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Agenda 09/13/2011 Item #10C9/13/2011 Item 10.C. EXECUTIVE SUMMARY Provide a staff response to the question of using fluoride in the public potable water supply distributed by the Public Utilities Division's Water Department, as directed by the Board of County Commissioners during its June 14, 201 -1 meeting. OBJECTIVE: To provide a staff response to the question of using, fluoride in the public potable water supply distributed by the Public Utilities Division's Water Department, in response to a Public Petition presented by Mr. Frank Oakes during Agenda-Item 6.D. at the Board of County Commissioner's June 14, 2011, meeting. C0NSIDERAU0NS. A recommendation to stop the use of fluoride in the county- supplied potable water was proposed during a Public Petition by Mr. Frank Oakes, a private citizen and customer -of the Public Utilities Division's Water Department. The ;Board. of County Commissioners voted to bring the issue back at a later meeting so that they could hear from staff on this issue. The Board asked that staff review the use and safety of adding fluoride to the public potable water supply, and provide a presentation. Three exhibits are provided for information and review: • Exhibit A Fluoridation and Neurotoxicity, was provided by an interested citizen, and is included by request; it includes a one -page release by the United States Environmental Protection Agency and a web - article from Mercola.com by Drs. Paul and Ellen Connett • Exhibit B, Fluoridation Facts, was provided by the American Dental Association. • Exhibit C, Fluoridation Information, provided by the Collier County Department of Health, is a compilation of fluoridation- related information from various agencies and organizations, including the United States Centers for Disease Control, the United States Public Health Service, Department of Health and Human Services, the Florida Dental Hygiene, Association, the Florida Medical Association, the Florida Journal of Environmental Health, the Florida Dental Association, the Association for Dental Research, and the Florida Department of Health. The fluoridation of the public water supply is not mandated by any regulatory agency. Rather, the question of whether or not to fluoridate the public water supply is one of public health. The Collier County Water Department has provided drinking water with the optimal amount of fluoride since August 28, 1984. There has been no finding or evidence of negative public health impact provided by the Florida Department of Health or the Collier County Department of Health. FISCAL VAPACT: The estimated annual cost of fluoridation is $32,600.00 the source of funding is Water User Fees. LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney and raises no legal issues. JAK. GROWTH MANAGEMENT IMPACT: There is no growth management impact; associated with this item. Packet Page - 864 9/13/2011 Item 10.C. RECOMMENDATION: That the Board of County Commissioners provide direction to staff regarding the use of fluoride in the public potable water supply distributed by the Public Utilities Divisioi 's Water Department. Prepared By: Paul E Mattausch, Director, Collier County Water Department Attachments I Packet Page -865 - 9/13/2011 Item 10.C. COLLIER COUNTY Board of County Commissioners Item Number: 10.C. Item Summary: Provide a staff response to the question of using fluoride in the public potable water supply distributed by the Public Utilities Division's Water Department, as directed by the Board of County Commissioners during its June 14, 2011 meeting. Meeting Date: 9/13/2011 Prepared By Approved By Name: Paul Mattausch Title: Director - Water,Water Date: 8/19/20112:59:24 PM Name: WidesTom Title: Director Operations Support - PUD,Utilities Fina Date: 8/19/20114:15:13 PM Name: BetancurNatali Title: Executive Secretary,Transportation Engineering& C Date: 8 /25/2011 10:00:29 AM Name: HapkeMargie Date: 8/26/2011 8:38:04 AM Name: YilmazGeorge Title: Director - Wastewater,Wastewater Date: 8/28/2011 10:35:24 PM Name: KlatzkowJeff Title: County Attorney, Date: 8/29/2011 11:42:39 AM Name: KlatzkowJeff Title: County Attorney, Date: 8/29/2011 1,•39:49 PM Packet Page -866- 9/13/2011 Item 10. C. Name: GreenwaldRandy Title: Management/Budget Analyst,Office of Management & B` Date: 8/29/2011 2;41:40 PM Name: OchsLeo Title: County Manager Date: 9/6/20113:12:44 PM �1 0 ow bum m is f. Packet Page -871- 9/13/2011 Item 10.C. ' y i F i r• a -r r• a - fu Cr i V, t i i L.I. l'7 � i ;v u tai' 1 1 i 1 i I f5 v a Packet Page -871- 9/13/2011 Item 10.C. 9/13/2011 Item 10.C. a%.nct r agc -U I -r- .A. - to im GL 44 11-P %J I _ a Z 08 lo A" 3 9/13/2011 Item 10.C. .4 — A w M 14 iii tDl -A. L) N A 43 10 a L a p n w! 3 (A 0 e K 10 0 -0 C 0 > 0 (`J 5 *Cd CL X0 13, as. M. 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Paul and Ellen Connett Paul Connect, co- author of the book, The Case Against Fluoride, isjoined by his wife, E&n, webmaster of the Fluoride Action Network (FAN), and Tara Blank, PhD, Science Liason Officer for FAN, in authoring this aftle on fluoride and the brain. Together they have recently provided an extensive commentary to the EPA's Office of Drinking water in response to its proposed safe reference dose for fluoddel. 1 Fluoride Action Network ,P'� t.i,e 12,536 In an ongoing effort to determine which chemicals may damage the developing brain, scientists from the U.S. Environmental Protection Agency (EPA) recently conducted an extensive literature review of over 400 chemicals, including fluoride. Fluoride is Classified as a Neurotoxin While the Centers for Disease Control (CDC) would have us all believe that fluoride is perfectly innocuous and safe, scientists from the EPA's National Health and Environmental Effects Research Laboratory have classified fluoride as a "chemical having substantial evidence of developmental neurotoxicity" 2 Consistent with the EPA's conclusion, a continually growing body of human and animal research strongly suggests that fluoride can damage the developing brain. Consider for example: • 24 studies have now reported an association between fluoride exposure and reduced IQ in children • Three studies have reported an association between fluoride exposure and impaired neurobehavioral development • Three studies have reported damage to the brain of aborted fetuses in high fluoride areas, and • Over 100 laboratory studies have reported damage to the brain and /or cognitive function among fluoride - exposed animals3. Most of the 30 studies linking fluoride to reduced IQ, impaired neurobehavioral development, and fetal brain damage have come from China where fluoride occurs at moderate to high levels in the drinking water in what is known as "endemic areas for fluorosis." While there have been shortcomings in the methodologies of some of these studies, they have been remarkably consistent in their findings. Children exposed to excessive fluoride have been consistently observed to suffer from some form of neurological impairment. Your Brain Under Attack Statistics tell us that our brains are under attack. For example: • Autism Spectrum Disorders: The rates in the U.S. are now 1 in 110 children and are "4 to 5 times more likely to occur in boys than in girls," or as many as 1 in 60 bons. • Attention Deficit Hyperactivity Disorder: According to a November 2010 CDC report, nearly 1 in 10 U.S. children have ADHD - an increase of about 22 percent from 2003. • Alzheimer's Disease: According to the Alzheimer's Association, 5.4 million Americans are living with it and every 69 seconds an American is diagnosed with it. By 2050, it is estimated that as many as 16 million Americans will have the disease. a —G- a — 1 9/13/2011 Item 10.C. Article Tools Print this Page Save as Favorites Current Newsletter Share Your Comment Podcest8 Submit My Story Newsletter Feed Health Bloc Feed BROWSE BY CATEGORY A°inp Alienoies Alzheimer's Artt iS Artificial Sweeteners Aspartame Asthma AuAism Rork Pain TRANSLATE THIS PAGE: For Online Shopping CUCKINHIM Top Products NO 1Ali Whole Food Multivitamin PLUS tablets (240 per bottle): 3 bottles Sale Price: $129.97 Discover More We do not know the causes for the alarming increases in these diseases but we do know that wherever possible, everything must be done by regulatory agencies and caregivers to protect the brain from known neurotoxins. http : / /articles.mercola.comisites /articles /archive /201 l /08l l 2lfluoride -and- the - brain -no- mar... 8/19/2011 Packet Page -887- I 1UV11UG L111AGU U! LV WGl 1%,1 4llu 1VGLLlu1Vs'lloal 1111�/t111111G111 9/13/2011 Item 10.C. Fluoride is a known neurotoxin and it is time to stop adding it to public drinking water systems. However, convincing U.S. regulatory authorities of this urgent necessity is proving very difficult. Developmental Neurotoxicity In 2007 Choi and Grandjean4 stated: 'In humans, only five substances have so far been documented as developmental neurotoxicants., lead, methy/mercury, polychlorinated biphenyls, arsenic, and toluene. From this evidence, including our own studies on some of these substances, parallels may be drawn that suggest that fluoride could well belong to the same class of toxins, but uncertainties remain...' Health Agencies are Ignoring Fluoride -Brain Studies Even though health agencies in the U.S. and other fluoridating countries have recognized that children are being grossly over- exposed to fluoride (41 percent of American children aged 12 -15 now have some form of dental fluorosis2), they are unwilling to concede that fluoride may be impacting the brain. Their approach has been either to ignore these studies completely or to challenge the relevance and the methodology of the fluoride -brain studies. They have thus far failed to conduct any IQ studies of their own. Bottie -Fed Babies at Risk The level of fluoride in mothers' milk is remarkably low; only about0.004 ppmg. In the view of many critics of fluoridation, including Arvid Carlsson, Nobel laureate in medicine /physiology, it is reckless to expose infants to levels of fluoride orders of magnitude higher than that found in breast milk. In the U.S., infants who are fed formula reconstituted with fluoridated tap water receive the highest levels of fluoride (per kilogram bodyweight) in the human population. Specifically, infants who are fed formula made with fluoridated water at the current level of 1 part-per- million (1 ppm = 1 mg/liter) fluoride will receive a dose up to 250 times more than the breastfed infant. Even with the proposal by the U.S. Department of Health and Human Services to lower fluoride to 0.7 porn in fluoridation schemes, bottle -fed infants will still receive up to 175 times more fluoride than the breastfed infant. In addition to bottle -fed infants, others at heightened risk include those with poor nutrition and both African American and Mexican - American children. Recent studies indicate that African American and Mexican - American children have higher rates of the more severe forms of dental fluorosis than white chikirenz. As dental fluorosis provides a visual indication that fluoride has exerted a toxic effect on your body, it is reasonable to assume that these same children will also be more vulnerable to other toxic effects of fluoride including damage to the brain. EPA Protecting Fluoridation Program, Not Public Health On January 7, 2011, the EPA's Office of Water (OW), while pursuing its mandate to set a new safe drinking water standard for fluoride, made it clear that it would do so without jeopardizing the water fluoridation program. According to Peter Silva, EPA Assistant Administrator for the OW: EPA's new analysis will help us make sure that people benefit from tooth decay prevention while at the same time avoiding the unwanted health effects from too much fluoride'I. Silva was referring to severe dental fluorosis, broken bones, and skeletal fluorosis as the unwanted health effects. These were the three health effects that the National Research Council of the National Academies in its 2006 report Fluoride in Drinking Water. A Scientific Review of EPA's Standards singled out. The report recommended that the EPA perform a new health risk assessment to determine a safe drinking water standard for fluoride because they found the current level of 4 ppm was not protective of health. In its first draft risk assessment, EPA claimed that the most sensitive health effect of fluoride was severe dental fluorosio. Brain effects were ignored by EPA even though many more studies have been published since the NRC made its recommendation. Science does not stand still. The NRC examined fire IQ studies; there have now been nearly five times more at 24! Making matters worse, the EPA's Office of Water risk assessment excluded the fetus and infants under 6 months of age, as the EPA does not expect them to get dental fluorosis! Whether fluoride impacts the growing tooth enamel during this period or not, this is a very important period for brain development. As noted above, an infant fed formula made with fluoridated water at the proposed lower level of 0.7 ppm will receive 175 times more fluoride than the breast -fed infant. EPA Research Laboratory Takes Different View Fortunately, the EPA does not speak with a single voice on fluoride's neurotoxicity. While the EPA's Office of Water ignored any brain effect in its 2011 risk assessment, the Neurotoxicology Division at the EPA's National Health and Environmental Effects http: / /ardcles.mercola.coml sites /articles /archive /2011108ll2 /fluoride- and - the - brain -no- mar... 8/19/2011 Packet Page -888- 11L1Vll4fr L1lll1V\4 tV 1JV •VVl 1,4 64114 l��+tll VlV �lV4l 1111tl1b11111v11L 1 __ J V l 9/13/2011 Item 10.C. Research Laboratory included fluoride in its list of "Chemicals with Substantial Evidence of Developmental Neurotoxicily", for a new project expected to be launched this year. Ultimately, therefore, the EPA administrator will have to resolve the following question: is it more important to protect our children's brains or the fluoridation experiment? Fluoridation Proponents` False Claim Proponents of fluoridation have dismissed the fluoride -IQ studies on the basis of the claim that the children in these studies were drinking water containing fluoride at much higher levels than used for water fluoridation (approximately 1 ppm). However, such claims do not bear close scrutiny, Xiangu estimated that the threshold for IQ lowering was 1.9 ppm and more recently Ding et al. (2011) found a lowering of IQ in the range of 0.3 to 3 ppm. These findings reveal that there is no adequate margin of safety to protect ALL American children drinking uncontrolled amounts of fluoridated water and ingesting fluoride from other sources (e.g. toothpaste). While we will discuss this crucial margin of safety argument in more detail below, suffice it to say here that when harm is found in a small human study a safety factor of 10 to 100 is typically applied in order to extrapolate to a level designed to protect a whole population from harm. The NRC (20061) Review of Fluoride The NRC panel devoted a whole chapter on the brain in its 507 -page 2006 review and concluded: "it is apparent that fluorides have the ability to interfere with the functions of the brain and the body by direct and indirect means." Of the five IQ studies reviewed by the NRC the panel drew special attention to the study by Xiang at al?2, which they indicated had the strongest design. The panel described this study: 'This study compared the intelligence of 512 children (ages 8-13) living in two villages with different fluoride concentrations in the water. The IQ test was administered in a double -blind manner. The high - fluoride area had a mean water concentration of 2.47 t 0.79 mg& (range 0.57 -4.50 milligrams per liter fmg&]), and the low - fluoride area had a mean water concentration of 0.36 t 0.15 mgr& (range 0.18 -0.76 mg1L). The populations studied had comparable iodine and creatinine concentrations, family incomes, family educational levels, and other factors. The populations were not exposed to other significant sources of fluoride, such as smoke from coal fires, industrial pollution, or consumption of brick tea. Thus, the difference in fluoride exposure was attributed to the amount in the drinking water... the average intelligence quotient (iQ) of the children in Wamiao was found to be significantly lower (92.2 t 13.00; range, 54126) than that in Xinhuai (100.41 t 13.21; range, 60 -128). The IQ scores in both males and females declined with increasing fluoride exposure." The shift in the IQ curves for both males and females are shown in Figures 1 and 2. 4C i XliliU.il a . 1 -------- --- �, 0 70 7S Bo 81 40.205 110 119 120 :25 IN t 1•; :�t�O:n�: Figure 1. Distribution of IQ scores from males in Waamiso and Xlnuai. Source: data from Xiang at al. 2003a (as shown in NRC, 2006, Figure 7 -2, p. 207). http: // articles. mercola .comisiteslarticleslarchive /2011108ll2 /fluoride- and - the - brain -no- mar... 8/19/2011 Packet Page -889- riuvrtuc i,uixcu w L.vwci iy tutu tvcuuvivgiuzu L,,pauiuciu 9/13/2011 Item 10.C. •J 'L - w '1 b7 ♦y7 :11.79 q0<.+.4 46•1(11t I11 -11? ::' :^a I II i; ca'egcrt�e:� Figure 2. Distribution of IQ scores from females in Waamiao and Xinuai. Source: data from Xiang at at 2003a (as shown in NRC, 2006, Figure 7 -1, p. 207). According to the NRC (p. 206): "A. follow -up study to determine whether the lower 10 scores of the children in Wamiao might be related to differences in lead exposure disclosed no significant difference in blood lead concentrations in the two groups of childrertR " Xiang extrapolating from the whole set of data estimated that the threshold for IQ lowering would be 1.9 ppm. Below we use this estimate in a margin of safety analysis to calculate a level that would be sufficient to protect all children drinking fluoridated water. The NRC panel's overall conclusion based on its review of these five IQ studies was: "A few epidemiologic studies of Chinese populations have reported IQ deficits in children exposed to fluoride at 2.5 to 4 mgt in drinking water. Although the studies lacked sufficient detail for the committee to fully assess their quality and relevance to U.S. populations, the consistency of the results appears significant enough to warrant additional research on the effects of fluoride on intelligence. " Incredibly, no fluoridating country has followed up on this. We continue to fly blind on this critical issue. One of the animal studies reviewed by the NRC was the study by Julie A. Varner and co- workersz from the State University of New York at Binghamton. These authors fed rats for one year with 1 ppm fluoride in their water. One group received sodium fluoride, the other aluminum fluoride. In the rats treated with either fluoride compound, Varner at al. discovered the following: • Morphological changes in the kidney and the brain • An increased uptake of aluminum into the brain • The formation of beta - amyloid deposits, which are a hallmark for Alzheimer's disease More Brain Studies Published Since NRC 2006 Review Since the NRC panel wrote its report in 2006 many more animal studies have been published and another 14 IQ studies have either been published or translated. Five more IQ studies wait translation from the original Chinese. This brings the total to 24 IQ studies that have found exposure to fluoride associated with lowered IQL. At least 16 studies on animals have shown that fluoride has an effect upon the hippocampus and nine of these have been published since the NRC's 2006 review. Damage in this area of your brain usually results in difficulties in forming new memories and recalling events that occurred prior to the damage. Xiang Updates His Work17 An updated version of Xiang et al's (2003a) work ", which included new information about the relationship between the level of fluoride in the children's plasma and IQ was accepted for publication in Environmental Health Perspectives (the journal of the National Institute of Environmental Health Sciences) and made available online on December 17, 2010. This article was later withdrawn when it was found that some of the material had been previously published. However, for those who have used criticisms of the methodologies of some of the 2410 studies to justify ignoring the issue completely, it is important to note that the Xiang et al, paper successfully passed the peer - review process of this important journal. http:// articles. mercola .com /siteslarticleslarchive /2011 /08/ 12 /fluoride- and - the - brain -no- mar... 8/19/2011 Packet Page -890- nuonue 1,1 1KeU LU LVWCf IV d11U 1VCU1v1VrIL;a1 1111jJaULI1G11L 9/13/2011 Item 10.C. Another Important Fluoride IQ Study An IQ study published in 2011 by Ding at al.12 investigated the effects of low levels of fluoride on IQ. Children were exposed to 0.3 to 3 mg F/L fluoride via drinking water. The authors found a very significant linear correlation (p <0.0001) between fluoride levels in the children's urine and lowered IQ (Figure 3). They calculated that there will be a lowering of IQ by 0.59 points for each increase of 1 mg/L urinary fluoride. Figure 3. The relationship between /Q differences and urine fluoride concentrations. Multiple linear regression model was carried out to confirm the association with urine fluoride exposure and /Q scores (F =9.85, p < 0.0001) (Figure 2, Ding at al., 2011) Margin of Safety: The Safety Factors Used in Toxicological Assessments Promoters of fluoridation, either through ignorance or design, betray little understanding of the concept of margin of safety. This is revealed when they dismiss studies carried out at levels higher than 1 ppm as being irrelevant for assessing the risks posed by water fluoridation. This indicates that they have no appreciation of the difference between concentration and dose. Someone drinking three liters of water with 1 ppm fluoride would get a higher dose (3 mg) than someone drinking one liter of water with 2 ppm fluoride (2 mg). In other words, it is the dose that hurts people, and thus finding harm at levels as high as 4 ppm are still relevant to a high water consumer drinking water at 1 ppm. i''N Toxicologists usually have to work from high dose animal experiments to extrapolate to a safe level for humans. This typically requires the application of a safety factor of 10, when extrapolating from the dose that causes harm in animals to predict a safe dose for humans (in order to account for the potential variation between species). Then a second safety factor of 10 is commonly applied to take into account the full range of sensitivity to any toxic substance that is to be expected in any large population. In other words some individuals are likely to be 10 times more sensitive to fluoride than others. In the case of fluoride we are in the unusual situation of having quite a large amount of human data to work with, especially in the case of its neurotoxic effects, so it is only necessary to address the variation in sensitivity expected in a large population. In its January 7, 2011, draft risk assessment the EPA Office of Water took the most unusual tack of not using any safety factor at all when extrapolating from the dose that causes severe dental fluorosis2g. In other words they believed that they had enough data to state - with no uncertainty—that no one consuming less than 0.08 mg of fluoride per kilogram bodyweight per day would develop severe dental fluorosis. For them to legitimately forego any safety factor they need to demonstrate that this purported "threshold" dose is based on sufficiently large numbers of subjects to represent the full range of different vulnerabilities and sensitivities in the U.S. population. Such variations include: age, income levels, nutritional status, genetic and ethnic variability. It is notable therefore, that the study on which the EPA's calculations were base' did not include African American or Mexican - American children, or children from a full range of family income levels. Dr. Paul Connett, director of the Fluoride Action Network believes that the EPA Office of Water was forced to choose this "uncertainty factor" of 1 in order to produce a "safe reference dose" that was higher than the dose deemed necessary to protect teeth against decay. In other words, this was a political decision made to protect the water fluoridation program. Even more political was the EPA's willingness to ignore the studies that indicate that fluoride lowers IQ. No Margin of Safety for Fluoride The level at which Ding at al. (2011) researchers found a lowering of IQ (0.3 -3 ppm) overlaps the range at which fluoride is added to water in the US (0.7 -1.2 ppm). Even without applying a safety margin to this finding, it would suggest that there is no safe level rte. that would protect ALL of America's children from potential interference with mental development from fluoride exposure via the water supply. http:// articles. mercola .comisiteslarticieslarchivel2O l l /08/ l 2lfluoride- and - the - brain -no -mar... 8/19/2011 Packet Page -891- 111� riuonue i mKcu to l.uwcr iy auu ivcuuvivgiL;ui iiupauiuviu . _ - .1. 9/13/2011 Item 10.C. However, Ding et al. state that this is a preliminary finding, and more work should be done to control for possible confounding factors. Meanwhile, it is possible to use the findings of Xiang at al.22 to estimate a safe reference dose to protect all American children from this effect. This is the task that the EPA Office of Water should have undertaken. However, as indicated above, their preliminary calculations for the safe reference dose published on January 7, 2011, failed to consider fluoride's potential to lower IQ. The EPA defended its decision to only consider severe dental fluorosis, by claiming that this is the most sensitive endpoint of fluoride's toxicity. The EPA made this claim despite the fact that, in both the Ding and Xiang studies, reductions in IQ were observed among children without severe dental fluorosis. This clearly challenges the EPA's claim that severe dental fluorosis is the most sensitive adverse effect of fluoride. Other Human Brain Studies Three other studies from China2l indicate that aborted fetuses in endemic areas for fluorosis show signs of brain changes compared to aborted fetuses in non - endemic areas. Moreover, in a study from Mexico24, Rocha- Amador at al found that children exposed to moderate levels of fluoride had impaired visual - spatial recognition abilities. Such impairments could affect a child's development. In 2009 the Rocha- Amador team performed tests on children exposed to various neurotoxicants (Fluoride, Arsenic, Lead, DDT, DDE or PCBs). Fluoride exposed children were selected If they had dental fluorosis (a bio- marker for fluoride over - exposure). All the children exposed to the various neurotoxicants "had very poor performance in Copy and Immediate Recall tests and in general they recalled less information on the Construction/Memory score." As the authors of these studies note, fluoride's impact on the brain may be evident in the absence of crude reductions in IQ. Indeed, the authors note that IQ tests may well fail to detect fluoride's more subtle effects on cognitive function. Consistent with Rocha- Amadoes research on non -IQ effects, Li et al.� reported that infants born in areas with high fluoride levels had "significant differences in the non - biological visual orientation reaction and biological visual and auditory orientation reaction" compared to infants born in areas with low fluoride levels. Establishing a Safe Drinking Water Level for Fluoride MCLG The most important step in setting a federally enforceable safe drinking water standard (maximum contaminant level or MCL) is the determination of the Maximum Contaminant Level Goa! (MCLG). This determination is made by the EPA's Office of Water. The MCLG is the level of a contaminant in water below which there is no known or reasonably anticipated risk to health. The MCLG is the basis for setting the enforceable standard (MCL). This enforceable standard takes into account the cost of removing the contaminant and is therefore not as protective as the MCLG level. For example the MCLG for arsenic is zero, but the MCL is set at 15 ppb (parts per billion) due to the costs of removing natural arsenic from some water supplies. For fluoride, Xiang et al. (2003a, b) estimated that the lowest water concentration associated with a lowering of IQ was 1.9 mg F /L. Ironically, this is the same threshold that the EPA's Office of Water offers for severe dental fluorosis. We convert this to a dose by assuming that the children in the Xiang study were consuming on average one liter of water a day. One liter of water at 1.9 mg F/L translates into a dose of 1.9 mg /day. This is called the lowest observable adverse effect level (LOAEL). Because these studies only dealt with 500 children, with fairly similar genetics, lifestyles and nutritional status, we would need at least the standard uncertainty factor of 10 to account for the full range of sensitivity expected in the whole population in the U.S. to arrive at a safe daily dose. 1.9 mg F /day divided by 10 equals 0.19 mg F /day and thus a safe daily dose should be set no higher than this. Such a dose would be exceeded by a child drinking less than one glass of water (250 ml) at 1 ppm (1 ppm = 1 mg/liter). In other words water fluoridation is not safe; some children could have their mental development impaired by drinking as little as one glass of fluoridated water on a daily basis. As far as setting a maximum contaminant level goal (MCLG) for safe drinking water is concerned, we should note that this safe daily dose of 0.19 mg /day is already being exceeded from other sources. For example the EPA OW estimates that mean fluoride ingestion from toothpaste among children between the ages of 1 and 4 is 0.34 mg/day2z. Fluoride intake from toothpaste alone, therefore, contributes twice the safe daily dose of 0.19 mg /day. Thus, since some children will exceed the safe dose of fluoride from non -water sources alone, it is difficult to understand how the MCLG for fluoride could be set any higher than ZERO if the EPA were to acknowledge the existence of these IQ studies and follow routine procedures. Of all the dangers posed by fluoridation (and there are many others) the potential to impact a child's mental development must be considered one of the most serious. Just how long can promoters continue to ignore the voluminous evidence of these dangers? And how long will the public let them? http:// articles. mercola .com /siteslarticleslarchive /2011 /08/ 12 /fluoride- and - the - brain -no- mar... 8/19/2011 Packet Page -892- tluortde LmKea to Lower tt,l ana iNeurmogicai impairment rdt'c i vi 7 9/13/2011 Item 10.C. Importantl The producers of this powerful film are allowing a full and FREE preview through August 13th in celebration of Fluoride Awareness Week (Aug 7 -13)1 You can support Fluoride Action Network by purchasing the Professional Perspectives DVD at a special price of $10 during Fluoride Awareness Week. What You Can Do TODAY! The Fluoride Action Network has a game plan to END water fluoridation in both Canada and the United States, and this Fluoride Awareness Week will hopefully bring us a lot closer to that goal by spreading mass awareness. Our fluoride initiative will primarily focus on Canada since 60 percent of Canada is already non - fluoridated. if we can get the rest of Canada to stop fluoridating their water, we believe the U.S. will be forced to follow. Please, join the anti - fluoride movement in Canada, New Zealand and the United States by contacting the representative for your area below. H you are a mom and want to see an end to water fluoridation, you can also contact a new group called "Moms Against Fluoridation" by sending an email to: info MMomsAuainstFluoridation.om. Contact Information for Canadian Communities: 1. If you live in Ontario, Canada, please join the ongoing effort by contacting Diane Sprules at d iane.sprules0coaeco.ca. 2. The point -of- contact for Toronto, Canada is Aliss Terpstra. You may email her at aliss0nutrimom.ca. Contact Information for American Communities: We're also going to address three US communities: New York City, Austin, and San Diego: 1. New York City, NY: With the recent victory in Calgary, New York City is the next big emphasis. The anti - fluoridation movement has a great champion in New York City councilor Peter Vallone, Jr. who introduced legislation on January 18 "prohibiting the addition of fluoride to the water supply." A victory there could signal the beginning of the end of fluoridation in the U.S. If you live in the New York area I beg you to participate in this effort as your contribution could have a MAJOR difference. Remember that one person can make a difference. The point person for this area is Carol Kopf, at the New York Coalition Opposed to Fluoridation (NYSCOF). Email her at NYSCOFQaol.com . Please contact her if you're interested in helping with this effort. 2. Austin, Texas: Join the effort by contacting Rae Nadler- Olenick at either info0fluoridefreeaustin.com or fluoride. infofvahoo.com, or by regular mail or telephone: POB 7486 Austin, Texas 78713 Phone: (512) 371 -3786 3. San Diego, California: Contact Patty Ducey - Brooks, publisher of the Presidio Sentinel at pbrooks9360aol.com. Contact Information for New Zealand Communities: 1. New Zealand: Contact Mary Byrne if you would like to be involved in stopping fluoridation in New Zealand. Mary would like to hear from you! Email her at: mbvme64Qyahoo.co.nz In addition, you can: - Tell the EPA you expect them to uphold their duty to protect you and your children from this toxic food fumigant. http: // articles. mercola.comisiteslarticles /archive/ 2011 /08 /l2/ fluoride - and - the - brain -no- mar... 8/19 /2011 Packet Page -893- nuorice LinKeCt to Lower ilk euila vgvLuvivgii cu 1uitpa.fL1J<f L1L 9/13/2011 Item 10.C. • Make a generous tax - deductible donation to the Fluoride Action Network, to help them fight for your rights to fluoride -free food and water. �� • Check out FAN's Action Page, as they are working on multiple fronts to rid our food and water supplies of fluoride. - For timely updates, join the Fluoride Action Network Facebook Page. References: 1 FAN (Fluoride Action Network). 20118. Comments on the U.S. EPA's Report Fluoride: Dose-response analysis for non- carheer effects. Submission to the U.S. Environmental Protection Agency. April 21, 2011 (revlsed). Online at =*//ft KNidWhkw oralfan- dose- rasponse.00mmems. nor .2011.Di f hltw //Auorl+salet or 'bin exomm revised.4- 22 -11.DM 3 Mundy W, Padilla S, Shafer T, Gften M, Breier J. Cowden J, Crof inn K Herr D, Jansen K Raffaele K. Radio N, Schumacher K Undated. Building a database of developmental neurotordcanla: Evidence from human and animal studies. U.S. Environments Protection Agency. Online at °n m+-nr'-3' s/sumMW46P%ZOMunOMk20TDAS Odf 3 Collett P, Beck J, Modem HS. 2010. Appendix 1, Fluoride and the Brain in 7?w Cisep � °ceirritf F/r.p-w.,.s How Hazardow Waste Ended Up lw OurDdnNIW MW snnd de Bad Science and Powered FoWics That K W If There. Chelsea Green Publishing, VT. 2010. Ding Y, YanhuiGao, Sun H, Han H, Wang W, Ji X, Liu X, Sun D. 2011. The relationships between low levels of urine fluoride on c hildrom's MHailigence, dental fluorosfs in endemic fduorosts areas in Hulunbulr, Inner Mongolia, Chins. Journal of Hazardous Materiels Fab 20;188(2- 3):1942 -6. A Choi AL and Grendjean P. 2007, PolerNels for developmental fluoride naumwWc j. XXVIITH Cohen mm of fhe Irtt motional Society for Fluoride Research, October S-12,2007. Baying Chine. s Betritri-Aguilar ED, Barker L, Dye B. 2010. Prevalence and severity of rental fluorosls in the Unhad States ,.1999- 2004..NCHS Data Brief No. 53. U.S. DHHS, CDC, National Center for Health Statistics. Online at NRC (National Research Council of the National Academies). 2008. Fluoride in Ddnldng water. A Scientific Review of EPA's Standards. Washington D.C.: The National Academes Prow. Online at hlo•Uwww nao.adWzdW o.Dho?rewrd i&I1571 I see Tattle 23 from BellrBn- ApWlar at al., 2005 s HHS (U.S. Depxanem of Health and Human Services). 2011. HHS and EPA announce new scientific assessments and actions on fluoride. News Release. January 7. Online at heo- /tvwvw ft.mv /rewslores+n01 I presfflIMI 10107s, taml a EPA OW (Office of water). 2010x. Fluoride: Dose - response analysis for non•cancer effects. Office or Science and Technology, Health and Ecological Criteria Division. 820- R -I"19, U.S. Environmental Protection Agency. Online at httwilfluondea atoraRan-dwo- response comments eer.2011.odf EPA OW (Office of Wser). 2010b. Fluoride: Egosure and relative source contribution analysis. Office of Sc eroe and Technology, Health and E000gical Criteria Division. 820-R- 14015, U.S. Environments! Protection Agency. Online at http• /loco fluondealen ordeoe.exwsure source.on.2011.00 Kaplan S. 2010. EPA develops neurotoxicants list, new lasting. Investigative Reporting Wodcafop. December 22. Online at ))gpl/investimtivareportlnaworksloD oro/mveatistationartoxic- influenGB/smrvlepe- develops- natsoowcarts•IisV ��, 11 Xiang 0, Lung Y. Chen L, Wang C, Chan 8, Chen X, Zhou M. 2003a. Effect of fluoride in drinking water on Children's intelligence. Fluoride 38(2):8494. Online at jtM•Ifl wxWeled rru(sdwr%xiano -2003a odf Xiang 0, Liang Y, Zhou M, Zhang H. 2003b. Blood lead of children in Wamiao-Xintuuai intelligence study. Fluoride 36(3):19&199.Orelne at htp• /Muaidsaert.orolsc U Xiang Q, Liang Y, Chen I- Wang C, Chan B, Chen X, Zhou M. 2003x. Effect of fluoride In drinking water on children's intelligence. Fluoride 36(2):84-94. Online at him• //Auoridealen ordscher/danC -2003a Ddf 12 Xiang 0, lasing Y, 21= M, Zhang H. 2003b. Blood lead of children in Womiao- Xinhusi intelligence study. Fluoride 36(3):19&199. Online at hay //fly 'deelertoraftcl+ertxieno-2003b.odf 1! Varner JA, Jensen KF, Horvath W, Isaacson RL. 1998. Chronic administration of aluminum - fluoride and sodium- 6uoride to rats in drinking water alterations in neuronal and carobrovascular Integrity. Brain Research. 784(1 - 2):284 -29e. February te. 15 FAN (Fluoride Action Network). 2011c. Fluoride 810: The Studies. January. Online at hfp' //fuoddoo oratQ studies html 14 Bhemagar M, Rao P, Sushms J, Bhatnagar R. 2002. Neurotoxicry of fluoride: neuaodegeneration in hippocampus of female mice. Indian Journal of Experimental Biology 40: 54 6-54. Chtrumari K. Reddy PK. 2007. Dose-dependent effects of fluoride on neurochemical milieu in the hippocampus and neocortex or rat brain, Fluoride 40(2):101 -10. Online at hft p, NwwwfluondemsearMora (40Z"os/FJ2007 v4O n2 0101- 110odf Inkielswicz 1, Krechmak J. 2003. Fluoride content in soft tissues and urine of rats exposed to sodium fluoride in drinking water. Fluoride 36 (4):283- 6e.OMine at Wollwww fluorida- Key AR, Miles R, Wong RK. 1988. Imracell iar fluoride alters file kinetic properties of calcium currents Initiating ore investigation of sy11813tic events in hippoca copal neurons. J Neurosci. 6 (10):2915 -20. Online at http /Aluoddealen aolrelkav -1988 pdf Niu R. at al. 2009- Decreased eemlg ability and low Nppocampus gluternae in offspring rats exposed to fluoride and Wad. Environmental Toxicology and PharmsoolM 28:254 -58. Pereira M, Dombrowski PA, Losso EM, at al. 2009. Memory impairment induced by sodium fluoride is associated with changes in brain m01`108111ine levels. Neurotmdcity Research, December 2009 (in press). van der Voet G8, Sdnjm O, de WPM FA. 1999. Fluoride enhances the efect of aluminium chloride on interconnections between aggregates of hippocempal neurons. Archives of Physiology and Biochemistry 107(1):15 -21. February, Verner JA, Jensen KF, Horvath W, Isaacson RL. 1998. Chronic administration of at rninurn- fluor(de and sodium - fluoride to rats in drinking water: alerab" in neuronal and cerebrovascular Integrity,. Brain Research. 784(1- 2):264 -295. February 16. Xia T, Zhang M, He W H, at al. 2007. Effects of fluoride on neural cell adhesion molecules mRNA and protein expression levels in primary rat hipporampal neurons. (Article in Chinese). Zhonghus Yu Fang Yi Xue Za ZW 41(e):475 -7& Zhai JX, Guo ZY, Hu CL, at al. 2003. Studies on fluoride concentration and cholinesterase activity in rat hippocampus. (Article in Chinese). Zhonghua Lao Dong Wei Shang Zhn Ye Bing Ze Zhi2l (Z):102 -4. Zhang J, at al. 2010. Effect of fluande on c8oum ion concentration and expression of nuclear transcription factor Kappe-B Rho85 in rat hippocampus. Experimental and Toxicologic Pathology [m press; available online March 19, 20101. Zhang M, Wang A, He W, at al. 2007. Effects of fluoride on the expression of NCAM, oxidative stress and apoptosis in primary cultured hlppocamtpel neurons. Toxicology236(3):208-16. Zhang M, Wang A, Me T, He P. 2008. Effects of fluoride on DNA damage, S•phase call-cycle sweat and the expression of NF- KappaB in primary cultured rat hippocampet neurons. Todc0logy Letters 179(1):1.5. http: // articles. mercola. com / sites /articles /archive /2011 /08/ 12 /fluoride- and - the - brain -no- mar... 8/19/2011 Packet Page -894- rwonue j Iww:u LV i uwvi 1y allu l�ctuvlvglt.tu <lllluatii a�iu ' "^� ' `- ' 9/13/2011 Item 10.C. Zhang Z, Shen X XU X 2001. Effects of selenium on to damage of laamirp-memory ability of mice induced by fluoride. (Article in Chinese). Wei Sharp Yen Jiu. 30(3):1446. Zhang Z, Xu X, Shen X. Xu X. 2008. Effect of fluoride expowm on synaptic structure of brain areas related to learnin g-memory In mica. Fluoride 41(2)139 -143. Aprikhme. Online at hire, h ^ dense orcV412rdosfi� r2nn6 v41 n2o139 -143 ode Zhu W, Zhang J, Zhong Z. 2011. Effects of fluoride an synaptic membrane fluidly and PSD-95 expression level in rat hippoeampus. Biological Trace Element Research 139(2):197 -203. Feb. 11 Xiang at al. 2010 le Xiang 0, Usng Y, Chen L Wang C, Chen B, Chan X, Zhou M. 20D3s. Effect of fluoride in drinking water an children's intelligence. Fluoride 36(2):84.94. Onkm at =://ttu 'd"lwj.crdschgM law -20D3a ode is Ding Y, YonhuiGoo, Sun H, Han H, Wang W, Ji X, Liu X, Sun D. 2011. The relationships bemoan low levels of urine fluoride on children's intelligence, dental fluorosis in endemic tworedis areas in Huknbwr, Inner Mongolia, Chins. Journal of Hazardous Materials Feb 26;180(2 - 3):1942$. m EPA OW (Office of Water). 2010s. Fluoride: Dose- response analysis for non - cancer effects. Office Of Science and Technology, HsalM and Ecological Criteria Division. 620- R- 10.019, U.S. Erivironnedia Protection Agency. Online at htlo•' -� - --' - _ - - - ••,• orn, tirr r- Dean HT, Arnold FA Jr., EWovs E. 1942. Domestic water and dental caries, V. Additional studies of to relation of fluoride domatic waters to dental caries experience in 4425 while children, age 12 -14 years, of 13 cities in 4 states. Public Health Reports 57:1155 -79. Online at II Xiang 0, Uang Y, Chan L Wang C. Chan B, Chun X, Zhou M. 20D3o. Effect of fluoride in drinking water on children's intelligence. Fluoride 36(2):8494. Online at Xiang 0, Limp Y, Zhou M. Zhang H. 2003b. Blood lead of children in Wamiso- Xindur intelligence study. Fluoride 36(3):198-199. Online at htto• //Iluo en.orolseh@Mdo w- 2003b.od Xiang at d. 2010 IV Translated into English and published in 2008; Du at al., He at al.. Yu at al. 21 Roder- Amsdor D. Navarro ME. Canizalas L Morales R, CsldwM J. 2007. Decreased intelligence in children and exposure to fluoride and arsenic in drinking wear. Cademos de Sande Pubace 23(suppl.4) Rio de Janeiro. Online at itii0•llwww srJeloso orolsdelo 0Fw?srxiol=sci &Mwd ,old= S0102.371X20M1WW1 Z•v Roche- Amador D, Navarro M, Tree- Acevedo A, at al. 2009. Use of to Rey- Ostemeth Complex Figure Test for neuromxkJty evaluation of mixtures in children. Neurotoxicology Nov;30 (6):1149.54. = Li J. Yoo L Shoo QL VW CY. 2008. Effects of high fluoride on neonatal n9umbehwAcrd development Fluoride 41(2):165-70. Online at hW, //www fl-.. 'deresearc'^ ord412MW,/QJ2000 V41 Q 0185 -170 ZZ (EPA, 2010b, Table 6.4, p. 94) EPA OW (Office of Water). 2010b. Fluoride: Exposure and relative source cw& button ansfy". Office of Science and Technology. Health add Ecological Criteria Division. 82D-R- 10-015, U.S. Environmental Protadim Agency. Orrkns at httm'ltwkw fllorid+aertor" exoost_ so4ra tan 2011 odf Additional Sources: Beltr6n- Aguilar ED, Barker LK Canto MT, at al. 2005. Surveillance for dental codes, dorsal sealants, tooth retention, ardenlWism, and enamel f uorosts- United States, 1988. 1994 and 1999- 2002. CDC, MM WR, Surveillance Summaries, August 28, 2005, vat. 54, No SS-3, pp. 1-44. See Table 23 at hay /MtuorbeeterLOrMahk23 html - Full article online at htro• /Iwww cols nov /mnwAxevmWnr mbtmVtAS40381 htm Brunelle JA. Carlos JP. 1990, Recent trends In dental darks In U.S. children and the effect of water f uoridebon. Journal of Decibel Research 69, (Special edition), 723727. Du L Wan C, Coo X, Uu J. 2008. The effect of fluorine on the developing human brain. Fluoride 41(4):327 -30. Online at htto•llwww flworideMsearch %tV414/fdesIFJ2000 v41 04 0327- FAN (fluoride Action Nehvork). 2011 d. PubMed refuses to include the most referonced journal in a U.S. landmark report on fluoride. Controversy and Censorship in Science: Fluoride and Fluoridation. Online at htto,l/www fllmrwrealen ornrnro2006 mostated tdml Goo Q, Liu YJ, Guan ZZ. 2009. Decreased looming and memory ability in rats with fluorci is: Increased oxidative stress and reduced cholinesterase activity. Fluoride 42(4):277-85. Online at two /Avww fluoddereswrch crad4241424MWoIFJ2009 v42 rA 0277 -285 colt Guan ZZ, Wang YN, Xiao KQ at al. 1998. Influence of cixcruic fluorosis on membrane lipids in rat brain. Naurotoxicdogy and Tera1010020(5):537 -42. He H, Chong Z, Uu WQ. 2006. Effects of fluorine on the human fetus. Fluoride 41(4):321 -26. Online at htb' //www Buorideresemch ord414/fdes/FJ20-W v41 114 0321.320.odf Komarek A, Lesaffre E, Hafkanen T. Dederck D, Virrenen JI. 2005. A Bayesion analysts of multivariate doubly - interval- consaed dental data. Biostatisbcs 6(1):45-55. January. Li XS, Zhi JL Goo RL 1895. Effect of fluoride exposure on intalligence, in dtikfren. Fluoride. 2S(4):189-192. Online a hfloymuoridealert orat$&Or/1i- 1995.odf LW YJ, Goo Q, Wu CX. Guan ZZ. 2010. Alterations of nAChRs and ERK1/2 in the brains of rats with iconic fluorosis and [heir connections with to decreased capadty of learning and memory. Toxicology Lotwsig2(3):324 -28. Mullow P, Denbesten PK, Sehunior A, Keman AU. 1995. Netrotoxicity of sodium fluoride in rats. Neurotoxicology and Teratology 17(2):169 -177. Mar -Aux. Yu Y. Yang W, Dong Z, Wan C, Zhang J. Uu J. )Gan K Huang Y, W B. 2008. Neurokansmiber and receptor changes in the trains of fetuses from areas of endemic fluorosis. Fluoride 41 (2):13438. Online at ht ihvww fluonderesearch orcV4lM5/FJ200B v41 n2 01341381) Zhao LB, Lung GH. Zhi g DN, Wu XR. 1996. Effect of high -fluoride water supply on ehikimys intelligence. Fluoride 29(4):190-192. Online at htto /lfluaidealert ordlsdherhhao1998.0df ;Alp' One like. �,qr '.ip to see what your friends like. Related Links: Fluoride Awareness Week http: / /articles.mercola.com /sites /articles /archive /2011 /08/ 12 /fluoride- and - the - brain -no- mar... 8/19/2011 Packet Page -895- /0�! Flu.,...or"i.�dalion American Dental Association www.ada.org Packet Page -896- DEDICATION This 2005 edition of Fluoridation Facts is dedicated to Dr. Herschel Horowitz, talented researcher, renowned dental epidemiologist and tireless advocate of community water fluoridation. ABOUT FLUORIDATION ACKNOWLEDGMENTS All A' American Dental Association www.ada.org ADA Statement Commemorating the 60t' Anniversary of Community Water Fluoridation Sixty years ago, Grand Rapids, Michigan became the world's first city to adjust the level of fluoride in its water supply. Since that time, fluoridation has dramatically improved the oral health of tens of millions of Americans. Community water fluoridation is the single most effective public health measure to prevent tooth decay. Additionally, the Centers for Disease Control and Prevention proclaimed community water fluoridation as one of 10 great public health achievements of the 20th century. Fluoridation of community water supplies is simply the precise adjustment of the existing naturally occurring fluoride levels in drinking water to an optimal fluoride level recommended by the U.S. Public Health Service (0.7 — 1.2 parts per million) for the prevention of dental decay. Based on data from 2002, approximately 170 million people (or over two- thirds of the population) in the United States are served by public water systems that are fluoridated. Studies conducted throughout the past 60 years have consistently indicated that fluoridation of community water supplies is safe and effective in preventing dental decay in both children and adults. It is the most efficient way to prevent one of the most common childhood diseases — tooth decay (5 times as common as asthma and 7 times as common as hay fever in 5- to17 -year- olds). Early studies, such as those conducted in Grand Rapids, showed that water fluoridation reduced the amount of cavities children get in their baby teeth by as much as 60% and reduced tooth decay in permanent adult teeth nearly 35 %. Today, studies prove water fluoridation continues to be effective in reducing tooth decay by 20 -40 %, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste. The average cost for a community to fluoridate its water is estimated to range from approximately $0.50 a year per person in large communities to approximately $3.00 a year per person in small communities. For most cities, every $1 invested in water fluoridation saves $38 in dental treatment costs. The American Dental Association continues to endorse fluoridation of community water supplies as safe and effective for preventing tooth decay. This support has been the Association's position since policy was first adopted in 1950. The ADA's policies regarding community water fluoridation are based on the overwhelming weight of peer - reviewed, credible scientific evidence. The ADA, along with state and local dental societies, continues to work with federal, state, local agencies and community coalitions to increase the number of communities benefiting from water fluoridation. 