1. Fluorides for the Future: Science, Policy and the Public’s Health John W. Stamm, DDS Univ. of North Carolina 2008 Statewide Oral Health Conference Greensboro, NC July 15, 2008

2. Presentation Aims 1. Economic context for dental prevention and care 2. Update on water fluoridation 3. Touch on fluoride toothpastes 4. Mention Fluoride supplements 5. Consider dental fluorosis as a driver for change in public health practice 6. Imagine some future policy and research options

3. U.S. Dental Expenditures  $91.5 billion in 2006 (est.)  $305.0 per capita  4.3% of total health expenditures  44.4% out of pocket  49.5% via insurance  5 % from Medicaid  1% other sources US Centers for Medicare and Medicaid Services and US Department of Commerce, Jan-Feb, 2008.

4. Water fluoridation: It is the foundation for caries prevention !

5. “The four horsemen of public health are the pasteurization of milk, the purification of water, the immunization against disease, and controlled fluoridation. None of these gains has been achieved easily -- none of the four measures has endured more severe obstruction than fluoridation.” Dr. Luther Terry Surgeon General, USPHS Water Fluoridation

6. Benefits of Fluorides  Less dental decay  Less restorative dentistry  Less tooth loss  Less pain  Less absenteeism from school, work  Fewer iatrogenic disorders  Generally more esthetic dentition  Cost-effective prevention

7. Water Fluoridation USA  184 million persons in the U.S. live in fluoridated communities (2006)  69.2% of population with water systems receive F water (2006)  44/50 largest U.S. cities are fluoridated  Cost per person per year $0.72 (2003):  $0.68 (water system > 50K)  $0.98 (water system 10K – 50K)  $3.00 (water system <10K)

8. Populations Receiving Optimally Fluoridated Water – US, 1992 - 2006  MMWR 07-11-2008  National trend: 1992 -- 62.1% 2000 -- 65.0% 2006 -- 69.2 %  Goal for 2010 remains at 75% CDC MMWR Weekly, July 11, 2008/57(27):737-741.

9. North Carolina – Population Receiving Optimally Fluoridated Water in 2006  North Carolina 2006 5,689,906 people, representing 87.6% of those on community water systems.  Rank 20 th in the nation  Represents 4.3% improvement over 2000 CDC MMWR Weekly, July 11, 2008/57(27):737-741.

10. Water Fluoridation Effectiveness  Historical estimates revealed 40 - 50 percent effectiveness in caries reduction, based on permanent dentition in children  NIDR 1986-87 children’s survey found DMFS 18% lower in children with life-long fluoridated water intake, versus those with life-long non- fluoridated water intake.  The 18% difference underestimates water fluoridation’s impact on caries prevention because of epidemiological factors and food/beverage manufacturing and distribution practices.

11. Water Fluoridation Effectiveness  18 - 20 % effectiveness, year after year, is still a significant public health benefit  With 44/50 of the largest US cities fluoridated, manufactured foods/beverages carry dietary fluoride to non-fluoride communities, exerting benefit there  Mean annual cost of $0.68 – $3.00 per person makes fluoridation the most cost-effective caries preventive available.  Powerful passive caries prevention measure  Disproportionally benefits those at highest risk to caries; fulfills social equity objectives.

12. Current Recommendations for Water Fluoridation  Continue water fluoridation at currently recommended levels (0.7 – 1.2 ppm F)  Control F concentration within 0.2 ppm F of recommended levels for the region  Ensure that funding exists for fluoridation equipment maintenance and appropriate replacement  Allocate budget to ensure professional development for filtration plant personnel  Fluoridate 75% of U.S. population by 2010

13. Dentifrices are a Major Fluoride Vehicle !

14. The Toothpaste Market is Big, and it Delivers Fluoride

15. World Toothpaste Market, US$ mn Region20002006 % Growth Asia Pacific3,3284,20820.9 Australasia 136 20953.7 Eastern Europe 6281,19790.6 Latin America1,8372,12515.7 Mid. East & Africa 557 72930.9 North America2,1032,26707.8 Western Europe 2,5463,70245.4 World 11,135 14,43729.7 Adapted from Euromonitor Intl.

16. Fluoride Dentifrices  Fluoride dentifrice use is nearly ubiquitous in the United States  Fluoride dentifrices (1000-1100 ppm F) are a major caries prevention modality  Efficacy of 15%-30% may be expected  NaF dentifrices modestly (6-7%) superior to MFP dentifrices  Marginal cost of including fluoride in a dentifrice is very low, resulting in good cost-effectiveness

17. Optimizing Fluoride Dentifrices for Children There is a dose-response curve for dentifrice fluoride concentration and caries increment reduction Dose response relationship is less clear for concentrations under 1000 ppm F Clinical trials of low dose (~500 ppm F) fluoride dentifrices have demonstrated efficacy, though not consistently

18. Effect of Dentifrice Fluoride Level on 32-month Caries Increment, 12-year Olds DMFS Dentifrice Sample Increment Significance 250 ppmF 365 4.29 1000 ppmF 360 3.61p<.05 Adapted from Mitropoulos et al, 1984

19. Current Recommendations for Fluoride Dentifrices Recommend use of 1000-1100 ppm F dentifrices for adults Recommend children (2-6 years) use only pea- sized quantity of F dentifrice on the brush Reserve higher F concentration dentifrices for use in high caries risk patients, age > 12 years

