two-year subpopulation estimate. Sources Discharge Abstract Database and National Ambulatory Care Reporting System, 2010–2011 and 2011–2012, Canadian Institute for Health Information; CANSIM Table 051-0001, Geozones Aboriginal File and 2006 Census, Statistics Canada. 3.1 x 3.9 x 8.6 x as high for children from rural (versus urban) neighbourhoods as high for children from the least (versus the most) affluent neighbourhoods as high for children from neighbourhoods with high (versus low) Aboriginal populations

11. What is fluoride and fluoridation? Fluoride is a mineral that naturally occurs in rocks, soil, and water. –Fluoride makes the outer layer of teeth (the enamel) stronger. –Hydrofluorosilicic acid used for CWF. Produced during phosphate production – National Sanitation Foundation standards. Fluoridation: adding fluoride to municipal water supply to the concentration range to optimize dental benefits while avoiding adverse effects. –Health Canada Maximum Allowable Concentration is 1.5 parts per million. (mg/L) Recommended 0.7 mg/L for dental benefits. Supported by measurements of fluoride consumption rates for children and adults.

12. The Legality of Fluoridation in Ontario Municipal councils are legally authorized under the Fluoridation Act to “establish, maintain and operate, a fluoridation system in connection with the waterworks system”. Safe Drinking Water Act: 0.5 to 0.8 mg/L fluoride required for CWF.

13. The Effectiveness and Safety of CWF: Systematic Reviews Guidelines for Canadian Drinking Water Quality: Guideline Technical Document - Fluoride Prepared by the Federal-Provincial-Territorial Committee on Health and the Environment December 2010 Health Canada Expert Panel, 2007. Health Canada Expert Panel, 2007 Water Fluoridation: An Analysis of the Heath Benefits and Risks, Institut National de Sante Publique Du Quebec, 2007 A Systematic Review of the Efficacy and Safety of Fluoridation. National Health and Medical Research Council, Australian Government, 2007 A Systematic Review of the Efficacy and Safety of Fluoridation Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. US CDC, 2001 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States Forum on Fluoridation. Ireland, 2001 Forum on Fluoridation Oral Health in America: A Report of the Surgeon General, 2000 Oral Health in America Systematic Review of Water Fluoridation. UK/International study, 2000 Systematic Review of Water Fluoridation

14. Effectiveness of CWF Review of studies comparing communities with and without community water fluoridation, meeting selection criteria for relevance and quality Outcomes: –35 original studies (2 systematic reviews): before-after, cross sectional, prospective / retrospective cohort, time series studies –14.3% - 15.5% increase in children free of dental decay –Reduction of 2.61 decayed / missing / filled teeth per child A Systematic Review of the Efficacy and Safety of FluoridationA Systematic Review of the Efficacy and Safety of Fluoridation. National Health and Medical Research Council, Australian Government, 2007

15. Change in proportion (%) of children without caries in fluoridated compared with non-fluoridated areas (mean difference and 95% confidence interval) Source: Systematic review of water fluoridation. BMJ 2000;321;. McDonagh, M. et al

16. Change in decayed, missing, and filled teeth for primary/ permanent teeth (mean difference and 95% confidence interval) Source: Systematic review of water fluoridation. BMJ 2000;321;. McDonagh, M. et al

17. Comparing Ontario and Quebec caries Prov6-yr-olds6 -11-yr-olds12-19-yr-olds defDMF>0Mean defDMF defDMF>0Mean defDMF DMF>0Mean DMF Que47.52.4255.02.3562.82.82 6.4% F27%13%19.5% Ont37.31.9050.12.0856.42.36 75.9% F Goel, V. Analysis of the Globe and Mail Article on Fluoridation. May 15, 2010 Oral Health Component Results Canada Health Measures Survey 2007-9

18. Johnston, J. Executive Director of the British Columbia Dental Association to the Board of Directors. May 28, 2010 Comparing Canada to BC

19. CWF: Tooth Decay and Social Deprivation British Fluoridation Society, One in a Million: the facts about water fluoridation. 3 rd Ed. March 2012. www.bfsweb.org/onemillion2012.htmlwww.bfsweb.org/onemillion2012.html