2005 211 East Chicago Avenue Chicago, Illinois 60611 -2678 Permission is hereby granted to reproduce and distribute this ADA Statement Commemorating the 60th Anniversary of Community Water Fluoridation in its entirety, without modification. To request any other copyright permission please contact the American Dental Association at 1- 312 -440 -2879. Fluoridation Facts Packet Page -898- TABLE OF CONTENTS ADA Statement Commemorating the 60th Anniversary of Community Water Fluoridation Executive Summary Introduction 1 4 6 BENEFITS Question Topic 10 Page 1. What is fluoride? 10 2. How does fluoride help prevent dental decay? 10 3. What is water fluoridation? 11 4. How much fluoride is in your water? 11 5. Fluoride additives? 12 6. Natural vs adjusted? 12 7. Effectiveness? 13 S. Still effective? 14 9. Discontinuance? 15 10. Is decay still a problem? 16 11. Adult benefits? 16 12. Dietary supplements? 17 13. Fluoride for children? 18 14. Alternatives? 19 15. Bottled water? 19 16. Home treatment (filter) systems? 21 SAFETY 22 Question Topic Page 17. Harmful to humans? 22 18. More studies needed? 23 19. Total intake? 24 20. Daily intake? 25 21. Prenatal dietary fluoride 26 supplements? 22. Body uptake? 26 23. Bone health? 27 24. Dental fluorosis? 28 25. Prevent fluorosis? 30 26. Warning label? 31 27. Toxicity? 31 28. Cancer? 32 29. Enzyme effects? 33 30. Thyroid gland? 34 31. Pineal gland? 34 32. Allergies? 34 31 Genetic risk? 35 34. Fertility? 35 35. Down Syndrome? 35 36, Neurological impact? 36 37. Lead poisoning? 37 38. Alzheimer's disease? 37 39. Heart disease? 38 40. Kidney disease? 38 41. Erroneous health claims? 39 2 Packet Page -899- American Dental Association FLUORIDATION PRACTICE Question Topic 40 Page 42. Water quality? 40 43. Regulation? 41 44. Standards? 42 45. Source of additives? 43 46. System safety concerns? 43 47. Engineering? 44 48, Corrosion? 44 49. Environment? PUBLIC POLICY Question Topic 45 46 Page 50. Valuable measure? 46 51. Courts of law? 47 52. Opposition? 47 53. Internet? 51 54. Public votes? 51 55. International fluoridation? 54 56. Banned in Europe? 54 COST EFFECTIVENESS Question Topic 56 Page 57. Cost effective? 56 58. Practical? 57 /'", Fluoridation Facts Call to Action 57 References 58 Statements from Five Leading Health 68 Organizations Regarding Community Water Fluoridation Compendium 69 Figures 1. Reviewing Research 7 2. Effectiveness List 13 3. ADA.org - Bottled Water 20 4. Safety List 23 5. 1998 Consumers' Opinions 48 6. Approval of Fluoridating 48 Drinking Water 7. Opposition Tactics 50 8. ADA.org - Fluoride and 51 Fluoridation 9. Largest Fluoridated Cities 52 10. States Meeting National Goals 53 Tables 1. Dietary Fluoride Supplements 18 2. Bottled Water 20 3. Dietary Reference Intakes 25 4. Categories of Dental Fluorosis 28 Packet Page -900- 3 EXECUTIVE SUMMARY • Fluoridation of community water supplies is the sin- • For most cities, every $1 invested in water fluorida- gle most effective public health measure to prevent tion saves $38 in dental treatment costs. dental decay. • Water that has been fortified with fluoride is simi- • Throughout more than 60 years of research and prac - lar to fortifying salt with iodine, milk with vitamin tical experience, the overwhelming weight of credi- D and orange juice with vitamin C. ble scientific evidence has consistently indicated that fluoridation of community water supplies is safe. • Simply by drinking water, people can benefit from fluoridation's cavity protection whether they are at • The Centers for Disease Control and Prevention has home, work or school. proclaimed community water fluoridation (along with vaccinations and infectious disease control) as • The average cost for a community to fluoridate its wa- one of ten great public health achievements of the ter is estimated to range from approximately $0.50 a 20th century. year per person in large communities to approximately $3.00 a year per person in small communities. • More than 100 national and international health, ser- vice and professional organizations recognize the pub - 0 More than two- thirds of the population in the United , lic health benefits of community water fluoridation for States are served by public water systems that are preventing dental decay. optimally fluoridated. • Studies prove water fluoridation continues to be ef- • In the past five years (2000 through 2004), more fective in reducing dental decay by 20 -40 %, even in than 125 U.S. communities in 36 states have voted an era with widespread availability of fluoride from to adopt fluoridation. other sources, such as fluoride toothpaste. • Fluoridation has been thoroughly tested in the Unit- • Community water fluoridation benefits everyone, es- ed States' court system, and found to be a proper pecially those without access to regular dental care. means of furthering public health and welfare. No It is the most efficient way to prevent one of the most court of last resort has ever determined fluoridation common childhood diseases — dental decay (5 times to be unlawful. as common as asthma and 7 times as common as hay fever in 5-to-17-year-olds). Without fluoridation, • Be aware of misinformation on the Internet and other there would be many more than the estimated 51 junk science related to water fluoridation. million school hours lost per year in this country be- cause of dental - related illness. • One of the most widely respected sources for in- formation regarding fluoridation and fluorides is • Community water fluoridation is the adjustment of the American Dental Association. The ADA main - fluoride that occurs naturally in water to optimal lev- tains Fluoride and Fluoridation Web pages at els to protect oral health. bttr)://www.ada.org/cioto/fluoride. Permission is hereby granted to reproduce and distribute this Fluoridation Facts Executive Summary in its entirety, without modification. To request any other copyright permission please contact the American Dental Association at 1- 312 -440 -2879. 4 Packet Page -901- American Dental Association I Packet Page -902- INTRODUCTION Ince 1956, the American Dental Association (ADA) has published Fluoridation Facts. Revised periodically, Fluoridation Facts answers frequently asked questions about community water fluoridation. In this 2005 edition issued as part of the 60th Anniversary celebration of com- munity water fluoridation, the ADA Council on Access, Prevention and Interprofessional Relations provides up- dated information for individuals and groups interested in the facts about fluoridation. The United States now has over 60 years of practical experience with community wa- ter fluoridation. Its remarkable longevity is testimony to fluoridation's significance as a public health measure. In recognition of the impact that water fluoridation has had on the oral and general health of the public, in 1999, the Centers for Disease Control and Prevention named fluori- dation of drinking water as one of ten great public health achievements of the 201h century. 1,2 Support for Water Fluoridation Since 1950, the American Dental Association (ADA), along with the United States Public Health Service (USPHS), has continuously and unreservedly endorsed the optimal fluoridation of community water supplies as a safe and effective public health measure for the prevention of dental decay. The ADA's policy is based on its continuing evaluation of the scientific research on the safety and effectiveness of fluoridation. Since 1950, when the ADA first adopted policy recommending com- munity water fluoridation, the ADA has continued to reaffirm its position of support for water fluoridation and has strongly urged that its benefits be extended to communities served by public water systems.3 The 2005 "ADA Statement Commemorating the 60th Anni- versary of Community Water Fluoridation" reinforced that position .4 Fluoridation is the most effective public health measure to prevent dental decay for children and adults, reduce oral health disparities and improve oral health over a lifetime.5 The American Dental Association, the U.S. Public Health Service, the American Medical Association and the World Health Organization all support community water fluoridation. Other national and international health, service and professional organizations that rec- ognize the public health benefits of community water fluoridation for preventing dental decay are listed on the inside back cover of this publication. Scientific Information on Fluoridation The ADA's policies regarding community water fluorida- tion are based on generally accepted scientific knowledge. This body of knowledge is based on the efforts of nation- ally recognized scientists who have conducted research 6 using the scientific method, have drawn appropriate bal- anced conclusions based on their research findings and have published their results in refereed (peer- reviewed) professional journals that are widely held or circulated. Studies showing the safety and effectiveness of water fluoridation have been confirmed by independent sci- entific studies conducted by a number of nationally and internationally recognized scientific investigators. While opponents of fluoridation have questioned its safety and effectiveness, none of their charges has ever been sub- stantiated by generally accepted science. With the advent of the Information Age, a new type of "pseudo- scientific literature" has developed. The public often sees scientific and technical information quoted in the press, printed in a letter to the editor or distributed via an Internet Web page. Often the public accepts such information as true simply because it is in print. Yet the information is not always based on research conducted according to the scientific method, and the conclusions drawn from research are not always scientifically justifi- able. In the case of water fluoridation, an abundance of misinformation has been circulated. Therefore, sci- entific information from all print and electronic sources must be critically reviewed before conclusions can be drawn. (See Figure 1.) Pseudo - scientific literature may peak a reader's interest but when read as science, it can be misleading. The scientific validity and relevance of claims made by opponents of fluoridation might be best viewed when measured against criteria set forth by the U.S. Supreme Court. Additional information on this topic may be found in Question 52. History of Water Fluoridation Research into the beneficial effects of fluoride began in the early 1900s. Frederick McKay, a young dentist, opened a dental practice in Colorado Springs, Colo- rado, and was surprised to discover that many local residents exhibited brown stains on their permanent teeth. Dr. McKay could find no documentation of the condition in the dental literature and eventually con- vinced Dr. G.V. Black, dean of the Northwestern Univer- sity Dental School in Chicago, to join him in studying the condition. Through their research, Drs. Black and McKay determined that mottled enamel, as Dr. Black termed the condition, resulted from developmental imperfections in teeth. (Mottled enamel is a historical term. Today, this condition is called dental or enamel fluorosis.) Drs. Black and McKay wrote detailed de- scriptions of mottled enamel .6,7 In the 1920s, Dr. McKay, along with others, suspected that something either in or missing from the drinking Packet Page -903- American Dental Association It is important to review information about fluorida- tion with a critical eye. Listed below are key elements to consider when reviewing information about fluori- dation research. 1. Credentials: The author's background and cre- dentials should reflect expertise in the area of research undertaken. 2. Date: The year of the publication should be ap- parent. The information should be relatively cur- rent, although well- designed studies can stand the test of time and scientific scrutiny. A review of existing literature can provide insight into whether the results of older studies have been superseded by subsequent studies. 3. Accuracy: If the information is a review of other studies, it should be accurate and representative of the original research. Information quoted di- rectly from other sources should be quoted in its entirety. 4. Statistical Methods: The methods used to ana- lyze the data should be generally accepted and appropriate. 5. Comparability: The research should be applica- ble to community water fluoridation and use an appropriate type and amount of fluoride. Many research projects investigate the use of fluoride at much higher levels than recommended for community water fluoridation. For example, the results of a study using a concentration of 125 parts per million (ppm) fluoride are not compa- rable to research findings regarding water fluori- dated at 0.7 to 1.2 ppm. Fluoridation Facts 6. Type of Research: How the research is conducted is relevant. Research conducted in vitro (outside the living body and in a laboratory environment) may not have the same results as research conducted in vivo (in a living human or other animal). 7. Research Model: A good study will try to repli- cate real life situations as close as possible. For example, results from animal studies using high doses of fluoride that are injected rather than provided in drinking water should be cautiously interpreted. Such studies are highly question- able as a predictor of the effects of human ex- posure to low concentrations of fluoride, such as those used to fluoridate water. 8. Peer Review: Publications presenting scientific information should be peer reviewed to help ensure that scientifically sound articles are pub- lished. Peer review involves evaluation and rat- ing of the scientific and technical merit of an ar- ticle by other qualified scientists. 9. Weight of Evidence: Conclusions from one partic- ular study or one particular researcher should be weighed against the bulk of established, gener- ally accepted, peer- reviewed science. No single study by itself is conclusive. If other researchers have not been able to replicate the results of a particular study or the work of one researcher, the results of that study or body of research should be viewed with some skepticism. 10. Easily Accessible: Reputable studies on fluori- dation are typically published in peer- reviewed journals and other vehicles that are easily obtain- able through a medical /dental library or through PubMed, a service of the National Library of Medicine which can be accessed via the Internet at htto: / /www.nlm.nih.ciov /. Packet Page -904- 7 water was causing the mottled enamel. Dr. McKay wrote to the Surgeon General in 1926 indicating that he had identified a number of regions in Colorado, New Mexico, Arizona, California, Idaho, South Dakota, Texas and Vir- ginia where mottled enamel existed. Also in the late 20s, Dr. McKay made another significant discovery — these stained teeth were surprisingly resistant to decay.' Following additional studies completed in the early 1930s in St. David, Arizona" and Bauxite, Arkansas,9 it was determined that high levels of naturally occurring fluoride in the drinking water were causing the mottled enamel. In Arizona, researchers scrutinized 250 resi- dents in 39 local families and were able to rule out he- reditary factors and environmental factors, except for one - fluoride in the water which occurred naturally at levels of 3.8 to 7.15 ppm. In Bauxite, H. V. Churchill, chief chemist with the Aluminum Company of America (later changed to ALCOA), was using a new method of spectrographic analysis in his laboratory to look at the possibility that the water from an abandoned deep well in the area might have high levels of aluminum - containing bauxite that was causing mottled teeth. What he found was that the water contained a high level of naturally occurring fluoride (13.7 ppm). When Dr. McKay learned of this new form of analysis and Dr. Churchill's findings, he forwarded samples of water from areas where mottled enamel was commonplace to Dr. Churchill. All of the samples were found to have high levels of fluoride when compared to waters tested from areas with no mottled enamel .7 During the 1930s, Dr. H. Trendley Dean, a dental of- ficer of the U.S. Public Health Service, and his associ- ates conducted classic epidemiological studies on the geographic distribution and severity of fluorosis in the United States.10 These early studies were aimed at evaluating how high the fluoride levels in water could be before visible, severe dental fluorosis occurred. By 1936, Dean and his staff had made the critical discovery that fluoride levels of up to 1.0 part per million (ppm) in the drinking water did not cause the more severe forms of dental fluorosis. Dean additionally noted a correla- tion between fluoride levels in the water and reduced incidence of dental decay. 11,12 In 1939, Dr. Gerald J. Cox and his associates at the Mel- lon Institute evaluated the epidemiological evidence and conducted independent laboratory studies. While the is- sue was being discussed in the dental research commu- nity at the time, they were the first to publish a paper that proposed adding fluoride to drinking water to prevent dental decay.73 In the 1940s, four classic, community - wide studies were carried out to evaluate the addition of sodium fluoride to fluoride- deficient water supplies. The first community water fluoridation program, under the direction of Dr. Dean, began in Grand Rapids, Michigan, in January 1945. The other three studies were conducted in Newburgh, New York (May 1945); Brantford, Ontario (June 1945) and Evanston, Illinois (February 1947.)13 -1s The astounding success of these studies firmly estab- lished fluoridation as a practical and safe public health measure to prevent dental decay that would quickly be embraced by other communities. The history of water fluoridation is a classic example of a curious professional making exacting clinical observa- tions which led to epidemiologic investigation and even- tually to a safe and effective community -based public health intervention which even today remains the corner- stone of communities' efforts to prevent dental decay. "The Centers for Disease Control and Prevention named fluoridation of drinking water one of ten great public health achievements of the 20th century noting that it is a major factor responsible for the decline in dental decay. Water Fluoridation as a Public Health Measure Throughout decades of research and more than sixty years of practical experience, fluoridation of public water supplies has been responsible for dramatically improving the public's oral health. In 1994, the U.S. Department of Health and Human Services issued a report which reviewed public health achievements. Along with other successful public health measures such as the virtual eradication of polio and reductions in childhood blood lead levels, fluoridation was laud- ed as one of the most economical preventive inter- ventions in the nation .17 A policy statement on water fluoridation reaffirmed in 1995 by the USPHS stated that water fluoridation is the most cost - effective, prac- tical and safe means for reducing the occurrence of dental decay in a community.18 In 1998, recognizing the ongoing need to improve health and well being, the USPHS revised national health objectives to be achieved by the year 2010. Included under oral health was an objective to significantly expand the fluorida- tion of public water supplies. Specifically, Objective 21 -9 states that at least 75% of the U.S. population served by community water systems should be receiv- ing the benefits of optimally fluoridated water by the year 2010.19 In 1999, the Centers for Disease Control and Preven- tion named fluoridation of drinking water one of ten Packet Page -905- American Dental Association el—\ great public health achievements of the 201h century not- ing that it is a major factor responsible for the decline in dental decay. 1,2 Former U.S. Surgeon General David Satcher issued the first ever Surgeon General report on oral health in May 2000. In Oral Health in America: A Report of the Sur- geon General, Dr. Satcher stated that community water fluoridation continues to be the most cost - effective, prac- tical and safe means for reducing and controlling the oc- currence of dental decay in a community.5,21 Additionally, Dr. Satcher noted that water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations. Studies have shown that fluoridation may be the most significant step we can take toward reducing the disparities in dental decay.5,21-24 In the 2003 National Call to Action to Promote Oral Health, U.S. Surgeon General Richard Carmona called on policymakers, community leaders, private industry, health professionals, the media and the public to affirm that oral health is essential to general health and well be- ing. Additionally, Surgeon General Carmona urged these groups to apply strategies to enhance the adoption and maintenance of proven community -based interventions such as community water fluoridation .25 Community water fluoridation is a most valuable public health measure because: • Optimally fluoridated water is accessible to the en- tire community regardless of socioeconomic status, educational attainment or other social variable S.21 • Individuals do not need to change their behavior to obtain the benefits of fluoridation. • Frequent exposure to small amounts of fluoride over time makes fluoridation effective through the life span in helping to prevent dental decay. • Community water fluoridation is more cost effec- tive than other forms of fluoride treatments or ap- plications.21 Water Fluoridation's Role in Reducing Dental Decay Water fluoridation and the use of topical fluoride have played a significant role in improving oral health. Early studies showed that water fluoridation can re- duce the amount of cavities children get in their baby teeth by as much as 60% and can reduce dental decay in permanent adult teeth by nearly 35 %. Since that time, numerous studies have been published mak- ing fluoridation one of the most widely studied public health measures in history. Later studies prove water fluoridation continues to be effective in reducing den- tal decay by 20 -40 %, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste .211,29 Increasing numbers of adults Fluoridation Facts are retaining their teeth throughout their lifetimes due in part to the benefits they receive from water fluoridation. Dental costs for these individuals are likely to have been reduced and many hours of need- less pain and suffering due to untreated dental decay have been avoided. "Water fluoridation continues to be effective in reducing dental decay by 20 -40 %, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste. It is important to note that dental decay is caused by dental plaque, a thin, sticky, colorless deposit of bacte- ria that constantly forms on teeth. When sugar and oth- er carbohydrates are eaten, the bacteria in plaque pro- duce acids that attack the tooth enamel. After repeated attacks, the enamel breaks down, and a cavity (hole) is formed. There are a number of factors that increase an individual's risk for dental decay: 27,30-33 • Recent history of dental decay • Elevated oral bacteria count • Inadequate exposure to fluorides • Exposed roots • Frequent intake of sugar and sugary foods • Poor or inadequate oral hygiene • Decreased flow of saliva • Deep pits and fissures in the chewing surfaces of teeth Exposure to fluoride is not the only measure avail- able to decrease the risk of decay. In formulating a de- cay prevention program, a number of intervention strat- egies may be recommended such as changes in diet and placement of dental sealants. However, fluoride is a key component in any recommended strategy. Ongoing Need for Water Fluoridation Because of the risk factors for dental decay noted previously, many individuals and communities still experience high levels of dental decay. Although wa- ter fluoridation demonstrates an impressive record of effectiveness and safety, only 67.3 % of the United States population on public water supplies receives fluoridated water containing protective levels of flu - oride.34 Unfortunately, some people continue to be confused about this effective public health measure. If the number of individuals drinking fluoridated water is to increase, the public must be accurately informed about its benefits. Packet Page -906- BENEFITS Q 1. What is fluoride? P. 10 Q 2. How does fluoride help prevent dental decay? p. 10 Q 3. What is water fluoridation? P. 11 Q 4. How much fluoride is in your water? p. 11 Q 5. Fluoride additives? p. 12 QUESTION 1. What is fluoride? Q 6. Natural vs adjusted? p. 12 Q 7. Effectiveness? p. 13 Q 8. Still effective? p. 14 Q 9. Discontinuance? p. 15 Q 10. Is decay still a problem? p. 16 Q 11. Adult benefits? p. 16 Q 12. Dietary supplements? p. 17 Answer. Fluoride is a naturally occurring compound that can help prevent dental decay. Fact. The fluoride ion comes from the element fluorine. Fluorine is an abundant element in the earth's crust in the form of the fluoride ion. As a gas, it never oc- curs in its free state in nature, but exists only in com- bination with other elements as a fluoride compound. Fluoride compounds are components of minerals in rocks and soil. Water passes over rock formations and dissolves the fluoride compounds that are present, re- leasing fluoride ions. The result is that small amounts of fluoride are present in all water sources. Gener- ally, surface water sources such as lakes, rivers and streams have very low levels of fluoride. For example, Lake Michigan's fluoride level is 0.17 ppm.35 As water moves through the earth, it contacts fluoride-contain- ing minerals and carries away fluoride ions. The con- centration of fluoride in groundwater varies according to such factors as the depth at which the water is found and the quantity of fluoride bearing minerals in the area .16 In the United States, the natural level of fluoride in groundwater varies from very low levels to over 4 ppm. The fluoride level of the oceans ranges from 1.2 to 1.4 ppm.37,36 Fluoride is naturally present to some extent in all foods and beverages, but the concentrations vary widely.3s41 QUESTION 2. How does fluoride help prevent dental decay? Answer. Fluoride protects teeth in two ways — systemically and topically. 10 Q 13. Fluoride for children? p. 18 Q 14. Alternatives? P. 19 Q 15. Bottled water? P. 19 Q 16. Home treatment p. 21 (filter) systems? Fact. Systemic fluorides are those ingested into the body. During tooth formation, ingested fluorides become in- corporated into tooth structures. Fluorides ingested regularly during the time when teeth are developing (preeruptively) are deposited throughout the entire tooth surface and provide longer - lasting protection than those applied topically.42 Systemic fluorides can also give topical protection because ingested fluoride is present in saliva, which continually bathes the teeth providing a reservoir of fluoride that can be incorporat- ed into the tooth surface to prevent decay. Fluoride also becomes incorporated into dental plaque and facilitates further remineralization.43 Sources of systemic fluoride in the United States include fluoridated water, dietary fluoride supplements in the forms of tablets, drops or lozenges and fluoride present in food and beverages. "Fluoride protects teeth in two ways - systemically and topically. " While it was originally believed that fluoride's action was exclusively systemic or preeruptive, by the mid - 1950s, there was growing evidence of both systemic and topical benefits of fluoride exposure.44 'J Additional information on this topic may be found in Question 11. Topical fluorides strengthen teeth already present in the mouth (posteruptively). In this method of delivery, fluoride is incorporated into the surface of teeth making them more decay- resistant. Topically applied fluoride provides local protection on the tooth surface. Topical fluorides include toothpastes, mouthrinses and profes- sionally applied fluoride foams, gels and varnishes. As mentioned previously, systemic fluorides also pro- vide topical protection. Low levels of fluoride in saliva and plaque from sources such as optimally fluoridated water can prevent and reverse the process of dental decay.45 In clarifying the effectiveness of water fluorida- tion, John D.B. Featherstone, PhD, Professor and Chair, Packet Page -907- American Dental Association �1 /'1 Department of Preventive and Restorative Dental Ser- vices, University of California San Francisco, noted: "... There is irrefutable evidence in numerous studies that fluoride in the drinking water works to reduce dental caries in populations. This is still the case. 1141 "John D.B. Featherstone, PhD, Professor and Chair, Department of Preventive and Restorative Dental Services, University of California San Francisco, noted. '...There is irrefutable evidence in numerous studies that fluoride in the drinking water works to reduce dental caries in populations. "' The remineralization effect of fluoride is important. Flu- oride ions in and at the enamel surface result in fortified enamel that is not only more resistant to decay (loss of minerals or demineralization), but enamel that can repair or remineralize early dental decay caused by acids from decay- causing bacteria .112,11-51 Fluoride ions necessary for remineralization are provided by fluoridated water as well as various fluoride products such as toothpaste. The maximum reduction in dental decay is achieved when fluoride is available preeruptively (systemically) for incorporation during all stages of tooth formation and posteruptively (topically) at the tooth surface. Wa- ter fluoridation provides both types of exposure .14,52-14 QUESTION 3. What is water fluoridation? Answer. Water fluoridation is the adjustment of the natural fluo- ride concentration of fluoride - deficient water to the level recommended for optimal dental health. Fact. Based on extensive research, the United States Public Health Service (USPHS) established the optimum con- centration for fluoride in the water in the United States in the range of 0.7 to 1.2 parts per million. This range effectively reduces dental decay while minimizing the occurrence of dental fluorosis. The optimum level is de- pendent on the annual average of the maximum daily air temperature in the geographic area .55 One milligram per liter (mg /L) of fluoride in water is identical to one part per million (ppm). At 1 ppm, one part of fluoride is diluted in a million parts of water. Large numbers such as a million can be very difficult to visual- ize. While not exact, the following comparisons can be of assistance in comprehending one part per million: 1 inch in 16 miles 1 minute in 2 years 1 cent in $10,000 Fluoridation Facts For clarity, the following terms and definitions are used in this booklet: Community water fluoridation is the adjustment of the natural fluoride concentration in water up to the level recommended for optimal dental health (a range of 0.7 to 1.2 ppm). Other terms used interchangeably in this booklet are water fluoridation, fluoridation and op- timally fluoridated water. Optimal levels of fluoride may be present in the water naturally or by adjusted means. (+ Additional information on this topic may be found in Question 6. Sub - optimally fluoridated water is water that natural- ly contains less than the optimal level (below 0.7 ppm) of fluoride. Other terms used interchangeably in this booklet are nonfluoridated water and fluoride- deficient water. QUESTION 4. Flow much fluoride is in your water? Answer. If your water comes from a public /community water supply, the options to learn the fluoride level of the wa- ter include contacting the local water supplier or the local /county /state health department, reviewing your Consumer Confidence Report (CCR) and using the Inter- net based "My Water's Fluoride." If your water source is a private well, it will need to be tested and the results obtained from a certified laboratory. Fact. The fluoride content of the local public or community wa- ter supply can be obtained by contacting the local water supplier or the local /county /state health department. In 1999, the U.S. Environmental Protection Agency (EPA) began requiring water suppliers to put annual drinking water quality reports into the hands of its cus- tomers. Typically available around July 15' each year, these Water Quality Reports, or Consumer Confidence Reports (CCRs), may be mailed to your home, placed in the local newspaper or made available through the Internet .56 To obtain a copy of the report, contact the local water supplier. The name of the water system (of- ten not the name of the city) can be found on the water bill. If the name of the public water system is unknown, contact the local health department. There are two sites on the Internet that supply in- formation on water quality. The online source for water quality reports or CCRs is the EPA web site at http://www.er)a.gov/safewater/dwinfo/index.htmI.fi7 Additionally, the Centers for Disease Control and Prevention's (CDC) fluoridation Web site, "My Water's Fluoride," is available at http: / /apps.nccd.cdc.ciov /MWF/ Index.asp.58 For those states that have provided infor- mation to the CDC, the site lists fluoridation status by water system. Packet Page -908- 11 5. The EPA does not have the authority to regulate private drinking water wells. However, the EPA recom- mends that private well water be tested every year. While the EPA does not specifically recommend testing for the level of fluoride, health professionals will need this information prior to consideration of prescription of dietary fluoride supplements or to counsel patients about alternative water sources to reduce the risk of fluorosis if the fluoride levels are above 2 ppm.59 (+ Additional information on this topic may be found in Questions 12, 24, 25 and 42. Always use a state certified laboratory that conducts drinking water tests.59 For a list of state certified labs, con- tact the local, county or state water /health department. QUESTION 5. What additives are used to fluoridate water supplies in the United States? Answer. Sodium fluoride, sodium fluorosilicate and fluorosilicic acid are the three additives approved for community water fluoridation in the United States. Sodium fluoro- silicate and fluorosilicic acid are sometimes referred to as silicofluoride additives. Fact. The three basic additives used to fluoridate water in the United States are: 1) sodium fluoride which is a white, odorless material available either as a powder or crys- tals; 2) sodium fluorosilicate which is a white or yellow - white, odorless crystalline material and 3) fluorosilicic acid which is a white to straw - colored liquid .11,60 While fluoridation began in 1945 with the use of so- dium fluoride, the use of silicofluorides began in 1946 and, by 1951, they were the most commonly used ad- ditives.61 First used in the late 1940s, fluorosilicic acid is currently the most commonly used additive to fluori- date communities in the U.S.16,11 "To ensure the public's safety, standards have been established to ensure the safety of fluoride additives used in water treatment in the U.S." To ensure the public's safety, standards have been established to ensure the safety of fluoride additives used in water treatment in the U.S. Specifically, addi- tives used in water fluoridation meet standards of the American Water Works Association (AWWA) and NSF International (NSF). (+ Additional information on the topic of fluoride addi- tives may be found in Fluoridation Practice Section. 12 QUESTION 6. Is there a difference in the effectiveness between natu- rally occurring fluoridated water (at optimal fluoride levels) and water that has fluoride added to reach the optimal level? Answer. No. The dental benefits of optimally fluoridated water occur regardless of the fluoride's source. Fact. Fluoride is present in water as "ions" or electrically charged atoms.36 These ions are the same whether ac- quired by water as it seeps through rocks and sand or added to the water supply under carefully controlled conditions. When fluoride is added under controlled conditions to fluoride- deficient water, the dental ben- efits are the same as those obtained from naturally fluo- ridated water. Fluoridation is merely an increase of the level of the naturally occurring fluoride present in all drinking water sources. "Fluoridation is merely an increase of the level of the naturally occurring fluoride present in all drinking water sources." Some individuals use the term "artificial fluorida- tion" to imply that the process of water fluoridation is unnatural and that it delivers a foreign substance into a water supply when, in fact, all water sources contain some fluoride. Community water fluoridation is a natu- ral way to improve oral health." (Additional information on this topic may be found in Question 45. Prior to the initiation of "adjusted" water fluoridation, several classic epidemiological studies were conducted that compared naturally occurring fluoridated water to fluoride- deficient water. Strikingly low decay rates were found to be associated with the continuous use of water with fluoride content of 1 part per million .12 A fluoridation study conducted in the Ontario, Cana- da, communities of Brantford (optimally fluoridated by adjustment), Stratford (optimally fluoridated naturally) and Sarnia (fluoride- deficient) revealed much lower de- cay rates in both Brantford and Stratford as compared to nonfluoridated Sarnia. There was no observable dif- ference in decay- reducing effect between the naturally occurring fluoride and adjusted fluoride concentration water supplies, proving that dental benefits were simi- lar regardless of the source of fluoride.16 Packet Page -909- American Dental Association i"\ I,--. QUESTION 7. Is water fluoridation effective in helping to prevent den- tal decay? Answer. Overwhelming evidence exists to prove the effective- ness of water fluoridation. Water fluoridation is a very effective method for preventing dental decay for chil- dren, adolescents and adults. Continued assessment, however, is important as the patterns and extent of dental decay change in populations. Fact. The effectiveness of water fluoridation has been docu- mented in scientific literature for over 60 years. (See Figure 2.) Even before the first community fluoridation program began in 1945, epidemiologic data from the 1930s and 1940s revealed lower number of cavities in children consuming naturally occurring fluoridated wa- ter compared to children consuming fluoride- deficient water.' ,12 Since that time, thousands of studies have been done which continue to prove fluoride's effective- ness in decay reduction. In Grand Rapids, Michigan, the first city in the world to fluoridate its water supply, a 15 -year landmark study showed that children who consumed fluoridated water from birth had 50 -63% less dental decay than children who had been examined during the original baseline survey completed in nonfluoridated Muskegon, Michigan.63 Ten years after fluoridation in Newburgh, New York, 6- to 9- year -olds had 58% less dental decay than their counterparts in nonfluoridated Kingston, New York, which was fluoride- deficient. After 15 years, 13- to 14- year -olds in Newburgh had 70% less decay than the children in Kingston.6' • Centers for Disease Control and Prevention. Recom- mendations for Using Fluoride to Prevent and Control Dental Caries in the United States. MMWR 2001;50 (No. RR -14). (Guidelines on the use of fluoride.) • Horowitz HS. The effectiveness of community wa- ter fluoridation in the United States. J Public Health Dent 1996;56(5 Spec No):253 -8. (A review of fifty years of water fluoridation.) • Murray JJ. Efficacy of preventive agents for dental caries. Caries Res 1993;27(Suppl 1):2 -8.(A review of studies conducted from 1976 through 1987.) • Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49(5):279 -89. (The analysis of the results of 113 studies in 23 countries.) • Ripa LW. A half- century of community water fluorida- tion in the United States: review and commentary. J Public Health Dent 1993;53(1):17 -44. (The analysis of fifty years of water fluoridation.) Fluoridation Facts After 14 years of fluoridation in Evanston, Illinois, 14- year -olds had 57% fewer decayed, missing or filled teeth than the control group in Oak Park, Illinois, who drank water low in fluoride.66 In 1983, a study was undertaken in North Wales (Great Britain) to determine if the decay rate of fluori- dated Anglesey continued to be lower than that of non - fluoridated Arfon, as had been indicated in a previous survey conducted in 1974. Decay rates of life -long resi- dents in Anglesey, aged 5, 12 and 15, were compared with decay rates of identically aged residents in nonflu- oridated Arfon. Study results demonstrated that a de- cline in decay had occurred in both communities since the previous survey in 1974. However, the mean decay rate of the children in fluoridated Anglesey was still 45% lower than that of those living in nonfluoridated Arfon .66 These findings indicated a continuing need for fluorida- tion although decay levels had declined .67 In the United States, an epidemiological survey of nearly 40,000 schoolchildren was completed in 1987.29 Nearly 50% of the children in the study aged 5 to 17 years were decay -free in their permanent teeth, which was a major change from a similar survey in 1980 in which approximately 37% were decay -free. This dra- matic decline in decay rates was attributed primarily to the widespread use of fluoride in community water supplies, toothpastes, supplements and mouthrinses. Although decay rates had declined overall, data also revealed that the decay rate was 25% lower in children with continuous residence in fluoridated communities when the data was adjusted to control for fluoride ex- posure from supplements and topical treatments. A controlled study conducted in 1990 demonstrated that average dental decay experience among schoolchil- dren who were lifelong residents of communities with low fluoride levels in drinking water was 61 -100% high- er as compared with dental decay experience among schoolchildren who were lifelong residents of a com- munity with an optimal level of fluoride in the drinking water.68 In addition, the findings of this study suggest that community water fluoridation still provides signifi- cant public health benefits and that dental sealants can play a significant role in preventing dental decay. Using data from the dental surveys in 1991 -2 and 1993 -4, a British study predicted that on average, water fluoridation produces a 44% reduction in dental decay in 5- year -old children. The study further demonstrated that children in lower socioeconomic groups derive an even greater benefit from water fluoridation with an average 54% reduction in dental decay. Therefore, children with the greatest dental need benefit the most from water fluoridation.69 In 1993, the results of 113 studies in 23 countries were compiled and analyzed .70 (Fifty -nine out of the 113 stud- ies analyzed were conducted in the United States.) This review provided effectiveness data for 66 studies in pri- mary teeth and for 86 studies in permanent teeth. Taken Packet Page -910- 13 0 together, the most frequently reported decay reductions observed were: 40 -49% for primary teeth or baby teeth; and 50 -59% for permanent teeth or adult teeth. In a second review of studies conducted from 1976 through 1987,26 when data for different age groups were separated, reductions in dental decay in fluoridated communities were: 30 -60% in the primary dentition or baby teeth; 20 -40% in the mixed dentition* (aged 8 to 12); ( *A mixed dentition is composed of both baby teeth and adult teeth.) 15 -35% in the permanent dentition or adult teeth (aged 14 to 17); and 15 -35% in the permanent dentition (adults and seniors). A comprehensive analysis of the 50 -year history of community water fluoridation in the United States further demonstrated that the inverse relationship be- tween higher fluoride concentration in drinking water and lower levels of dental decay discovered a half -cen- tury ago continued to be true .71 Baby bottle tooth decay is a severe type of early child- hood decay that seriously affects babies and toddlers in some populations. Water fluoridation is highly effective in preventing decay in baby teeth, especially in children from low socioeconomic groups.72 In a 1998 review of the effectiveness of methods currently used to prevent this type of decay, water fluoridation received the high- est rating. For very young children, water fluoridation is the only means of prevention that does not require a dental visit or motivation of parents and caregivers .13 In 2001, the National Institutes of Health (NIH) held a consensus development conference, "Diagnosis and Management of Dental Caries Throughout Life." As part of the Consensus Statement issued at the conclusion of the conference, the panel noted that water fluoridation is widely accepted as both effective and of great impor- tance in the primary prevention of tooth decay.74 "Children with the greatest dental need benefit the most from water fluoridation ... The U.S. Task Force strongly recommended that community water fluoridation be included as part of a comprehensive population -based strategy to prevent or control tooth decay in communities." A systematic review of published studies conducted in 2001 by a team of experts on behalf of the U.S. Task Force on Community Preventive Services found that flu- oridation was effective in reducing tooth decay among populations. Based on strong evidence of effectiveness, the Task Force strongly recommended that community water fluoridation be included as part of a comprehen- sive population -based strategy to prevent or control tooth decay in communities .15-18 14 QUESTION S. With other forms of fluoride now available, is water flu- oridation still an effective method for preventing dental decay? Answer. Although other forms of fluoride are available, persons in nonfluoridated communities continue to demon- strate higher dental decay rates than their counterparts in communities with water fluoridation. 68,70,72,79.83 Fact. In the 1940s, children in communities with optimally fluoridated drinking water had reductions in decay rates of approximately 60% as compared to those living in nonfluoridated communities. At that time, drinking wa- ter was the only source of fluoride other than fluoride that occurs naturally in foods. Recent studies reveal that decay rates have declined in naturally or adjusted fluoridated areas and nonfluo- ridated areas as well. One factor is the high geographic mobility of our populations. In other words, it is becom- ing increasing difficult to study large numbers of people in one location who have a history of consuming only fluoridated or nonfluoridated water. "Even in an era with widespread availability of fluoride from other sources, studies prove water fluoridation continues to be effective in reducing dental decay by 20 -40 %. " A second factor is the universal availability of fluo- ride from other sources including food, beverages, den- tal products (toothpaste, rinses, professionally applied foams, gels and varnish) and dietary supplements .84 Foods and beverages processed in optimally fluoridated cities can contain higher levels of fluoride than those processed in nonfluoridated communities. These foods and beverages are consumed not only in the city where processed, but may be distributed to and consumed in nonfluoridated areas.256 This "halo" or "diffusion" effect results in increased fluoride intake by people in nonfluori- dated communities, providing them increased protection against dental decay. 