20. Multi-function Toothpaste: The Current Trend in Dentifrice Development

21. Six Functions of Modern Toothpastes 1. Caries prevention  Fluoride delivery  Biofilm control  Demineralization (diminish)  Remineralization (promote) 2. Plaque control and gingivitis prevention 3. Calculus prevention 4. Tooth whitening (extrinsic stain reduction) 5. Dentin hypersensitivity reduction 6. Breath freshening

22. Touching briefly on fluoride supplements!

23. Fluoride Supplements In the past, approximately 50% of children had some experience with fluoride supplements Consistent compliance below 20% Cost approximately $3-$20 per year Effectiveness is very variable Significant risk factor for enamel fluorosis Current supplement schedule adopted 1994

24. U.S. Fluoride Supplement Schedule,1994 Community Fluoridation Level Age 0.6ppm 0 mos.- 6 mos. 0 0 0 6 mos.- 3 yrs.0.25mg 0 0 3 yrs. - 6 yrs.0.50mg 0.25mg 0 6 yrs. - 16 yrs.1.0 mg 0.50mg 0 ADA, AAP, AAPD

25. Current Prescribing Guidelines for Fluoride Supplements 1. Establish F level in child’s drinking water 2. Establish appropriate use of F dentifrice 3. Prescribe F supplements, liquids or tablets, according to 1994 schedule 4. Do not prescribe F supplements in areas served by fluoridated water (F>0.6 ppm) 5. Do not prescribe pre-natal F supplements 6. Recommend F supplements only to high caries risk patients

26. Prevention with fluorides has benefited US school children

27. Trends in Dental Caries Prevalence in the Permanent Dentition (DMFT). United States 1970s to 1990s

28. Trends in Dental Caries in the Primary Dentition (dft), United States, 1970s to 2000 Mean dft

29. A Clean and Healthy Mouth

30. But fluorosis persists, and intake studies raise concerns!

31. MODERATE

32. Severe

33. Risks Associated with Excess Fluoride Ingestion Two categories of risk 1. Acute toxicity 2. Chronic toxicity -- dental & skeletal

34. Risk Sources for Enamel Fluorosis  Risk from fluoride containing water consumption  Risk from fluoride supplement use/misuse  Risk from ingestion of dentifrices  Risk from other forms of chronic, excess fluoride ingestion

35. Dental Fluorosis As much as 70% of the risk of dental fluorosis may be related to inappropriate early use of fluoride dentifrices and a history of fluoride supplement ingestion Other simultaneous forms of fluoride ingestion will account for the balance of fluorosis risk

36. Prevalence of Enamel Fluorosis among US 5-17yr. Old School Children, 1986-87 None77.0% Questionable Very mild21.6% Mild Moderate 1.1% Severe 0.3%

37. QUESTIONABLE

38. VERY MILD

39. Association of Enamel Fluorosis with F Supplement Use Started Before Age 1 Yr. Period of FAdjusted 99% Conf. Suppl. Useodds ratio Limit None 1.0 --- Year 1 1.80.8 - 4.4 Year 3-6 2.2 0.8 - 5.8 Years 1 & 3-6 4.01.4 - 11.4 Pendrys & Katz, 1988

40. Association of Enamel Fluorosis with F Supplements, 8-Yr Olds, Umea Age SupplementFluorosisRelative Confidence Use Started N Yes No Risk Limits (95%) Never 20 3 17 1.0 --- 36 mos. 6 2 4 1.2 0.2 - 33.8 24 mos. 8 3 5 2.5 0.3 - 32.9 12 mos. 51 30 21 3.9 1.9 - 47.1 6 mos. 21 17 4 5.4 3.8 - 176.0 Adapted from Holm & Anderson, 1982

41. Association of Enamel Fluorosis with Early Use of F Dentifrice, Controlling on Mother’s Education, 8-10 Yr. Olds, Toronto, Can. Age Brushing NumberOdds Confidence Started (mos.) Cases Controls Ratio Limits (95%) Late (25-60) 12 54 1.0 -- Early (6-24) 53 20 11.0 4.8 – 25.2 Adapted from Osuji et al, 1988

42. Fluoridation Policy Changes: International Perspectives Australia, Canada, Hong Kong, Ireland and Singapore have adopted the following public health policies:  Reduce water fluoride to 0.6 – 0.7 ppm F.  Cease recommending fluoride supplements.  Introduce pediatric fluoride toothpastes, i.e. 450 – 600 ppm F.  Monitor dietary intake of fluoride (0 – 36 months).

43. Fluoride Policy for the Future: A 3-Element Change Agenda 1. Restrict fluoride supplement prescriptions to very high caries risk children 2. Advocate strongly and persistently for pediatric fluoride toothpastes 3. Investigate and potentially revise the recommended water fluoride concentration

44. An Agenda for Fluoride Research 1. Surveillance research should be increased to study water fluoridation compliance 2. Epidemiological studies are needed to document trends in fluorosis prevalence 3. More research is needed on fluoride ingestion in the first 36 months of life 4. Need to re-evaluate the relationship of ambient air temperature, fluid intake, caries prevention and fluorosis prevalence. 5. More research on gene-fluoride interactions

45. Thank you for your courtesy and attention!!