20. CWF is highly cost effective. Tchouaket E, Brousselle A, Fansi A, Dionne PA, Bertrand E, Fortin C. The economic value of Quebec’s water fluoridation program..J Public Health, published online: June 2013; Cobiac LJ, Vos T. Cost-effectiveness of extending the coverage of water supply fluoridation for the prevention of dental caries in Australia. Community Dent Oral Epidemiol 2012; 40: 369–376; Kroon J, Van Wyk PJ. A retrospective view on the viability of water fluoridation in South Africa to prevent dental caries. Community Dent Oral Epidemiol 2012; 40: 441–450; Campain AC, Marino RJ, Wright FAC, Harrison D, Bailey D, Morgan MV. The impact of changing dental needs on cost savings from fluoridation. Australian Dental Journal 2010; 55: 37–44; Kumar JV, Adekugbe O, Melnik TA. Geographic Variation in Medicaid Claims for Dental Procedures in New York State: Role of Fluoridation Under Contemporary Conditions. Public Health Reports / September–October 2010 / Volume 125; Griffin SO, Jones K, Tomar SL. An Economic Evaluation of Community Water Fluoridation. J Public Health Dent 2001;61(2):78-86.

21. CWF greatly reduces dental program $ Spending for Dental Programs Health Unit and Municipal Costs (2009-10) Health Unit Halton – 90% Fluoridated Simcoe Muskoka – 7% Fluoridated CINOT Spending 2010 (25% Municipal dollars) $381,555 ($95,389) $1,040,050 ($260,013) OW Dental <18 Yr Spending 2010 (20% Municipal dollars) $148,380 ($29,676) $555,902 ($111,180) OW Dental Adult Spending 2009 (20% Municipal dollars) $225,107 ($45,021) $357,501 ($71,500) OW Adult dentures 2009 (20% Municipal dollars) $160,360 ($32,072) $654,603 ($130,921) Total Spending (Municipal Dollars) $915,402 ($202,158) $2,608,066 ($573,614) CINOT = Children in Need of Treatment (Dental Program); OW = Ontario Works (Dental Program)

22. Alternatives are very expensive (3 to 50 times greater): Muskoka Target PopulationNumber Annual Budget One Time Cost (e.g. dental equipment, etc.) Option 1 – Cost of Topical Application of Fluoride by Public Health Dental Hygienists Twice per Year plus Promotion of Service All children, all seniors + adults under LICO (Low Income Cut Off) 25,680$1,143,274$1,317,127 All children + all adults under LICO14,300$636,636$733,447 All people under LICO2,985$132,892$153, 101 Option 2 – Cost of Topical Application of Fluoride by Private Dentists Twice per Year plus Promotion of Service All children, all seniors + adults under LICO (Low Income Cut Off) 25,680$2,468,618$22,598 All children + all adults under LICO14,300$1,374,659$12,584 All people under LICO2,985$286,948$2,627 Annual Cost of Fluoridation in Muskoka = $43,200

23. Dental fluorosis Fluorosis occurs with increased levels of fluoride consumption Prevalence of visually apparent fluorosis is very low with community water fluoridation (0.3% moderate to severe fluorosis) Prevalence of moderate dental fluorosis in Canada is low and declining since 1996 No increase in moderate / severe fluorosis with infant formula feeding Vermont Department of Health

24. Proportion of population with fluorosis of aesthetic concern by water fluoride concentration (plotted on untransformed scale because of linear association between this and log (odds) of “aesthetic fluorosis”). Each circle represents a study area in which the proportion of people with fluorosis is estimated—the larger the circle, the higher the precision of the estimate. Source: Systematic review of water fluoridation. BMJ 2000;321;. McDonagh, M. et al. Dental fluorosis

25. Fluorosis in Canada Report on the Findings of the Oral Health Component of the Canadian Health Measures Survey 2007-9. Health Canada 2010 *Only 3 cases of moderate/severe fluorosis and all had recently immigrated to Canada from countries that had high naturally- fluoridated water supply.

26. Safety of community water fluoridation The evidence does not support a link between exposure to fluoride in drinking water at 1.5 ppm and any adverse health effects, including: –Cancer McDonagh review (2000) of 26 studies: 24 found no increase, 1 found an increase, 1 found a reduction in cancer rates Osteosarcoma – Bassin study (2006) found an increase for 7 year-old boys – Douglas letter (2006), larger data set found no increase. Kim study (2011) with more accurate exposure measurements (bone fluoride concentrations) found no increase in cancer Fluoride in Drinking Water. Prepared by the Federal-Provincial-Territorial Committee on Drinking Water. Health Canada. Comment period ended November 27, 2009: http://www.hc-sc.gc.ca/ewh-semt/consult/_2009/fluoride-fluorure/draft-ebauche-eng.php#t5http://www.hc-sc.gc.ca/ewh-semt/consult/_2009/fluoride-fluorure/draft-ebauche-eng.php#t5 An Assessment of Bone Fluoride and Osteosarcoma. Kim et al. J Dent Res 90(10):1171-1176, 2011.