52,11,16 As a result of the widespread availability of these various sources of fluoride, the dif- ference between decay rates in fluoridated areas and nonfluoridated areas is somewhat less than several de- cades ago but it is still significant.67 Failure to account for the diffusion effect may result in an underestimation of the total benefit of water fluoridation especially in ar- eas where large quantities of fluoridated products are brought into nonfluoridated communities .86 Even in an era with widespread availability of fluo- ride from other sources, studies prove water fluorida- tion continues to be effective in reducing dental decay by 20 -40 %.28,19 Packet Page -911- American Dental Association /—*.. ?01 QUESTION 9. What happens if water fluoridation is discontinued? Answer. Over time, dental decay can be expected to increase if water fluoridation in a community is discontinued, even if topical products such as fluoride toothpaste and fluo- ride rinses are widely used. Fact. The following paragraphs provide a summary of key his- torical studies that have been conducted on the discon- tinuation of water fluoridation. Antigo, Wisconsin began water fluoridation in June 1949, and ceased adding fluoride to its water in Novem- ber 1960. After five and one -half years without opti- mal levels of fluoride, second grade children had over 200% more decay, fourth graders 70% more, and sixth graders 91% more than those of the same ages in 1960. Residents of Antigo re- instituted water fluoridation in October 1965 on the basis of the severe deterioration of their children's oral health.88 Because of a government decision in 1979, fluorida- tion in the northern Scotland town of Wick was discon- tinued after eight years. The water was returned to its sub - optimal, naturally occurring fluoride level of 0.02 ppm. Data collected to monitor the oral health of Wick children clearly demonstrated a negative health effect from the discontinuation of water fluoridation. Five years after the cessation of water fluoridation, decay in permanent (adult) teeth had increased 27% and decay in primary (baby) teeth increased 40 %. This increase in decay occurred during a period when there had been a reported overall reduction in decay nationally and when fluoride toothpaste had been widely adopted.89 These data suggest that decay levels in children can be expected to rise where water fluoridation is interrupted or terminated, even when topical fluoride products are widely used. In a similar evaluation, the prevalence of decay in 10- year -old children in Stranraer, Scotland increased after the discontinuation of water fluoridation, result- ing in a 115% increase in the mean cost of restorative dental treatment for decay and a 21% increase in the mean cost of all dental treatment. These data support the important role water fluoridation plays in the re- duction of dental decay.90 A U.S. study of 6- and 7- year -old children who had re- sided in optimally fluoridated areas and then moved to the nonfluoridated community of Coldwater, Michigan, revealed an 11% increase in decayed, missing or filled tooth surfaces (DMFS) over a 3 -year period from the time the children moved. These data reaffirm that relying only on topical forms of fluoride is not an effective or prudent public health practice."," Decay reductions are greatest where water fluoridation is available in addition to topical fluorides, such as fluoride toothpaste and fluoride rinses. Finally, a study that reported the relationship be- tween fluoridated water and decay prevalence focused Fluoridation Facts on the city of Galesburg, Illinois, a community whose public water supply contained naturally occurring fluoride at 2.2 ppm. In 1959, Galesburg switched its community water source to the Mississippi River. This alternative water source provided the citizens of Gales- burg a sub - optimal level of fluoride at approximately 0.1 ppm. During the time when the fluoride content was below optimal levels, data revealed a 10% de- crease in the number of decay -free 14- year -olds (oldest group observed), and a 38% increase in dental decay. Two years later, in 1961, the water was fluoridated at the recommended level of 1.0 ppm.92 There have been several studies from outside the United States that have reported no increase in den- tal decay following the discontinuation of fluoridation. However, in all of the cases reported, the discontinua- tion of fluoridation coincided with the implementation of other measures to prevent dental decay. For example, in La Salud, Cuba a study on dental decay in children indicated that the rate of dental de- cay did not increase after fluoridation was stopped in 1990. However, at the time fluoridation was discontin- ued a new topical fluoride program was initiated where all children received fluoride mouthrinses on a regular basis and children two to five received fluoride varnish once or twice a year.93 In Finland, a longitudinal study of Kuopio (fluoridat- ed from 1959 to 1992) and Jyvaskyla (low levels of natu- ral fluoridation) showed little differences in decay rates between the two communities. This was attributed to a number of factors. The populations are extremely simi- lar in terms of ethnic background and social structure. Virtually all children and adolescents used the govern- ment- sponsored, comprehensive, free dental care. The dental programs exposed the Finnish children to intense topical fluoride regimes and dental sealant programs. The result was that the effect of water fluoridation ap- peared minimal. Because of these unique set of factors, it was concluded these results could not be replicated in countries with less intensive preventive dental care programs.94 No significant decrease in dental decay was seen after fluoridation was discontinued in 1990 in Chemniz and Plauen which are located in what was formerly East Germany. The intervening factors in this case include improvements in attitudes toward oral health behav- iors, broader availability and increased use of other preventive measures including fluoridated salt, fluoride toothpaste and dental sealants.95 A similar scenario is reported from the Netherlands. A study of 15- year -old children in Tiel (fluoridated 1953 to 1973) and Culemborg (nonfluoridated) was conduct- ed comparing dental decay rates from a baseline in 1968 through 1988. The lower dental decay rate in Tiel after the cessation of fluoridation was attributed in part to the initiation of a dental health education program, free dietary fluoride supplements and a greater use of professionally applied topical fluorides .96 Packet Page -912- 15 10. 11. 12, QUESTION 10. Is dental decay still a serious problem? Answer. Yes. Dental decay or tooth decay is an infectious disease that continues to be a significant oral health problem. Fact. Dental decay is, by far, the most common and costly oral health problem in all age groups.97 It is one of the principal causes of tooth loss from early childhood through middle age.911,99 Decay continues to be problem- atic for middle -aged and older adults, particularly root decay because of receding gums. Older adults may ex- perience similar or higher levels of dental decay than do children.100 In addition to its effects in the mouth, dental decay can affect general well -being by interfering with an individual's ability to eat certain foods and by impact- ing an individual's emotional and social well -being by causing pain and discomfort. Dental decay, particularly in the front teeth, can detract from appearance, thus af- fecting self- esteem and employability. "Decay continues to be problematic for middle -aged and older adults, particularly root decay because of receding gums. Despite a decrease in the overall decay experience of U.S. schoolchildren over the past two decades, dental decay is still a significant oral health problem, especial- ly in certain segments of the population. The 1986 -1987 National Institute of Dental Research (NIDR) survey of approximately 40,000 U.S. school children found that 25% of students ages 5 to 17 accounted for 75% of the decay experienced in permanent teeth.97 Despite prog- ress in reducing dental decay, individuals in families living below the poverty level experience more dental decay than those who are economically better off.20 Some of the risk factors that increase an individual's risk for decay are inadequate exposure to fluoride, irregular dental visits, deep pits and fissures in the chewing sur- faces of teeth, inadequate flow of saliva, frequent sugar intake and very high oral bacteria counts. Dental decay is one of the most common childhood diseases — five times as common as asthma and seven times as common as hay fever in 5- to 17- year -olds. Without fluoridation, there would be many more than the estimated 51 million school hours lost per year in this country because of dental - related illness.101 In addition to impacting emotional and social well- being, the consequences of dental disease are reflected in the cost of its treatment. According to the Centers for Medicare and Medicaid Services, the nation's total bill (including private and public spending) for dental services in 2003 was estimated to be $74.3 billion. This figure does not include indirect expenses of oral health 16 problems or the cost of services by other health care providers.102 Again, the goal must be prevention rather than repair. Fluoridation is presently the most cost -ef- fective method for the prevention of dental decay for residents of a community in the United States .113,114 QUESTION 11. Do adults benefit from fluoridation? Answer. Fluoridation plays a protective role against dental de- cay throughout life, benefiting both children and adults. In fact, inadequate exposure to fluoride places children and adults in the high risk category for dental decay. Fact. While the early fluoridation trials were not designed to study the possible benefits fluoridation might have for adults, by the mid- 1950s, there was growing evidence of both systemic and topical benefits of fluoride exposure. It soon became evident that fluoridation helped prevent decay in adults, too.d4 Fluoride has both a systemic and topical effect and is beneficial to adults in two ways. The first is through the remineralization process in enamel, in which early decay does not enlarge, and can even re- verse, because of frequent exposure to small amounts of fluoride. Studies have clearly shown that the avail- ability of topical fluoride in an adult's mouth during the initial formation of decay can not only stop the decay process, but also make the enamel surface more resis- tant to future acid attacks. Additionally, the presence of systemic fluoride in saliva provides a reservoir of fluo- ride ions that can be incorporated into the tooth surface to prevent decay.63 Additional information on this topic may be found in Question 2. "People in the United States are living longer and retaining more of their natural teeth than ever before. "; Another protective benefit for adults is the prevention of root decay.111,105 -107 Adults with gum recession are at risk for root decay because the root surface becomes ex- posed to decay- causing bacteria in the mouth. Studies have demonstrated that fluoride is incorporated into the structure of the root surface, making it more resistant to decay. 118-112 In Ontario, Canada, lifelong residents of the naturally fluoridated (1.6 ppm) community of Stratford had significantly lower root decay experience than those living in the matched, but nonfluoridated, community of Woodstock."' People in the United States are living longer and retain- ing more of their natural teeth than ever before. Because older adults experience more problems with gum reces- Packet Page -913- American Dental Association �1 sion, the prevalence of root decay increases with age. A large number of exposed roots or a history of past root decay places an individual in the high risk category for de- cay.30 Data from the 1988 -1991 National Health and Nutri- tion Examination Survey (NHANES III) showed that 22.5% of all adults with natural teeth experienced root decay. This percentage increased markedly with age: 1) in the 18- to 24- year -old age group, only 6.9% experienced root decay; 2) in the 35- to 44- year -old age group, 20.8% experienced root decay; 3) in the 55- to 64- year -old age group, 38.2% showed evidence of root decay; and 4) in the over -75 age group, nearly 56% had root decay.1' In addition to gum recession, older adults tend to ex- perience decreased salivary flow, or xerostomia, due to the use of medications or medical conditions. 114,111 In- adequate flow of saliva places an individual in the high risk category for decay.30 This decrease in salivary flow can increase the likelihood of dental decay because sa- liva contains calcium, phosphates and fluorides — all necessary for early repair of dental decay. There are data to indicate that individuals who have consumed fluoridated water continuously from birth receive the maximum protection against dental decay. However, teeth present in the mouth when exposure to water fluoridation begins also benefit from the topical effects of exposure to fluoride. In 1989, a small study in the state of Washington suggested adults exposed to fluoridated water only during childhood had similar decay rates as adults exposed to fluoridated water only after age 14. This study lends credence to the topical and systemic benefits of water fluoridation. The topical effects are reflected in the decay rates of adults exposed to water fluoridation only after age 14. The study also demonstrates that the preeruptive, systemic effects of fluoridation have lifetime benefits as reflected in the de- cay rates of adults exposed to fluoridation only during childhood. The same study also noted a 31% reduction of dental disease (based on the average number of de- cayed or filled tooth surfaces) in adults with a continu- ous lifetime exposure to fluoridated water as compared to adults with no exposure to water fluoridation.110 "Water fluoridation contributes much more to overall health than simply reducing dental decay. it prevents needless infection, pain, suffering and loss of teeth; improves the quality of life and saves vast sums of money in dental treatment costs. " A Swedish study investigating decay activity among adults in optimal and low fluoride areas revealed that not only was decay experience significantly lower in the optimal fluoride area, but the difference could not be Fluoridation Facts explained by differences in oral bacteria, buffer capacity of saliva or salivary flow. The fluoride concentration in the drinking water was solely responsible for decreased decay rates.116 Water fluoridation contributes much more to overall health than simply reducing dental decay: it prevents needless infection, pain, suffering and loss of teeth; improves the quality of life and saves vast sums of money in dental treatment costs.26 Additionally, fluori- dation conserves natural tooth structure by preventing the need for initial fillings and subsequent replacement fillings.117.116 � Additional information on this topic may be found in Question 2. QUESTION 12, Are dietary fluoride supplements effective? Answer. For children who do not live in fluoridated communi- ties, dietary fluoride supplements are an effective alter- native to water fluoridation for the prevention of dental decay. 119-122 Fact. Dietary fluoride supplements are available only by pre- scription in the United States and are intended for use by children living in nonfluoridated areas to increase their fluoride exposure so that it is similar to that received by children who live in optimally fluoridated areas. 123,124 Di- etary fluoride supplements are available in two forms: dropsfor infants aged six months orolder, and chewable tablets for children and adolescents .12' Fluoride supple- ments should only be prescribed for children living in nonfluoridated areas. The correct amount of a fluoride supplement is based on the child's age and the existing fluoride level in the drinking water. 126 Because fluoride is so widely available, it is recommended that dietary fluoride supplements be used only according to the rec- ommended dosage schedule and after consideration of all sources of fluoride exposure .30,126 For optimum ben- efits, use of supplements should begin at six months of age and be continued daily until the child is at least 16 years old .121 The current dietary fluoride supplement schedule is shown in Table 1 on the next page. The relatively higher cost and need for compliance over an extended period of time is a major procedural and economic disadvantage of community -based fluo- ride supplement programs, one that makes them imprac- tical as an alternative to water fluoridation as a public health measure. In a controlled situation, as shown in a study involving children of health professionals, fluoride supplements achieve effectiveness comparable to that of water fluoridation. However, even with this highly edu- cated and motivated group of parents, only half continued to give their children fluoride tablets for the necessary number of years .121 Additional studies have verified that Packet Page -914- 17 13. 14. 15. Ana Fluoride ion level in drinking water (ppm)* * 1.0 part per million (ppm) = 1 milligram /liter (mg /L) ** 2.2 mg sodium fluoride contains 1 mg fluoride ion. individual patterns of compliance vary greatly. 128,121,130 In- dependent reports from several countries, including the United States, have demonstrated that community -wide trials of fluoride supplements in which tablets were dis- tributed for use at home were largely unsuccessful be- cause of poor compliance .131 While total costs for the purchase of supplements and administration of a program are small (compared with the initial cost of the installation of water fluori- dation equipment), the overall cost of supplements per child is much greater than the per capita cost of com- munity fluoridation.104 In addition, community water fluoridation provides decay prevention benefits for the entire population regardless of age, socioeconomic sta- tus, educational attainment or other social variables. 26 This is particularly important for families who do not have access to regular dental services. (+ Additional information on this topic may be found in Questions 4, 13, 24 and 25. QUESTION 13. Does the ADA recommend fluoride for children under six years of age? Answer. Yes. The ADA recognizes that lack of exposure to fluo- ride places individuals of any age at risk for dental decay. Fluoride exposure may take many forms including wa- ter fluoridation and dietary fluoride supplements. Fact. For children who live in nonfluoridated communities, dietary fluoride supplements are an effective alterna- tive to water fluoridation to help prevent dental decay. Dietary fluoride supplements are available only by pre- scription and are intended for use by children living in nonfluoridated areas to increase their fluoride exposure so that it is similar to that experienced by children who live in optimally fluoridated areas. 124 The dietary fluoride supplement schedule is just that — a supplement schedule (Table 1). Recognizing 18 that children will receive fluoride from other sources (food and beverages) even in nonfluoridated areas, the amounts in the table reflect the additional amount of fluoride intake necessary to achieve an optimal anti - cavity effect. The dietary fluoride supplement schedule is just that - a supplement schedule." The dietary fluoride supplement schedule should not be viewed as recommending the absolute upper limits of the amount of fluoride that should be ingested each day. In 1997, the Food and Nutrition Board of the Institute of Medicine developed the Dietary Reference Intakes, a comprehensive set of reference values for dietary nutri- entvalues.The newvalues present nutrient requirements to optimize health and, for the first time, set maximum - level guidelines to reduce the risk of adverse effects from excessive consumption of a nutrient. In the case of fluo- ride, levels were established to reduce dental decay with- out causing moderate dental fluorosis.123 For example, the dietary fluoride supplement sched- ule recommends that a two- year -old child living in a non - fluoridated area (where the primary water source contains less than 0.3 ppm fluoride) should receive 0.25 mg of supplemental fluoride per day. This does not mean that this child should ingest exactly 0.25 mg of fluoride per day. On the contrary, a two - year -old child could re- ceive important anti - cavity benefits by taking 0.25 mg of supplemental fluoride a day without causing any ad- verse effects on health. This child would most probably be receiving fluoride from other sources (foods and bev- erages) even in a non - fluoridated area and the recom- mendation of 0.25 mg of fluoride per day takes this into account. In the unlikely event the child did not receive any extra fluoride from food and beverages, the 0.25 mg per day could be inadequate fluoride supplementation to achieve an optimal anti- cavity effect. The following statement is correct. "The dosage has been lowered two different times as evidenced of too much fluoride has appeared." Rather than being a prob- Packet Page -915- American Dental Association <0.3 ppm 0.3 -0.6 ppm >0.6 ppm Birth — 6 months None None None 6 months — 3 years 0.25 mg /day ** None None 3 — 6 years 0.50 mg /day 0.25 mg /day None 6 — 16 years 1.0 mg /day 0.50 mg/day None * 1.0 part per million (ppm) = 1 milligram /liter (mg /L) ** 2.2 mg sodium fluoride contains 1 mg fluoride ion. individual patterns of compliance vary greatly. 128,121,130 In- dependent reports from several countries, including the United States, have demonstrated that community -wide trials of fluoride supplements in which tablets were dis- tributed for use at home were largely unsuccessful be- cause of poor compliance .131 While total costs for the purchase of supplements and administration of a program are small (compared with the initial cost of the installation of water fluori- dation equipment), the overall cost of supplements per child is much greater than the per capita cost of com- munity fluoridation.104 In addition, community water fluoridation provides decay prevention benefits for the entire population regardless of age, socioeconomic sta- tus, educational attainment or other social variables. 26 This is particularly important for families who do not have access to regular dental services. (+ Additional information on this topic may be found in Questions 4, 13, 24 and 25. QUESTION 13. Does the ADA recommend fluoride for children under six years of age? Answer. Yes. The ADA recognizes that lack of exposure to fluo- ride places individuals of any age at risk for dental decay. Fluoride exposure may take many forms including wa- ter fluoridation and dietary fluoride supplements. Fact. For children who live in nonfluoridated communities, dietary fluoride supplements are an effective alterna- tive to water fluoridation to help prevent dental decay. Dietary fluoride supplements are available only by pre- scription and are intended for use by children living in nonfluoridated areas to increase their fluoride exposure so that it is similar to that experienced by children who live in optimally fluoridated areas. 124 The dietary fluoride supplement schedule is just that — a supplement schedule (Table 1). Recognizing 18 that children will receive fluoride from other sources (food and beverages) even in nonfluoridated areas, the amounts in the table reflect the additional amount of fluoride intake necessary to achieve an optimal anti - cavity effect. The dietary fluoride supplement schedule is just that - a supplement schedule." The dietary fluoride supplement schedule should not be viewed as recommending the absolute upper limits of the amount of fluoride that should be ingested each day. In 1997, the Food and Nutrition Board of the Institute of Medicine developed the Dietary Reference Intakes, a comprehensive set of reference values for dietary nutri- entvalues.The newvalues present nutrient requirements to optimize health and, for the first time, set maximum - level guidelines to reduce the risk of adverse effects from excessive consumption of a nutrient. In the case of fluo- ride, levels were established to reduce dental decay with- out causing moderate dental fluorosis.123 For example, the dietary fluoride supplement sched- ule recommends that a two- year -old child living in a non - fluoridated area (where the primary water source contains less than 0.3 ppm fluoride) should receive 0.25 mg of supplemental fluoride per day. This does not mean that this child should ingest exactly 0.25 mg of fluoride per day. On the contrary, a two - year -old child could re- ceive important anti - cavity benefits by taking 0.25 mg of supplemental fluoride a day without causing any ad- verse effects on health. This child would most probably be receiving fluoride from other sources (foods and bev- erages) even in a non - fluoridated area and the recom- mendation of 0.25 mg of fluoride per day takes this into account. In the unlikely event the child did not receive any extra fluoride from food and beverages, the 0.25 mg per day could be inadequate fluoride supplementation to achieve an optimal anti- cavity effect. The following statement is correct. "The dosage has been lowered two different times as evidenced of too much fluoride has appeared." Rather than being a prob- Packet Page -915- American Dental Association `N ^. lem, as those opposed to the use of fluoride might imply, this is evidence that the ADA is doing the right thing. The ADA continually reviews available scientific evidence, and revises its statements based on the most current scien- tific information. In 1994, a Dietary Fluoride Supplement Workshop cosponsored by the ADA, the American Acad- emy of Pediatric Dentistry and the American Academy of Pediatrics was held in Chicago. Based on a review of scien- tific evidence, a consensus was reached on a new dosage schedule developed in recognition that numerous sources of topical and systemic fluoride are available today that were not available many years ago. 125 The revised dietary fluoride supplement schedule appears as Table 1. QUESTION 14. In areas where water fluoridation is not feasible be- cause of engineering constraints, are alternatives to water fluoridation available? Answer. Yes. Some countries outside the United States that do not have piped water supplies capable of accommodat- ing community water fluoridation have chosen to use salt fluoridation. Fact. Salt fluoridation is used extensively in a number of countries in Europe (examples: France, Hungary, Ger- many, Spain and Switzerland) and Central and South America (examples: Boliva, Colombia, Cuba, Domini- can Republic, Ecuador, El Salvador, Honduras, Nica- ragua, Venezuela, Costa Rica, Jamaica, Mexico, Peru and Uruguay. )132,133 The Pan American Health Organi- zation (PAHO), a regional division of the World Health Association (WHO), with responsibilities for health matters in North, South and Central America as well as the Caribbean has been active in developing strate- gies to implement decay prevention programs in the regions of the Americas using both water and salt fluoridation .133,134 Studies evaluating the effectiveness of salt fluoridation outside the U.S. have concluded that fluoride delivered via salt may produce decay reductions similar to that of optimally fluoridated water. 135 An analysis of published results of studies from some countries shows that, for 12- year -old children, the initial level of decay reduction due to salt fluoridation is between 35% and 80% 135,131 An advantage of salt fluoridation is that it does not require a centralized piped water system. This is of par- ticular use in many developing countries that do not have such water systems. When both domestic salt and bulk salt (used by commercial bakeries, restaurants, in- stitutions, and industrial food production) is fluoridated, the decay- reducing effect may be comparable to that of water fluoridation over an extended period of time. 135 On the other hand, when only domestic salt is fluori- dated, the decay- reducing effect may be diminished .131 Fluoridation Facts Salt fluoridation has several disadvantages that do not exist with water fluoridation. Challenges occur with implementation of salt fluoridation when there are mul- tiple sources of drinking water in an area. The natural fluoride level of each source must be determined and, if the level is optimal or excessive, fluoridated salt should not be distributed in that area .1311 Finally, there is general agreement that a high consumption of sodium is a risk factor for hypertension (high blood pressure) .131,140 Peo- ple who have hypertension or must restrict their salt in- take may find salt fluoridation an unacceptable method of receiving fluoride. (Additional information on this topic may be found in Question 56. Fluoridated milk has been suggested as another alterna- tive to community water fluoridation in countries outside the U.S. WHO has supported milk fluoridation feasibil- ity projects in the United Kingdom, People's Republic of China, Peru and Thailand. 141 Studies among small groups of children have demonstrated a decrease in dental de- cay levels resulting from consumption of fluoridated milk; however, these studies were not based on large -scale sur- veys. More research is needed before milk fluoridation can be recommended as an alternative to water or salt fluoridation .142 The rationale for adding fluoride to milk is that this method "targets" fluoride directly to children, but the amount of milk consumed by children is quite variable, more so than water. Concerns have been raised about decreased widespread benefits due to the slower absorption of fluoride from milk than from water and the considerable number of persons, especially adults, who do not drink milk for various reasons.143 The monitoring of fluoride content in milk is technically more difficultthan for drinking water because there are many more dairies than communal water supplies. In addition, because fluo- ridated milk should not be sold in areas having natural or adjusted fluoridation, regulation would be difficult, and established marketing patterns would be disrupted." QUESTION 15. Can the consistent use of bottled water result in indi- viduals missing the benefits of optimally fluoridated water? Answer. Yes. The majority of bottled waters on the market do not contain optimal levels (0.7 -1.2 ppm) of fluoride."" -148 Fact. Individuals who drink bottled water as their primary source of water could be missing the decay preventive effects of optimally fluoridated water available from their community water supply. The consumption of bottled water in the United States has been growing by at least one gallon per person each year - more than doubling in the last ten years. Consump- tion rates for the past five years are shown in Table 2.14 Packet Page -916- 19 lira Table 2. U.S. Bottled Water Market'" Per Capita Consumption 2000 -2004 In 2004, total U.S. sales of bottled water surpassed 6.8 billion gallons, an 8.6% advance over 2003 with whole- sale dollar sales reaching a record of approximately $9.2 billion. This category includes sparkling and non -spar- kling water, domestic and imported water, water in single - serve bottles and larger packages as well as vended and direct delivered waters. U.S. residents now drink more bottled water annually (23.8 gallons per person in 2004) than any other beverage with the exception of carbonated soft drinks. 149,150 In 2004, consumption of carbonated soft drinks fell for the sixth straight year after several decades of uninhibited growth (53.7 gallons per person in 2004 compared to 54.8 gallons per person in 1999).150 "Individuals who drink bottled water as their primary source of water could be missing the decay preventive effects of optimally fluoridated water available from their community water supply." In 1994, a small study at two community health centers in Rhode Island showed that 55% of the total households responding used only bottled water for drinking while 59% of the households with children reported using only bottled water for drinking. The vast majority of these bottled wa- ters had less than optimal levels of fluoride. While most of the patient population of the health centers was either on public assistance (60 %) or uninsured (20 %), families spent their limited resources to purchase bottled water. It was reported that 52% of children on public assistance and 35% of the uninsured children used bottled water. 151 The fluoride content of bottled water can vary greatly. A 1989 study of pediatric dental patients and their use of bottled water found the fluoride content of bottled water from nine different sources varied from 0.04 ppm to 1.4 ppm.152 In a 1991 study of 39 bottled water samples, 34 had fluoride levels below 0.3 ppm. Over the two years the study was conducted, six products showed a two- to four -fold drop in fluoride content.153 A similar study of five national brands of bottled water conducted in 2000, showed that significant differences in fluoride concentra- tion existed between the five brands and that three of the 20 five brands tested demonstrated significant differences between the various batches tested of the same brand .154 In evaluating how bottled water consumption affects fluoride exposure, there are several factors to consider. First isthe amount of bottled water consumed during the day. Second is whether bottled water is used for drink- ing, in meal preparation and for reconstituting soups, juices and other drinks. Third is whether another source of drinking water is accessed during the day such as an optimally fluoridated community water supply at day- care, school or work. A final important issue is determining the fluoride content of the bottled water. While drinking water is reg- ulated by the U.S. EPA,155 bottled water is regulated by the U.S. Food and Drug Administration (FDA) which has established standards for its quality.156 3 Additional information on this topic may be found in Question 43. Bottled water is defined as water that is intended for human consumption sealed in bottles or other containers with no added ingredients except that it may optionally contain safe and suitable antimicrobial agents. The FDA has established maximum allowable levels for physical, chemical, microbiological, and radiological contaminants in the bottled water quality standard regulations. The FDA has also approved standards for the optional addition of fluoride. 156 Effective in 1996, FDA regulations require fluo- ride content of bottled water to be listed on the label only if fluoride is added during processing.t51 If the fluoride level is not shown on the label of the bottled water, the company can be contacted, or the water can be tested to obtain this information. For additional information on bottled water and fluo- ride exposure, view the ADA's Web page "Bottled Water, Home Water Treatment Systems and Fluoride Exposure" at http• / /www.ada.org/cioto /bottledwater. (Figure 3) A MISSING INGREDIENT? http: / /www.ada.org /goto /bottledwater • Does your bottled water contain fluoride? • Does your water filter remove fluoride? American Dental Association www.ada.org Many ADA resources are at your fingertips 24/7/365. Order a library book or products online, read JADA articles, discuss important topics with colleagues, find helpful information on professional topics from accredi- tation to X -rays and recommend our dental education animations, stories and games to your patients. Be resourceful. Visit ADA.org today! Packet Page -917- American Dental Association Gallons Annual Year Per Capita % Change 2000 17.2 - -- 2001 18.7 8.7% 2002 20.7 10.8% 2003 22.1 7.0% 2004 23.8 7.6% In 2004, total U.S. sales of bottled water surpassed 6.8 billion gallons, an 8.6% advance over 2003 with whole- sale dollar sales reaching a record of approximately $9.2 billion. This category includes sparkling and non -spar- kling water, domestic and imported water, water in single - serve bottles and larger packages as well as vended and direct delivered waters. U.S. residents now drink more bottled water annually (23.8 gallons per person in 2004) than any other beverage with the exception of carbonated soft drinks. 149,150 In 2004, consumption of carbonated soft drinks fell for the sixth straight year after several decades of uninhibited growth (53.7 gallons per person in 2004 compared to 54.8 gallons per person in 1999).150 "Individuals who drink bottled water as their primary source of water could be missing the decay preventive effects of optimally fluoridated water available from their community water supply." In 1994, a small study at two community health centers in Rhode Island showed that 55% of the total households responding used only bottled water for drinking while 59% of the households with children reported using only bottled water for drinking. The vast majority of these bottled wa- ters had less than optimal levels of fluoride. While most of the patient population of the health centers was either on public assistance (60 %) or uninsured (20 %), families spent their limited resources to purchase bottled water. It was reported that 52% of children on public assistance and 35% of the uninsured children used bottled water. 151 The fluoride content of bottled water can vary greatly. A 1989 study of pediatric dental patients and their use of bottled water found the fluoride content of bottled water from nine different sources varied from 0.04 ppm to 1.4 ppm.152 In a 1991 study of 39 bottled water samples, 34 had fluoride levels below 0.3 ppm. Over the two years the study was conducted, six products showed a two- to four -fold drop in fluoride content.153 A similar study of five national brands of bottled water conducted in 2000, showed that significant differences in fluoride concentra- tion existed between the five brands and that three of the 20 five brands tested demonstrated significant differences between the various batches tested of the same brand .154 In evaluating how bottled water consumption affects fluoride exposure, there are several factors to consider. First isthe amount of bottled water consumed during the day. Second is whether bottled water is used for drink- ing, in meal preparation and for reconstituting soups, juices and other drinks. Third is whether another source of drinking water is accessed during the day such as an optimally fluoridated community water supply at day- care, school or work. A final important issue is determining the fluoride content of the bottled water. While drinking water is reg- ulated by the U.S. EPA,155 bottled water is regulated by the U.S. Food and Drug Administration (FDA) which has established standards for its quality.156 3 Additional information on this topic may be found in Question 43. Bottled water is defined as water that is intended for human consumption sealed in bottles or other containers with no added ingredients except that it may optionally contain safe and suitable antimicrobial agents. The FDA has established maximum allowable levels for physical, chemical, microbiological, and radiological contaminants in the bottled water quality standard regulations. The FDA has also approved standards for the optional addition of fluoride. 156 Effective in 1996, FDA regulations require fluo- ride content of bottled water to be listed on the label only if fluoride is added during processing.t51 If the fluoride level is not shown on the label of the bottled water, the company can be contacted, or the water can be tested to obtain this information. For additional information on bottled water and fluo- ride exposure, view the ADA's Web page "Bottled Water, Home Water Treatment Systems and Fluoride Exposure" at http• / /www.ada.org/cioto /bottledwater. (Figure 3) A MISSING INGREDIENT? http: / /www.ada.org /goto /bottledwater • Does your bottled water contain fluoride? • Does your water filter remove fluoride? American Dental Association www.ada.org Many ADA resources are at your fingertips 24/7/365. Order a library book or products online, read JADA articles, discuss important topics with colleagues, find helpful information on professional topics from accredi- tation to X -rays and recommend our dental education animations, stories and games to your patients. Be resourceful. Visit ADA.org today! Packet Page -917- American Dental Association /'N QUESTION 16. Can home water treatment systems (e.g. water filters) affect optimally fluoridated water supplies? Answer. Yes. Some types of home water treatment systems can reduce the fluoride levels in water supplies potentially decreasing the decay- preventive effects of optimally fluoridated water. Fact. There are many kinds of home water treatment systems including water filters (for example: carafe filters, faucet filters, under the sink filters and whole house filters), reverse osmosis systems, distillation units and water softeners. There has not been a large body of research regarding the extent to which these treatment systems affect fluoridated water. Available research is often con- flicting and unclear. However, it has been consistently documented that reverse osmosis systems and distilla- tion units remove significant amounts of fluoride from the water supply.` 158,159 On the other hand, repeated studies regarding water softeners confirm earlier re- search indicating the water softening process caused no significant change in fluoride levels.15o,151 With water filters, the fluoride concentration remaining in the water depends on the type and quality of the filter being used, the status of the filter and the filter's age. Some acti- vated carbon filters containing activated alumina may remove significant amounts of the fluoride. 162 Each type of filter should be assessed individually.159 Individuals who drink water processed by home wa- ter treatment systems as their primary source of water could be losing the decay preventive effects of opti- mally fluoridated water available from their community water supply. Consumers using home water treatment systems should have their water tested at least annu- ally to establish the fluoride level of the treated water. More frequent testing may be needed. Testing is avail- able through local and state public health departments. Private laboratories may also offer testing for fluoride levels in water. Information regarding the existing level of fluoride in a community's public water system can be obtained by asking a local dentist, contacting your local or state health department, or contacting the local water supplier. (+ Additional information on this topic may be found in Question 4. For additional information on home water treatment systems and fluoride exposure, view the ADA's Web page "Bottled Water, Home Water Treatment Systems and Flu- oride Exposure" at http:/ /www.ada.org /goto /`bottledwater. (Figure 3) Fluoridation Facts Packet Page -918- 21 17. 18. SAFETY Q 17. Harmful to humans? p. 22 Q 18. More studies needed? p. 23 Q 19. Total intake? p. 24 Q20. Daily intake? p. 25 Q 21. Prenatal dietary fluoride supplements? p. 26 Q 22. Body uptake? p. 26 Q 23. Bone health? p. 27 Q 24. Dental fluorosis? p. 28 Q 25. Prevent fluorosis? p. 30 Q 26. Warning label? p. 31 Q 27. Toxicity? p. 31 Q 28. Cancer? p. 32 Q 29. Enzyme effects? p. 33 Q 30. Thyroid gland? p. 34 Q 31. Pineal Gland? p. 34 032. Allergies? p. 34 Q 33. Genetic risk? p. 35 QUESTION 17. Does fluoride in the water supply, at the levels recom- mended for the prevention of dental decay, adversely affect human health? Answer. The overwhelming weight of scientific evidence indi- cates that fluoridation of community water supplies is safe. (See Figure 4.) Fact. For generations, millions of people have lived in ar- eas where fluoride is found naturally in drinking water in concentrations as high or higher than those recom- mended to prevent dental decay. Research conducted among these persons confirms the safety of fluoride in the water supply.84-163.166 In fact, in August 1993, the National Research Council, a branch of the National Academy of Sciences, released a report prepared for the Environmental Protection Agency (EPA) that confirmed that the currently allowed fluoride levels in drinking water do not pose a risk for health prob- lems such as cancer, kidney failure or bone disease.16' Based on a review of available data on fluoride tox- icity, the expert subcommittee that wrote the report concluded that the EPA's ceiling of 4 ppm for naturally occurring fluoride in drinking water was "appropri- ate as an interim standard. "167 Subsequently, the EPA announced that the ceiling of 4 ppm would protect against adverse health effects with an adequate mar- gin of safety and published a notice of intent not to revise the fluoride drinking water standard in the Fed- eral Register.166 As with other nutrients, fluoride is safe and effective when used and consumed properly. No charge against the benefits and safety of fluoridation has ever been sub- Q 34. Fertility? p. 35 Q 35. Down Syndrome? p. 35 Q 36. Neurological impact? p.36 Q 37. Lead poisoning? p. 37 Q 38. Alzheimer's disease? p. 37 Q 39. Heart disease? p. 38 Q 40. Kidney disease? p. 38 Q 41. Erroneous health claims? p. 39 stantiated by generally accepted scientific knowledge. After 60 years of research and practical experience, the preponderance of scientific evidence indicates that fluo- ridation of community water supplies is both safe and effective .169 "After 60 years of research and practical experience, the preponderance of scientific evidence indicates that fluoridation of community water supplies is both safe and effective." Many organizations in the U.S. and around the world involved with health issues have recognized the value of community water fluoridation. The American Dental Association (ADA) adopted its original resolu- tion in support of fluoridation in 1950 and has repeat- edly reaffirmed its position publicly and in its House of Delegates based on its continuing evaluation of the safety and effectiveness of fluoridation.3 The 2005 "ADA Statement Commemorating the 601h Anniver- sary of Community Water Fluoridation" reinforced that position.4 The American Medical Association's (AMA) House of Delegates first endorsed fluoridation in 1951. In 1986, and again in 1996, the AMA reaffirmed its sup- port for fluoridation as an effective means of reducing dental decay. 