1. Dr. Charles Gardner, Medical Officer of Health,
Muskoka Simcoe Dental Society
May 11th, 2017
Community Water Fluoridation Pursuing a Legacy of Healthy Teeth in Simcoe Muskoka

2. Overview Public Health and Community Water Fluoridation (CWF)
Status of CWF in Simcoe Muskoka
Advocacy for Provincially mandated CWF

3. 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 diseases1
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)
1Community Dentistry and Oral Epidemiology, August 2009
University of Toronto, Faculty of Dentistry. Water Fluoridation; Questions and Answers (April 2012). 3

4. What is fluoride and fluoridation?
Fluoride is a mineral that naturally occurs in rocks, soil, and water.
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.

5. The Effectiveness and Safety of CWF: Systematic Reviews
Water fluoridation to prevent tooth decay Iheozor-Ejiofor et al. Cochrane Database of Systematic Reviews, 2015
Health effects of water fluoridation: An evidence review Health Research Board, 2015
Water fluoridation: Health monitoring report for England Public Health England, 2014
Health effects of water fluoridation: A review of the scientific evidence Prepared by The Royal Society of New Zealand TA, 2014
Guidelines for Canadian Drinking Water Quality: Guideline Technical Document - Fluoride Prepared by the Federal-Provincial-Territorial Committee on Health and the Environment, 2010
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

6. 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% % 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 Fluoridation. National Health and Medical Research Council, Australian Government, 2007

7. CWF: Tooth Decay and Social Deprivation
British Fluoridation Society, One in a Million: the facts about water fluoridation. 3rd Ed. March

8. Prevalence of Tooth Decay: Simcoe Muskoka

9. CWF Safety
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
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:
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

10. Dental fluorosis
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.

11. Support for community water fluoridation
Ontario
Canada
International
Chief Medical Officer of Health of Ontario
Royal College of Dental Surgeons of Ontario
Ontario Dental Association
Ontario Association of Public Health Dentistry
College of Dental Hygienists of Ontario
Ontario Medical Association
Association of Local Public Health Agencies (alPHa)
Health Canada
Public Health Agency of Canada
Canadian Association of Public Health Dentistry
Canadian Dental Association
Canadian Dental Hygienists Association
Canadian Pediatric Society
Canadian Cancer Society
Canadian Public Health Association
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

12. CWF Public Support in Simcoe Muskoka

13. Opposition issues –1950 to today
Health Allegations:
Fluoride accumulates in the body;
Allergies, environmental toxicity;
Carcinogenic, cause of cancer, kidney disease, skeletal fluorosis;
Damages intelligence
Industrial Allegations:
It’s a “toxic hazardous waste product of the aluminum and fertilizer industries”; 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 minority of) doctors, dentists, researchers; alternative medical practitioners; health food store operators; members of religious and political minority groups

15. Declining Fluoridation Coverage in ON
1945: First Canadian City – Brantford, Ontario
: Brantford – Stratford – Sarnia study
2016: 67.3% of Ontario’s population received fluoridated community water (Ontario Ministry of the Environment)
Reviewed and Maintained
Reviewed and Not Commenced
CWF Discontinued
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
Gravenhurst
Thunder Bay
Dryden
Orillia
Niagara Region
Waterloo
Lakeshore
Amherstburg
Windsor
Tottenham
Muskoka District
Lake of Bays Township
Huntsville

16. Simcoe Muskoka: Oral Health Concerns in 2009
Data Sources: Dental Indices Survey, extracted August 2008 and SMDHU Screening Data ( )
Results from the Ontario Dental Health Indices Survey. PHERO 1996:
Ontario Association of Public Health Dentistry (OAPHD) Survey of Ontario Health Units, August 2008.
Source: Simcoe Muskoka District Health Unit Oral Health Report Focus on Health 2009

17. Fluoridation / Dental Caries in Ontario: 2009

18. CWF in Simcoe Muskoka: 2009 vs 2014
Please place a map with the coverage in 2008, showing its presence in the following locations
Tottenham
Base Borden
All of Muskoka

19. Losing Fluoridation in Tottenham
Only CWF ever in Simcoe (apart from federal Base Borden)
Commenced in Tottenham in 1973
Advocacy local dentist, Dr. Gerry Ross
2009: CWF opposition by a New Tecumseth councilor, after reading our focus report
Initial council support for CWF discontinuation
CWF successfully defended by SMDHU, Dr. Ito (with local data), Dr. Keith Morley, Dr. Peter Cooney
2013: Challenged again by same councilor
Unsuccessful joint response (including Dr. Gerry Ross)
Discontinued on October 15, 2013

20. New Tecumseth (excluding Tottenham)
Comparison of Dental Decay in 7-Year-Olds from Tottenham and rest of New Tecumseth
Dental Index
Tottenham
(N = 24)
New Tecumseth (excluding Tottenham)
(N = 87)
DMFT
1.67
2.16
% Caries Free
54%
49% 16

21. Not Gaining Fluoridation in Orillia
Orillia never fluoridated;
Unsuccessfully promoted by community dentists in 1960’s and 1980’s
March 9, 2009 City of Orillia motion to review CWF
SMDHU presentation to new council
Tour of Gravenhurst facility
June 27, 2011 – endorsed review process with City staff
Community engagement and consultation +++ (SMDS Jan/12)
Orillia staff report and motion supportive of CWF
Council defeated motion in July 16th, 2012

22. Orillia’s high rate of child dental decay

23. Elevated severe dental decay in Orillia

24. Muskoka: Losses and Successes
Local fluoridation commenced between 1988 and 2004 – District bylaw, 2003
SMDHU presentations to District Council in response to challenge in April 2011, and October 21, 2013
Oct 21 Council decision to strike District CWF bylaw
Engagement of Area Municipalities
January 20, 2014 District Council Bylaw NO – continued CWF in Bracebridge, Gravenhurst, Townships of Georgian Bay and Muskoka Lakes
September, 2016 – motion to Muskoka Lakes Council to discontinue CWF
Presentations (SMDHU and Dr. Eric Luks) successful in overturning, September 16

25. Protecting CWF: Mandated by State/ National Governments
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)

26. Motion of the SMDHU Board of Health / alPHa: 2014
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.

27. Provincial Statements of Support
January 7, 2016, Minister of Health and Chief Medical Officer of Health letter of support to municipal councils for CWF
October 06, 2016 private member’s motion (MPP Bob Delaney) ongoing
“That, in the opinion of this House, the Province of Ontario…
…act to replace the outdated Fluoridation Act with an updated section of the Health Protection and Promotion Act…
…the Province of Ontario work with municipalities to provide financial and technical assistance…
…to begin water fluoridation”.

28. Conclusions
CWF is a safe and effective way to reduce dental caries, particularly for vulnerable children
It is increasingly difficult to maintain CWF with rising organized and dedicated opposition
Ontario has had a high population coverage of CWF – but is losing coverage in recent years
In the past decade, Simcoe Muskoka has been losing its very limited CWF coverage, despite our collective best efforts
Many have made the case for CWF to be provincially mandated