28. Bone fractures A Systematic Review of the Efficacy and Safety of Fluoridation National Health and Medical Research Council, Australian Government, 2007: –Based on the Jones (21 studies), McDonagh (27 studies) and the Demos (27) reviews –Ecological, cross sectional, cohort and case control studies –Finds: “U-shaped curve” – possible reduction in fractures with water fluoride at 1 PPM compared to lower or higher (4.3 to 7.9) concentrations

29. Safety of community water fluoridation The evidence does not support a link between exposure to fluoride in drinking water at 1.5 ppm and any adverse health effects, including: –Immunotoxicity –Reproductive / developmental toxicity –Genotoxicity –Fractures / skeletal fluorosis –Neurotoxicity / intelligence Studies of communities in China, Mexico – high fluoride concentrations, other causal factors (eg. lead, iodine) not reported “There are significant concerns regarding the available studies, including quality, credibility, and methodological weaknesses.” Fluoride in Drinking Water. Prepared by the Federal-Provincial-Territorial Committee on Drinking Water. Health Canada. Comment period ended November 27, 2009: http://www.hc-sc.gc.ca/ewh-semt/consult/_2009/fluoride-fluorure/draft-ebauche-eng.php#t5http://www.hc-sc.gc.ca/ewh-semt/consult/_2009/fluoride-fluorure/draft-ebauche-eng.php#t5 Critical review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridating agents of drinking water. Scientific Committee on Health and Environmental Risks. European Commission. 2010.

30. Support for community water fluoridation Ontario Ontario Association of Public Health Dentistry Royal College of Dental Surgeons of Ontario Chief Medical Officer of Health of Ontario Ontario Medical Association Association of Local Public Health Agencies (alPHa) Ontario Dental Association Ontario College of Dental Hygienists Canada Health Canada Canadian Association of Public Health Dentistry Canadian Dental Association Canadian Public Health Association Canadian Pediatric Society Canadian Cancer Society International World Health Organization (WHO) Pan American Health Organization (PAHO) Centers for Disease Control and Prevention (CDC) Recent US Surgeon General’s Report Federation Dentaire Internationale (FDI) American Cancer Society American Medical / Dental Associations

31. Individual choice vs. population benefit Wellesley Institute: –“Due to the oral health benefits of fluoride and the safe, equitable, and cost-effective nature of water fluoridation, Wellesley Institute recommends that water fluoridation be continued by municipalities or instituted if it has not been.” Public Health Ethics Committee (CESP) of the Institut National de Sante Publique du Quebec: –“The benefits of fluoridation outweigh its potential negative effects on health and the environment and that such benefits justify impinging on the freedom of choice of people who do not wish to have their water fluoridated. This opinion offers ways to mitigate these negative consequences on target populations; these include informing and consulting the public and inviting it to participate in the process”

32. Public Support for CWF in Ontario

33. Fluoridation history 1945: –In January added to Grand Rapids, Michigan water system –First Canadian City – Brantford, Ontario –1945- 1962: Brantford – Stratford – Sarnia study By 1950: –Community water fluoridation (CWF) was official US Public Health Service policy By 1960: –50 million Americans were on CWF Between 1971 and 1991 –The prevalence of any dental caries among children aged 12--17 years declined from 90.4% to 67%; severity declined from 6.2 decayed / missing / filled teeth to 2.8 per child http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm By 2006: –69% of U.S. population on public water systems were getting fluoride (includes 3% on naturally fluoridated municipal water); 62% of the total population Present –76 % of Ontarians receive fluoridated municipal water

34. Social history and fluoridation 1950s and early 60s: Generally thought of as high points of scientific optimism and faith in experts. Reality was growing anxiety about medical and scientific progress and expert opinion –Concerns over nuclear fallout –DDT and other pesticides –Doctors and dentists might be influenced by large corporations –Further research would show more dangers not yet known –Also a persistent interest in alternative medicine –CWF was a flashpoint and cities across the U.S. and Canada debated whether or not to do it Late 1960s and early 1970s: –Revolt against experts more pronounced –Political arguments had appeal for people on both the right (e.g. individual rights) and the left (e.g. environmentalists)