171 The World Health Organization, which initially recommended the practice of water fluorida- tion in 1969,171 reaffirmed its support for fluoridation in 1994 stating that: "Providing that a community has a piped water supply, water fluoridation is the most effective method of reaching the whole population, so that all social classes benefit without the need for active participation on the part of individuals. "738 Fol- lowing a comprehensive 1991 review and evaluation of 22 Packet Page -919- American Dental Association /,-\ ?O"N • Institute of Medicine, Food and Nutrition Board. Dietary reference intakes for calcium, phospho- rus, magnesium, vitamin D and fluoride. Report of the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Wash- ington, DC: National Academy Press;1997. National Research Council. Health effects of in- gested fluoride. Report of the Subcommittee on Health Effects of Ingested Fluoride. Washing- ton, DC: National Academy Press;1993. • US Department of Health and Human Services, Public Health Service. Review of fluoride: ben- efits and risks. Report of the Ad Hoc Subcommit- tee on Fluoride. Washington, DC; February 1991. • World Health Organization. Fluorides and hu- man health. Monograph series no 59. Geneva, Switzerland;1970. the public health benefits and risks of fluoride, the U.S. Public Health Service reaffirmed its support for fluori- dation and continues to recommend the use of fluoride to prevent dental decay.B4 Recent statements by five leading health authorities on community water fluoridation can be found in the back of this publication. National and international health, service and pro- fessional organizations that recognize the public health benefits of community water fluoridation for prevent- ing dental decay are listed on the inside back cover of this publication. QUESTION 18. Are additional studies being conducted to determine the effects of fluorides in humans? Answer. Yes. Since its inception, fluoridation has undergone a nearly continuous process of reevaluation. As with other areas of science, additional studies on the effects of fluorides in humans can provide insight as to how to make more effective choices for the use of fluoride. The American Dental Association and the U.S. Public Health Service support this on -going research. Fact. For more than 60 years, thousands of reports have been published on all aspects of fluoridation .84,161 The accumulated dental, medical and public health evi- dence concerning fluoridation has been reviewed and evaluated numerous times by academicians, commit- Fluoridation Facts tees of experts, special councils of government and most of the world's major national and internation- al health organizations. The verdict of the scientific community is that water fluoridation, at recommend- ed levels, safely provides major oral health benefits. The question of possible secondary health effects caused by fluorides consumed in optimal concentra- tions throughout life has been the object of thorough medical investigations which have failed to show any impairment of general health throughout life. 138,163-166 "The verdict of the scientific community is that water fluoridation, at recommended levels, safely provides major oral health benefits." In scientific research, there is no such thing as "final knowledge." New information is continuously emerg- ing and being disseminated. Under the Safe Drinking Water Act (SDWA), the U. S. Environmental Protection Agency (EPA) must periodically review the existing Na- tional Primary Drinking Water Regulations (NPDWRs) "not less often than every 6 years." This review is a routine part of the EPA's operations as dictated by the SDWA.172 In April 2002, the EPA announced the results of its preliminary revise /not revise decisions for 68 chemi- cal NPDWRs. Fluoride was one of the 68 chemicals re- viewed. The EPA determined that it fell under the "Not Appropriate for Revision at this Time" category, but not- ed that it planned to ask the National Academy of Sci- ence (NAS) to update the risk assessment for fluoride. The NAS had previously completed a review of fluoride for EPA approximately 12 years ago which was pub- lished as "Health Effects of Ingested Fluoride" in 1993 by the National Research Council. At the request of the NAS, the National Research Council's Committee on Toxicology created the Sub- committee on Fluoride in Drinking Water to review toxicologic, epidemiologic, and clinical data pub- lished since 1993 and exposure data on orally ingest- ed fluoride from drinking water and other sources (e.g., food, toothpaste, mouthrinses). Based on this review the Subcommittee will evaluate the scien- tific and technical basis of the EPA's maximum con- taminant level (MCL) of 4 milligram per liter (mg /L or ppm) and secondary maximum contaminant level (SMCL) of 2 mg /L for fluoride in drinking water. The Subcommittee will advise the EPA on the adequacy of its fluoride MCL and SMCL to protect children and others from adverse health effects and identify data gaps and make recommendations for future research relevant to setting the MCL and SMCL for fluoride. The Subcommittee began its work in November 2002 and is currently projected to complete the project in early 2006.173 The definition of a contaminant is a function of the National Primary Drinking Water Regulations. The EPA Packet Page -920- 23 19. 20. considers a contaminant to be ANYTHING found in wa- ter that may be harmful to human health. The EPA has designated 90 microorganisms, minerals and chemicals as contaminants. 7415 While research continues, the weight of scientific evi- dence indicates water fluoridation is safe and effective in preventing dental decay in humans .84 (+ Additional information on this topic may be found in Questions 7, 8, and 42. QUESTION 19. Does the total intake of fluoride from air, water and food pose significant health risks? Answer. The total intake of fluoride from air, water and food, in an optimally fluoridated community in the United States, does not pose significant health risks. Fact. Fluoride from the Air The atmosphere normally contains negligible concen- trations of airborne fluorides. Studies reporting the lev- els of fluoride in air in the United States suggest that ambient fluoride contributes little to a person's overall fluoride intake.179,180 Fluoride from Water In the United States, the natural level of fluoride in ground water varies from very low levels to over 4 ppm. Public water systems in the U.S. are monitored by the Environmental Protection Agency (EPA), which requires that public water systems not exceed fluoride levels of 4 ppm.168 The optimal concentration for fluoride in water in the United States has been established in the range of 0.7 to 1.2 ppm. This range will effectively reduce den- tal decay while minimizing the occurrence of mild den- tal fluorosis. The optimal fluoride level is dependent on the annual average of the maximum daily air tempera- ture in the geographic area .36 Children living in a community with water fluori- dation get a portion of their daily fluoride intake from fluoridated water and a portion from dietary sources which would include food and other beverages. When considering water fluoridation, an individual must con- sume one liter of water fluoridated at 1 part per million (1 ppm) to receive 1 milligram (1 mg) of fluoride.42.178 Children under six years of age, on average, consume less than one -half liter of drinking water a day.178 There- fore, children under six years of age would consume, on average, less than 0.5 mg of fluoride a day from drink- ing optimally fluoridated water (at 1 ppm). A ten -year comparison study of long -time residents of Bartlett and Cameron, Texas, where the water sup- plies contained 8.0 and 0.4 parts per million of fluo- ride, respectively, included examinations of organs, bones and tissues. Other than a higher prevalence of 24 dental fluorosis in the Bartlett residents, the study in- dicated that long term consumption of dietary fluoride (resident average length of fluoride exposure was 36.7 years), even at levels considerably higher than recom- mended for decay prevention, resulted in no clinically significant physiological or functional effects .161 Fluoride in Food Foods and beverages commercially processed (cooked or reconstituted) in optimally fluoridated cities can contain higher levels of fluoride than those processed in nonfluoridated communities. These foods and bev- erages are consumed not only in the city where pro- cessed, but may be distributed to and consumed in nonfluoridated areas.26 This "halo" or "diffusion" ef- fect results in increased fluoride intake by people in nonfluoridated communities, providingthem increased protection against dental decay.71.85,86 As a result of the widespread availability of these various sources of fluoride, the difference between decay rates in fluo- ridated areas and nonfluoridated areas is somewhat less than several decades ago but still significant .87 Failure to account for the diffusion effect may result in an underestimation of the total benefit of water fluo- ridation especially in areas where a large amount of fluoridated products are brought into nonfluoridated communities .86 Water and water -based beverages are the chief source of dietary fluoride intake. Conventional estimates are that approximately 75% of dietary fluoride comes from water and water -based beverages.179 The average daily dietary intake of fluoride (ex- pressed on a body weight basis) by children residing in optimally fluoridated (1 ppm) communities is 0.05 mg/ kg /day; in communities without optimally fluoridated water, average intakes for children are about 50% low - er.123 Dietary fluoride intake by adults in optimally fluo- ridated (1 ppm) areas averages 1.4 to 3.4 mg /day, and in nonfluoridated areas averages 0.3 to 1.0 mg /day.123 In looking at the fluoride content of food and bever- ages over time, it appears that fluoride intake from di- etary sources has remained relatively constant. Except for samples prepared or cooked with fluoridated wa- ter, the fluoride content of most foods and beverages is not significantly different between fluoridated and nonfluoridated communities. When fluoridated water is used to prepare or cook the samples, the fluoride content of foods and beverages is higher as reflected in the intake amounts noted in the previous paragraph. This difference has remained relatively constant over time. 180,181 The fluoride content of fresh solid foods in the Unit- ed States generally ranges from 0.01 to 1.0 part per million.102,178 It has long been known that fish, such as sardines, may contribute to higher dietary fluoride in- take if the bones are ingested as fluoride has an affin- ity for calcified tissues. Additionally, brewed teas may also contain fluoride concentrations of 1 ppm to 6 ppm depending on the amount of dry tea used, the water flu- Packet Page -921- American Dental Association r\ oride concentration and the brewing time. 182 The fluo- ride value for unsweetened instant tea powder appears very high when reported as a dry powder because this product is extremely concentrated. However, when one teaspoon of the unsweetened tea powder is added to an eight ounce cup of tap water, the value for prepared instant tea is similar to the values reported for regular brewed tea. 779 Unveiled in 2004, the National Fluoride Database is a comprehensive, nationally representative database of the fluoride concentration in foods and beverages con- sumed in the United States. The database for fluoride was designed for use by epidemiologists and health re- searchers to estimate fluoride intake and to assist in the investigation of the relationships between fluoride in- take and human health. The database contains fluoride values for beverages, water, and some lower priority foods. 179 QUESTION 20. How much fluoride should an individual consume each day to reduce the occurrence of dental decay? Answer. The appropriate amount of daily fluoride intake var- ies with age and body weight. As with other nutrients, fluoride is safe and effective when used and consumed properly. Fact. In 1997, the Food and Nutrition Board of the Institute of Medicine developed a comprehensive set of reference values for dietary nutrient intakes. 123 These new refer- ence values, the Dietary Reference Intakes (DRI), replace the Recommended Dietary Allowances (RDA) which had been set by the National Academy of Sciences since 1941. The new values present nutrient requirements to optimize health and, for the first time, set maximum - level guidelines to reduce the risk of adverse effects from excessive consumption of a nutrient. Along with calcium, phosphorous, magnesium and vitamin D, DRIs for fluoride were established because of its proven ef- fect on dental decay. As demonstrated in Table 3, fluoride intake in the United States has a large range of safety. The first DRI reference value is the Adequate In- take (AI) which establishes a goal for intake to sustain a desired indicator of health without causing side ef- fects. In the case of fluoride, the Al is the daily intake level required to reduce dental decay without causing moderate dental fluorosis. The Al for fluoride from all sources (fluoridated water, food, beverages, fluoride dental products and dietary fluoride supplements) is set at 0.05 mg /kg /day (milligram per kilogram of body weight per day). Using the established Al of 0.05 mg /kg, the amount of fluoride for optimal health to be consumed each day has been calculated by gender and age group (expressed as average weight). See Table 3 in this Question. The DRIs also established a second reference value for maximum -level guidelines called tolerable upper intake levels (UL). The UL is higher than the Al and is not the recommended level of intake. The UL is the es- timated maximum intake level that should not produce unwanted effects on health. The UL for fluoride from all sources (fluoridated water, food, beverages, fluoride dental products and dietary fluoride supplements) is set at 0.10 mg /kg /day (milligram per ki logram of body weight per day) for infants, toddlers, and children through eight years of age. For older children and adults, who are no longer at risk for dental fluorosis, the UL for fluoride is set at 10 mg /day regardless of weight. Table 3. Dietary Reference Intakes for Fluoride rooa and Nutrition Board of the Institute of Medicine 1997123 Age Group Reference Weights kg (lbs)* Adequate Intake: (mg /day) Tolerable Upper Intake (mg /day) Infants 0 -6 months 7 (16) 0.01 0.7 Infants 7 -12 months 9 (20) 0.5 0.9 Children 1 -3 years 13 (29) 0.7 1.3 Children 4 -8 years 22 (48) 1.0 2.2 Children 9 -13 years 40 (88) 2.0 10.0 Boys 14 -18 years 64 (142) 3.0 10.0 Girls 14 -18 years 57 (125) 3.0 10.0 Males 19 years and over 76 (166) 4.0 10.0 Females 19 years and over 61 (133) 3.0 10.0 * Value based on data collected during 1988 -94 as part of the Third National Health and Nutrition Examination Survey (NHANES III) in the United States. 123 Fluoridation Facts Packet Page -922- 25 21 22, 2S. Using the established ULs for fluoride, the amount of fluoride that may be consumed each day to reduce the risk of moderate dental fluorosis for children under eight, has been calculated by gender and age group (ex- pressed as average weight). (See Table 3.) As a practical example, daily intake of 2 mg of fluoride is adequate for a nine to 13- year -old child weighing 88 pounds (40 kg). This was calculated by multiplying 0.05 mg /kg /day (AI) times 40 kg (weight) to equal 2 mg. At the same time, that 88 pound (40kg) child could consume 10 mg of fluoride a day as a tolerable upper intake level. Children living in a community with water fluori- dation get a portion of their daily fluoride intake from fluoridated water and a portion from dietary sources which would include food and other beverages. When considering water fluoridation, an individual must con- sume one liter of water fluoridated at 1 part per million 0 ppm) to receive 1 milligram (1 mg) of fluoride .42,178 Children under six years of age, on average, consume less than one -half liter of drinking water a day. 178 There- fore, children under six years of age would consume, on average, less than 0.5 mg of fluoride a day from drink- ing optimally fluoridated water (at 1 ppm). If a child lives in a nonfluoridated area, the dentist or physician may prescribe dietary fluoride supplements. As shown in Table 1 "Dietary Fluoride Supplement Schedule 1994" (See Question 12), the current dosage schedule rec- ommends supplemental fluoride amounts that are below the Al for each age group. The dosage schedule was de- signed to offer the benefit of decay reduction with margin of safety to prevent mild to moderate dental fluorosis. For example, the Al for a child 3 years of age is 0.7 mg /day. The recommended dietary fluoride supplement dosage for a child 3 years of age in a nonfluoridated community is 0.5 mg /day. This provides leeway for some fluoride intake from processed food and beverages, and other sources. Decay rates are declining in many population groups because children today are being exposed to fluoride from a wider variety of sources than decades ago. Many of these sources are intended for topical use only; however, some fluoride is ingested inadvertently by children.18' Inappropriate ingestion of fluoride can be prevented, thus reducing the risk for dental fluorosis without jeopardizing the benefits to oral health. For example, it has been reported in a number of studies that young children inadvertantly swallow an average of 0.30 mg of fluoride from fluoride toothpaste at each brushing.' 84,185-189 If a child brushes twice a day, 0.60 mg may be ingested inappropriately. This may slightly exceed the Adequate Intake (AI) values from Ta- ble 3. The 0.60 mg consumption is 0.10 mg higher than the Al value for children 6 to 12 months and is 0.10 mg lower than the Al for children from 1 -3 years of age.123 Although toothpaste is not meant to be swallowed, chil- dren may consume the daily recommended Adequate Intake amount of fluoride from toothpaste alone. In or- der to decrease the risk of dental fluorosis, the American Dental Association since 1992 has recommended that parents and caregivers put only one pea -sized amount 26 of fluoride toothpaste on a young child's toothbrush at each brushing. Also, young children should be super- vised while brushing and taught to spit out, rather than swallow, the toothpaste. Consult with your child's den- tist or physician if you are considering using fluoride toothpaste before age two. Additional information on this topic may be found in Question 25. It should be noted that the amounts of fluoride dis- cussed here are intake, or ingested, amounts. When flu- oride is ingested, a portion is retained in the body and a portion is excreted. This issue will be discussed further in Question 22. QUESTION 21. Is there a need for prenatal dietary fluoride supplemen- tation? Answer. There is no scientific basis to suggest any need to in- crease a woman's daily fluoride intake during preg- nancy or breastfeeding to protect her health. At this time, scientific evidence is insufficient to support the recommendation for prenatal fluoride supplementation for decay prevention for infants. 123,190 Fact. The Institute of Medicine has determined that, "No data from human studies document the metabolism of fluoride during lactation. Because fluoride concen- trations in human milk are very low (0.007 to 0.011 ppm) and relatively insensitive to differences in the fluoride concentrations of the mother's drinking water, fluoride supplementation during lactation would not be expected to significantly affect fluoride intake by the nursing infant or the fluoride requirement of the mother.""' The authors of the only prospective, randomized, double blind study to evaluate the effectiveness of prenatal dietary supplementation have concluded that the data do not support the hypothesis that prenatal fluoride has a strong decay preventive effect.190 More- over, prenatal dietary fluoride supplementation will not have an affect on the baby's permanent teeth be- cause permanent teeth do not begin to develop during pregnancy.191 QUESTION 22. When fluoride is ingested, where does it go? Answer. Much of the fluoride is excreted. Of the fluoride retained, /-N almost all is found in calcified (hard) tissues, such as bones and teeth. Fluoride helps to prevent dental decay when incorporated into the teeth. Packet Page -923- American Dental Association Fact. After ingestion of fluoride, such as drinking a glass of optimally fluoridated water, the majority of the fluoride is absorbed from the stomach and small intestine into the blood stream .112 This causes a short term increase in fluoride levels in the blood. The fluoride levels in- crease quickly and reach a peak concentration within 20 -60 minutes.193 The concentration declines rapidly, usually within three to six hours following peak lev- els, due to the uptake of fluoride by calcified tissues and efficient removal of fluoride by the kidneys.182 Ap- proximately 50% of the fluoride absorbed each day by young or middle -aged adults becomes associated with hard tissues within 24 hours while virtually all of the remainder is excreted in the urine. Approximately 99% of the fluoride present in the body is associated with hard tissues, 192 Ingested or systemic fluoride becomes incorporated into forming tooth structures. Fluoride ingested regularly during the time when teeth are developing is deposited throughout the entire surface of the tooth and contrib- utes to long lasting protection against dental decay. 112 3 Additional information on this topic may be found in Question 2. An individual's age and stage of skeletal devel- opment will affect the rate of fluoride retention.The amount of fluoride taken up by bone and retained in the body is inversely related to age. More fluoride is retained in young bones than in the bones of older a d u Its. 183,192,193 According to generally accepted scientific knowl- edge, the ingestion of optimally fluoridated water does not have an adverse effect on bone health.t94-798 Evidence of advanced skeletal fluorosis, or crippling skeletal fluorosis, "was not seen in communities in the United States where water supplies contained up to 20 ppm (natural levels of fluoride). 11123,191 In these communities, daily fluoride intake of 20 mg /day would not be uncom- mon.123 Crippling skeletal fluorosis is extremely rare in the United States and is not associated with optimally fluoridated water; only 5 cases have been confirmed during the last 35 years. 121 (+ Additional information on this topic may be found in Question 23. The kidneys play the major role in the removal of fluoride from the body. Normally kidneys are very ef- ficient and excrete fluoride very rapidly. However, de- creased fluoride removal may occur among persons with severely impaired kidney function who may not be on kidney dialysis.t61 No cases of dental fluorosis or symptomatic skeletal fluorosis have been reported among persons with impaired kidney function; how- ever, the overall health significance of reduced fluoride removal is uncertain and continued follow -up is recom- mended especially for children with impaired kidney function.B4 (+ Additional information on this topic may be found in Question 40. Fluoridation Facts QUESTION 23. Will the ingestion of optimally fluoridated water over a lifetime adversely affect bone health? Answer. No, the ingestion of optimally fluoridated water does not have an adverse effect on bone health. 194-198,203-205 Fact. The weight of scientific evidence does not provide an adequate basis for altering public health policy regard- ing fluoridation because of bone health concerns. A number of investigations have studied the effects on bone structure of individuals residing in communi- ties with optimal and higher than optimal concentra- tions of fluoride in the drinking water. These studies have focused on whether there exists a possible link between fluoride and bone fractures. Additionally, the possible association between fluoride and bone cancer has been studied. In 1991, a workshop, co- sponsored by the Nation- al Institute of Arthritis and Musculoskeletal and Skin Diseases and the then National Institute of Dental Re- search, addressed the potential relationship of hip frac- ture and bone health in humans to fluoride exposure from drinking water. Meeting at the National Institutes of Health, researchers examined historic and contem- porary research on fluoride exposure and bone health. At that time, participants concluded there was no basis for altering current public health policy regarding cur- rent guidelines for levels of fluoride in drinking water. Recommendations were made regarding additional re- search in several area 6.194 In 1993, two studies were published demonstrating that exposure to fluoridated water does not contribute to an increased risk for hip fractures. One study looked at the risk of hip fractures in residents of two similar communities in Alberta, Canada .195 In this study, re- searchers compared a city with fluoridated drinking water optimally adjusted to 1 ppm to a city whose residents drank water containing naturally occurring fluoride at a concentration of only 0.3 ppm. No signifi- cant difference was observed in the overall hip frac- ture hospitalization rates for residents of both cities. "These findings suggest that fluoridation of drinking water has no impact, neither beneficial nor deleteri- ous, on the risk of hip fracture. "195 The second study examined the incidence of hip frac- ture rates before and after water fluoridation in Roches- ter, Minnesota.796 Researchers compared the hip fracture rates of men and women aged 50 and older from 1950 to 1959 (before the city's water supply was fluoridated in 1960) with the ten -year period after fluoridation. Their findings showed that hip fracture rates had decreased, and that the decrease began before fluoridation was in- troduced, and then continued. These data demonstrate no increase in the risk of hip fracture associated with water fluoridation. Packet Page -924- 27 24, An ecological study conducted in eastern Germany compared the incidence of hip fractures for adults living in Chemnitz (optimally fluoridated) and Halle (fluoride - deficient). The results suggested the consumption of optimally fluoridated water reduced the incidence of hip fractures in elderly individuals, especially women over 84 years of age.200 The ingestion of optimally fluoridated water does not have an adverse effect on bone health .194-198,200 Exposure to fluoride at levels considered optimal for the prevention of dental decay appears to have no significant impact on bone mineral density or risk of bone fracture 201 -205 Some studies have reported hip fracture risk increased slightly, decreased slightly or was unchanged in fluoridated areas compared to nonfluoridated areas. A recent systematic review of these studies concluded there was no clear as- sociation with water fluoridation and hip fracture .201 / "Exposure to fluoride at levels considered optimal for the prevention of dental decay appears to have no significant impact on bone mineral density or risk of bone fracture." While a number of studies reported findings at a population level, both the Hillier and Phipps studies examined risk on an individual rather than a commu- nity basis taking into account other risk factors such as medications, age of menopause, alcohol consumption, smoking, dietary calcium intake and physical activity. Using these more rigorous study designs, Hillier and Phipps reported no change or lower hip fracture risk in those drinking fluoridated water. os,204 In Bone Health and Osteoporosis: A Report of the Sur- geon General issued in 2004, fluoride is listed as a nutri- ent that has potentially beneficial effects on bone .201 Lastly, the possible association between fluoride and bone cancer has been studied. In the early 1990s, two studies were conducted to evaluate the carcinogenicity of sodium fluoride in laboratory animals. The first study was conducted by the National Toxicology Program (NTP) of the National Institute of Environmental Health Sciences 201, The second study was sponsored by the Proctor and Gam- ble Company209 In both studies, higher than optimal con- centrations of sodium fluoride (25, 100 and 175 ppm) were consumed by rats and mice. When the NTP and the Proctor and Gamble studies were combined, a total of eight indi- vidual sex/species groups became available for analysis. Seven of these groups showed no significant evidence of malignant tumor formation. One group, male rats from the NTP study, showed "equivocal" evidence of carcinoge- nicity, which is defined by NTP as a marginal increase in neoplasms — i.e., osteosarcomas (malignant tumors of the bone) —that may be chemically related. The Ad Hoc Sub- committee on Fluoride of the U.S. Public Health Service combined the results of the two studies and stated: "Taken together, the two animal studies available at this time fail to establish an association between fluoride and cancer. 1184,210 (+ Additional information on this topic may be found in Question 28. QUESTION 24. What is dental fluorosis? Answer. Dental fluorosis is a change in the appearance of teeth and is caused when higher than optimal amounts of fluoride are ingested in early childhood while tooth enamel is forming. The risk of dental fluorosis can be greatly reduced by closely monitoring the proper use of fluoride products by young children. Fact. Dental fluorosis is caused by a disruption in enamel for- mation which occurs during tooth development in early childhood related to a higher than optimal intake of flu- oride .1B2 Enamel formation of permanent teeth, other than third molars (wisdom teeth), occurs from about the time of birth until approximately five years of age. After tooth enamel is completely formed, dental fluorosis can- not develop even if excessive fluoride is ingested 211 Older children and adults are not at risk for the development of dental fluorosis. Dental fluorosis becomes apparent only after the teeth erupt. Because dental fluorosis occurs while teeth are forming under the gums, teeth that have erupted are not at risk for dental fluorosis. It should be noted that many other developmental changes that affect the appear- ance of tooth enamel are not related to fluoride intake. Table 4. Dental fluorosis .Classification by H.T. Dean - 19422'2 Classification Criteria — Description of Enamel Normal Smooth, glossy, pale creamy -white translucent surface Questionable A few white flecks or white spots Very Mild Small opaque, paper -white areas covering less than 25% of the tooth surface Mild Opaque white areas covering less than 50% of the tooth surface Moderate All tooth surfaces affected; marked wear on biting surfaces; brown stain may be present Severe All tooth surfaces affected; discrete or confluent pitting; brown stain present 28 Packet Page -925- American Dental Association 10"N /"'111N Dental fluorosis has been classified in a number of ways. One of the most universally accepted classifications was developed by H. T. Dean in 1942; its descriptions can be easily visualized by the public (see Table 4) .212 In using Dean's Fluorosis Index, each tooth present in an individual's mouth is rated according to the fluo- rosis index in Table 4. The individual's fluorosis score is based upon the severest form of fluorosis recorded for two or more teeth. Dean's Index, which has been used for more than 60 years, remains popular for prevalence studies in large part due to its simplicity and the ability to make comparisons with findings from a number of earlier studies.213 Very mild to mild fluorosis has no effect on tooth function and may make the tooth enamel more resis- tant to decay. These types of fluorosis are not readily apparent to the affected individual or casual observ- er and often require a trained specialist to detect. In contrast, the moderate and severe forms of dental fluorosis, characterized by esthetically (cosmetically) objectionable changes in tooth color and surface ir- regularities, are typically easy to detect. Most investi- gators regard even the more advanced forms of dental fluorosis as a cosmetic effect rather than a functional adverse effect. 121 The U.S. Environmental Protection Agency, in a decision supported by the U.S. Surgeon General, has determined that objectionable dental fluorosis is a cosmetic effect with no known health ef- fects.166 Little research on the psychological effects of dental fluorosis on children and adults has been con- ducted, perhaps because the majority of those who have the milder forms of dental fluorosis are unaware of this condition .84 In a 1986 -7 national survey of U.S. school children conducted by the National Institute of Dental Research (NIDR), dental fluorosis was present in 22.3% of the children examined using Dean's Index.8' These children were exposed to a variety of sources of fluoride (fluori- dated water, food, beverages, fluoride dental products and dietary supplements). The prevalence of the types of dental fluorosis observed was: Very mild fluorosis 17.0% Mild fluorosis 4.0% Moderate fluorosis 1.0% Severe fluorosis 0.3% Total 22.3% The incidence of moderate or severe fluorosis com- prised a very small portion (6 %) of the total amount of fluorosis. In other words, 94% of all dental fluorosis was the very mild to mild form of dental fluorosis. This survey conducted by NIDR remains the only source of national data regarding the prevalence of den- tal fluorosis. Ina study that compared this data with data recorded by H. Trendley Dean in the 1930s, it was de- termined that the greatest increase in fluorosis from the 1930s to the 1980s appeared in the group with subopti- mally fluoridated water. During the last ten years of this period, children were exposed to fluoride from multiple Fluoridation Facts sources including water, infant formula, foods, foods and drinks prepared with fluoridated water as well as dietary supplements and the ingestion of fluoride tooth- paste making it difficult to pinpoint the effect any one item had on the development of fluorosis. As part of the most recent National Health and Nutrition Examination Survey (NHANES) 1999 -2002, new fluorosis data has been collected as a representative sample of the U.S. population. By comparing NIDR and the latest NHANES data, researchers will be able to determine trends in the prevalence and severity of dental fluorosis in the past 15 years and examine if changes in exposure to systemic fluorides such as infant formulas, toothpaste and dietary fluoride supplements have had some effect.214 Using the same NIDR study, researchers looked at chil- dren aged 12 -14 years who had never received dietary fluoride supplements and had only lived in one home. Through their analysis, they found that approximately 2% of U.S. school children may experience perceived es- thetic problems which could be attributed to the currently recommended levels of fluoride in drinking water. They reported that dental fluorosis in the esthetically important front teeth occurs less often and is less severe than when looking at all teeth in an individual. While the researchers were not able to provide a cost estimate associated with the treatment of this fluorosis, they did note that such estimates are frequently an overestimation of the actual costs. Additionally, any change recommended to the cur- rent fluoridation policy would need to be weighed against fluoridation's lifetime benefits and the feasibility and as- sociated costs of alternative solutions 215 As with other nutrients, fluoride is safe and effective when used and consumed properly. The recommended optimum water fluoride concentration of 0.7 to 1.2 ppm was established to maximize the decay preventive ben- efits of fluoride, and the same time minimize the likeli- hood of mild dental fluorosis.64 "The risk of teeth forming with the very mildest form of fluorosis must be weighed against the benefit that the individual's teeth will also have a lower level of dental decay thus saving dental treatment costs, patient discomfort and tooth loss." The benefits and risks of community water fluoridation have been examined and are discussed extensively in the Benefits Section and the safety of water fluoridation is discussed in great detail in the remainder of this (Safety) Section of this document. In assessing the risks of den- tal fluorosis, scientific evidence indicates it is probable that approximately 10% of children consuming optimally fluoridated water, in the absence of fluoride from all other sources, will develop very mild dental fluorosis.10 As de- fined in Table 4, very mild fluorosis is characterized by small opaque, paper -white area covering less than 25% of the tooth surface. The risk of teeth forming with the very Packet Page -926- 29 25. 26. 27 mildest form of fluorosis must be weighed against the benefit that the individual's teeth will also have a lower level of dental decay thus saving dental treatment costs, patient discomfort and tooth IoSS.11.12 In addition, the risk of fluorosis may be viewed as an alternative to having dental decay, which is a disease that may cause cosmetic problems much greater than dental fluorosis 216 In 1994, a review of five recent studies indicated that the amount of dental fluorosis attributable to water flu- oridation was approximately 13 %. This represents the amount of fluorosis that might be eliminated if com- munity water fluoridation was discontinued.B5 In other words, the majority of dental fluorosis can be associ- ated with other risk factors such as the inappropriate ingestion of fluoride products. (+ Additional information on this topic may be found in Question 25. The type of fluorosis seen today remains largely limited to the very mild and mild categories; however, the preva- lence of dental fluorosis in both fluoridated and nonfluo- ridated communities in the United States is higher than it was when the original epidemiological studies were con- ducted approximately 60 years ago .84 The inappropriate use of fluoride- containing dental products is the largest risk factor for increased fluorosis as fluoride intake from food and beverages has remained constant overtime.18 °.181 The risk of fluorosis can be greatly reduced by following la- bel directions for the use of these fluoride products.123,167 (+ Additional information on this topic may be found in Question 25. QUESTION 25-. What can be done to reduce the occurrence of dental fluorosis in the U.S.? Answer. The vast majority of dental fluorosis in the United States can be prevented by limiting the ingestion of topical fluoride products (such as toothpaste) and the appropriate use of dietary fluoride supplements with- out denying young children the decay prevention ben- efits of community water fluoridation. Fact. During the period of enamel formation in young children (before teeth appear in the mouth), inappropriate ingestion of high levels of fluoride is the risk factor for dental fluoro- SIS.65'217 Studies of fluoride intake from the diet including foods, beverages and water indicate that fluoride ingestion from these sources has remained relatively constant for over half a century and, therefore, is not likely to be associ- ated with an observed increase in dental fluorosis.180.182 (+ Additional information on this topic may be found in Question 19. Dental decay has decreased because children today are being exposed to fluoride from a wider variety of sources than decades ago. Many of these sources are intended for 30 topical use only; however, some fluoride is ingested inad- vertently by children.183 Inappropriate ingestion of topical fluoride can be minimized, thus reducing the risk for den- tal fluorosis without reducing decay prevention benefits. Since 1992, the American Dental Association (ADA) has required manufacturers of toothpaste to include the phrase "Use only a pea -sized amount (of toothpaste) for children under six" on fluoride toothpaste labels with the ADA Seal of Acceptance. The rationale for choosing six years of age for the toothpaste label is based on the fact that the swallowing reflex is not fully developed in chil- dren of preschool age and they may inadvertently swal- low toothpaste during brushing. In addition, the enamel formation of permanent teeth is basically complete at six and so there is a decreased risk of fluorosis. Because dental fluorosis occurs while teeth are forming under the gums, individuals whose teeth have erupted are not at risk for dental fluorosis. Additional information on this topic may be found in Question 24. Numerous studies have established a direct relation- ship between young children brushing with more than a pea -sized amount of fluoride toothpaste and the risk of very mild or mild dental fluorosis in both fluoridated and nonfluoridated communities. 189.218.219 It was noted that 34% of the dental fluorosis cases in a nonfluoridated community were explained by children having brushed more than once per day during the first two years of life. In the optimally fluoridated community, 68% of the fluo- rosis cases were explained by the children using more than a pea -sized amount of toothpaste during the first year of life .221 Parents and caregivers should put only one pea -sized amount of fluoride toothpaste on a young child's toothbrush at each brushing. Young children should be supervised while brushing and taught to spit out, rather than swallow, the toothpaste. Consult with your child's dentist or physician if you are considering using fluoride toothpaste before age two. Additionally, it has been shown that 65% of the fluo- rosis cases in a nonfluoridated area were attributed to fluoride supplementation under the pre -1994 protocol. Thirteen percent of fluorosis cases in a fluoridated com- munity could be explained by a history of taking dietary fluoride supplements inappropriately."' Dietary fluoride supplements should be prescribed as recommended in the dietary fluoride supplement schedule approved by the American Dental Association, the American Acade- my of Pediatrics and the American Academy of Pediatric Dentistry in 1994 (see Table 1).30,125 Fluoride supplements should only be prescribed for children living in nonfluori- dated areas. Because of many sources of fluoride in the diet, proper prescribing of fluoride supplements can be complex. It is suggested that all sources of fluoride be evaluated with a thorough fluoride history before sup- plements are prescribed for a child." That evaluation should include testing of the home water supply if the fluoride concentration is unknown. Additional information on this topic may be found in Question 42. Packet Page -927- American Dental Association 1'\ I *� /'\ Parents, caretakers and health care professionals should judiciously monitor use of all fluoride-contain- ing dental products by children under age six. As is the case with any therapeutic product, more is not always better. Care should be taken to adhere to label directions on fluoride prescriptions and over - the - counter products (e.g. fluoride toothpastes and rinses). The ADA recom- mends the use of fluoride mouthrinses, but not for chil- dren under six years of age because they may swallow the rinse. These products should be stored out of the reach of children. Finally, in areas where naturally occurring fluoride levels in ground water are higher than 2 ppm, consum- ers should consider action to lower the risk of dental fluorosis for young children. (Adults are not affected because dental fluorosis occurs only when develop- ing teeth are exposed to elevated fluoride levels.) Families on community water systems should contact their water supplier to ask about the fluoride level. Consumers with private wells should have the source tested yearly to accurately determine the fluoride con- tent. Consumers should consult with their dentist re- garding water testing and discuss appropriate dental health care measures. In homes where young children are consuming water with a fluoride level greater than 2 ppm, families should use an alternative primary water source, such as bottled water, for drinking and cooking. It is also important to remember that the ADA recommends dietary fluoride supplements only for children living in areas with less than optimally fluori- dated water. (+ Additional information on this topic may be found in Questions 4, 72 and 42. QUESTION 26. Why is there a warning label on a tube of fluoride tooth- paste? Answer. The American Dental Association originally required manufacturers to place a label on fluoride toothpaste in 1991 to ensure proper use and therefore reduce the risk of dental fluorosis. Fact. In 1991, the American Dental Association (ADA) began requiring toothpaste manufacturers to include the follow- ing language on all ADA- Accepted toothpastes: "Do not swallow. Use only a pea -sized amount for children under six. To prevent swallowing, children under six years of age should be supervised in the use of toothpaste." "To ensure children's safety, the ADA limits' the total amount of fluoride allowed in ADA- Accepted toothpaste. " Fluoridation Facts The ADA warning labels were adopted to help reduce the risk of mild dental fluorosis. This type of fluorosis is not readily apparent to the affected individual or ca- sual observer and often requires a trained specialist to detect. Dental fluorosis only occurs when more than the optimal daily amount of fluoride is ingested. Additionally, to ensure children's safety, the ADA lim- its the total amount of fluoride allowed in any one tube of ADA- Accepted toothpaste. Since 1997, the U.S. Food and Drug Administration (FDA) has required the label language, "If you acci- dentally swallow more than used for brushing, seek professional help or contact a poison control center im- mediately" on all fluoride toothpastes sold in the U.S. The new FDA labels are consistent with the ADA statements, with the exception of the poison control warning. The ADA Council on Scientific Affairs believes that the last sentence on the label could unnecessarily fright- en parents and children and that this portion of the label overstates any demonstrated or potential danger posed by fluoride toothpastes. The ADA notes that a child could not absorb enough fluoride from one tube of toothpaste to cause a seri- ous problem and that the excellent safety record on fluoride toothpaste argues against any unnecessary regulation .221 QUESTION 27. Is fluoride, as provided by community water fluorida- tion, a toxic substance? Answer. No. Fluoride, at the concentrations found in optimally fluoridated water, is not toxic according to generally ac- cepted scientific knowledge. Fact. Like many common substances essential to life and good health - salt, iron, vitamins A and D, chlorine, oxygen and even water itself - fluoride can be toxic in excessive quantities. Fluoride in the much lower con- centrations (0.7 to 1.2 ppm) used in water fluoridation is not harmful or toxic. Acute fluoride toxicity occurring from the ingestion of optimally fluoridated water is impossible. 1112 The amount of fluoride necessary to cause death for a hu- man adult (155 pound man) has been estimated to be 5 -10 grams of sodium fluoride, ingested at one time .222 This is more than 10,000- 20,000 times as much fluoride as is consumed at one time in a single 8 ounce glass of optimally fluoridated water. Chronic fluoride toxicity may develop after 10 or more years of exposure to very high levels of fluoride, levels not associated with optimal fluoride intake in drinking water. The primary functional adverse effect associated with long term excess fluoride intake is Packet Page -928- 31 28. 29 skeletal fluorosis. The development of skeletal fluoro- sis and its severity is directly related to the level and duration of fluoride exposure. For example, the inges- tion of water naturally fluoridated at approximately 5 ppm for 10 years or more is needed to produce clinical signs of osteosclerosis (a mild form of skeletal fluorosis that can be seen as a change in bone density on x -rays) in the general population. In areas naturally fluoridat- ed at 5 ppm, daily fluoride intake of 10 mg /day would not be uncommon. 123 A survey of X -rays from 170,000 people in Texas and Oklahoma whose drinking water had naturally occurring fluoride levels of 4 to 8 ppm revealed only 23 cases of osteosclerosis and no cases of crippling skeletal fluorosis.223 Evidence of advanced skeletal fluorosis, or crippling skeletal fluorosis, "was not seen in communities in the United States where water supplies contained up to 20 ppm (natural levels of fluoride)." 123,199 In these communities, daily fluoride intake of 20mg /day would not be uncommon .123 Crip- pling skeletal fluorosis is extremely rare in the United States and is not associated with optimally fluoridated water; only 5 cases have been confirmed during the last 35 years. 123 3 Additional information on this topic may be found in Question 20. The Agency for Toxic Substances and Disease Regis- try (ATSDR) prepares toxicological profiles for various hazardous substances most commonly found at facili- ties on the CERCLA National Priorities List (Superfund Sites). The Toxicological Profile for Fluorides, Hydrogen Fluoride and Fluorine was revised in 2003. The ATSDR states that existing data indicates that subsets of the population may be unusually susceptible to the toxic ef- fects of fluoride and its compounds at high doses. How- ever, there are no data to suggest that exposure to the low levels associated with community water fluorida- tion would result in adverse effects in these potentially susceptible population S.221 "The possibility of adverse health effects from continuous low level consumption of fluoride over long periods has been studied extensively. As with other nutrients, fluoride is safe and effective when used and consumed properly. " The possibility of adverse health effects from con- tinuous low level consumption of fluoride over long periods has been studied extensively. As with other nutrients, fluoride is safe and effective when used and consumed properly. No charge against the benefits and safety of fluoridation has ever been substantiated by generally accepted scientific knowledge. After 60 years of research and practical experience, the preponder- ance of scientific evidence indicates that fluoridation of community water supplies is both safe and effective. 