1. Community Water Fluoridation Community Water Fluoridation Maintaining a Legacy of Healthy Teeth in Muskoka Dr. Charles Gardner, Medical Officer of Health Bracebridge Public Meeting December 17 th, 2013

2. Oral health is important Dental decay is the most common chronic health condition in children Poor oral health impacts children’s development Affects up to 96% of adults in Canada (average of over 10 teeth affected). 1, 2 Those of lower income are at increased risk of dental decay 1. Nelson, W E. Textbook of Pediatrics. Philadelphia: WB Saunders, 1996. p. 628. Vol. 15. 2. Health Canada. Report on the Findings of the Oral Health Component of the Canadian Health Measures Survey 2007-2009. Ottawa : 2010.

3. Health Unit’s mandate To protect and promote health and prevent disease in Simcoe Muskoka Oral health services includes screening in schools, treatment of low income families

4. Community water fluoridation in Muskoka Most Muskoka communities fluoridated since 2004 Muskoka’s children have a lower rate of tooth decay compared to the unfluoridated communities in Simcoe County (SMDHU screening data, 2011-2013) Systematic reviews conclude that community water fluoridation is a safe and effective way to reduce tooth decay

5. Fluoridation: A challenging, polarizing issue Perceived health risks Vulnerable groups such as infants / children Industrial source Distrust of health, science and government authorities Concerns regarding legality and rights Health unit goal: to provide accurate, valid, science-based information and advice

6. Reviewing the research Systematic Reviews To answer a question –Example: Does fluoridation cause cancer? Examines all relevant articles Considers the quality of articles Draws conclusions based on the overall findings of studies of acceptable quality Selective Reviews To prove a point Picks and chooses articles to support the point to be made No quality criteria

7. Major systematic reviews on fluoridation Health Canada Expert Panel, 2007 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 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 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

8. Effectiveness of community water fluoridation 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

9. Children benefit from community water fluoridation

10. Benefits increase with age

11. 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 Findings and Recommendations of the Fluoride Expert Panel. Health Canada. January 2007: http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluorure/index-eng.php http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluorure/index-eng.php Health Canada. Report on the Findings of the Oral Health Component of the Canadian Health Measures Survey 2007-2009. Ottawa : 2010.

12. 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.

13. 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.

14. Muskoka  Muskoka-Simcoe Dental Society  North Simcoe Muskoka LHIN Leadership Council 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 Support for community water fluoridation

15. Public support in Muskoka

16. Other considerations A collective solution to help reduce dental decay Inexpensive and cost effective Can reduce public dental costs by more than half –Simcoe Muskoka: $2,608,066 –Halton: $915,402 Alternatives (e.g. topical fluoride applications) cost between 3 to 50 times more and still do not reach everyone

17. Conclusions Children in Muskoka and Bracebridge have reduced dental decay in part due to community water fluoridation Community water fluoridation is a safe and cost-effective public health measure that addresses inequalities in oral health and benefits all members of the community Continuing community water fluoridation is recommended to help maintain the good oral health of the citizens of area municipalities in Muskoka For more information visit the health unit’s website at www.simcoemuskokahealth.org www.simcoemuskokahealth.org

19. Community Water Fluoridation greatly reduces public dental program costs. Data: 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)

20. Alternatives to Water Fluoridation are very expensive (up to 50 times greater). Target PopulationNumberAnnual BudgetOne 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 A - All children, all seniors + adults under LICO (Low Income Cut Off) 25,680$1,143,274$1,317,127 B – All children + all adults under LICO 14,300$636,636$733,447 C – All people under LICO 2,985$132,892$153, 101 Option 2 – Cost of Topical Application of Fluoride by Private Dentists Twice per Year plus Promotion of Service D - All children, all seniors + adults under LICO (Low Income Cut Off) 25,680$2,468,618$22,598 E – All children + all adults under LICO 14,300$1,374,659$12,584 F – All people under LICO 2,985$286,948$2,627 Annual Cost of Fluoridation in Muskoka = $43,200