35. Opposition issues –1950 to today Health Allegations: fluoride accumulates in the body; people are allergic; it causes cancer, heart disease, kidney disease, damages intelligence, skeletal fluorosis; environmental toxicity; etc Industrial Allegations: it’s a “toxic hazardous waste product of the aluminum and fertilizer industries”; it’s a means for industry to get rid of toxic waste which is very expensive to get rid of properly Civil Libertarian Issues: a conflict between individual rights and the common good; forced “medication” without consent (legal challenges raised) Led by: (a few) doctors, dentists, researchers; alternative medical practitioners; health food store operators; members of religious and political minority groups

37. Declining Fluoridation Coverage in ON In Ontario, 76% of the population received fluoridated community water in 2007 (Health Canada) CWF Discontinued: Niagara Region, Waterloo, Lakeshore, Amherstburg, Windsor, Tottenham, Muskoka District, Lake of Bays Township, and Huntsville 3.66% of population affected Reviewed and decided not to commence: Thunder Bay, Dryden, and Orillia Reviewed and maintained: Atikokan, Norfolk County, Toronto, Hamilton, Peel, Halton, London, Carleton Place, Cornwall, West Nipissing, Petrolia, Lambton Shores, Point Edward, Warwick, Georgian Bay Township, Muskoka Lakes Township, and Gravenhurst.

38. State and national government mandated CWF Jurisdictions that have legislated fluoridation at the state, territorial or national level of government have been much more effective in providing CWF to their respective municipal populations – with resulting reductions in dental decay. USA – 13 States, DC, Puerto Rico mandate CWF California: increase in population coverage from 17% in 1995 to 62.5% in 2011 Australia – 7 of 9 States mandate CWF. 80% population fluoridated Queensland increased population coverage from 5% in 2008 to 86% in 2012 – has since discontinued state mandated CWF resulting in 18 municipalities discontinuing CWF. Countries mandating CWF: Brazil, Hong Kong, Singapore, Ireland, Malaysia, Israel (until 2014)

39. Provincial financial & legislative support “The Association of Local Public Health Agencies call for the Province of Ontario to provide support, including provincial legislation and funding to municipalities for the fluoridation of community drinking water.” RNAO and OPHA: “that the regulations of the Safe Drinking Water Act be amended to mandate the fluoridation of municipal drinking supplies at the optimal concentration of 0.7 ppm or a range of 0.5 ppm to 0.8 ppm.”

40. Provincial Financing as an Incentive Wellesley Institute: –“The provincial government also has a key role to play in ensuring that individuals have access to fluoridated water wherever they live and enabling municipalities across the province to be able to deliver it by subsidizing costs where necessary.”

41. Motion of the SMDHU Board of Health NOW THEREFORE BE IT RESOLVED THAT the Province of Ontario should amend regulations of the Safe Drinking Water Act requiring community water fluoridation for all municipal water systems (when source-water levels are below the Health Canada-recommended level of 0.7 mg/L) to prevent dental caries; AND FURTHER THAT the Province should provide the funding and technical support to municipalities required for community water fluoridation.

42. Thank you!

43. Premises Dental decay has a substantial burden of illness in Ontario, despite gains made over the past half century, and is much greater in low- income populations. The evidence is strong that community water fluoridation (CWF) is a substantial contributor to the prevention of dental decay, with enhanced benefit for low-income populations. The overall evidence does not support that there are negative health effects from CWF. CWF is highly cost effective, saving substantial costs in health care.

44. Premises The population health and health equity benefits of CWF justify the associated compromise on individual choice (and there are many other examples of such collective solutions in society). Despite the above, there is a substantial movement of opposition on the basis of a strong ideology of individual choice and of distrust of central authority. Under the Ontario Fluoridation Act, the decision of fluoridate community water supplies is made by municipal governments. In recent years a number of communities have discontinued CWF in Ontario (and in other provinces), and many others have never had CWF, because of political opposition.

45. Premises Jurisdictions that have legislated fluoridation at the state, territorial or national level of government have been more effective in providing CWF to their respective municipal populations – with resulting reductions in dental decay. Given the very low cost of fluoridation ($1 per person per year), the provision of financial support alone from the province for fluoridation is unlikely to sufficiently motivate the provision of CWF by municipalities. alPHa, OPHA, OAPHD and RNAO have all called for the province to provide financial and legislative support for CWF.

46. Motion of the SMDHU Board of Health NOW THEREFORE BE IT RESOLVED THAT the Province of Ontario should amend regulations of the Safe Drinking Water Act requiring community water fluoridation for all municipal water systems (when source-water levels are below the Health Canada- recommended level of 0.7 mg/L) to prevent dental caries; AND FURTHER THAT the Province should provide the funding and technical support to municipalities required for community water fluoridation.