32 At one time, high concentrations of fluoride additives were used in insecticides and rodenticides 36 Today fluo- ride additives are rarely used in pesticides because more effective additives have been developed.183 While large doses of fluoride may be toxic, it is im- portant to recognize the difference in the effect of a massive dose of an extremely high level of fluoride versus the recommended amount of fluoride found in optimally fluoridated water. The implication that fluorides in large doses and in trace amounts have the same effect is completely unfounded. Many sub- stances in widespread use are very beneficial in small amounts, but may be harmful in large doses — such as salt, chlorine and even water itself. QUESTION 28. Does drinking optimally fluoridated water cause or ac- celerate the growth of cancer? Answer. According to generally accepted scientific knowledge, there is no association between cancer rates in humans and optimal levels of fluoride in drinking water.225 Fact. Since community water fluoridation was introduced in 1945, more than 50 epidemiologic studies in different populations and at different times have failed to dem- onstrate an association between fluoridation and the risk of cancer.B4 Studies have been conducted in the United State S,226-231 Japan '232 the United Kingdom,233 -235 Canada 236 and Australia .211 In addition, several indepen- dent bodies have conducted extensive reviews of the scientific literature and concluded that there is no rela- tionship between fluoridation and cancer. 64,163,165,176,206,236 The U.S. Environmental Protection Agency (EPA) fur- ther commented on the safety of appropriate fluoride exposure in the December 5, 1997, Federal Register .219 In a notice of a final rule relating to fluoride additives; the EPA stated, "...the weight of evidence from more than 50 epidemiological studies does not support the hypothesis of an association between fluoride expo- sure and increased cancer risk in humans. The EPA is in agreement with the conclusions reached by the Na- tional Academy of Sciences (NAS)." Despite the abundance of scientific evidence to the contrary, claims of a link between fluoridation and in- creased cancer rates continue. This assertion is largely based on one study comparing cancer death rates in ten large fluoridated cities versus ten large nonfluoridated cities in the United States. The results of this study have been refuted by a number of organizations and research - ers.240 Scientists at the National Cancer Institute analyzed the same data and found that the original investigators failed to adjust their findings for variables, such as age and gender differences, that affect cancer rates. A review by other researchers pointed to further shortcomings in Packet Page -929- American Dental Association 10�1 ?0_14k. A*01N the study. The level of industrialization in the fluoridated cities was much higher than the nonfluoridated cities. Researchers noted that a higher level of industrialization is usually accompanied by a higher incidence of cancer. While the researchers noted that the fluoridated cities did have higher cancer rates over the twenty year study, the rate of increase in the nonfluoridated cities was exactly the same (15 %) as the fluoridated cities. Following fur- ther reviews of the study, the consensus of the scientific community continues to support the conclusion that the incidence of cancer is unrelated to the introduction and duration of water fluoridation .14 In the early 1990s, two studies using higher than optimal levels of fluoride were conducted to evaluate the carcinogenicity of sodium fluoride in laboratory animals. The first study was conducted by the National Toxicology Program (NTP) of the National Institute of Environmental Health Sciences .208 The second study was sponsored by the Proctor and Gamble Company.209 In both studies, higher than optimal concentrations of sodium fluoride (25, 100 and 175 ppm) were consumed by rats and mice. When the NTP and the Proctor and Gamble studies were combined, a total of eight indi- vidual sex /species groups became available for anal- ysis. Seven of these groups showed no significant evidence of malignant tumor formation. One group, male rats from the NTP study, showed "equivocal" evi- dence of carcinogenicity, which is defined by NTP as a marginal increase in neoplasms — i.e., osteosarcomas (malignant tumors of the bone) — that may be chemi- cally related. The Ad Hoc Subcommittee on Fluoride of the U.S. Public Health Service combined the results of the two studies and stated: "Taken together, the two animal studies available at this time fail to establish an association between fluoride and cancer. "84,210 Since that time, a number of studies have examined the hypothesis that fluoride is a risk factor for bone can- cer. None of these studies reported an association be- tween optimal levels of fluoride in drinking water and cancer of the bone .241-244 (Additional information on this topic may be found in Question 23. In a 1990 study, scientists at the National Cancer In- stitute evaluated the relationship between fluoridation of drinking water and cancer deaths in the United States during a 36 year period, and the relationship between fluoridation and the cancer rate during a 15 year period. After examining more than 2.3 million cancer death re- cords and 125,000 cancer case records in counties using fluoridated water, the researchers saw no indication of a cancer risk associated with fluoridated drinking water. 84 In 2001, researchers from Japan analyzed data on cancers taken from the International Agency for Re- search on Cancer World Health Organization in 1987, 1992 and 1997 and concluded that fluoridation may increase the risk for numerous types of cancers .245 However, the methodology used in this analysis was inherently flawed as there are major and obvious dif- ferences in a number of factors relevant to the risk Fluoridation Facts for cancer in the fluoridated and nonfluoridated com- munities. For example, this analysis did not control for differences in urbanization, socioeconomic status, geographic region, occupations, industries, diet, medi- cal practices or tobacco use between the fluoridated and nonfluoridated communities. Thus any attempt to interpret cancer risk between these communities with this number of uncontrolled variables is scientifically inappropriate. "The American Cancer Society states, 'Scientific studies show no connection between cancer rates in humans and adding fluoride to drinking water.'" In a document entitled "Fluoride and Drinking Water Fluoridation," the American Cancer Society states, "Sci- entific studies show no connection between cancer rates in humans and adding fluoride to drinking water. 11225 QUESTION 29. Does fluoride, as provided by community water fluori- dation, inhibit the activity of enzymes in humans? Answer. Fluoride, in the amount provided through optimally flu- oridated water, has no effect on human enzyme activity according to generally accepted scientific knowledge. Fact. Enzymes are organic compounds that promote chem- ical change in the body. Generally accepted scientific knowledge has not indicated that optimally fluoridat- ed water has any influence on human enzyme activity. There are no available data to indicate that, in humans drinking optimally fluoridated water, the fluoride af- fects enzyme activities with toxic consequences .246 The World Health Organization report, Fluorides and Human Health states, "No evidence has yet been pro- vided that fluoride ingested at 1 ppm in the drinking water affects intermediary metabolism of food stuffs, vitamin utilization or either hormonal or enzymatic activity. 11247 The concentrations of fluoride used in laboratory studies to produce significant inhibition of enzymes are hundreds of times greater than the concentration pres- ent in body fluids or tissues .212 While fluoride may af- fect enzymes in an artificial environment outside of a living organism in the laboratory, it is unlikely that ad- equate cellular levels of fluoride to alter enzyme activi- ties would be attainable in a living organism.251 The two primary physiological mechanisms that maintain a low concentration of fluoride ion in body fluids are the rapid excretion of fluoride by the kidneys and the uptake of fluoride by calcified tissues. Packet Page -930- 33 30. 31 32. 34. QUESTION 30. Does the ingestion of optimally fluoridated water ad- versely affect the thyroid gland or its function? Answer. There is no scientific basis that shows fluoridated wa- ter has an adverse effect on the thyroid gland or its function. Fact. In an effort to determine if fluoride in drinking water af- fects the function, shape and size of the thyroid gland, researchers conducted a study comparing one group of people who consumed water that contained natural fluoride levels of 3.48 ppm and one group who con- sumed water with extremely low fluoride levels of 0.09 ppm. The researchers noted that all study participants had been residents of their respective communities for more than 10 years. The researchers concluded that prolonged ingestion of fluoride at levels above optimal to prevent dental decay had no effect on thyroid gland size or function. This conclusion was consistent with earlier animal studies .241 In addition, two studies have explored the associa- tion between fluoridated water and cancer of the thy- roid gland. Both studies found no association between optimal levels of fluoride in drinking water and thyroid cancer .226,249 In an effort to link fluoride and decreased thyroid func- tion, those opposed to fluoridation cite one small study from the 1950's in which 15 patients who had hyperthy- roidism (an overactive thyroid) were given relative large amounts of sodium fluoride orally or by injection in an ef- fort to inhibit the thyroid's function. The researchers con- cluded that efforts to treat hyperthyroidism with fluoride was successful only occasionally among persons sub- jected to massive doses of fluoride. This study does not support claims that low fluoride levels in drinking water would cause hypothyroidism (an underactive thyroid ).251 QUESTION 31. Does water fluoridation affect the pineal gland causing the early onset of puberty? Answer. Generally accepted science does not suggest that wa- ter fluoridation causes the early onset of puberty. Fact. The pineal gland is an endocrine gland located in the brain which produces melatonin.21t Endocrine glands secrete their products into the bloodstream and body tissues and help regulate many kinds of body functions. The hormone, melatonin, plays a role in sleep, aging and reproduction. A single researcher has published one study in a peer - reviewed scientific journal regarding fluoride accumula- 34 tion in the pineal gland. The purpose of the study was to discover whether fluoride accumulates in the pineal gland of older adults. This limited study, conducted on only 11 cadavers whose average age at death was 82 years, indicated that fluoride deposited in the pineal gland was significantly linked to the amount of calcium in the pineal gland. It would not be unexpected to see higher levels of calcium in the pineal gland of older indi- viduals as this would be considered part of a normal ag- ing process. As discussed in Question 22, approximately 99% of the fluoride present in the body is associated with hard or calcified tissues. 192 The study concluded fluoride levels in the pineal gland were not indicators of long- term fluoride exposure .252 The same researcher has theorized in unpublished reports posted on the Internet that the accumulation of fluoride in children's pineal gland leads to an earlier on- set of puberty. However, the researcher notes that there is no verification that fluoride accumulates in children's pineal glands. Moreover, a study conducted in New- burgh (fluoridated) and Kingston (non - fluoridated), New York found no statistical significance between the onset of menstruation for girls living in a fluoridated verses non - fluoridated area .253 QUESTION 32. Can fluoride, at the levels found in optimally fluoridated drinking water, alter immune function or produce aller- gic reaction (hypersensitivity)? Answer. There is no scientific evidence of any adverse effect on specific immunity from fluoridation, nor have there been any confirmed reports of allergic reaction .254 Fact. There is no scientific evidence linking problems with immune function such as HIV or AIDS (acquired im- mune deficiency syndrome) with community water fluoridation."' There are no confirmed cases of allergy to fluoride, or of any positive skin testing in human or animal mod - eIs.254 A committee of the National Academy of Sciences evaluated clinical reports of possible allergic responses to fluoride and reported, "The reservation in accepting (claims of allergic reaction) at face value is the lack of similar reports in much larger numbers of people who have been exposed to considerably more fluoride than was involved in the original observations. "39 The World Health Organization also judged these cases to repre- sent "a variety of unrelated conditions" and found no evidence of allergic reactions to fluoride .256,211 A 1996 review of the literature on fluoride and white cell function examined numerous studies and conclud- ed that there is no evidence of any harmful effect on specific immunity following fluoridation nor any con- firmed reports of allergic reactions.254 Packet Page -931- American Dental Association QUESTION 33. QUESTION 34. Is fluoride, as provided by community water fluorida- Does fluoride at the levels found in water fluoridation tion, a genetic hazard? affect human reproduction, fertility or birth rates? Answer. Following a review of generally accepted scientific knowledge, the National Research Council of the Na- tional Academy of Sciences supports the conclusion that drinking optimally fluoridated water is not a ge- netic hazard. 167 Fact. Chromosomes are the DNA - containing bodies of cells that are responsible for the determination and transmis- sion of hereditary characteristics. Genes are the func- tional hereditary unit that occupies a fixed location on a chromosome. Many studies have examined the pos- sible effects of fluoride on chromosome damage. While there are no published studies on the genotoxic (dam- age to DNA) effect of fluoride in humans, numerous studies have been done on mice.167 These studies have shown no evidence that fluoride damages chromo- somes in bone marrow or sperm cells even at fluoride levels 100 times higher than that in fluoridated water .2„- 264 Another independent group of researchers reported a similar lack of fluoride- induced chromosomal damage to human white blood cells, which are especially sensi- tive to agents which cause genetic mutations. Not only did fluoride fail to damage chromosomes, it protected them against the effect of a known mutagen (an agent that causes changes in DNA) .261,266 The genotoxic effects of fluoride were also studied in hamster bone marrow cells and cultured hamster ovarian cells. Again, the re- sults supported the conclusion that fluoride does not cause chromosomal damage, and therefore, was not a genetic hazard .261 In further tests, fluoride has not caused genetic mutations in the most widely used bac- terial mutagenesis assay (the Ames test) over a wide range of fluoride levels. 267-270 The National Research Council (NRC) of the Nation- al Academy of Sciences supports the conclusion that drinking optimally fluoridated water is not a genetic hazard. In a statement summarizing its research, the NRC states, "in vitro data indicate that: 1) the genotoxicity of fluoride is limited primarily to doses much higher than those to which humans are exposed, 2) even at high doses, genotoxic effects are not al- ways observed, and 3) the preponderance of the genotoxic effects that have been reported are of the types that probably are of no or negligible genetic significance. 11161 The lowest dose of fluoride reported to cause chro- mosomal changes in mammalian cells was approxi- mately 170 times that found normally found in human cells in areas where drinking water is fluoridated, which indicates a large margin of safety. 167 Fluoridation Facts Answer. There is no credible, scientific evidence that fluorida- tion has an adverse effect on human reproduction, fer- tility or birth rates. Fact. Very high levels of fluoride intake have been associated with adverse effects on reproductive outcomes in many animal species. Based on these findings, it appears that fluoride concentrations associated with adverse repro- ductive effects in animals are far higher (100 -200 ppm) than those to which human populations are exposed. Consequently, there is insufficient scientific basis on which to conclude that ingestion of fluoride at levels found in community water fluoridation (0.7 — 1.2 ppm) would have adverse effects on human reproduction .167 One human study compared county birth data with county fluoride levels greater than 3 ppm and attempt- ed to show an association between high fluoride lev- els in drinking water and lower birth rates.271 However, because of serious limitations in design and analysis, the investigation failed to demonstrate a positive cor- relation.212 A study examining the relative risk of stillbirths and congenital abnormalities (facial clefts and neural tube defects) found no evidence that fluoridation had any ef- fect of these outcomes .271 The National Research Council (NRC) of the National Academy of Sciences (NAS) supports the conclusion that drinking optimally fluoridated water is not a genetic hazard.',' (+ Additional information on this topic may be found in Question 33. QUESTION 35'. Does drinking optimally fluoridated water cause an increase in the rate of children born with Down Syndrome? Answer. There is no known association between the consump- tion of optimally fluoridated drinking water and Down Syndrome. Fact. This question originally arose because of two studies published in 1956 and 1963 by a psychiatrist. Data col- lected in several Midwest states in 1956 formed the basis for his two articles published in French journals, purporting to prove a relationship between fluoride in the water and Down Syndrome .214,271 Experienced epidemiologists and dental research- ers from the National Institute of Dental Research and Packet Page -932- 35 36. 37 38. staff members of the National Institute of Mental Health have found serious shortcomings in the statistical pro- cedures and designs of these two studies. Among the most serious inadequacies is the fact that conclusions were based on the fluoridation status of the commu- nities where the mothers gave birth, rather than the status of the rural areas where many of the women lived.during their pregnancies .222 In addition, the num- ber'of Down Syndrome cases found in both fluoridat- ed and nonfluoridated communities were much lower than the rates found in many other parts of the United States and the world, that casting doubt on the validity of findings. The following paragraphs provide a summary of nu- merous studies that have been conducted which refute the conclusions of the 1956 studies. A British physician reviewed vital statistics and records from institutions and school health officers, and talked with public health nurses and others caring for children with Down Syndrome. The findings noted no indication of any relationship between Down Syndrome and the level of fluoride in water consumed by the mothers 276 These findings were confirmed by a detailed study of approximately 2,500 Down Syndrome births in Massa- chusetts. A rate of 1.5 cases per 1,000 births was found in both fluoridated and nonfluoridated communities, providing strong evidence that fluoridation does not in- crease the risk of Down Syndrome .277 Another large population -based study with data re- lating to nearly 1.4 million births showed no association between water fluoridation and the incidence of con- genital malformations including Down Syndrome .2711 In 1980, a 25 -year review of the prevalence of con- genital malformations was conducted in Birmingham, England. Although Birmingham initiated fluoridation in 1964, no changes in the prevalence of children born with Down Syndrome occurred since that time .171 A comprehensive study of Down Syndrome births was conducted in 44 U.S. cities over a two -year period. Rates of Down Syndrome were comparable in both flu- oridated and nonfluoridated cities. 280 QUESTION 31. Does ingestion of optimally fluoridated water have any neurological impact? Answer. There is no generally accepted scientific evidence es- tablishing a causal relationship between consumption of optimally fluoridated water and central nervous sys- tem disorders, attention deficit disorders or effects on intelligence. Fact. There have been claims that exposure to fluoride pres- ents a neurotoxic (harmful or damaging to nerve tis- sue) risk or lowered intelligence. Such claims are based 36 partly on one 1995 study in which rats were fed fluoride at levels up to 125 times greater than that found in opti- mally fluoridated water.281 The study attempted to dem- onstrate that rats fed extremely high levels of fluoride (75 ppm to 125 ppm in drinking water) showed behav- ior- specific changes related to cognitive deficits. In addition, the experiment also studied the off- spring of rats who were injected two to three times a day with fluoride during their pregnancies in an effort to show that prenatal exposure resulted in hyperactiv- ity in male offspring. However, two scientists who reviewed the 1995 study282 have suggested that the observations made can be readily explained by mechanisms that do not involve neurotoxicity. The scientists found inadequa- cies in experimental design that may have led to in- valid conclusions. For example, the results of the experiment were not confirmed by the use of control groups which are an essential feature of test valida- tion and experimental design. In summary the scien- tists stated, "We do not believe the study by Mullenix et al. can be interpreted in any way as indicating the potential for NaF (sodium fluoride) to be a neurotoxi- cant." Another reviewer182 noted, "...it seems more likely that the unusually high brain fluoride concen- trations reported in Mullenix et al. were the result of some analytical error." "A seven -year study compared the health and behavior of children from birth through six years of age in communities with optimally fluoridated water ...The results suggested that there was no evidence to indicate that exposure to optimally fluoridated water had any detectable effect on children's health or behavior. " A seven -year study compared the health and be- havior of children from birth through six years of age in communities with optimally fluoridated water with those of children the same age without exposure to optimally fluoridated water. Medical records were re- viewed yearly during the study. At age six and seven, child behavior was measured using both maternal and teacher ratings. The results suggested that there was no evidence to indicate that exposure to opti- mally fluoridated water had any detectable effect on children's health or behavior. These results did not differ even when data was controlled for family social background .2112 The research conducted by Mullenix et al discussed in this question has not been replicated by other researchers. (+ Additional information on how to critically review re- search can be found in the Introduction and Figure 1. Packet Page -933- American Dental Association /011%, 140"\ QUESTION 37. Does drinking fluoridated water increase the level of lead in the blood or cause lead poisoning in children? Answer. Generally accepted scientific evidence has not shown any association between water fluoridation and blood lead levels. Fact. One set of researchers has claimed that the silicofluo- ride additives used in community water fluoridation may be responsible for acidic drinking water which leaches lead from plumbing systems thereby increas- ing lead uptake by children. They go on to theorize that communities that use the silicofluorides have greater numbers of children with high levels of lead in their blood than nonfluoridated communities and that the results of the use of silicofluorides are reflected in these communities' residents exhibiting higher rates of learning disabilities, attention deficit disorders, vio- lent crimes and criminals who were using cocaine at the time of arre st.284 From his research, Masters has claimed to be able to predict the estimated cost of increased prison popula- tions due to water fluoridation. For example, in a 2003 appearance before the Palm Beach County (Florida) Commission, Masters stated that if the county fluoridat- ed with silicofluorides, they could expect an additional 819 violent crimes per year directly related to water fluoridation with a minimum additional annual cost of imprisonment of $14,391,255.284 Scientists from the Environmental Protection Agency (EPA) have reviewed the basic science that was the foundation for the claim that silicofluorides leach lead from plumbing systems and found that many of the chemical assumptions made and statisti- cal methods utilized in the original ecological study were scientifically unjustified. They went on to state that the research was inconsistent with accepted scientific knowledge and the authors of the original studies (Masters et al) failed to identify or account for these inconsistencies. Overall, the EPA scientists concluded that "no credible evidence exists to show that water fluoridation has any quantitatable effects on the solubility, bioavailability, bioaccumulation, or reactivity of lead (0) or lead (II) compound S.215 According to the Centers for Disease Control and Prevention, the average blood lead levels of young children in the U.S. have continued to decline since the 1970s primarily due to the phase -out of leaded gaso- line and the resulting decrease in lead emissions. The primary remaining sources of childhood lead exposure are deteriorated leaded paint, house dust contaminated by leaded paint and soil contaminated by both leaded paint and decades of industrial and motor vehicle emis- sions.286 Approximately 95% of the primary sources of Fluoridation Facts adult lead exposure are occupational. Adult blood lead levels have continued to decline over the last ten years due largely to improved prevention measures in the workplace and changes in employment patters .2117 It should be noted that since the 1970s, while blood lead levels have continued to decline, the percentage of the population receiving optimally fluoridated water has continued to increase." The research conducted by Masters et al discussed in this question has not been replicated by other researchers. Additional information on how to critically review re- search can be found in the Introduction and Figure 1. QUESTION 3$. Does drinking optimally fluoridated water cause Alzheim- er's disease? Answer. Generally accepted science has not demonstrated an association between drinking optimally fluoridated wa- ter and Alzheimer's disease. Fact. The exact cause of Alzheimer's disease has yet to be identified. Scientists have identified the major risk fac- tors for Alzheimer's as age and family history. Sci- entists believe that genetics may play a role in many Alzheimer's cases. Other possible risk factors that are being studied are level of education, diet, environment and viruses to learn what role they might play in the development of this disease .21111 A study published in 1998289 raised concerns about the potential relationship between fluoride and Al- zheimer's disease. However, several flaws in the experi- mental design preclude any definitive conclusions from being drawn .290 Interestingly, there is evidence that aluminum and fluoride are mutually antagonistic in competing for absorption in the human body.42.211 While a conclusion cannot be made that consumption of fluoridated wa- ter has a preventive effect on Alzheimer's, there is no generally accepted scientific knowledge to show con- sumption of optimally fluoridated water is a risk factor for Alzheimer's disease. Packet Page -934- 37 39. 40. QUESTION 33. Does drinking optimally fluoridated water cause or con- tribute to heart disease? Answer. Drinking optimally fluoridated water is not a risk factor for heart disease. Fact. This conclusion is supported by results of a study conducted by the National Heart and Lung and Blood Institute of the National Institutes of Health. Research- ers examined a wide range of data from communities that have optimally fluoridated water and from areas with insufficient fluoride.The final report concluded that: "Thus, the evidence from comparison ofthe health of fluoridating and nonfluoridating cities, from medical and pathological examination of persons exposed to a lifetime of naturally occurring fluo- rides or persons with high industrial exposures, and from broad national experience with fluorida- tion all consistently indicate no adverse effect on cardiovascular health. 11292 'The American Heart Association states: 'No evidence exists that adjusting the fluoride content of public water supplies to a level of about one part per million has any harmful effect on the cardiovascular system."' The American Heart Association states: "No evidence exists that adjusting the fluoride content of public water supplies to a level of about one part per million has any harmful effect on the cardiovascular system. "293 The American Heart Association identifies aging, male sex, heredity, cigarette and tobacco smoke, high blood cho- lesterol levels, high blood pressure, physical inactivity, obesity and diabetes mellitus as major risk factors for cardiovascular disease. 294 A number of studies have considered trends in ur- ban mortality in relation to fluoridation status. In one study, the mortality trends from 1950 -70 were studied for 473 cities in the United States with populations of 25,000 or more. Findings showed no relationship be- tween fluoridation and heart disease death rates over the 20 -year period .221 In another study, the mortality rates for approximately 30 million people in 24 fluori- dated cities were compared with those of 22 nonfluo- ridated cities for two years. No evidence was found of any harmful health effects, including heart disease, at- tributable to fluoridation. As in other studies, crude dif- ferences in the mortality experience of the cities with fluoridated and nonfluoridated water supplies were explainable by differences in age, gender and race composition .227 38 QUESTION 40. Is the consumption of optimally fluoridated water harm- ful to kidneys? Answer. The consumption of optimally fluoridated water has not been shown to cause or worsen human kidney disease. Fact. Approximately 50% of the fluoride ingested daily is re- moved from the body by the kidneys.162,112,113 Because the kidneys are constantly exposed to various fluoride concentrations, any health effects caused by fluoride would likely manifest themselves in kidney cells. How- ever, several large community -based studies of people with long -term exposure to drinking water with fluoride concentrations up to 8 ppm have failed to show an in- crease in kidney disease. 166,253,295 In a report issued in 1993 by the National Research Council, the Subcommittee on Health Effects of Ingest- ed Fluoride stated that the threshold dose of fluoride in drinking water which causes kidney effects in animals is approximately 50 ppm - more than 12 times the max- imum level allowed in drinking water by the Environ- mental Protection Agency. Therefore, they concluded that "ingestion of fluoride at currently recommended concentrations is not likely to produce kidney toxicity in humans. "167 Many people with kidney failure depend on hemo- dialysis (treatment with an artificial kidney machine) for their survival. During hemodialysis, the patient's blood is exposed to large amounts of water each week (280 -560 quarts). Therefore, procedures have been designed to ensure that the water utilized in the process contain a minimum of dissolved substances that could diffuse indiscriminately into the patient's bloodstream.296 Since the composition of water var- ies in different geographic locations in the United States, the U.S. Public Health Service recommends dialysis units use techniques such as reverse osmosis and de- ionization to remove excess iron, magnesium, aluminum, calcium, and other minerals, as well as fluoride, from tap water before the water is used for dia lySi8.296,297 (+ Additional information on this topic is available in Ques- tion 22. Packet Page -935- American Dental Association 100,11, QUESTION 4 1. What are some of the erroneous health claims made against water fluoridation? Answer: From sources such as the Internet, newsletters, and personal anecdotes in e- mails, community water fluo- ridation is frequently charged with causing all of the following adverse health effects: • AIDS • Allergic Reactions (loss of hair, skin that burns and peels after contact with fluoridated water) • Alzheimer's disease • Arthritis • Asthma • Behavior Problems (attention deficit disorders) • Bone Disease (osteoporosis — increased bone /hip fractures) • Cancer (all types including osteosarcoma or bone cancer) • Chronic Bronchitis • Colic (acute abdominal pain) • Down Syndrome • Emphysema • Enzyme Effects (gene - alterations) • Flatulence (gas) • Gastrointestinal Problems (irritable bowel syndrome) • Harmful Interactions with Medications • Heart Disease • Increased Infant Mortality • Kidney Disease • Lead Poisonings • Lethargy (lack of energy) • Lower IQ (mental retardation) • Malpositioned Teeth • Pineal Gland (early puberty) (chronic insomnia) • Reproductive Organs (damaged sperm) (reduced fertility) • Skin Conditions (redness, rash /welts, itching) • Sudden Infant Death Syndrome (SIDS) • Thyroid Problems (goiter and obesity due to hy- pothroidism) AND • Tooth Decay Fact. As discussed throughout this booklet, the overwhelming weight of credible scientific evidence has consistently in- dicated that fluoridation of community water supplies is safe and effective. The possibility of any adverse health effects from continuous low -level consumption of fluo- ride has been and continues to be extensively studied. It has been determined that approximately 10% of dental fluorosis is attributable to water fluoridation. This type of very mild to mild fluorosis has been determined to be a cosmetic effect rather than an adverse health effect. Of the thousands of credible scientific studies on fluorida- tion, none has shown health problems associated with the consumption of optimally fluoridated water. Fluoridation Facts "Of the thousands of credible scientific studies on fluoridation, none has shown health problems associated with the consumption of optimally fluoridated water. Packet Page -936- 39 FLUORIDATION PRACTICE Q 42. Water quality? Q 43. Regulation? p. 40 p. 41 Q 45. Source of additives? p. 43 Q 48. Corrosion? p. 44 Q 46. System safety concerns? p. 43 Q 49. Environment? p. 45 Q 44. Standards? p. 42 Q 47. Engineering? QUESTION 42. Will the addition of fluoride affect the quality of drink- ing water? Answer. Optimal levels of fluoride do not affect the quality of water. All ground and surface water in the United States contain some naturally occurring fluoride. Fact. Nearly all water supplies must undergo various water treatment processes to be safe and suitable for hu- man consumption. During this process, more than 40 chemicals /additives are typically used including alumi- num sulfate, ferric chloride, ferric sulfate, activated car- bon, lime, soda ash and, of course, chlorine. Fluoride is added only to water that has naturally occurring levels lower than optimal 36 Fluoridation is the adjustment of the fluoride concen- tration of fluoride- deficient water supplies to the recom- mended range of 0.7 to 1.2 parts per million of fluoride for optimal dental health. The U.S. Environmental Protec- tion Agency (EPA) recognizes that fluoride in children's drinking water at levels of approximately 1.0 ppm reduc- es the number of dental cavities .298 The optimal level is dependent on the annual average of the maximum daily air temperature in a given geographic area.31,55 3+ Additional information on this topic may be found in Questions 3 and 6. Under the Safe Drinking Water Act, the EPA has es- tablished drinking water standards for a number of sub- stances, including fluoride, in order to protect the public's health. There are several areas in the United States where the ground water contains higher than optimal levels of naturally occurring fluoride. Therefore, federal regula- tions were established to require that naturally occurring fluoride levels in a community water supply not exceed a concentration of 4.0 mg /L.298 Under the Safe Drinking Water Act, this upper limit is the Maximum Contaminant Level (MCL) for fluoride. Under the MCL standard, if the naturally occurring level of fluoride in a public water sup- ply exceeds the MCL (4.0 mg /L for fluoride), the water supplier is required to lower the level of fluoride below the MCL. This process is called defluoridation. The EPA has also set a Secondary Maximum Con- taminant Level (SMCL) of 2.0 mg /L, and requires con- sumer notification by the water supplier if the fluoride 40 p. 44 level exceeds 2.0 mg /L. The SMCL, while not federally enforceable, is intended to alert families that regular consumption of water with natural levels of fluoride greater than 2.0 mg /L by young children may cause moderate to severe dental fluorosis in the developing permanent teeth, a cosmetic condition with no known adverse health effect.298 The notice to be used by water systems that exceed the SMCL must contain the follow- ing points: 1. The notice is intended to alert families that children under nine years of age who are exposed to levels of fluoride greater than 2.0 mg /liter may develop dental fluorosis. 2. Adults are not affected because dental fluorosis oc- curs only when developing teeth are exposed to el- evated fluoride levels. 3. The water supplier can be contacted for information on alternative sources or treatments that will insure the drinking water would meet all standards (includ- ing the SMCL). The 1993 National Research Council report, "Health Effects of Ingested Fluoride," reviewed fluoride toxicity and exposure data for the EPA and concluded that the current standard for fluoride at 4.0 mg /L (set in 1986) was appropriate as an interim standard to protect the public health .167 In EPA's judgment, the combined weight of hu- man and animal data support the current fluoride drinking water standard. In December 1993, the EPA published a notice in the Federal Register stating the ceiling of 4 mg /L would protect against adverse health effects with an ad- equate margin of safety and published a notice of intent not to revise the fluoride drinking water standards. 168 The EPA further commented on the safety of fluo- ride in the December 5, 1997, Federal Register .211 In a notice of a final rule relating to fluoride additives the EPA stated, "There exists no directly applicable scien- tific documentation of adverse medical effects at levels of fluoride below 8 mg /L (0.23mg /kg /day)." The EPA's Maximum Concentration Limit (MCL) of 4.0 mg /L (0.114 mg /kg /day) is one half that amount, providing an ade- quate margin of safety. Under the Safe Drinking Water Act (SDWA), the EPA must periodically review the existing National Primary Drinking Water Regulations (NPDWRs) "not less often than every 6 years." This review is a routine part of the EPAs operations as dictated by the SDWA. NPDWRs, or primary standards, are legally enforceable standards that Packet Page -937- American Dental Association ?0-\ apply to public water systems. Primary standards protect public health by limiting the levels of contaminants in drinking water. In April 2002, the EPA announced the results of its preliminary revise /not revise decisions for 68 chemi- cal NPDWRs. Fluoride was one of the 68 chemicals re- viewed. The EPA determined that it fell under the "Not Appropriate for Revision at this Time" category, but not- ed that it planned to ask the National Academy of Sci- ence (NAS) to update the risk assessment for fluoride. The NAS had previously completed a review of fluoride for EPA approximately 12 years ago which was pub- lished as "Health Effects of Ingested Fluoride" in 1993 by the National Research Council. At the request of the NAS, the National Research Council's Committee on Toxicology created the Sub- committee on Fluoride in Drinking Water to review toxicologic, epidemiologic, and clinical data published since 1993 and exposure data on orally ingested fluo- ride from drinking water and other sources (e.g., food, toothpaste, dental rinses). Based on this review the Subcommittee will evaluate the scientific and technical basis of the EPA's maximum contaminant level (MCL) of 4 milligram per liter (mg /L or ppm) and secondary maxi- mum contaminant level (SMCL) of 2 mg /L for fluoride in drinking water and advise EPA on the adequacy of its fluoride MCL and SMCL to protect children and others from adverse health effects. Additionally, the Subcom- mittee will identify data gaps and make recommenda- tions for future research relevant to setting the MCL and SMCL for fluoride. The Subcommittee began its work in November 2002 and is currently projected to complete the project in early 2006.13 QUESTION 43. Who regulates drinking water additives in United States? Answer. The United States Environmental Protection Agency regulates drinking water additives. Fact In 1974, Congress passed the original Safe Drinking Water Act (SDWA) which protects the public's health by regulating the nation's public drinking water supply.299 The SDWA, as amended in 1986 and 1996,299 requires the U.S. Environmental Protection Agency (EPA) ensure the public is provided with safe drinking water.'"' On June 22, 1979, the U.S. Food and Drug Administra- tion (FDA) and the EPA entered into a Memorandum of Understanding (MOU) to clarify their roles and respon- sibilities in water quality assurance. The stated purpose of the MOU is to "avoid the possibility of overlapping jurisdiction between the EPA and FDA with respect to control of drinking water additives. The two agencies agreed that the SDWA's passage in 1974 implicitly re- Fluoridation Facts pealed FDA's jurisdiction over drinking water as a 'food' under the Federal Food, Drug and Cosmetic Act (FFDCA). Under the agreement, EPA enjoys exclusive regulatory authority over drinking water served by public water supplies, including any additives in such water. FDA re- tains jurisdiction over bottled drinking water under Sec- tion 410 of the FFDCA and over water (and substances in water) used in food or food processing once it enters the food processing establishment. "155 "From time to time, states and communities have had to deal with legislation or ballot initiatives aimed at requiring the approval of the FDA before any agent can be added to community water systems ... On the surface, this may appear to be a 'common sense' approach. However, its only real purpose is to defeat efforts to provide water fluoridation. That is because it would require the FDA - which does NOT regulate water systems - to approve any water additive. By mistakenly (and perhaps craftily) naming the wrong federal agency, the probable outcome is to stop or prevent water fluoridation. From time to time, states and communities have had to deal with legislation or ballot initiatives aimed at re- quiring the approval of the FDA before any agent can be added to community water systems. Often referred to as the Fluoride Product Quality Control Act, Water Product Quality Ordinance or Pure Water Ordinance, the legislation is specifically used by those opposed to wa- ter fluoridation as a tool to prevent water systems from providing community water fluoridation. Often this leg- islation does not mention fluoride or fluoridation. Those supporting this type of legislation may claim that they are not against water fluoridation but are proponents of pure water and do not want anything added to water that has not been approved by the FDA. On the surface, this may appear to be a "common sense" approach. However, its only real purpose is to defeat efforts to provide water fluoridation. That is be- cause it would require the FDA -which does NOT reg- ulate water systems — to approve any water additive. By mistakenly (and perhaps craftily) naming the wrong federal agency, the probable outcome is to stop or pre- vent water fluoridation. Packet Page -938- 41 45 46 QUESTION 44. What standards have been established to ensure the safety of fluoride additives used in community water fluoridation in the United States? Answer. The three fluoride additives used in the U.S. to fluori- date community water systems (sodium fluoride, so- dium fluorosilicate, and fluorosilicic acid) meet safety standards established by the American Water Works Association (AWWA) and NSF International (NSF). Fact. Additives used in water treatment meet safety stan- dards prepared in response to a request bythe Environ- mental Protection Agency (EPA) to establish minimum requirements to ensure the safety of products added to water for its treatment, thereby ensuring the public's health. Specifically, fluoride additives used in water fluoridation meet standards established by the Ameri- can Water Works Association (AWWA) and NSF Inter- national (NSF). Additionally, the American National Standards Institute (ANSI) endorses both AWWA and NSF standards for fluoridation additives and includes its name on these standards. The American Water Works Association is an interna- tional nonprofit scientific and educational society dedi- cated to the improvement of drinking water quality and supply. AWWA is the authoritative resource for knowl- edge, information, and advocacy to improve the quality and supply of drinking water in North America and be- yond. Founded in 1881, AWWA is the largest organiza- tion of water supply professionals in the world .300 NSF International, a not- for - profit, non - governmental organization, is the world leader in standards develop- ment, product certification, education, and risk -man- agement for public health and safety. For 60 years, NSF has been committed to public health, safety, and protec- tion of the environment. NSF is widely recognized for its scientific and technical expertise in the health and environmental sciences. Its professional staff includes engineers, chemists, toxicologists, and environmental health professionals with broad experience both in pub- lic and private organization S.3111 The American National Standards Institute (ANSI) is a private, non - profit organization that administers and coordinates the U.S. voluntary standardization and con- formity assessment system. The Institute's mission is to enhance both the global competitiveness of U.S. business and the U.S. quality of life by promoting and facilitating voluntary consensus standards and conformity assess- ment systems, and safeguarding their integrity.302 The purpose of AWWA standards for fluoride ad- ditives is to provide purchasers, manufacturers and suppliers with the minimum requirements for fluoride additives, including physical, chemical, packaging, shipping and testing requirements. In part, the AWWA standards for fluoride additives state, "The [fluoride compound] supplied under this standard shall contain 42 no soluble materials or organic substances in quanti- ties capable of producing deleterious or injurious ef- fects on the health of those consuming water that has been properly treated with the [fluoride compound]." Certified analyses of the additives must be furnished by the manufacturer or supplier." NSF Standard 60 ensures the purity of drinking wa- ter additives. NSF Standard 61 provides guidance for equipment used in water treatment plants. The NSF/ ANSI Standards were developed by a consortium of associations including NSF, AWWA, the Association of State Drinking Water Administrators and the Con- ference of State Health and Environmental Manag- ers with support from the EPA. In part, they establish minimum requirements for the control of potential adverse human health effects from products added to water for its treatmen t.303,304 Fluoride additives, like all of the more than 40 addi- tives typically used in water treatment, are "industrial grade" additives. The water supply is an industry and all additives used at the water plant are classified as in- dustrial grade additives. Examples of other "industrial grade" additives which are commonly used in water plant operations are chlorine (gas), ferrous sulfate, hy- drochloric acid, sulfur dioxide and sulfuric acid .36 Sometimes antifluoridationists express the view that they are not really opposed to fluoridation, but are op- posed to the use of "industrial grade" fluoride additives. They may even go so far as to state that they would sup- port fluoridation if the process was implemented with pharmaceutical grade fluoride additives that were ap- proved by the Food and Drug Administration (FDA). On the surface, this may appear to be a "common sense" approach. In fact, this is usually a ploy whose only real purpose is to stop fluoridation. The EPA, not the FDA, regulates additives in drinking water. (- Additional information on this topic may be found in Question 43. The claim is sometimes made that no studies on safety exist on the additives used in water fluoridation. The scientific community does not study health effects of concentrated additives as put into water; studies are done on the health effects of the treated water. While sodium fluoride was the first additive used in water fluoridation, the use of silicofluoride additives (sodium fluorosilicate and fluorosilicic acid) began in the late 1940s. By 1951, silicofluorides had become the most commonly used fluoride additives in water fluorida- tion." Many of the early studies on the health effects of fluoridation were completed in communities that were using the silicofluoride additives, most generally fluo- rosilicic acid .305 -3,o However, at that time, the additives used to fluoridate were not always identified in research reports. As the body of research on fluoridation grew, it became evident that there was no adverse health ef- fects associated with water fluoridation regardless of which fluoride additive was used. 3 Additional information on this topic may be found in Question 5. Packet Page -939- American Dental Association /0—\ Additionally, over time, a number of comprehensive reviews of the health effects of fluoridation have been published. These reviews which support the safety of water fluoridation include many studies conducted in large fluoridated communities which used the silicoflu- oride additives .71,84,163,165,167,311-313 Beyond the foundation that has been established through the overwhelming weight of credible, peer - reviewed scientific evidence, there is over 60 years of practical experience that lends additional credence to the science that concludes that fluoridation is safe. QUESTION 45. What is the source of the additives used to fluoridate water supplies in the United States? Answer. Fluoride additives used in the United States are derived from the mineral apatite. Fact. The three fluoride additives used in the United States for water fluoridation (sodium fluoride, sodium fluoro- silicate, and fluorosilicic acid) are derived from apatite which is a type of limestone deposit used in the produc- tion of phosphate fertilizers. Apatite contains 3 -7% fluo- ride and is the main source of fluorides used in water fluoridation .36 During processing, apatite is ground up and treated with sulfuric acid, producing phosphoric acid (the main ingredient in the production of phosphate fertilizer) plus a solid and two gases. The solid, calcium sulfate (also known as gypsum) is the material used to form drywall or sheetrock. The two gases, hydrogen fluoride and silicon tetrafluoride, are captured in water to form fluo- rosilicic acid which today is the most commonly used fluoride additive in the United States.60 The two remaining fluoride additives (sodium fluoride and sodium fluorosilicate) are derived from fluorosilicic acid. Sodium fluoride is produced when fluorosilicic acid is neutralized with caustic soda. Fluorosilicic acid is neutralized with sodium chloride or sodium carbonate to produce sodium fluorosilicate.36 From time to time opponents of fluoridation al- lege that fluoridation additives are byproducts of the phosphate fertilizer industry in an effort to infer the additives are not safe. Byproducts are simply materi- als produced as a result of producing something else — they are by no means necessarily bad, harmful or waste products. In the chemical industry, a byproduct is anything otherthan the economically most important product produced. Byproducts may have certain char- acteristics which make them valuable resources. For example, in addition to orange juice, various byprod- ucts are obtained from oranges during juice produc- tion that are used in cleaners, disinfectants, flavorings and fragrance S.314 Fluoridation Facts "To ensure the public's safety, additives used in water fluoridation meet standards of the American Water Works Association (AWWA) and NSF International (NSF)." Fluoride additives are valuable byproducts produced as a result of producing phosphate fertilizer. To ensure the public's safety, additives used in water fluoridation meet standards of the American Water Works Associa- tion (AWWA) and NSF International (NSF). (+ Additional information on this topic may be found in Question 44. QUESTION 4,115. Does the process of water fluoridation present unusual safety concerns for water systems and water operators? Answer. No. With proper planning, maintenance and monitor- ing, water fluoridation is a safe process. Fact. Water plant facilities and water plant personnel per- form a valuable public service by carefully adjusting the level of fluoride in water to improve the oral health of the community. Facilities and personnel are subject to a number of regulations designed to ensure safety. The Occupational Safety and Health Administration (OSHA) provides guidelines for the safety of employ- ees in the workplace .61,315 Additionally, the American Water Works Association publishes detailed guidance on safety and safe working conditions for water plant personnel. Furthermore, the Centers for Disease Con- trol and Prevention has established safety procedures designed specifically for water plant operators in charge of implementing fluoridation .315 Adherence to these guidelines helps to ensure continuous levels of optimally fluoridated drinking water while maintain- ing water operator safety. As part of the safety procedures, water plant per- sonnel receive training on the management of the chemicals /additives in water plants. While the optimal fluoride concentration found in drinking water has been proven safe, water plant operators and engi- neers may be exposed to much higher fluoride levels when handling fluoride additives at the water treat- ment facility.36 Fluoride additives present comparable risks as other chemicals /additives in common use at water treatment facilities, such as hypochloride, quick -lime, aluminum sulfate, sodium hydroxide and ferrous sulfate. In fact, the fluoride additives are much less dangerous than chlorine gas commonly used in water plant operations. Today's equipment allows water treatment personnel to easily monitor and maintain the desired fluoride con- Packet Page -940- 43 47. 48, 49. centration. Automatic monitoring technology is available that can help to ensure that the fluoride concentration of the water remains within the recommended range. It is important that the water treatment operators re- sponsible for monitoring the addition of fluoride to the water supply be appropriately trained and that the equip- ment used for this process is adequately maintained."' As with any mechanical equipment, water fluoridation equipment should be tested, maintained and replaced as needed. With over 60 years of experience and thou- sands of water systems in operation, there have been remarkably few untoward incidents. QUESTION 47. Does fluoridation present difficult engineering problems? Answer. No. Properly maintained and monitored water fluo- ridation systems do not present difficult engineering problems. Fact. With proper planning and maintenance of the system, fluoride adjustment is compatible with other water treatment processes. Today's equipment allows water treatment personnel to easily monitor and maintain the desired fluoride concentration. Automatic monitoring technology is available that can help to ensure that the fluoride concentration of the water remains within the recommended range. When added to community water supplies the con- centrated fluoride additives become greatly diluted. For example, fluorosilicic acid is diluted approximately 180,000 times to reach the recommended range of 0.7 to 1.2 parts per million. At 1 ppm, one part of fluoride is diluted in a million parts of water. Large numbers such as a million can be difficult to visualize. While not exact, the following comparisons can be of assistance in comprehending one part per million: 1 inch in 16 miles 1 minute in 2 years 1 cent in $10,000 "Because there is more than 60 years of experience with water fluoridation, there is considerable guidance on sound engineering practices to design, construct, operate and maintain water fluoridation systems. " Because there is more than 60 years of experience with water fluoridation, there is considerable guidance on sound engineering practices to design, construct, operate and maintain water fluoridation systems. Fluoride addi- tives are introduced to the water supply as liquids, but are measured by two basic types of devices, dry feeders or 44 solution feeders (metering pumps). By design, and with proper maintenance and testing, water systems limit the amount of fluoride that can be added to the system (i.e., the use of a day tank that only holds one day's supply of fluoride) so prolonged over - fluoridation becomes a me- chanical impossibility.36 QUESTION 48. Will fluoridation corrode water pipes or add lead, arse- nic and other toxic contaminants to the water supply? Answer. Allegations that fluoridation causes corrosion of water delivery systems are not supported by current scientific evidence .36 Furthermore, the concentrations of con- taminants in water as a result of fluoridation do not ex- ceed, but, in fact, are well below regulatory standards set to ensure the public's safety. Fact. Water fluoridation has no impact on the acidity or pH of drinking water and will not cause lead and copper to be leached from water pipes. Corrosion of pipes by drink- ing water is related primarily to dissolved oxygen con- centration, pH, water temperature, alkalinity, hardness, salt concentration, hydrogen sulfide content and the presence of certain bacteria. Under some water quality conditions, a small increase in the acidity of drinking water that is already slightly acidic may be observed af- ter treatment with alum, chlorine, fluorosilicic acid or sodium florosilicate. In such cases, further water treat- ment is indicated by water plant personnel to adjust the pH upward to neutralize the acid. This is part of routine water plant operations. Note that the Water Quality Re- port or Consumer Confidence Report that all water sys- tems send to customers on a yearly basis, lists the pH of the system's finished water and compares that level against the standard set at a pH of 7.0 (neutral) or higher indicating that the water leaving the plant is non - acidic. + Additional information on this topic may be found in Question 4. A 1999 study316 charged that fluorosilicic acid and so- dium silicofluoride did not disassociate completely when added to water systems and may be responsible for low- er pH levels of drinking water, leaching lead from plumb- ing systems and increasing lead uptake by children. In response to the study, scientists from the U.S. En- vironmental Protection Agency (EPA) have reviewed the basic science that was the foundation for the claim that silicofluorides leach lead from water pipes and found that many of the chemical assumptions made in the original research were scientifically unjustified. Fluoride additives do disassociate very quickly and completely releasing fluoride ions into the water. The research was inconsistent with accepted scientific knowledge and the authors of the original studies failed to identify or account for these inconsistencies. The EPA scientists discounted Packet Page -941- American Dental Association /00*N, this study and said there was no credible data to suggest any link between fluoridation and lead .215 Fluorosilicic acid is the additive used to fluoridate the vast majority of community water systems in the U.S. Be- cause it is a natural substance derived from apatite which is mined from the earth, fluorosilicic acid may contain minute amounts of contaminants such as lead and arse- nic. However, existing regulations and standards require that these contaminants, including arsenic and lead, be at levels considered safe by the EPA when the fluorosilicic acid is diluted to produce optimally fluoridated water. 317,318 Evidence of testing by the fluoride additive manufacturer documents that the concentrations of these contaminants do not exceed, but, in fact, are well below regulatory stan- dards set to ensure the public's safety. Most batches of the additive do not contain any detectable amount of either lead or arsenic. On average, the concentration of arsenic and lead in optimally fluoridated drinking water created using fluorosilicic acid is less than 0.1 part per billion 319 QUESTION 49. Does fluoridated water harm the environment? Answer. Scientific evidence supports the fluoridation of public water supplies as safe for the environment and benefi- cial for people. Fact. The U.S. Environmental Protection Agency (EPA) has set an enforceable Federal drinking water standard for fluoride at 4.0 mg /L. As long as the 4.0 mg /L standard is not exceeded, State and local authorities determine whether or not to fluoridate .321) "Under the Washington's State Environmental Protection Act (SEPA), a study concluded that there are 'no probable significant adverse environmental impacts."' " Under the Washington's State Environmental Protec- tion Act (SEPA), a study was conducted in Tacoma - Pierce County to investigate the environmental consequences of adding optimal levels of fluoride to drinking water. Noting that the amount of fluoride in the water does not reach levels that are harmful to plants or animals, the SEPA study concluded that there are "no probable significant adverse environmental impacts. "321 There is no evidence that optimally fluoridated wa- ter has any effect on gardens, lawns or plants.322 A comprehensive literature review conducted in 1990 revealed absolutely no negative environmental �. impacts as a result of water fluoridation. Historically, issues surrounding problems with fluoride and the en- vironment have involved incidents related to industrial pollution or accidents .323 Fluoridation Facts Packet Page -942- 45 50. PUBLIC POLICY Q50. Valuable measure? 051. Courts of law? p. 46 Q 53. Internet? p. 47 Q 54. Public votes? p. 51 p. 51 Q 52. Opposition? p. 47 Q55. International fluoridation? p. 54 QUESTION 50. Is water fluoridation a valuable public health measure? Answer. Yes. Water fluoridation is a public health measure that benefits people of all ages, is safe and is a community public health program that saves money. Fact. Throughout decades of research and more than 60 years of practical experience, fluoridation of public water sup- plies has been responsible for dramatically improving the public's oral health status. Former Surgeon General of the United States, Dr. Luther Terry, called fluoridation as vital a public health measure as immunization again disease, pas- teurization of milk and purification of water .7 Another for- mer U.S. Surgeon General Dr. C. Everett Koop stated that fluoridation is the single most important commitment that a community can make to the oral health of its citizens. "Former U.S. Surgeon General Dr. C. Everett Koop stated that fluoridation is the single most important commitment that a community can make to the oral health of its citizens." In 1994, the U.S. Department of Health and Human Services issued a report which reviewed public health achievements. Along with other successful public health measures such as the virtual eradication of polio and re- ductions in childhood blood lead levels, fluoridation was lauded as one of the most economical preventive values in the nation. 17 A policy statement on water fluoridation reaf- firmed in 1995 by the U.S. Public Health Service ( USPHS) stated that water fluoridation is the most cost - effective, practical and safe means for reducing the occurrence of dental decay in a community.'$ In 1998, recognizing the ongoing need to improve health and well being, the USPHS revised national health objectives to be achieved by the year 2010. Included under oral health was an ob- jective to significantly expand the fluoridation of public water supplies. Specifically, Objective 21 -9 states that at least 75% of the U.S. population served by community water systems should be receiving the benefits of opti- mally fluoridated water by the year 2010.19 46 Q56. Banned in Europe? p. 54 "Former U.S. Surgeon General David Satcher, noted that water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations." In 1999, the Centers for Disease Control and Preven- tion named fluoridation of drinking water one of ten great public health achievements of the 201h century noting that it is a major factor responsible for the de- cline in dental decay. 1,2 Former U.S. Surgeon General David Satcher, issued the first ever Surgeon General report on oral health in May 2000. In Oral Health in America: A Report of the Surgeon General, Dr. Satcher stated that community water fluoridation continues to be the most cost - effective, practical and safe means for reducing and controlling the occurrence of dental decay in a community. Additionally, Dr. Satcher noted that water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations. Studies have shown that fluoridation may be the most significant step we can take toward reducing the dis- parities in dental decay.21 -24 In the 2003 National Call to Action to Promote Oral Health, U.S. Surgeon General Richard Carmona called on policymakers, community leaders, private industry, health professionals, the me- dia and the public to affirm that oral health is essential to general health and well being. Additionally, Surgeon General Carmona urged these groups to apply strat- egies to enhance the adoption and maintenance of proven community -based interventions such as com- munity water fluoridation.25 Community water fluoridation is a most valuable public health measure because: • Optimally fluoridated water is accessible to the entire community regardless of socioeconomic status, edu- cational attainment or other social variables;26 • Individuals do not need to change their behavior to obtain the benefits of fluoridation. • Frequent exposure to small amounts of fluoride over time makes fluoridation effective through the life span in helping to prevent dental decay. • Community water fluoridation is more cost ef- fective than other forms of fluoride treatments or applications.27 Packet Page -943- American Dental Association eo-1 100� QUESTION 51. Has the legality of water fluoridation been upheld by the courts? Answer. Yes. Fluoridation has been thoroughly tested in the United States' court system, and found to be a proper means of furthering public health and welfare. No court of last resort has ever determined fluoridation to be unlawful. Moreover, fluoridation has been clearly held not to be an unconstitutional invasion of religious free- dom or other individual rights guaranteed by the First, Fifth or Fourteenth Amendments to the U.S. Constitu- tion. And while cases decided primarily on procedural grounds have been won and lost by both pro and anti fluoridation interests, to ADA's knowledge no final rul- ing in any of those cases has found fluoridation to be anything but safe and effective. "No court of last resort has ever determined fluoridation to be unlawful. The highest courts of more than a dozen states have confirmed the constitutionality of fluoridation. Fact. During the last sixty years, the legality of fluoridation in the United States has been thoroughly tested in our court systems. Fluoridation is viewed by the courts as a proper means of furthering public health and welfare 324 No court of last resort has ever determined fluoridation to be un- lawful. The highest courts of more than a dozen states have confirmed the constitutionality of fluoridation 325 In 1984, the Illinois Supreme Court upheld the constitution- ality of the state's mandatory fluoridation law, culminat- ing 16 years of court action at a variety of judicial level S.116 Moreover, the U.S. Supreme Court has denied review of fluoridation cases thirteen times, citing that no substantial federal or constitutional questions were involved .325 It has been the position of the American courts that a significant government interest in the health and wel- fare of the public generally overrides individual objec- tions to public health regulation 333 Consequently, the courts have rejected the contention that fluoridation ordinances are a deprivation of religious or individual freedoms guaranteed under the Constitution .325,321 In reviewing the legal aspects of fluoridation, the courts have dealt with this concern by ruling that: (1) fluoride is a nutrient, not a medication, and is present naturally in the environment; (2) no one is forced to drink fluo- ridated water as alternative sources are available; and (3) in cases where a person believes that fluoridation interferes with religious beliefs, there is a difference be- tween the freedom to believe, which is absolute, and the freedom to practice beliefs, which may be restricted in the public's interest. 328,329 Fluoridation Facts Fluoridation is the adjustment of a naturally occur- ring element found in water in order to prevent dental decay. Courts have consistently ruled that water fluo- ridation is not a form of compulsory mass medication or socialized medicine. 325,328,330 Fluoridation is simply the adjustment of a naturally occurring element found in water in order to prevent dental decay. In fact, water that has been fortified with fluoride is similar to forti- fying salt with iodine, milk with vitamin D and orange juice with vitamin C — none of which are medications. "To RDA's knowledge no final ruling in any of those cases has found fluoridation to be anything but safe and effective." In recent years, challenges to fluoridation have been dismissed for a variety of reasons, including that plaintiffs admitted they could not establish injury by virtue of fluoridation, and that state law supporting fluoridation prevailed over local attempts to oppose fluoridation. Interestingly, pro and anti fluoridation interests have each won and lost legal challenges re- garding which state or local agency has regulatory authority over fluoridation, which of course varies by state and locality. State law variances have also led to different rulings on other issues, such as whether downstream end users of fluoridation must be given an opportunity to vote on whether to fluoridate. While cases decided primarily on procedural grounds have been won and lost by both pro and anti fluoridation interests, to ADA's knowledge no final ruling in any of those cases has found fluoridation to be anything but safe and effective. QUESTION 52. Why does opposition to community water fluoridation continue? Answer. Fluoridation is considered beneficial by the overwhelm- ing majority of the health and scientific communities as well as the general public. However, a small faction continues to speak out against fluoridation of municipal water supplies. Some individuals may view fluorida- tion of public water as limiting their freedom of choice; other opposition can stem from misinterpretations or inappropriate extrapolations of the science behind the fluoridation issue. Fact. A vast body of scientific literature endorses water fluo- ridation as a safe means of reducing the incidence of dental decay. Support for fluoridation among scientists and health professionals, including physicians and den- tists, is nearly universal. Recognition of the benefits of Packet Page -944- 47 52. fluoridation by the American Dental Association, the American Medical Association, governmental agencies and other national health and civic organizations con- tinues as a result of published, peer- reviewed research. (See Compendium at back of booklet.) The majority of Americans also approves of water fluoridation. In June 1998, the Gallup Organization con- ducted a national survey of just over 1,000 adults on their attitudes toward community water fluoridation. When asked, "Do you believe community water should be fluo- ridated?", 70% answered yes, 18% answered no and 12% responded don't know (Figure 5). Results characterized by U.S. Census Region showed the level of support for community water fluoridation to be relatively constant throughout the United States, with 73% in the Northeast, 72% in the Midwest, 68% in the South and 70% in the West favoring community water fluoridation .331 These re- sults are consistent with a December 1991 Gallup survey that asked 1,200 parents, "Whether or not you presently have fluoridated water, do you approve or disapprove of fluoridating drinking water ?" More than three - quarters (78 %) of the responding parents approved, 10% disap- proved and 12% answered don't know or refused to an- swer the question (Figure 6). Disapproval ranged from 4% in communities where water was fluoridated to 16% in communities where it was not,332 Of the small faction that opposes water fluoridation for philosophical reasons, freedom of choice probably stands out as the most important single complaint.333 Some individuals are opposed to community action on any health issue, others because of environmental or economic arguments and some because they are mis- informed. Opposition to fluoridation has existed since the initi- ation of the first community programs in 1945 and con- Do You Believe Community Water Should Be Fluoridated? 48 tinues today with over 60 years of practical experience showing fluoridation to be safe and effective. An article that appeared in the local newspaper shortly after the first fluoridation program was implemented in Grand Rapids, Michigan, noted that the fluoridation program was slated to commence January 1 but did not actually begin until January 25. Interestingly, health officials in Grand Rapids began receiving complaints of physical ailments attributed to fluoridation from citizens weeks before fluoride was actually added to the water. 342 Since that time, antifluoridation leaders and orga- nizations have come and gone, but their basic beliefs have remained the same. These include: fluoride is tox- ic and causes numerous harmful health effects; fluoride does not prevent dental decay; fluoridation is costly; and fluoridation interferes with freedom of choice and infringes on individual rights. While the arguments against fluoridation have re- mained relatively constant over the years, the antifluo- ridationists have used different approaches that play upon the popular concerns of the public at the time. For example, in the 1950s fluoridation was a Communist plot. With America's growing concern for environmen- tal issues in the 1960s, fluoridation was pollution. After the Vietnam War in the 1970s, the antifluoridationists capitalized on the popularity of conspiracy theories by portraying fluoridation as a conspiracy between the U.S. government, the dental - medical establishment and industry. As Americans became more concerned about their health in the 1980s, antifluoridationists claimed fluoridation caused AIDS and Alzheimer's disease. In the 1990s, claims of hip fractures and cancer were de- signed to resonate with aging baby boomers. With the new millennium, overexposure and toxicity, in associa- tion with lead and arsenic poisoning, have surfaced as Whether or Not You Presently Have Fluoridated Water, Do You Approve or Disapprove of Fluoridating Drinking Water ?? Approve 78% Disapprove 10% Don't Know/ Refused 12% 0 10% 20% 30% 40% 50% 60% 70% 80% Percent of Parents Packet Page -945- American Dental Association /01*N /"%, common themes. None of these approaches has ever really disappeared, but are often recycled as antifluo- ridationists choose which approach will have the most effect on the intended audience.333 Antifluoridationists have eagerly embraced technol- ogy such as videos and the Internet to spread their mes- sage to the public. These two venues have allowed the small faction of antifluoridationists to be linked across the country and around the world and promote their message economically. A number of opposition videos are available from na- tional antifluoridation organizations. These economical- ly- priced videos make it affordable for every campaign to bring an antifluoridationist to the community via local cable access television. However, it has been the Internet that has breathed new life into the antifluoridation effort. The Internet has brought the antifluoridation message into voters' homes. With just a click of the mouse, search engines can locate hundreds of Web sites denouncing fluoridation, which may give the impression that this is a one -sided argument. Individuals who look to the Internet as a source of reliable information may fail to recognize that these sites often contain personal opinion rather than scientific fact. Newspaper stories, press releases and letters to the editor are often posted as documenta- tion of the "science" behind antifluoridationists' claims. All too often, the public accepts this type of information as true simply because it is in print. The techniques used by antifluoridationists are well known and have been discussed at length in a number of published articles that review the tactics used by an- tlfluorldatlonlStS,325,333,335 -339 Examples of a few of the techniques can be viewed in Figure 7 on the next page. "Reputable science is based on the scientific method of testing hypotheses in ways that can be reproduced and verified by others, junk science, which often provides too- simple answers to complex questions, often cannot be substantiated. " "Junk science," a term coined by the press and used over the past decade to characterize data derived from atypical or questionable scientific techniques, also can play a role in provoking opposition to water fluorida- tion. In fact, decision makers have been persuaded to postpone action on several cost - effective public health measures after hypothetical risks have made their way into the public media.340 Junk science impacts public policy and costs society in immeasurable ways. More people, especially those involved in policy decisions, need to be able to distinguish junk science from legiti- mate scientific research. Reputable science is based on the scientific method of testing hypotheses in ways that can be reproduced and verified by others; junk science, which often provides too - simple answers to complex questions, often cannot be substantiated. Fluoridation Facts In 1993 the U.S. Supreme Court issued a landmark de- cision that many view as likely to restrict the use of junk science in the federal courts and in those state courts which adopt this reasoning. The Court determined that while "general acceptance" is not needed for scientific evidence to be admissible, federal trial judges have the task of ensuring that an expert's testimony rests on a reasonable foundation and is relevant to the issue in question. According to the Supreme Court, many con- siderations will bear on whether the expert's underlying reasoning or methodology is scientifically valid and ap- plicable in a given case. The Court set out four criteria judges could use when evaluating scientific testimony: (1) whether the expert's theory or technique can be (and has been) tested, using the scientific method, (2) whether it has been subject to peer review and pub- lication (although failing this criteria alone is not nec- essarily grounds for disallowing the testimony), (3) its known or potential error rate and the existence and maintenance of standards in controlling its operation and (4) whether it has attracted widespread acceptance within a relevant scientific community, since a known tech- nique that has been able to attract only minimal sup- port may properly be viewed with skepticism. The scientific validity and relevance of claims made by opponents of fluoridation might be best viewed when measured against these criteria .141 "Opinions are seldom unanimous on any scientific subject. In fact, there may be no such thing as 'final knowledge,' since new information is continuously emerging and being disseminated. As such, the benefit evidence must be continually weighed against risk evidence. Health professionals, decision makers and the public should be cooperating partners in the quest for accountability where decisions are based on proven benefits measured against verified risks. Opinions are seldom unanimous on any scientific sub- ject. In fact, there may be no such thing as "final knowl- edge," since new information is continuously emerging and being disseminated. As such, the benefit evidence must be continually weighed against risk evidence. Health professionals, decision makers and the public should be cooperating partners in the questfor accountability where decisions are based on proven benefits measured against verified risks .335 (Additional information on this topic may be found in the Introduction and Figure 1. Packet Page -946- 49 53. 50 Targeting Politicians and Community Leaders Antifluoridation Web sites contain draft letters to be sent to newspaper publishers, water departments, and community public officials warning them of their "liability" should they support or endorse water fluo- ridation. Leaders are urged to remain "neutral" and allow fluoridation decisions to be put to a public vote therefore relieving the leaders of any and all respon- sibility in the matter. Antifluoridationists use the time gained to conduct a public referendum to bombard the public with misinformation designed to turn pub- lic opinion against fluoridation. Unproven Claims Antifluoridationists have repeatedly claimed fluo- ridation causes an entire laundry list of human ill- nesses including AIDS, Alzheimer's disease, cancer, Down Syndrome, genetic damage, heart disease, lower intelligence, kidney disease and osteoporosis (hip factures). These allegations are often repeated so frequently during campaigns that the public as- sumes they must be true. Their appearance in print, even if only in letters to the editor of the local news- paper, reinforces the allegation's credibility. With just a small amount of doubt established, the op- position slogan, "If in doubt, vote it out," may ring true with voters. Innuendo The statement, "Fifty years ago physicians and den- tists posed for cigarette ads," is an example of innu- endo or, more specifically, guilt by association. Even though fluoridation is not mentioned, individuals are expected to make the connection that the medical community changed its position on smoking so it is possible health professionals are wrong about fluori- dation, too. Outdated Studies and Statements from "Experts" Antifluoridation Web sites often offer a list of "re- spected medical professionals and scientists" who have spoken out against fluoridation. One of those often quoted is Dr. Charles Gordon Heyd who is not- ed to be a Past President of the American Medical Association (AMA). What is not disclosed is the source of the quote or that Dr. Heyd was President of the AMA in 1936 — almost ten years before wa- ter fluoridation trials began. His decades -old quote certainly does not represent the current AMA posi- tion of support for water fluoridation and is charac- teristic of antifluoridationists' use of items that are out of date. Additionally, antifluoridationists have claimed that fourteen Nobel Prize winners have "opposed or expressed reservations about fluori- dation." It should be noted that the vast majority of these individuals were awarded their prizes from 1929 through 1958. Statements Out of Context One of the most repeated antifluoridation state- ments is, "Fluoride is a toxic chemical. Don't let them put it in our water." This statement ignores the scientific principle that toxicity is related to dosage and not just to exposure to a substance. Examples of other substances that can be harmful in the wrong amounts but beneficial in the correct amounts are salt, vitamins A and D, iron, iodine, as- pirin and even water itself. In another example, a press release from the New York State Coalition Opposed to Fluoridation ( NYSCOF) posted on the Internet in August 2001, and again in March 2005, stated, "Fluoridation is based more on unproven theories than scientific evidence, according to a revised dental textbook by leaders in the field." The press release also includes a number of items "quoted" from the textbook. The American Dental Association contacted the textbook authors who immediately wrote a letter responding to the press release. Drs. Brian A. Burt and Dr. Stephen A. Eklund responded, "The NYSCOF article takes a se- ries of disconnected quotes from our textbook (Burt BA, Eklund SE. The Dentist, Dental Practice, and the Community 5th edition. Philadelphia: Saunders, 1999) and puts its own interpretation on them. The result is to portray Drs. Burt and Eklund as being op- posed to fluoridation, which is most definitely not the case." Moving Targets In venues ranging from the media to the courts, opponents have been known to shift their theories of opposition frequently and mid- stream. This of- ten appears to occur when one of their originally advanced points of opposition has been unveiled as being without merit. Some examples: A parent who told the media that he would need to move his family out of town because of past allergies to fluoride had to change his position after it was disclosed that the family had previously lived in a fluoridated community; and opponents filing re- peated amendments to their legal complaints, in one case moving from an all out attack to the posi- tion that that they are not opposed to fluoridation, but just to one particular chemical - without telling the court that the chemical has been safely and ex- tensively used for decades. Packet Page -947- American Dental Association ,^ 1'\ QUESTION 53. Where can reliable information about water fluorida- tion be found on the Internet and World Wide Web? Answer. The American Dental Association, as well as other rep- utable health and science organizations, and govern- ment agencies have sites on the Internet /Web that pro- vide information on fluorides and fluoridation. These sites provide information that is consistent with gener- ally accepted scientific knowledge. Fact. The Internet and World Wide Web are evolving as ac- cessible sources of information. However, not all "sci- ence" posted on the Internet and World Wide Web is based on scientific fact. Searching the Internet for "fluoride" or "water fluoridation" directs individuals to a number of Web sites. Some of the content found in the sites is scientifically sound. Other less scientific sites may look highly technical, but contain information based on science that is unconfirmed or has not gained widespread acceptance. Commercial interests, such as the sale of water filters, may also be promoted. One of the most widely respected sources for infor- mation regarding fluoridation and fluorides is the Ameri- can Dental Association's (ADA) Fluoride and Fluoridation Web site at http:www.ada.org /goto /fluoride (Figure 8). From the ADA Web site individuals can link to other Web sites, such as the Centers for Disease Control and Pre- vention, National Institute of Dental and Craniofacial Re- search, Institute of Medicine, National Cancer Institute, and state /local health departments for more information about fluoride and water fluoridation. FLUORIDATION AT YOUR FINGERTIPS! http: / /www.ada.org /goto /fluoride • ADA Fluoridation Resources • Fluoridation Facts Online • ADA Fluoridation News Stories • ADA Policy and Statements • Links to Additional Fluoridation Web Sites American Dental Association ww,A: ada.org Many ADA resources are at your fingertips 24/7/365. Order a library book or products online, read JADA articles, discuss important topics with colleagues, find helpful information on professional topics from accredi- tation to X -rays and recommend our dental education animations, stories and games to your patients. Be resourceful. Visit ADA.org today! Fluoridation Facts QUESTION 54. Why does community water fluoridation sometimes lose when it is put to a public vote? Answer. Voter apathy or low voter turnout due the vote being held as a special election or in an "off" year, confusing ballot language (a "no" vote translates to support for fluoridation), blurring of scientific issues, lack of leader- ship by elected officials and a lack of political campaign skills among health professionals are some of the rea- sons fluoridation votes are sometimes unsuccessful. Fact. Despite the continuing growth of fluoridation in this country over the past decades, millions of Americans do not yet receive the protective benefits of fluoride in their drinking water. Centers for Disease Control and Prevention (CDC) data from 2002 indicate, only two - thirds (67.3 %) of the population served by public water systems have access to fluoridated water .34 Forty -two of the 50 largest cities are fluoridated by adjustment. Another two have natural optimal levels of fluorida- tion (Figure 9). The remaining six nonfluoridated cities are: Fresno, California; San Jose, California; Colorado Springs, Colorado; Honolulu, Hawaii; Wichita, Kansas and Portland, Oregon. In 1998, recognizing the ongo- ing need to improve health and well being, the U.S. Public Health Service revised national health objec- tives to be achieved by the year 2010. Included under oral health was an objective to significantly expand the fluoridation of public water supplies. Specifically, Ob- jective 21 -9 states that at least 75% of the U.S. popu- lation served by community water systems should be receiving the benefits of optimally fluoridated water by the year 2010.79 Although water fluoridation reaches some residents in every state, 2002 data indicates that only 24 states are providing these benefits to 75% or more of their residents .34 (Figure 10). Social scientists have conducted studies to exam- ine why fluoridation fails when put to a public vote. Among the factors noted are lack of funding, public and professional apathy, the failure of many legislators and community leaders to take a stand because of per- ceived controversy, low voter turnout and the difficulty faced by an electorate in evaluating scientific informa- tion in the midst of emotional charges by opponents. Unfortunately, citizens may mistakenly believe their water contains optimal levels of fluoride when, in fact, it does not. "Clever use of emotionally charged 'scare' propaganda by fluoride opponents creates fear, confusion and doubt within a community when voters consider the use of fluoridation. " Packet Page -948- 51 Figure 9. o of the fifty Largest Cities in the U.S. are Supplied Two cities (Jacksonville, Florida and El Paso, Texas) are naturally fluoridated. Seattle Minneapolis • ?*Boston Milwaukee Buffalo Detroit Clevela ew York Chicago Toledo Pittsburgh Philadelphia Sacramento Omaha Columbus f • • sBaltimore Oa 9 nd • Indianapolis Cincinnati Washington San Francisco Denver Kansas City St. Louis Virginia Beach j1 Nashville- Davidson Charlotte Los Angeles Tulsa • • 1 • • Memphis Long Beach Albuquerque Oklahoma City e • Phoenix Atlanta Fort Worth • •Dallas El Paso (natural) • Jacksonville (natural) New Orleans Austin • • Houston Q 0 Miami C2 D o-p0 ^G �J *Data compiled by the American Dental Association and Centers for Disease Control and Prevention /Division of Oral Health. Information current as of May 2005. Clever use of emotionally charged "scare" propa- ganda by fluoride opponents creates fear, confusion and doubt within a community when voters consider the use of fluoridation.342,343 Defeats of referenda or the discontinuance of fluoridation have occurred most of- ten when a small, vocal and well organized group has used a barrage of fear - inspiring allegations designed to confuse the electorate. In addition to attempts to in- fluence voters, opponents have also threatened com- munity leaders with personal Iitigation.344 While no court of last resort has ever ruled against fluoridation, community leaders may be swayed by the threat of liti- gation due to the cost and time involved in defending even a groundless suit, not to mention threats of po- litical fallout. The American Dental Association (ADA) knows of no cases in which community leaders have been found liable for their pro - fluoridation efforts. In no instance has fluoridation been discontinued be- cause it was proven harmful in any way. 343-345 Adoption of fluoridation is ultimately a decision of state or local decision makers, whether determined by elected officials, health officers or the voting pub- lic. Fluoridation can be enacted through state legisla- tion, administrative regulation or a public referendum. While fluoridation is not legislated at the federal level, it is legislated at the state and local level. As with any pubic health measure, a community has the right and obligation to protect the health and welfare of its citi- zens, even if it means overriding individual objections to implement fluoridation. 52 Packet Page -949- American Dental Association ?01%` /'\ *Data Source: Centers for Disease Control and Prevention /Division of Oral Health. "Percentage of U.S. Population on Public Water Supply Systems Receiving Fluoridated Water" 2002. Available at http:// www2. cdc .aov /nohss/FluoridationV.asp. '7n the past five years (2000 through 2004), more than 125 communities in 36 states have decided to provide the benefits of fluoridation for their residents. " Each spring as part of the yearly Community Water Fluoridation Awards program, the ADA, Association of State and Territorial Dental Directors and the CDC Division of Oral Health compile a list of water sys- tems /communities in the United States that have ad- opted community water fluoridation in the past year. This list is posted on the ADA Web site at http: / /www. ada.org /goto /fluoride. In the past five years (2000 Fluoridation Facts through 2004), more than 125 communities in 36 states have decided to provide the benefits of fluori- dation for their residents. The size of these water sys- tems /communities varies greatly — from those with a few thousand residents to the Metropolitan Water District of Southern California which will provide flu- oridated water to more than 18 million people. Technical assistance with fluoridation efforts is avail- able from the Council on Access, Prevention and Inter - professional Relations at the ADA. Additional support for fluoridation is available from ADA's Division of Legal Affairs, Division of Communications and Department of State Government Affairs. Packet Page -950- 53 55. QUESTION 55. Is community water fluoridation accepted by other countries? Answer. Over 405 million people in more than 60 countries worldwide enjoy the benefits of fluoridated water.7 ' a "The value of water fluoridation is recognized internationally ...Considering the extent to which fluoridation has already been implemented throughout the world, the lack ` of documentation of adverse health effects is remarkable testimony to its safety." Fact. The value of water fluoridation is recognized interna- tionally. Countries and geographic regions with exten- sive water fluoridation include the U.S., Australia, Brazil, Canada, Chile, Columbia, Ireland, Israel, Malaysia, New Zealand, People's Republic of China (Hong Kong only), Singapore and the United Kingdom.132 Thorough inves- tigations of fluoridation have been conducted in Britain and Australia supporting the safety and effectiveness of waterfluoridation.163,165,346 Considering the extent to which fluoridation has already been implemented throughout the world, the lack of documentation of adverse health effects is remarkable testimony to its safety.84,153- 187,210 The World Health Organization (WHO) and the Pan American Health Organization have endorsed the practice of water fluoridation since 1964. In 1994, an expert committee of WHO published a report which reaffirmed its support of fluoridation as being safe and effective in the prevention of dental decay, and stated that "provided a community has a piped water supply, water fluoridation is the most effective method of reaching the whole population, so that all social classes benefit without the need for active participation on the part of individuals. "138 In many parts of the world, fluoridation is not feasible or a high priority, usually due to the lack of a central water supply, the exis- tence of more life threatening health needs or the lack of trained technical personnel or sufficient funds for start- up and maintenance costs. QUESTION 5-6. Is community water fluoridation banned in Europe? Answer. No country in Europe has banned community water fluoridation. Fact. The claim that fluoridation is banned in Europe is frequently used by fluoridation opponents. In truth, European coun- 54 tries construct their own water quality regulations within the framework of the 1980 European Water Quality Direc- tive. The Directive provides maximum admissible con- centrations for many substances, one of which is fluoride. The Directive does not require or prohibit fluoridation, it merely requires that the fluoride concentration in water does not exceed the maximum permissible con - centration.341 Many fluoridation systems that used to operate in Eastern and Central Europe did not function properly and, when the Iron Curtain fell in 1989 -90, shut down because of obsolete technical equipment and lack of knowledge as to the benefits of fluoridated water.348 Wa- ter fluoridation is not practical in some European coun- tries because of complex water systems with numerous water sources. As an alternative to water fluoridation, many European countries have opted for the use of fluo- ride supplements or salt fluoridation. Basel, Switzerland is one such example. Those op- posed to water fluoridation claimed a large victory when Basel voted to cease water fluoridation in 2003. The facts are that Basel was the lone city with fluoridated water surrounded by communities that used fluoridated salt. In the mid 90s, trade barriers that had prevented fluoridated salt from being sold to those living in Basel fell and soon it was evident that residents were receiv- ing fluoride from salt as well as through drinking water. The government voted to cease water fluoridation in 2003 in light of availability and use of fluoridated salt in the community. Basel, Switzerland did not stop fluori- dating. Officials simply chose another type of fluorida- tion - salt fluoridation .319 3 Additional information on this topic may be found in Question 14. No European country has imposed a 'ban' on water fluoridation." Again, no European country has imposed a "ban" on water fluoridation, it has simply not been imple- mented for a variety of technical, legal, financial or political reasons. Political actions contrary to the recommendations of health authorities should not be interpreted as a negative response to water fluoridation. For example, although fluoridation is not carried out in Sweden and the Netherlands, both countries support World Health Organization's recommendations regarding fluoridation as a preventive health measure, in addition to the use of fluoride toothpastes, mouthrinses and dietary fluoride supplements. 138.350 Packet Page -951- American Dental Association �N U, f L Fluoridation Facts Packet Page -952- 55 57 58 COST EFFECTIVENESS Q 57. Cost effective? p. 56 Q 58. Practical? p. 57 QUESTION 57. Is water fluoridation a cost - effective means of prevent- ing tooth decay? Answer. Yes. Fluoridation has substantial lifelong decay preven- tive effects and is a highly cost- effective means of pre- venting tooth decay in the United States, regardless of socioeconomic status.97,103,104,351-353 Fact. The cost of community water fluoridation can vary in each community depending on the following factors .351 1. Size of the community (population and water usage); 2. Number of fluoride injection points where fluoride additives will be added to the water system; 3. Amount and type of equipment used to add and monitor fluoride additives; 4. Amount and type of fluoride compound used, its price, and its costs of transportation and storage; and 5. Expertise of personnel at the water plant. The annual cost for a U.S. community to fluoridate its water is estimated to range from approximately $0.50 per person in large communities to approximately $3.00 per person in small communities .351 "For most cities, every $1 invested in water fluoridation saves $38 in dental treatment costs. " It can be calculated from these data that the average lifetime cost per person to fluoridate a water system is less than the cost of one dental filling. When it comes to the cost of treating dental disease, everyone pays. Not just those who need treatment, but the entire com- munity- through higher health insurance premiums and higher taxes. For most cities, every $1 invested in wa- ter fluoridation saves $38 in dental treatment costs. 355 Cutting dental care costs by decreasing dental decay is something a community can do to improve oral health and save money for everyone. With the escalating cost of health care, fluoridation remains a preventive mea- sure that. benefits members of the community at mini- mal cost.25 Fluoridation is a community public health measures that saves money. 56 School -based dental disease prevention activities (such as fluoride mouthrinse or tablet programs), pro- fessionally applied topical fluorides and dental health education are beneficial but have not been found to be as cost - effective in preventing dental decay as com- munity water fluoridation.351 Fluoridation remains the most cost - effective and practical form of preventing decay in the United States and other countries with es- tablished municipal water systems. 17,97,104,355 Because of the decay- reducing effects of fluoride, the need for restorative dental care is typically lower in fluoridated communities. Therefore, an individual residing in a fluoridated community will typically have fewer restorative dental expenditures during a lifetime. Health economists at a 1989 workshop con- cluded that fluoridation costs approximately $3.35 per tooth surface when decay is prevented, mak- ing fluoridation "one of the very few public health procedures that actually saves more money than it costs. "155 Considering the fact that the national aver- age fee for a two surface amalgam (silver) restoration in a permanent tooth placed by a general dentist is $101.94 *, fluoridation clearly demonstrates signifi- cant cost savings.355 In a study conducted in Louisiana, Medicaid - eligible children (ages 1 -5) residing in communities without fluoridated water were three times more likely than Medicaid - eligible children residing in communities with fluoridated water to receive dental treatment in a hospital and the cost of dental treatment per eligible child was approximately twice as high. In addition to community water fluoridation status, the study took into account per capita income, population and num- ber of dentists per county.358 "The economic importance of fluoridation is underscored by the fact that frequently the cost of treating dental disease is paid not only by the affected individual, but also by the general public through services provided by health departments, community health clinics, health insurance premiums, the military and other publicly supported medical programs. " Packet Page -953- American Dental Association ^. The economic importance of fluoridation is under- scored by the fact that frequently the cost of treating dental disease is paid not only by the affected individual, but also by the general public through services pro- vided by health departments, community health clinics, health insurance premiums, the military and other pub- licly supported medical programs.10' Indirect benefits from the prevention of dental decay may include: • freedom from dental pain • a more positive self image • fewer missing teeth • fewer cases of malocclusion aggravated by tooth loss • fewer teeth requiring root canal treatment • reduced need for dentures, bridges and implants • less time lost from school or work because of dental pain or visits to the dentist These intangible benefits are difficult to measure economically, but are extremely important. 97.257 . *The survey data should not be interpreted as con- stituting a fee schedule in any way, and should not be used for that purpose. Dentists must establish their own fees based on their individual practice and market considerations. CALL i n April 2003, Surgeon, General Richard H. Car - mona issued a National Call to Action to Promote Oral Health. The report was a wake -up call, raising a powerful voice against the silence. It called upon policymakers, community leaders, private industry, health professionals, the media, and the public to af- firm that oral health is essential to general health and well -being and to take action. While the effectiveness of preventive interventions such as community water fluoridation have been persuasively demonstrated, less than half of the fifty states have implemented fluoridation at the level to meet the national health objectives to be achieved by the year 2010. Specifically, Objective 21 -9 states that at least 75% of the U.S. population served by commu- Fluoridation Facts QUESTION 58. Why fluoridate an entire water system when the vast majority of the water is not used for drinking? Answer. It is more practical to fluoridate an entire water supply than to attempt to treat individual water sources. Fact. It is technically difficult, perhaps impossible, and cer- tainly more costly to fluoridate only the water used for drinking. Community water that is chlorinated, softened, or in other ways treated is also used for watering lawns, washing cars and for most industrial purposes. The cost of additives for fluoridating a community's water supply is inexpensive on a per capita basis; therefore, it is prac- tical to fluoridate the entire water supply. Fluoride is but one of more than 40 different chemi- cals /additives that may be used to treat water in the United States. Most are added for aesthetic or conve- nience purposes such as to improve the odor or taste, prevent natural cloudiness or prevent staining of clothes or porcelain.36 The American Water Works Association, an interna- tional nonprofit scientific and educational society dedi- cated to the improvement of drinking water quality and supply, supports the practice of fluoridation of public water supplies .311 Additional information on this topic may be found in Question 44. Packet Page -954- 57 REFERENCES n 1. Centers for Disease Control and Prevention. Ten great 19. US Department of Health and Human Services. pubic health achievements - United States, 1990 -1999. Healthy People 2010. 2nd ed. With understanding MMWR 1999;48(12):241 -3. and improving health and objectives for improving health. 2 vols. Washinton, DC:US Government Print - 2. Centers for Disease Control and Prevention. Fluo- ing Office;November 2000. ridation of drinking water to prevent dental caries. 20. 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U.S. Environmental Protection Agency, Office of an si/overview/overview. aspx? menu i d= 1 >. Accessed Water, Office of Science and Technology. Fluoride: February 18, 2005. a regulatory fact sheet.' 66 Packet Page -963- American Dental Association �t 321. Tacoma - Pierce County Health Department. Tacoma- 343. Margolis FJ, Cohen SN. Successful and unsuccess- Pierce County Health Department fluoridation ful experiences in combating the antifluoridationists. resolution. WAC197 -11 -960 environmental checklist. Pediatrics 1985;76(1):113 -8. August 2002. 344. Easley MW. The new antifluoridationists: who are 322. Pollick PF. Water fluoridation and the environment: they and how do they operate? J Public Health Dent current perspective in the United States. Int J Occup 1985;45(3):133 -41. Environ Health 2004;10:343 -50. 345. Wulf CA, Hughes KF, Smith KG, Easley MW. Abuse 323, Osterman JW. Evaluating the impact of municipal of the scientific literature in an antifluoridation water fluoridation on the aquatic environment. Am J pamphlet. Baltimore: American Oral Health Insti- Public Health 1990;80:1230 -5. tute;1985. 324. Safe Water Association, Inc. v. City of Fond du Lac, 346. National Health and Medical Research Council. The 184 Wis.2d 365, 516 N.W.2d 13 (Wis. Ct. App. 1994). effectiveness of water fluoridation. Canberra, Austra- lia: Australian Government Publishing Service;1991. 325. Block LE. Antifluoridationists persist: the constitu- tional basis for fluoridation. J Public Health Dent 347. Jones S. Water fluoridation in Europe. Paper 1986;46(4):188 -98. presented to the British Association for the Study of Community Dentistry, 1996 Spring Scientific 326. Christoffel T. Fluorides, facts and fanatics: public Meeting. Dundee, Scotland. health advocacy shouldn't stop at the courthouse 348. Marthaler TM. Water fluoridation results in Basel door. Am J Public Health 1985;75(8):888 -91. since 1962: health and political implications. J Public 327, McMenamin JP. Fluoridation of water in Virginia: the Health Dent 1996 Spec Iss;56(5):265 -70. tempest in the teapot. J Law Ethics Dent 1988;1(1): 349. Meyer J, Marthaler TM, Burgi H. The change from 42 -6. water to salt as the main vehicle for community -wide 328. Roemer R. Water fluoridation: public health responsi- fluoride exposure in Basle, Switzerland (Editorial). bility and the democratic process. Am J Public Health Community Dent Oral Epidemiol 2003;31(6):401 -2. 1965;55(9):1337 -48. 350. Roemer R. Legislation on fluoridation of water 329. Strong GA. Liberty, religion and fluoridation. J Am supplies. In: Experience on water fluoridation in Dent Assoc 1968;76:1398 -1409. Europe. Copenhagen: World Health Organiza- 330. Easlick KA. An appraisal of objections to fluoridation. tion;1987:23 -36. J Am Dent Assoc 1962;65:868 -93. 351. Klein SP, Bohannan HM, Bell RM, Disney JA, Foch 331. American Dental Association, Survey Center. 1998 CB, Graves RC. The cost and effectiveness of school - Consumers' opinions regarding community water based preventive dental care. Am J Public Health fluoridation. Chicago;June 1998. 1985;75(4):382 -91. 332. Gallup Organization, Inc. A Gallup study of parents' 352. Federation Dentaire Internationale. Cost - effectiveness behavior, knowledge and attitudes toward fluoride. of community fluoride programs for caries preven- Princeton, NJ: Gallup Organization, Inc.;1991. tion: technical report 13. Chicago: Quintessence;1981. 333. Newbrun E. The fluoridation war: a scientific dispute 353. Ringelberg ML, Allen SJ, Brown LJ. Cost of fluorida- or a religious argument? J Public Health Dent tion: 44 Florida communities. J Public Health Dent 1996;56(5)(Spec Iss):246 -52. 1992;52(2):75 -80. 334. Scott DB. The dawn of a new era. J Public Health 354. Centers for Disease Control and Prevention. Recom- Dent 1996;56(5)(Spec Iss):235 -8. mendations for using fluoride to prevent and control dental caries in the United States. MMWR 335. Park B, Smith K, Malvitz D, Furman L. Hazard vs 2001;50(No.RR- 14):22. outrage: public perception of fluoridation risks. 355. Griffin SO, Jones K, Tomar SL. An economic evalua- J Public Health Dent 1990;50(4):285 -7. tion of community water fluoridation. J Public Health 336. Neenan ME. Obstacles to extending fluoridation in the Dent 2001;61(2):78 -86. United States. Comm Dent Health 1996;13(Suppl 2): 356. American Dental Association, Survey Center. 2003 10 -20. survey of dental fees. Chicago;April 2004. 337. Lowry R. Antifluoridation propaganda material -the 357. American Water Works Association. Fluoridation tricks of the trade. Br Dent J 2000;189(10):528 -30. of public water supplies. Adopted by the Board of 338. Mandel I. A symposium of the new fight for fluo- Directors Jan. 25, 1976, reaffirmed Jan. 31, 1982 rides. J Public Health Dent 1985;45(3):133 -41. and revised Jan. 20, 2002. Available at <http: / /www. 339. Lang P, Clark C. Analyzing selected criticisms of awwa.org/ About /OandC /officialdocs /AWWASTAT. water fluoridation. J Can Dent Assoc 1981;47(3) :i -xii. cfm>. Accessed April 29, 2005. 340. Lieberman AJ, The American Council on Science and 358. Centers for Disease Control and Prevention. Water Health. Facts versus fears: a review of the 20 greatest fluoridation and costs of Medicaid treatment unfounded health scares of recent times. 2nd ed. New for dental decay - Louisiana, 1995 -1996. MMWR York;1997. 1999;48(34):753 -7. 341. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113, S.Ct. 2786 (1993). 342. Frazier PJ. Fluoridation: a review of social research. J Public Health Dent 1980;40(3):214 -33. Ruoridateon Facts Packet Page -964 - 67 Statements from Five Leading Health Organizations Regarding Community Water Fluoridation AMERICAN DENTAL ASSOCIATION (ADA) "The Association endorses communitywaterfluoridation as a safe, beneficial and cost - effective public health measure for preventing dental caries. This support has been the Association's policy since 1950." — ADA Operational Policies and Recommendations Regarding Community Water Fluoridation (Trans. 1997:673 ). CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) "During the 201h century, the health and life expectancy of persons residing in the United States improved dramatically. To highlight these advances, MMWR will profile 10 public health achievements in a series of reports published through December 1999 (Fluoridation of drinking water was chosen as one of these achievements and profiled in the October 22,1999 MMWR). Fluoridation safely and inexpensively benefits both children and adults by effectively preventing tooth decay, regardless of socioeconomic status or access to care. Fluoridation has played an important role in the reductions in tooth decay (40 % -70% in children) and of tooth loss in adults (40 %- 60 %)." CDC, Morbidity and Mortality Weekly Report. "Ten Great Public Health Achievements - United States 1900 - 1999" April 1999. AMERICAN MEDICAL ASSOCIATION (AMA) "The AMA recognizes the important public health benefits of drinking properly fluoridated water and encourages its member physicians and medical societies to work with local and state health departments, dental societies, and concerned citizens to assure the optimal fluoridation of community drinking water supplies." — AMA Letter to the American Dental Association, March 10, 1995. 68 U.S. SURGEON GENERAL "A significant advantage of water fluoridation is that all residents of a community can enjoy its protective benefit - at home, work, school or play - simply by drinking fluoridated water or beverages and foods prepared with it ... Water fluoridation is a powerful strategy in our efforts to eliminate differences in health among people and is consistent with my emphasis on the importance of prevention... Fluoridation is the single most effective public health measure to prevent tooth decay and improve oral health over a lifetime, for both children and adults. While we can be pleased with what has already been accomplished, it is clearthatthere is much yetto be done. Policymakers, community leaders, private industry, health professionals, the media, and the public should affirm that oral health is essential to general health and well being and take action to make ourselves, our families, and our communities healthier. l join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing the oral health of all Americans. " — Surgeon General Richard H. Carmona, Statement on Community Water Fluoridation, July 28, 2004. NATIONAL INSTITUTE OF DENTAL & CRANIOFACIAL RESEARCH (NIDCR) "The National Institute of Dental and Craniofacial Research continues to support water fluoridation as a safe and effective method of preventing tooth decay in people of all ages. Community water fluoridation is a public health effort that benefits millions of Americans. For more than half a century, water fluoridation has helped improve the quality of life in the U.S. through reduced pain and suffering related to tooth decay, reduced tooth loss, reduced time lost from school and work, and less money spent on dental care." — NIDCR: Statement on Water Fluoridation, June 2000. Packet Page -965- American Dental Association /—%N '"N' COMPENDIUM National and International Organizations That Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay Academy of Dentistry International Academy of General Dentistry Academy for Sports Dentistry Alzheimer's Association America's Health Insurance Plans American Academy of Family Physicians American Academy of Nurse Practitioners American Academy of Oral and Maxillofacial Pathology American Academy of Orthopaedic Surgeons American Academy of Pediatrics American Academy of Pediatric Dentistry American Academy of Periodontology American Academy of Physician Assistants American Association for Community Dental Programs American Association for Dental Research American Association for Health Education American Association for the Advancement of Science American Association of Endodontists American Association of Oral and Maxillofacial Surgeons American Association of Orthodontists American Association of Public Health Dentistry American Association of Women Dentists American Cancer Society American College of Dentists American College of Physicians— American Society of Internal Medicine American College of Preventive Medicine American College of Prosthodontists American Council on Science and Health American Dental Assistants Association American Dental Association American Dental Education Association American Dental Hygienists' Association American Dietetic Association American Federation of Labor and Congress of Industrial Organizations American Hospital Association American Legislative Exchange Council American Medical Association American Nurses Association American Osteopathic Association American Pharmacists Association American Public Health Association American School Health Association American Society for Clinical Nutrition American Society for Nutritional Sciences American Student Dental Association American Veterinary Medical Association American Water Works Association Association for Academic Health Centers Association of American Medical Colleges Association of Clinicians for the Underserved Association of Maternal and Child Health Programs Association of State and Territorial Dental Directors Association of State and Territorial Health Officials Association of State and Territorial Public Health Nutrition Directors British Fluoridation Society Canadian Dental Association Canadian Dental Hygienists Association Canadian Medical Association Canadian Nurses Association Canadian Paediatric Society Canadian Public Health Association Child Welfare League of America Children's Dental Health Project Chocolate Manufacturers Association Consumer Federation of America Council of State and Territorial Epidemiologists Delta Dental Plans Association FDI World Dental Federation Federation of American Hospitals Hispanic Dental Association Indian Dental Association (U.S.A.) Institute of Medicine International Association for Dental Research International Association for Orthodontics International College of Dentists March of Dimes Birth Defects Foundation National Association of Community Health Centers National Association of County and City Health Officials National Association of Dental Assistants National Association of Local Boards of Health National Association of Social Workers National Confectioners Association National Council Against Health Fraud National Dental Assistants Association National Dental Association National Dental Hygienists' Association National Down Syndrome Congress National Down Syndrome Society National Eating Disorders Association National Foundation of Dentistry for the Handicapped National Head Start Association National Health Law Program National Healthy Mothers, Healthy Babies Coalition Oral Health America Robert Wood Johnson Foundation Society for Public Health Education Society of American Indian Dentists Special Care Dentistry Academy of Dentistry for Persons with Disabilities American Association of Hospital Dentists American Society for Geriatric Dentistry The Children's Health Fund The Dental Health Foundation (of California) U.S. Department of Defense U.S. Department of Veterans Affairs U.S. Public Health Service Centers for Disease Control and Prevention (CDC) National Institute of Dental and Craniofacial Research (NIDCR) World Federation of Orthodontists The list above was current at the time Fluoridation Facts went to press. As organizations and entities continue to be added to the Compen- dium, the most current Compendium can be viewed on ADA.org at http: / /www.ada.orci/goto /ffcompendium. Permission is hereby granted to reproduce and distribute this Fluoridation Facts Compendium in its entirety, without modification. To request any other copyright permission please contact the American Dental Association at 1- 312 -440 -2879. Fluoridation Facts Packet Page -966- 69 1 )r\® American Dental Association www.ada.org 211 East Chicago Avenue Chicago, Illinois 60611 -2678 Packet Page -967- i'en (irreat Public tiealtn Actilevements -- umtea Mates, iYvv -tyy7 9/13/2011 Item 10.C. Weekly December 24,19991 48(50);1141 Ten Great Public Health' Achievements -- United States, 1944 -1999 • Vaccination • Motor - vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water • Recognition of tobacco use as a health hazard Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402 -9371; telephone: (202) 512 -1800. Contact GPO for current prices. "Questions or messages regarding errors in formatting should be addressed to mnnvrq.&cdc.gov. Page converted: 12/21/1999 HOME i ABOUT MMWR i MMWR SEARCH I DOWNLOADS i R S i CONTACT POLICY i DISCLAIMER ( ACCESSIBILITY 6AF'Cfi • NZALTHiCh-PROPLV Morbidity and Mortality Weekly Report !,� Qppartment of Health Centers for Disease Control and Prevention5. Sgt and Human Services 1800 Clifton Rd, MallStop E -90, Atlanta, GA �awrnme d M ■aaEner 30333, U.S.A This page fast reviewed 5/2/01 http: / /,Aww.edc.gov /mmwr /preview /mmwr Packet Page -968- m 3/19/2009 � 7 � 7 Populations Receiving Optimally Fluoridated Public Drinking Water - -- United Sty `9/13/2011 1 - Item t /1 10. C. Weekly July 11, 2008167(27);737-741 Populations Receiving Optimally Fluoridated Public Drinking Water - -- United States, 1992 -- 2006 Water fluoridation has been identified by CDC as one of 10 great public health achievements of the 20th century. The decline in the prevalence and severity of dental caries (tooth decay) in the United States during the past 60 years has been attributed largely to the increased use of fluoride (1). Community water fluoridation is an equitable and cost - effective method for delivering fluoride to the community (2 - -�. A Healthy People 2010 objective is to increase to 75% the proportion of the U.S. population served by community water systems who receive optimally fluoridated water* (5). To update and revise previous reports on fluoridation in the United States (44 and describe progress toward the Healthy People 2010 objective, CDC analyzed fluoridation data for the period 1992- -2006 from the 50 states and District of Columbia (DC). The results indicated that the percentage of the U.S. population served by community water systems who received optimally fluoridated water increased from 62.1% in 1992, to 65.0% in 2000, and 69.2% in 2006, and those percentages varied substantially by state. Public health officials and policymakers in states with lower percentages of residents receiving optimal water fluoridation should consider increasing their efforts to promote fluoridation of community water systems to prevent dental caries. Since 1945, the U.S. Public Health Service and CDC,(beginning in 1975) have tracked the number of persons in the United States receiving fluoridated water.t The U.S. Environmental Protection Agency (EPA) does not regulate water fluoridation, and EPA's Safe Drinking Water Information System (SDWIS) only tracks fluoride concentrations in water systems with naturally occurring fluoride levels above the established regulatory maximum contaminant level (4.0 ppm §). Water fluoridation is managed at the state level, and CDC relies on states to provide data on individual community water systems (e.g., population served, fluoride concentration, and fluoride source). During 1998- -2000, CDC, in partnership with the Association of State and Territorial Dental Directors, developed the Water Fluoridation Reporting System (WFRS) to support management and tracking of state fluoridation programs. WFRS is a voluntary system designed, in part, to make additional use of community water system data that states were already required to report to EPA as part of SDWIS. In March 2007, CDC asked state dental directors and drinking water administrators to validate their state data reported via WFRS for 2006. Estimates of the population served by community water systems were based on the number of households served (i.e., service connections) and the number of persons in each household. Some states supplemented population data in WFRS with population data from SDWIS, which can differ slightly from WFRS. The percentage of the population served by community water systems who received optimally fluoridated water was calculated by dividing the population served by community water systems with optimal fluoride levels by the total population Packet Page -969 - http: / /www.cdc.gov /mmwr /preview /mmwr 3/19/2009 9/13/2011 Item 10.C. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Recommendations and Reports November 30, 2001 / 50(RR- 21);1 -13 Promoting Oral Health: Interventions for Preventing Dental Caries. Oral and Pharyngeal Cancers, and Sports - Related Craniofacial Injuries A Report on Recommendations of the Task Force on Community Preventive Services Report reinforces the efficacy of fluoridation Excerpt The Task Force on Community Preventive Services (the Task Force) conducted systematic reviews of the evidence of effectiveness of selected population -based interventions to prevent and control dental caries (tooth decay), oral (mouth) and pharyngeal (throat) cancers, and sports - related craniofacial injuries. The Task Force strongly recommends community water fluoridation. More widespread use of effective population -based interventions could help reduce the morbidity, mortality and economic burden associated with dental caries... Packet Page -970- 9/13/2011 Item 10.C. Oral Health in America: A Report of the Surgeon General May, 2000 Excerpt: Community water fluoridation remains one of the great achievements of public health twentieth century — an inexpensive means of improving oral health that benefits all residents of a community, young and old, rich and poor alike. Fluoridation remains an ideal public health measure based on the scientific evidence of its safety and effectiveness in preventing dental decay and its impressive cost effectiveness. Further, one of my highest priorities as Surgeon General is reducing disparities in health that persist among our various populations. Fluoridation holds great potential to contribute toward elimination of these disparities. I am pleased to join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing oral health protection for Americans. Report available on Internet: http: / /www.nider .nih.gov /sgr /oralhealth.htm U.S. PUBLIC HEALTH SERVICE DEPARTMENT OF HEALTH AND HUMAN SERVICES Packet Page -971- n 9/13/2011 Item 10.C. BMW Una FLORIDA DENTAL HYGIENE ASSOCIATION Leaders in Preventive orai Heatth March d, 2009 Harry W. Davis, DDS, MPH Public Health Dental Program Florida Department of Health HSFDF, Bin #A14 4052 Bald Cypress Way Tallahassee, Florida 32399 -1724 Dear Dr. Davis, The Florida Dental Hygiene Association advocates effective, preventive measures for comprehensive oral health and fully supports water'fluoridation for the citizens of Florida. With a distressed economy many cities and counties are looking at cast savings measures to function within a decreasing budget. The Florida Dental Hygiene Association is concerned that the decision to eliminate water fluoridation will detrimentally affect the citizens of Florida. The progressive, destructive nature of dental decay can significantly diminish the general health and quality of life for the affected person. Tooth decay is the most common chronic disease in children. By utilizing the benefits of water fluoridation in the early years of tooth development, costly and disruptive intervention can be avoided. According to reports from the Centers for. Disease Control and Prevention, for every $1 invested in fluoridation, $38 in dental treatment costs is saved, In addition, Medicaid programs costs are as much as 50% less in fluoridated communities compared to non - fluoridated communities. The United States Department of Health and Human Services (HHS) is leading The HOalFhy People 2010 initiative which addresses a vision of "a healthy, strong United States where diseases are prevented when possible, controlled when necessary, and treated when appropriate." Water fluoridation is an essential component of this plan. Sincerely$ Tami J. Miller, RDH, BS Executive Director p0 Box 30938 - Palm Beach Gardens, FL 33420 (860) 896-0603 phone; (860) 896 -0604 fax www.fdha.org Packet Page -972- FloridaMedical A S S 0 C i A T( 0 N Helping Physicians Practice Medicine. June 26, 2009 9/13/2011 Item 10.C. P.O. Box 10269 I Tallahassee, FL 1 32302 123 South Adams Street I Tallahassee, FL 132301 850.224.6496 I 850.224.6627 Fax I www.fmaonline.c.._ Steven R. West, M.D. President James B. Dolan, M.D. President -Elect Madelyn E. Butler, M.D. Vice President State Surgeon General Vincent A. DeGennaro, M.D. Secretary Florida Department of Health W. Alan Harmon, M.D. Treasurer 4052 Bald Cypress Way, BIN# A -14 Alan B. Plllersdorf, M.D. Tallahassee, FL 32399 -1724 Speaker David J. Becker, M.D. Vice Speaker Karl M. Altenburge , M.D. Re: Community Water Fluoridation Immediate Past President John N. Katopodis, M.D. District The Florida Medical Association (FMA) works with the Department of Health Eli N. Lerner, M.D. Districts to improve the health of the people of Florida and supports community water fluoridation. The FMA's Council on Public Health finds the Florida Dental David M. McKalip, M.D. District Association's resolution which states it "unequivocally supports the optimal Harold L. Greenberg, M.D. District D fluoridation of drinking water as a safe, effective, and economical way to Ralph J. Nobo, Jr., M.D, prevent dental caries" to be consistent with FMA and AMA policies, and E Distract ct E accordingly strongly endorses it for the stated purpose of preventing dental Nabil El Sa M.D. District F caries through appropriate fluoridation of public water supplies for the benefit Stephan Bake M.D. of the public's health. The FMA agrees that fluoridation serves as one of the most cost effective public health measures a community can take to help Silvio A. Garcia, M.D. At Large prevent dental decay and supports this measure as not just cost - effective but a Neal P. Dunn, M.D. At Large producer of cost - savings as well. We applaud and support your efforts to Lisa A. Cosgrove, M.D. provide for community water fluoridation. Primary Care Specialties Linda S, Cox, M.D. Medical Speclalties Sincerely, Alan S. Routman, M.D. Surgical Specialties Miguel A. Machado, M.D. Council on Legislation E. coy Irvin, M.D. John J. Lanza, M.D., PhD, MPH, FAAP Florida AMA Delegation da Chairman, FMA Council on Public Health James H. Rubenstein, M.D. FMA PAC M. Kernel Elzawahry, M.D. Specialty Society Section Ashley E. Booth, M.D. JJL: sf Young Physician Section Joel R. Judah, M.D. Resident & Fellow Section Jeremy L. Tharp Medical Student Section Donald F. Foy, Sr. Public Member Diane R. Andrews, Ph.D., R.N. FMA Alliance Karen Wendiand, M.S. Council of Florida Medical Society Executives Heir packet Page - 973 -lice Medicine Public Health Focus: Fluoridation of Community Water Systems 9/13/2011 Item 10.C. Weekly May 29, 1992141(21);372 -375, 381 Public Health Focus: Fluoridation of Community Water Systems Although fluoridation of community water is highly effective in reducing the occurrence of dental caries, the prevalence of dental caries remains high in the United States. For example, a survey of school -aged children during 1986 -1987 indicated that 50% of those aged 5 -17 years had caries in their permanent teeth, and among 17- year -olds; the prevalence of caries was 84% (1). In addition, among certain populations (e.g., rural and innef -city residents, children whose parents have less than a high school education, and some racial/ethnic minorities), the prevalence of dental caries among children ranges from 52% to 92 %. This report summarizes information regarding the efficacy, effectiveness, and cost - effectiveness of fluoridation of public water supplies in the United States. Efficacy/Effectiveness The association between fluoride in drinking water and reduction of dental caries was first documented in the 1930s in communities with naturally occurring fluoride (2). However, it became necessary to validate and quantify efficacy when alternate systemic and topical methods to deliver fluoride were proposed. In 1945 and 1946, independently conducted community trials to assess the effectiveness of water fluoridation were initiated in four communities in Canada and the United States (Brantford, Ontario; Evanston, Illinois; Grand Rapids, Michigan; and Newburgh, New York) (Table 1). Four nearby and demographically similar communities were selected for comparison. Following fluoridation for 13 -15 years, the prevalence of caries decreased 48 % -70% among 12- 14- year -olds in the four communities (2). Studies in other communities indicated that, following fluoridation for 10 years, the prevalence of caries decreased 45 % -94% (median: 58 %) among children (3). By the early 1980s, epidemiologic evidence indicated that the prevalence of dental caries was declining throughout the United States (5). From 1971 through 1987, three national surveys of U.S, children demonstrated a continued decrease in caries prevalence (1,6,7) (Figure i). The most recent national survey, conducted during 1986 -1987 (1), indicated that the prevalence of caries among children with a history of lifelong exposure to optimally fluoridated water decreased 18% when compared with the prevalence among children with no exposure to optimally fluoridated water. Prevalence decreased 25% when the analysis excluded children with any history of fluoride therapy (e.g., dietary supplements or professionally applied topical n treatments) (4). In addition, recent studies have found consistently lower caries prevalence, both on coronal and root surfaces, among adults who live in communities with optimal or greater fluoride than among those from communities with lower fluoride levels in the water supply (4) (Table 1): Packet Page -974- /1 t / / • / t . 1 /AA -1^ 1 1 . 711 A //%t\A/h Public Health Focus: Fluoridation of Community Water Systems 9/13/2011 Item 10.C. In clinical trials, epidemiologic studies, and national surveys conducted during 1973 -1988 (8), children aged 6 -13 years living in fluoridated communities averaged 0.8 new dental caries . ^ (decayed, missing, or filled surfaces (DMFS)) per year. In comparison, an average of 1.5 DMFS occurred each year among children living in fluoride - deficient communities. Cost - Effectiveness The direct cost of fluoridating public water supplies is related to a variety of factors, including size of the community, number of wells and treatment plants, amount and type of equipment, amount and type of fluoride chemical, and personnel costs (9). Annual costs of water fluoridation per capita varied inversely with community size, ranging from 12 cents to 21 cents for water systems serving populations greater than 200,000 persons, 18 cents to 75 cents for systems serving 10,000- 200,000 persons, and 60 cents to.$5.41 for'systems serving fewer than 10,000 persons; the mean national weighted estimate is 51 cents (10). Of all persons receiving optimally fluoridated community drinking water, approximately 856/o are served by water systems for which the annual per capita cost of fluoridation is 12 cents -75 cents (11). For 1990, the Health Care Financing Administration estimated that $34 billion (5% of all U.S. expenditures for health care) was spent for dental services (12); of which $4.5 billion (13.2 %) may have been spent on dental amalgam restorations (American Dental Association, personal communication, 1992). Based on a national average cost per restoration of $40 (I3) and a mean national weighted cost of 51 cents per person per year to fluoridate drinking water (10), each $1 expenditure for water fluoridation could result in a savings of $80 in dental treatment costs. Estimated nondiscounted per capita expenditures for water fluoridation during a lifetime ($38.25 at 51 cents per year for 75 years) are approximately equal to the average nondiscounted cost of one dental restoration. Reported by: Div of Oral Health, National Center for Prevention Svcs, CDC. Editorial Note Editorial Note: Since 1945, 9411 community water systems serving 8081 communities in the United States have instituted water fluoridation. By the end of 1989, approximately 70% of all U.S. cities with populations of more than 100,000 --including 42 of the 50 largest cities -- were fluoridating water. Thirty -five states, Puerto Rico, and the District of Columbia provide fluoridated water to more than half of their populations (11) (Figure 2), and nine states and Puerto Rico have enacted legislation for mandatory water fluoridation. Approximately 135 million U.S. residents are served by water supplies in which the fluoride concentration either has been adjusted to an optimal level (126 million persons) or the natural fluoride content is sufficient for improved dental health (9 million persons) (I1). Because efforts to fluoridate drinking water were effective in reducing the risk for dental caries, dental researchers developed other methods to deliver fluoride to the public (e.g., fluoride - containing dentifrices, fluoride gels, fluoride mouth rinses, and dietary fluoride supplements). In addition, foods and beverages processed in fluoridated cities may be sold in nonfluoridated areas. The widespread use of these products assures that virtually all persons are exposed to fluoride. This exposure may have contributed substantially to the decrease in caries reduction obsezvedduring 1986 -1987 (1) when comparing fluoridated and nonfluoridated communities. The possibility of adverse effects of water fluoridation has been investigated since this preventive measure was first introduced. Although recent reviews have confirmed the benefit of exposure to appropriate levels of fluoride for dental health (14,15), a Public Health Service Packet Page -975- - -- - - - -- • - - � i� n �nnnn Public Health Focus: Fluoridation of Community Water Systems 9/13/2011 Item 10.C. report (14) recommended further assessment of potential problems associated with or other aspects of fluoride use, such as the relation between fluoride intake and bone (i.e., osteosarcoma and bone fractures); the mechanisms of fluoride action on bone and teeth at the molecular level; the marginal risks, costs, and benefits of multiple fluoride regimens; the caries effect after a community discontinues water fluoridation; temporal changes in the prevalence of dental caries; and the prevalence and extent of dental fluorosis. One national health objective for the year 2000 is to increase to at least 75% the proportion of persons served by community water systems providing optimal levels of fluoride (objective 13.9) (16) -- a goal already achieved by 20 states and the District of Columbia (Figure 2) (11). To achieve this objective nationally, an additional 30 million persons must receive optimally fluoridated water from public water systems. References 1. National Institute of Dental Research. Oral health of United States children: the National Survey of Dental Caries in U.S. School Children: 1986 -87; national and regional frndings.Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1989; NIH publication no. 89 -2247. 2. Striffler DF, Young WO, Burt BA. Dentistry, dental practice, and the community. 3rd ed. Philadelphia: WB Saunders, 1983. 3. Dunning JM. Principles of dental public health. 4th edition. Cambridge, Massachusetts: Harvard University Press, 1986. 4. Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49:279 -89. 5. Burt BA. The future of the caries decline. J Public Health Dent 1985;45:261 -9. 6, NCHS. Basic data on dental examination findings of persons 1 -74 years: United States, 1971 -74. Hyattsville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, 1979; DHEW publication no. (PHS)79 -1662. (Vital and health statistics; series 11, no. 214). 7. National Institute of Dental Research. The prevalence of dental caries in United States children, 1979 -80: National Dental Caries Prevalence Survey. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1981; NIH publication no. 82 -2245. 8. Garcia Al. Caries incidence and costs of prevention programs. J Public Health Dent 1989;49:259 -71. 9. CDC. Water fluoridation: a manual for engineers and technicians. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, September 1986. 10. Burt BA. (Concluding statement). In: Proceedings for the workshop: cost effectiveness of caries prevention in dental public health. J Public Health Dent 1989;49:338 -40. Packet Page -976 - httn_// www. cdc. gnv/ snmwr /nreview /mmun- html /tl()ol6X4O htm Public Health Focus: Fluoridation of Community 'Water Systems 9/13/2011 Item 10.C. y 11. CDC. Fluoridation census 1989: summary. Atlanta: US Department of Health and Human Services, Public Health Service, 1991. 12. Palmer C. Dental spending hits,$34 billion. American Dental Association News 1992;23 :25. 13. American Dental Association. The 1990 survey of dental fees. Chicago: American Dental Association, 1992. 14, Public Health Service, Review of fluoride benefits and risks: report of the ad hoc subcommittee on fluoride of the committee to coordinate environmental health. and related programs. Washington, DC: US Department of Health-and Human Services, Public Health Service, 1991. 15. Kaminsky LS, Mahoney MC, Leach J, Melius J, Miller MJ. Fluoride: benefits and risks of exposure, Clinical Reviews in Oral Biology and Medicine 1990;1:261 -81. 16, Public Health Service. Healthy people 2000: national health promotion.and disease . prevention objectives -- full report, with commentary. Washington, DC: US Department Of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91- 50212. . o Ranges from 03 mg/L to 1.2 mg/L based on an annual average of the maximum daily air temperature. Disclaimer All MMWR HTML documents published before January 1993 are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version, Users should not rely on this HTML document, but are referred to the original MjVfWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402 -9371; telephone: (202) 512 -1800. Contact GPO for current prices. " *Questions or messages regarding errors in formatting should be addressed to mmwra(a,cdc.gov. Page converted: 08/05/98 - HOME I ABOUT MM WR 1 MMWR SEARCH I DOWNLOADS I RSS 1 CONTACT P. OLICY l DISCLAIMER i ACCESSIBILITY EAPSE R • H KAL'THLKF? • PCAPLC" Morbidity and Mort ality U41eeldy Report_ .: Department of Health Centers for Disease Control and PrevenE(on ,€'c�V and Human Services 1 Boo Clifton Rd, MallStop E -90, Atlanta, GA aq „e +nmr . iA.a.Ev r 30333, U.S.A ” This page last reviewed 5/2101 Packet Page -977- 9/13/2011 Item 10.C. n Florida Journal of Environmental Health, Vol. 191, Dec. 2005, pp. 14-20. Perspectives on the Science Supporting Florida's Public Health Policy for Community Water Fluoridation Michael W. Easley, DDS, MPH INTRODUCTION: Community water fluoridation has been utilized for more than 60 years as the principal public health measure to prevent the ravages of dental caries, a chronic infectious disease commonly referred to as dental cavities or dental decay. Dental caries can ultimately lead to acute or chronic dental infections (abscesses), pain, loss of teeth, speech impediments, compromised nutrition, systemic infections, complications for other chronic diseases, and occasionally death. Children are frequently absent from school because of the pain from acute dental infections or for dental treatment. The treatment of dental decay also results in substantial direct and indirect costs to individuals, their employers, insurance companies, consumers, and taxpayers. Community water fluoridation is one of the safest, most effective, and most economical programs that public officials can provide for their constituents in order to prevent the pain, suffering, and costs of dental caries. Community water fluoridation is generally easy and inexpensive to implement - costing public water systems, on average, about 50 cents per person per year in large communities to $3.00 per person a year for small communities to operate -2, 55 The return on investment is tremendous —with various studies reporting .$38-$80 in dental treatment cost savings for each dollar invested in community water fluoridation' "2,6,55 Few taxpayer- financed programs, result in such a large amount of savings for such a small investment. Moreover, since fluoridation has proven to be a safe, effective, efficient, economical, and environmentally sound means to prevent dental caries in children and adults, its implementation by public and private water systems serves as an excellent example of good public policy at work. What Is Fluoride And Why Is it Necessary? Fluoride is a naturally occurring substance that is present in virtually all sources of drinking water in the United States. It serves as an essential trace element necessary for the proper development of teeth and bones, and for the protection of teeth once they have erupted into the mouths -s,3"" Therefore, fluoride not only benefits children before their teeth have erupted, but it also protects the teeth of children and adults after all of their teeth are present in the mouth3" -"-'e. Those fortunate enough to have had access' to community water fluoridation experience 40 -60% fewer dental cavities3 s.s2 -ae Community water fluoridation is the precise adjustment of the existing naturally occurring fluoride levels in drinking water to a safe level that has been determined to be ideal for the prevention of dental caries in children and adults. There are even some locations in the United States where naturally occurring fluoride levels are adequate for the prevention of dental caries - these communities do not have to fluoridate their drinking water. However, most communities in the U. S. have insufficient levels of fluoride for effective prevention of dental caries and therefore require the addition of very small amounts of fluoride to achieve the optimal level for good health. Community water fluoridation mimics a naturally occurring process and can be considered to be a form of enrichment or supplementation of the drinking water. The process of fluoridation as a measure to prevent dental caries is very similar in concept to the supplementation of. milk and breads with Vitamin D to prevent rickets;.fruit drinks with Vitamin C to prevent scurvy; table salt with iodine to prevent goiter; breads and Packet Page -978- 9/13/2011 Item 10.C. pastas with fofic acid to prevent certain birth defects; various foods with calcium to prevent osteoporosis; and cereals with many different vitamins and minerals in order to provide for proper human development and to promote good health. Why Use The Public Water System To Provide Fluoride? First of all, public water systems have been used for the purpose of preventing diseases In the United States since the 1840's. The original reason for the establishment and widespread use of community water systems by cities and villages was to prevent the outbreak of serious diseases like cholera, hepatitis A, glardiasis, and typhoid fever. These and many other diseases, including dental caries, are prevented through the treatment of drinking water, Water treatment for disease prevention is considered to be a primary public health activity and is essential for the control of many diseases that would otherwise plague modern society. Don't We Have Other Ways Of Getting Fluoride? There are other ways to provide fluoride, but none are as effective as community water fluoridation for the prevention of dental decay in children and adults". Fluoride benefits teeth in two general ways - there are (1) benefits from systemic sources and (2) benefits from topical sources. (1) Systemic Sources of Fluoride:' Benefits from systemic sources are gained when one drinks water and eats-food that contain fluoride. Systemic benefits can also be obtained. by taking fluoride tablets or vitamins with fluoride that have been prescribed by a family's physician or dentist. More permanent in nature, the fluoride obtained from systemic sources actually becomes part of the tooth structure as baby teeth and permanent teeth develop under the gums of infants and children 4. These teeth are then considerably stronger and resist dental decay much better once they have . erupted into the mouth. This protection, gained from getting fluoride from systemic sources, generally stays with the teeth throughout life. Systemic sources of fluoride also benefit older children and ad ults4•sss -s7 Fluoride from food and drink eventually ends up in a person's saliva. The fluoride in the saliva constantly bathes the teeth. so that the teeth are protected continuously through exposure to small amounts of fluoride. For those older children and adults fortunate enough to live in fluoridated communities, this constant protection of the teeth by saliva containing small amounts of fluoride is substantial$. The fluoride from saliva not only prevents some cavities from ever starting, but It also repairs early dental decay through a process called remineralization5,5s-57 With remineralizaticm,'some very small cavities are not only prevented from getting larger, they actually can "heal" or repair themselves because of the action of these low levels of fluoride present in the salivas,5&'17. Fluoride in saliva also inhibits attachment, metabolism, and reproduction of the bacteria implicated in the decay process, such that it inhibits the ability of these bacteria to produce enamel - destroying acids"". It should be noted that community water fluoridation is much more effective, much safer, and much more economical than the use of prescribed fluoride supplements (fluoride tablets or fluoride vitamins) 4 5 ' ,57 .Community water fluoridation is always the . best choice to prevent dental decay in children and adults, not only because it is safer, more effective, and more economical, but because it benefits all people using the pub57 water system, regardless of, age, race, ethnic background, or socioeconomic status 4 '9 , Fluoride tablets or vitamins with fluoride can and should be used in the absence of community water fluoridation, but are meant only as a temporary substitute until a community's water system can be fluoridated. Because they must be prescribed by a Ili Packet Page -979- 9/13/2011 Item 10.C. physician or a dentist, fluoride tablets or vitamins with fluoride often are only available to people fortunate enough to be able to afford regular visits to a family dentist or physician. (2) Topical Sources of Fluoride: Benefits from topical sources tend to be temporary and are accrued when fluoride from external sources comes into direct contact with the surfaces of the teeth 4.8,57. Topical benefits can be obtained through use of such things as fluoride toothpaste, fluoride mouthrinses, fluoride varnishes, and fluoride treatments that are provided in dentists' offices. Fluoride toothpaste does a great job in helping to prevent dental decay, but only provides a temporary topical benefit to the tooth surfaces. Fluoride toothpaste, by itself, also does not prevent decay as well as fluoride from the previously mentioned systemic sourcesa'a,e•a.5fr57 Readily available from grocery stores, drug stores, and other commercial establishments, fluoride toothpaste is safe and should be used according to directions on the label. f=luoride toothpaste can be used by children and adults in areas served by fluoridated community water systems and does provide additional protection to teeth. Fluoride mouthrinses are effective in preventing dental decay, but also only provide a temporary benefit and are not as effective as fluoride from systemic sources3' 4,11-1,57 They are available over the counter (grocery stores, drug stores, etc.) or by prescription from dentists and physicians. Fluoride mouthrinses may be used at the same time that people are getting fluoride from systemic sources (community water fluoridation or fluoride tablets /vitamins with fluoride), however fluoride mouthrinses should only be used in these situations after consulting with the family's dentist or physician. Fluoride varnishes and topical fluoride treatments from a family's dentist also provide a temporary topical benefit to the tooth surfaces. 6-8.57: These topical fluoride treatments may be used at the same time that an individual is receiving fluoride from systemic sources, but only if the dentist has determined that there is a need for a fluoride varnish or topical fluoride treatment because of the level of decay present in that individual. It is important to remember that fluoride from topical sources, while effective in preventing dental decay, is not nearly as effective as fluoride from systemic sources"' Moreover, fluoride from topical sources should never be considered to serve as an adequate substitute for fluoride from systemic sources. The gold standard for dental disease prevention is community water fluoridationa,ess 57. Community water fluoridation should be implemented whenever it Is technically feasible. Fluoride tablets are meant to be used as a temporary substitute for community water fluoridation only until a community water system can be fluoridated. Topical sources of fluoride (fluoride toothpaste, fluoride mouthrinses, and fluoride treatments provided in dental offices) are only meant to be used as adjuncts to systemic sources of fluoride. How Much Fluoride Is Added To The Drinking Water? Only a very small amount of fluoride is added to the drinking water to achieve the desired Maximum benefits. The existing natural fluoride levels in drinking water supplies are adjusted slightly in order to raise them to between 0.7 and 1.2 parts per million , %". This very small amount of fluoride being added is considered to be a trace amount. The precise level of fluoride calculated to be appropriate for each individual community is determined based on that community's annual average daily temperature" "57. Depending on the precise calculation, each community's water fluoride levels will be adjusted to between 0.7 and 1.2 parts per million depending on where the community is 3 Packet Page -980- 9/13/2011 Item 10.C. located and what type of climate it has11,57 . Florida typically adjusts fluoride levels in its community water systems to 0.8 parts. per million. Whichever level of fluoride is determined to be the correct level for an individual community, it bears repeating that only a very small amount of.fluoride is ultimately added to the drinking water: It also is important to remember that the optimal amount of fluoride in fluoridated drinking water has been calculated to take into account the fluoride the people get from other sources, like food and drink. Fluoridated drinking water provides only about one -third to one -half the amount of fluoride that an individual should be getting on a daily basis12. Is The Amount Of Fluoride In Fluoridated Water Systems Safe? The amount of fluoride present in fluoridated community water systems Is miniscule and has been determined to be safe for all individuals, regardless of age, race, ender, or health status13, 39.48,57 In other words, community water fluoridation is safe for g 13, 39.48,57 infants, children, teenagers, young adults, mature adults, and senior citizens . it is safe for everyone, even those with chronic diseasesl3, 39 48,57 Community water fluoridation harms no one and it is also effective in preventing dental decay in people of all ages, races, ethnic groups, or socioeconomic backgrounds"; 39 -48,57 ' Fluoride, like many other substances that are required to sustain life and promote health, is beneficial in small amounts and harmful in large amounts. Such common substances as vitamins, minerals, table salt, food, even water, are helpful in the correct amounts and harmful in excessive amounts. For example, fluoride levels in fluoridated water are so low that an adult would have to consume 660 gallons of fluoridated water in a 2 to 4 hour period in order to get a toxic level of fluoride that would cause death ". It is physically impossible for an adult to ever consume that amount of water - the adult would die of other causes long before they were able to accumulate enough fluoride to cause a problemi.. Likewise, a 12 -18 month old child would have to drink 85 gallons of fluoridated water in a 2 to 4 hour period in order to get a toxic level of fluoride that would cause death, again a physical impossibility i4. ih order to suffer chronic skeletal effects of too much fluoride, an adult would have to consume roughly 6 to 14 gallons of fluoridated water every day for 10 to 20 years - again physically impossible for virtually all adultsl4. Most adults drink far less than 1 gallon of water or other liquids a day,'more likely drinking about a quart per day. Children consume even much lower amounts of liquids than do adults on a daily basis. ' A lifetime of exposure to water fluoridated at the optimum level (0.7 to 1.2 parts per million) results in no adverse effects to any individual or group of individuals 13, 39- d8,56- 57. Thousands of scientific studies have been completed which looked at individuals and ' groups who used water with optimum levels of fluoride their entire !Ives 13 39- 48,56 -57 Lifetime exposure to fluoridated water caused no diseases, no disabilitles, nor any other adverse conditions for any group or individualS13, 39. 48,56-57 Lifetime exposure to fluoridated water only resulted in benefits - lower rates of dental decay and lower health care billS13, 1111,56.57. How Widespread Is The Practice Of Community_ Water Fluoridation In the United States and in Florida? Currently over 152 million Americans are benefiting from community water fluoridation",56 Another 10 million Americans are fortunate enough to live in communities with adequate levels of naturally occurring fluoride",". That means that over 162 million Americans and more than 67 percent of those with access to community water systems currently benefit from fluoridation's continuous protection against dental decay"-". In addition, over 12 million people in Florida are benefiting from water fluoridationt5,58. This represents 76.8% of Florida's population having access to public Packet Page -981- 9/13/2011 Item 10.C. water suppliesia,ba While in 2002 Florida ranked 31't among the 51 recognized jurisdictions (50 states + the District of Columbia) in the percentage of those on community water systems benefiting from fluoridation, recent implementation of fluoridation by a number of communities appears to place Florida about 24th out of 51 s jurisdictions reporting to CDC's Water Fluoridation Reporting System (WFRS) . Florida's fluoridation efforts began more than half a century ago, with Gainesville commencing fluoridation in 1949, the same year that the Florida Department of Health strongly endorsed its use's-68. Miami and Dade County's population (currently numbering over 2.4 million people) has had access to the health benefits of community water fluoridation since 195216, a. Other large counties in Florida provide fluoridated water to the majority of their citizens (Broward, 1.6 million; Duval, 902,000; and Hillsborough, 780,000; Just to name a few)'b,ba The 162 million Americans benefiting from fluoridation live in more than 10,500 communities that are served by over 14,300 water systems",,". In addition, 46 of the 50 largest cities in the United States are currently fluoridating their water systems b . It is also important to remember that some communities in the United States have been fluoridating their public water systems since 1945, many since the 1950's and 1960's. We have over 60 years experience adjusting fluoride levels in community water systems. Are There States That Require Fluoridation of Some Community Water Systems? Many states have passed legislation requiring community water systems to �-• provide the benefits of water fluoridation for their customers. California, Connecticut, Delaware, Georgia, Illinois, Minnesota, Nebraska, Nevada, Ohio, and South Dakota require certain communities to fluoridate their public water systems 1. Both the Commonwealth of Puerto Rico and the District of Columbia have also legislatively mandated fluoridation's. Additionally, Kentucky requires statewide fluoridation by administrative regulationia. Moreover, many local governments, including local governments in Florida, have required fluoridation through laws, regulations, and ordinances. Who Benefits From The Cost Savings That Result From Fluoridation? The total cost to the nation for dental treatment services reported in 1997 was $50.6 billion, while $60.7 billion was spent in 2000; and the total has climbed to $78.2 billion in 2004 - a substantial amount usually paid for by individuals, employers, government agencies, and insurance companies t9,b9 . Nationally, the tax-funded Medicaid program aid $2.1 billion for dental services in 1998, $3.0 billion in 2001, and $4.4 billion in 2004 8. Florida's Medicaid Dental Program expended $94.7 million of taxpayers' money in FY 2001 -2002 at a utilization rate of 18.3% for children and only 8.3% for adults (which means that if all eligible patients sought services, the total annual cost for the program could be four to ten times the current rate). In FY 2002 -2003, the Medicaid Dental Program expended $84.7 million — $10 million lower than the previous year's total because all adult dental services (except emergency services) were eliminated as an attempt to lower program costs. Interestingly, while approximately $20 million was saved by eliminating adult services (which totaled $4.9 million for the year), the cost of children's dental services increased by over $10 million to $79.8 million for the year. Utilization rates for children had risen to 21,4%, while adult utilization rates plummeted to 3.0 %. Better utilization rates would yield much higher costs, but more widespread use of community -based prevention measures, such as community water fluoridation, goes a long way toward moderating the need for such expenditures. There are a number of ways in which individuals and groups benefit from the costs savings brought on by community water fluoridation, costs which are avoided 5 Packet Page -982- 9/13/2011 Item 10.C. because of the need for less dental treatment. For example, taxpayers benefit because public programs paying for dental care for disadvantaged populations require 20 fewer local, state, and federal tax dollars for each.person covered by the program . it is expected that in the Florida communities that implement water fluoridation, Medicaid dental costs would be reduced by at least one half. Other states have demonstrated significant cost savings in their Medicaid programs as a result of community water fluoridation 113 The Federation of American Societies for Experimental Biology, in testimony before the Congressional Biomedical Research Caucus (U.S. Congress) in February 1995, documented that the national cast savings resulting from fluoridation totaled $3.84 billion each year55. In addition, employers benefit because their costs for prepaid dental care fringe benefits for their employees are lower20. Employers also avoid the extra costs required when their employees are absent from work due to personal or family visits for dental care20. Consumers benefit because they pay lower costs for consumer goods since employers' costs for insurance and employee absences is lower20. In other words, the cost of doing business in a fluoridated community is lower for employers. Additionally, all patients benefit in several ways. First, their overall health care bills and insurance premiums are lower in fluoridated communities because there are fewer expensive hospital emergency room visits for dental emergencies, costs of which are usually passed on to everyone able to pay through their health care bills and insurance premiums". Secondly, patients in fluoridated communities avoid having to pay higher health care bills, dental bills, and insurance premiums that often result from the need for physicians, dentists, and hospitals to pass on their extra costs for uncompensated care ,•� to those who-can pay20. It is most apparent that everyone wins with fluoridation. Not only do individuals benefit because of their improved oral health, but they. benefit greatly because cost savings resulting directly and indirectly from a community's decision to fluoridate. Fluoridation ultimately promotes lower health care costs, lower insurance costs, lower tax - supported costs for public programs, lower business costs for employers, and lower costs for consumer goods and services20. What Other Impact Is Water Fluoridation Having On Consumer Or Taxpayer Costs? The extensive use of community water fluoridation in the United States has contributed substantially to decreasing consumer and taxpayer costs for supporting dental education. Because of lower levels of dental decay in the U. S. population, fewer dentists are needed to care for those currently in the health care system. As a result, seven dental schools have ceased operations since 198521. In addition since 1980, enrollment reductions in the remaining dental schools have been equivalent to the closure of another 20 average size dental schools21. Community water fluoridation has also had an impact on the costs of dentists' malpractice insurance. Dentists practicing in fluoridated communities pay significantly lower malpractice insurance premiums than dentists practicing in non - fluoridated communities22. These lower malpractice Insurance rates occur for several reasons. First, since the population suffers from much less decay in fluoridated communities, dentists do not spend as much time providing extensive reparative procedures and therefore are less likely to run into treatment complications. Secondly, dentists also require less use of general anesthesia and other forms of premedication in fluoridated communities because there are fewer cases of rampant decay in young children. Packet Page -983- 9/13/2011 Item 10.C. Who Supports Community Water Fluoridation? Most legitimate organizations representing health professionals, public health agencies, and scientists strongly support community water fluoridation. The American Medical Association, American Public Health Association, American Nurses Association, American Osteopathic Association, American Academy of Pediatrics, American Academy of Family Physicians, American Dental Association, American Dental Hygienists Association, Association of State & Territorial Health Officials, National Association of County & City Health Officials, American Dietetic Association, U. S. Public Health Service, National Institutes of Health, Centers for Disease Control, World Health Organization, American Water Works Association, and National Rural Water Association represent just a few of the hundreds of organizations that support fluoridation 23, It is important to note that these broadly based organizations represent millions of health practitioners, scientists and other professionals. These credible and respected organizations have also been working to improve the lives of Americans for many years. They are organizations and agencies with established administrative offices, some with state and local chapters, and many publishing peer - reviewed scientific journals. Community water fluoridation has also been repeatedly shown to have wide support of the American public2"'2b. Most recently, a national scientific poll taken by the prestigious ballup Organization documented that 70% of Americans thought community water systems should be fluoridated, 12% did not know, and only 18% thought that community water systems should not be fluoridated24. Who Opposes Community Water Fluoridation? While there is a small, very vocal, minority of the population that opposes the implementation of community water fluoridation, no credible national scientific or professional organization opposes the practicetB2B. Individuais who oppose fluoridation are often called'antifluoridationists." Most groups that claim to oppose fluoridation have few members, have no history because they have been organized for relatively short periods of time, have no established offices because they often operate out of individuals' homes, and have unfamiliar names and spokespersons ",". These groups have been granted no professional credibility or scientific standing by the scientific or healthcare communities, publish no accepted scientific journals, and frequently use multiple names in order to appear to have more support for their position than actually exists' 1,26,31, Most of the groups lack any stability, disbanding and reforming periodically as interest in their movement periodically increases or subsides", 21-31. The antifluoride groups often publish pseudoscientific propaganda pieces which, when vigorously reviewed and investigated, lack anybasis in science's, ""'. Many of these organizations operate exclusively though the Internet where there is little in place to protect consumers from their scientifically invalid claims and their extensive propaganda . Summary and Conclusions Community water fluoridation has served the American public extremely well as the cornerstone of dental caries prevention activities for more than 60 years. The dental health and general health benefits associated with the consumption of water -borne fluorides have been documented for over 100 years. Ongoing research, often conducted in response to the repeated allegations by those opposed to fluoridation, continues to confirm the safety, effectiveness, efficiency, cost- effectiveness, and environmental compatibility of community water fluoridation. Fluoridation also continues to be acclaimed as an important contributor to the health of the nation, most recently being named as one of the twentieth century's ten greatest public health achievements49. Dr. David Satcher, previously the Assistant 7 Packet Page -984- 9/13/2011 Item 10.C. Secretary for Health and the Surgeon General of the United States, reconfirmed the support of his office for community water fluoridation as part of his focus on America's oral health50-51. In addition, Vice Admiral Richard H. Carmona, the current Surgeon General of the United States, stated: "Policy makers, community leaders, private industry, health professionals, the media, and the public should affirm that oral health is essential to general health and well being and take action to make ourselves, our families, and our communities healthier. I join previous. Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing the oral health of all Americans: The adoption of community water fluoridation by local communities and state legislatures represents an excellent example of good public policy. Communities throughout the United States continue to exhibit sound decision- making and evidence their continued trust and faith in science and the health professions by adopting fluoridation. The acceptance of community water fluoridation by public officials ensures that all citizens of a community, regardless of age, race, ethnic background, religion, gender, educational status, or socioeconomic level, receive the same substantial dental disease prevention benefits currently available to the 162 milli on Americans on fluoridated water systems. REFERENCES' 1, Garcia Al: Caries incidence and costs of prevention programs. J Public Health Dent 1989; 49(5):259 -71. 2. U. S. Centers for Disease Control & Prevention. Public health focus: fluoridation of community water systems. MMWR: Update 1992; 41(21):372.5. 3, Murray JJ. Efficacy of preventive agents for dental caries. Caries Res 1993; -27(Suppl 1):2 -8. 4. Newbrun E. Fluorides and dental caries, 3rd ed. Springfield, IL; Charies•C. Thomas, publisher, 1986. 5. Lambrou D, Larsen MJ, Fejerskov O, & Tachos G. The effect of fluoride in saliva on remineralization of dental enamel in humans. Caries Res 1981; 15:341 -5. 6. Burt BA (ed.). The relative efficiency of methods of caries prevention in dental public health: proceedings of a workshop at the University of Michigan, Jun 5-8,1978. Ann Arbor, MI; University of Michigan Press, 1978. 7. Burt BA (ed.). Proceedings for the workshop: cost effectiveness of caries prevention in dental public health, held at Ann Arbor, Ml, May 17 -19, 1989. J Public Health Dent 1989; 56(5, Spec Issue):249 -344. 8. Murray JJ, Rugg -Gunn AJ, & Jenkins GN. Fluoride in caries prevention, 3r" ed. Oxford, England, UK; Wright, publisher, 1991. 9.- Levy SM, Kiritsy MC, & Warren JJ. Sources of fluoride intake in children. J Public Health Dent 1995; 55(1):39 -52. 10. U. S. Centers for Disease Control & Prevention. Water fluoridation: a manual for water plant operators. Atlanta, GA, The Agency, Apr 1994. 11. Galagan DJ & Vermillion JR. Determining optimum fluoride concentrations. Public Health Rep 1957; 72:491 -93. 12. National Academy of Sciences, Institute of Medicine (Food & Nutrition Board). Dietary reference intakes for calcium, phosphorous, magnesium, vitamin D, & fluoride; report of the standing,committes on scientific evaluation of dietary reference intakes. Washington, DC; National Academy Press; 2000. 13. U. S. Department of Health & Human Services, Public Health Service. Review of fluoride benefits and risks: report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related programs. Washington, DC; The Agency; Feb 1991. 14. Burt BA & Eklund SA. Dentistry, dental practic, & the community, 46-147. Philadelphia, PA; W. B. Saunders Company, publisher, Packet Page -985- 9/13/2011 Item 10.C. 15. U. S. Centers for Disease Control. Fluoridation Census, 2000. Atlanta, GA; The Agency; 2001.. 16. Easley, MW. The status of community water fluoridation In the United States. Public Health Rep 1990; 105(4):348 -353. 17. Delaware State Senate, 139b' General Assembly. Senate Bill No. 173 - An act to amend title 16 of the Delaware Code relating to fluoridation of water supplies. Delaware Online Legislative Information Service at http:l /www. state. de.us /govem /agencies /leg!sA!s /139/bllls/107796.htm. 18. Kentucky Administrative Regulations. Title 401, Chap. 8 - Public Water Supply; 401 KAR 8:650 - Supplemental Fluoridation. 19. Palmer C. Dental spending exceeds $50 billion. Am Dent Assoc News, 1998; 29(22):1,30. 20. White BA, Antczak- Bouckoms AA, Milton C, & Weinstein MC. Issues In the economic evaluation of community water fluoridation. J Dent Educ 1989; 53(11):646 -657. 21. Nash, DA. And the band played on. J. Dent Educ, 1998; 62(12):964 -974. 22. Conrad DA, Whitney C, Milgrom P, O'Hara D, Ammons R, Fiset L, & Vesneski W. Malpractice premiums in 1992: results of a national survey of dentists. J Am Dent Assoc, 1995; 126:1045 -1056. 23. American Dental Association (Council on Access, Prevention, & Interprofessional Relations). Fluoridation Facts. Chicago, IL; The Organization, 2005.70p. 24. Am. Dent A. (Survey Center). 1998 consumers' opinions regarding community water fluoridation. Chicago, IL; The Organization, Aug 1998. ' 25. Gallup Organization, Inc. A Gallup study of parents' behavior, knowledge, and attitudes toward fluoride. Princeton, NJ; The Organization, 1991. 26, Easley MW. The new antifluoridationists: who are they and how do they operate? J Public Health Dent 1985; 45(3):133 -141. 27. Barrett S & Rovin S (eds.). The tooth robbers: a pro - fluoridation handbook: Philadelphia, PA; George F. Stickley Company, 1980. 28. Wulf CA, Hughes KF, Smith KG, & Easley MW. Abuse of the scientific literature in an antifluoridation pamphlet (2nd ed.). Baltimore, MD; American Oral Health Institute Press; 1988. 29. Easley MW. Celebrating 50 years of fluoridation: a public health success story. British Dent J 1995; 178(2) :72 -5. 30. Easley MW. Fluoridation: a triumph of science over propaganda. Priorities (J American Council on Science & Health) 1996; 8(4):35 -39. 31. Easley MW. Community water fluoridation. p.48 -49, in American Council on Science & Health. Facts versus fears, special report: a review of the greatest unfounded health scares of recent times. New York, NY; The Organization, 1998. 32. McGuire S. A review of the impact of fluoride on adult caries. J Clin Dent 1993; 4(1):11 -13. 33. Melbert JR & Ripa LW. Fluoride In preventive dentistry: theory and clinical applications. Chicago, IL; Quintessence; 1983:41 -80, 34. Grembowski D, Fiset L & Spadafora A. How fluoridation affects adult dental caries: systemic and topical effects are explored. J Am Dent Assoc 1992; 123:49 -54. 35. Stamm JW, Banting DW & Imrey PB. Adult root caries survey of two similar communities with contrasting natural water fluoride levels. J Am Dent Assoc 1990; 120 :143 -149. 36, Newbrun E. Prevention of root caries. Gerodont 1986; 5(1) :33 -41. 37. Am. Dent A. (Council on Access, Prevention, & Interprofessional Relations). Caries diagnosis and risk assessment: a review of preventive strategies and management. J Am Dent Assoc 1995; . 126(Suppi). 38. Brown LJ, Winn DM, & White BA. Dental caries restoration and tooth conditions In U. S. adults, 1988 -1991. J Am Dent Assoc 1996; 127:1315 -1325. 9 Packet Page -986- 9/13/2011 Item 10.C. 39. Rugg -Gunn AJ. Nutrition and dental health. New York, NY; Oxford University Press; 1993. - 40. Kaminsky LS, Mahoney MC, Leach J, Melius J, & Miller MJ. Fluoride: benefits and risks of exposure. Crit Rev Oral Blot Med 1990;1:261 -281. 41. National Academy of Sciences (Committee on Animal Nutrition and the Subcommittee on Fluorosis). Effects of fluorides in animals. Washington, DC; The Organization; 1974. 42. Pendrys DG & Stamm JW. Relationship of total fluoride intake to beneficial effects and enamel fluorosis. J Dent Res 1990; 69(Spec lssue):529 -538. 43. Olson RE (ed.). Fluoride in food and water. Nutr Rev 1986; 44(7):233 -235. 44. Leone NC, Shimkin MB & Arnold FA, et al. Medical aspects of excessive fluoride in a water supply. Public Health Rep 1954; 69(10):925 -936, 45. Whitford GM. The metabolism and toxicity of fluoride (2nd rev. ed.) in Monographs in oral science. Basel, Switzerland; Karger; 1996. (Vol. 16). 46. Dean HT.. The investigation of physiological effects by the epidemiological method In Moulton FR (ed.). Fluorine and dental health. Washington, DC; Am Assoc Advancement Sci Publ. No. 19; 1942:23 -31. 47. Lewis DW & Banting DW. Water fluoridation! current effectiveness and dental fluorosis. "Community Dent Oral Epidemlol 1994; 22:153 -158. 48. National Research Council. Health effects of ingested fluoride: report of the Subcommittee on Health Effects of Ingested Fluoride. Washington, DC; National Academy Press; 1993. 49 United States, f1900 -1999. Morbidity &eMortality Weekly Reportll48 (12) :2 1-243 Achievements: April 2, 1999. 50. Satcher D. (U.S. Surgeon General). Letter to Collins, TR (Chairman, California Fluoridation Task Force). October 19, 1998. 51. Satcher D. (U.S. Surgeon General). Oral Health in America: A Report of the Surgeon General. Rockville, MD; U.S. Department of Health & Human Services; June 2000. 311p. 52. Barsley, R. Sutherland J. & McFarland L. Water Fluoridation and the Costs of Medicaid Treatment for Dental Decay, Louisiana, 1995 -1996. Morbidity & Mortality Weekly Report, 48(34):753 -757. September 3, 1999. 53, Texas Department of Health. Wafer Fluoridation Costs in Texas: Texas Health Steps (EPSDT- Medicaid). Austin, TX; The Agency; May 2000. 14p. 54. Carmona, RH. (U.S. Surgeon General). Official Signed Statement on Community Water Fluoridation. Press Release from the U.S. Department. of Health &. Human Services, Centers for Disease Control & Prevention. Atlanta, GA; July 28, 2004. 55. Silverstein, SC. Testimony Before Congressional Biomedical Research Caucus, U :S. Congress. Rayburn House Office Building, Capitol Hill, Washington, DC. February 10, 1995. ' 65. Griffin, SO. Jones, K., Tomar, SL.. An Economic Evaluation of Community Water Fluoridation. J. Public Health Dent 2001;61(12):78 -86. 56. Jones, S. Burt, BA. Petersen, PE. & Lennon, MA. The Effective Use of Fluorides in Public Health. Bull World Health Organization. Sept 2005. pp.670 -676. 57. Am Dent A. Fluoridation Facts. Chicago, IL, The Association. 2005. 70p. 58. Centers for Disease Control. Water Fluoridation Reporting System (WFRS), 2005. 59. USDHHS /CMS. Health Accounts: National Health Accounts /national Health Expenditures (Table 3) and National Health Expenditure Projections 2003 -13 (Table 8). http : / /cros.hhs.govistatisticslnhe/ ACKNOWLEDGEMENT: The editor wishes to thank Dr. Harry W. Davis, Dental Executive Director; Dr. Millard Howard, Dental Coordinator; and Mr. Sean P. Isaac, Fluoridation Coordinator; all of the Bureau of Dental Public Health; Florida Department of Health for their assistance in updating Florida health & demographic data and in reviewing the manuscript. Packet Page -987- rdmil About the Author:. 9/13/2011 Item 10.C. Dr. Michael W. Easley currently serves as Dental Coordinator for the Bureau of Dental Public Health, Division of Family Health, Florida Department of Health. He also serves as the volunteer Director of the National Fluoridation Center at Oral Health America. He has a doctorate in dentistry from Ohio State University & a masters in dental public health administration from the University of Michigan. He completed a one - year public health leadership fellowship with the National Public Health Leadership Institute at the University of California - Berkeley and completed a two -year residency in Dental Public Health through the University of Texas Health Science Center at Houston. Prior to coming to Florida, Dr. Easley served as the President & Chief Executive Officer of International Health Management & Research Associates, a public health 11-1k, consulting firm. He recently served as a full -time Associate Professor in the College of Health Sciences, Eastern Kentucky University, was a full -time Associate Professor in the Schools of Medicine and Dental Medicine, University at Buffalo, served a term as Governor Brereton Jones' appointee in the position of Director of Environmental Health & Community Safety for the Commonwealth of Kentucky, and served as the Commissioner of Health & Environment for the Middletown [Ohio] City Department of Health & Environment. Dr. Easley was Associate Director of Professional Relations for Procter & Gamble's Health Care Products Division and Coordinator of Worldwide Pharmaceutical Research for Procter & Gamble's Oral Care Research Section. He previously was Director of the Division of Dental Health for the Ohio Department of Health and also was Director of the Division of Dental Health for the Maryland Department of Health & Mental Hygiene. He served as a clinical general dentist in private practice and a clinical dental surgeon and hospital clinic manager in the U.S. Navy and U.S. Public Health Service. He also served as the Associate Director of Clinics (and Associate Professor) at the University of Detroit's School of Dentistry and was the manager of a large hospital dental clinic affiliated with the University of Detroit, Wayne State University, and Detroit Receiving Hospital. Doctor Easley has held a number of offices in national health and public health organizations, including President of the American Association of Public Health Dentistry, Chair of the Oral Health Section of the American Public Health Association, two terms as a member of the Board of Directors of the Association of State & Territorial Dental Directors, and two terms as President of the American Oral Health Institute. He has authored or co- authored several textbooks and monographs and has published ^ more than one hundred articles in professional journals. I I Packet Page -988- Cost Savings - Fact Sheets - Community Water Fluoridation - Oral Health Home About CDC Press Room A -Z Index Contact Us Community Water Fluoridation 9/13/2011 Item 10.C. Cc Search: 0 E -mail this pal g Printer - friend( Oral, Health Home > Community Water Fluoridation Home > Fact Sheets View by Topic Cost Savings of Community Water Fluoridation > Benefits Two published studies conducted by CDC reaffirm the benefits of community water fluoridatit > et S, e the studies continue to show that widespread community water fluoridation prevents cavities > Statistics money, both for families and the health care system. In fact, the economic analysis found tht: > Enalneering and communities of more than 20,000 people where it costs about 50 cents per person to fluoridt Operations every $1 invested In this preventive measure yields approximately $38 savings in dental trea > Offer Fluoride Products Contact Us > Fact Sheets "An Economic Evaluation of Community Water Fluoridation" t presents the results of an ecot modern conditions of widespread availability of fluorides. > F Qs analysis of water fluoridation under from CDC and Terry College of Business, University of Georgia, found that under typical con > Guidelines and annual per - person cost savings In fluoridated communities ranged from $16 in very small cot Recommendations ( <5,000) to nearly $19 for larger communities ( >20,000). The analysis takes Into account the > Journal Arlicleq installing and maintaining necessary equipment and operating water plants, the expected eff > Related rinks fluoridation, estimates of expected cavities in non - fluoridated communities, treatment of cavil lost visiting the dentist for treatment. Contact Info A related analysis found that children living in non- fluoridated communities in states that are Centers for Disease Control fluoridated receive partial benefits of fluoridation from eating foods and drinking beverages p Prevention and Prev Division a Oral Health fluoridated communities. This second study, Quantifying the Diffused Benefit from Water Flt reports that 12-year-old children living in states where-more than half of the communities ha), Mail Stop F-10 water have 26% fewer decayed tooth surfaces per year than 12- year -old children living in stz Highway NE 4770 Buford H igh less than one- quarter of the communities are fluoridated. Atlanta, GA 30341 "Widespread community water fluoridation prevents cavities even in neighboring communitie Contact Us fluoridated," according to Dr. Susan Griffin, the study's main author. "For instance, a 12 -year ...................................................... who has lived in a non- fluoridated community in a highly fluoridated state would typically hav cavity than a child in a low- fluoridated state." References 1. Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluor Publ Health Dent 2001;61(2):78 -86. View abstract on PubMed. 2. Griffin SO, Gooch BF, Lockwood SA, Tomar SL, Quantifying the diffused benefit fluoridation in the United States. Community Dent Oral Epidemiol2001;29:120 -1 abstract on PubMed. Related Links s Recommendations for Using_Fluoride to Pre_v_ent aand Control Dental Caries in the States. MMWR, Vol. 50, No. RR14;1 -42. (August 17, 2001) Water Fluoridation Fact Shee , 1992 Date last reviewed: September 26, 2007 Date last updated, August 9, 2007 Content source: Division of Orai Health, Nationai_Cenier for Chronic Disease Prevention and i"1 Promotion Home j Policies and Regulations I Disclaimer I e-Governmen I EQIA j C_0__nta_Gl1LLs Packet Page -989- ,_..._. hfm 3/19/2009 Fluoridation - Fact Sheets. Benefits �VJ'ater. Fluoridation Oral Health Home Water Fluoridation Key Resources on Topic } Home Fact Sheets ? Benefi y Safety y Statistics E itg neerin_o and Operations ? Other Fluoride Products Pubi €cations Related L€nks Contact Info Centers for Disease Control and prevention vislon of Oral Health .ail Stop F -10 4770 Buford Highway NE Atlanta, GA 30341 Contact Us IL Guidelines & Recommendations 9/13/2011 Item 10.C. ..................... . .......... I........................ .: p Email this papa rg Printer - friendly version .............. . .......................................... .: Questions & Answers The Benefits of Fluoride`s -��, l� From the Office of the Surgeon General, U.S. Department of Health and Human Services d May 2000 r7B� • Community water fluoridation is an effective, safe, and inexpensive way to prevent tooth decay. This method of fluoride delivery benefits Americans of all ages and socioeconomic status. • Brushing twice a day with a fluoride toothpaste Is an easy way to prevent tooth decay. • Fluoridation, which was started In Grand Rapids, Michigan in 1945, has been used successfully in the United States for more than 50 years. It benefits both children and adults. . Fluoride works by stopping or even reversing the decay process. It keeps tooth enamel strong and solid. . Community water fluoridation Is considered one of 10 great public health achievements of the 20th century. . Of the 50 largest cities In the United States, 42 have community water fluoridation (and 2 titles are have natural fluoride levels that are optimaQ. Fluoridation reaches 67 percent of the population on public water supplies — more than 170 million people. • The annual cost of fluoridation is approximately $0.50 In communities of Z 20,000 to approximately $3.00 per person In communities 5 5,000 (in 1995 dollars) for all but the smallest water systems. Even so, 100 million Americans do not have access to fluoridated water. • Communities with fluoridated drinking water in the United States, Australia, Britain, Canada, Ireland, and New Zealand show striking reductions In tooth decay —those with fluoridated drinking systems have 15-40 percent less tooth decay. • Nearly all tooth decay can be prevented when fluoridation Is combined with dental sealants and other fluoride products, such as toothpaste. • Fluoride dietary supplements can provide fluoride to those who do not have adequate levels in their drinking water. They are available as tablets, drops, or lozenges. • Over-the-counter fluoride dental products such as toothpastes and mouth rinses are effective In preventing. decay. o Products with high concentrations of fluoride that are applied in the dental office or prescribed for home use offer additional protection for those at Increased risk of tooth decay. . Because older Americans are now keeping their teeth longer, fluoride will continue to be Important for �\ preventing tooth decay In this age group. Older Americans are especially susceptible to tooth decay because of exposed root surfaces and mouth dryness that may result from many medications. . For more information, contact: ftcJ// C€ Documents °.520and %20SettingaftsmacSP/ Desktop / Fluoridation°/. 20-'/` 2OFact %2OSheets• /*20- %2OBcnoflEs.him(1 of2)9127/200610:42:58AM Packet Page -990- Osteosarcoma - Safety - Community Water Fluoridation - Oral Health 9/13/2011 Item 10. C. Home About CDC Press Room A -Z Index Contact Us Search: Community Water Fluoridation 0 frig papas Printer- friendlt ,.��, rime Oral Health Home > Community Water Fluoridation Home > Safet View by Topic CDC Statement on Water Fluoridation and Osteosarcoma > Benefit > Safety Osteosarcoma is a type of rare bone cancer. About 400 children and adolescents in the Unit, > Statistics diagnosed each year, approximately 250 of whom are males. An observed association betw( to fluoride in drinking water and the incidence (new cases) of osteosarcoma In young males I > Enclineerina and reported in a paper entitled Age- specific Fluoride Exposure In Drinking Water and'Osteosarc Operations States) (Bassin et al., 2006). No apparent association was observed in females. This researc > Other Fluoride Products author describes as an exploratory analysis, adds to the scientific knowledge base on this tol > Fact Sheets author acknowledges that this study has limitations and further research Is required to confirl this observation. > FAQs > Guidelines and This paper Is based on the analysis of an initial set of cases from a 15 -year effort to study flu Recommendations osteosarcoma by the Harvard School of Dental Medicine and collaborating organizations. Th > Journal Articles investigator for the overall study cautions against over interpreting or generalizing the results > Related Links Bassin analysis, stressing that preliminary analysis of a second set of cases does not appeal the findings (Douglass et al., 2006). Publications from the forthcoming analyses are expecte( further information as to whether and to what extent an association may exist between osteo Contact Info exposure to fluoride. Centers for Disease Control and Prevention A number of studies regarding water fluoridation and osteosarcoma have been published in I Division of Oral Health this time, the weight of the scientific evidence, as assessed by independent committees of e) Mail Stop F -10 comprehensive systematic reviews, and review of the findings of individual studies does not 4770 Buford Highway NE association between water fluoridated at levels optimal for oral health and the risk for cancer Atlanta, GA 30341 osteosarcoma. in a report issued in March 2006, Fluoride in Drinking Water; A Scientific Rev Standard, the National Research Council (NRC, 2006) considered all available evidence on i Contact Us osteosarcoma, including pre - publication data from the analysis by Dr. Bassin. The NRC Corr the overall evidence on osteosarcoma to be tentative and mixed, and no recommendations v ....................... ..........I.................... related to this health concern for revising current allowable fluoride levels in drinking water. stated that the results of the larger Harvard study, once published, may provide an important addition to the weight of scientific evidence regarding this condition. CDC's mission includes monitoring health, detecting and investigating health problems, deve advocating for sound public health policies, implementing prevention strategies, promoting h, behaviors, and fostering safe and healthful environments. The overriding goal and concern I. the health and well being of the public. CDC continually monitors and evaluates scientific inft fluoridation as part of its responsibility for public health assurance and protection, CDC, alon! experts in the scientific community, will review published studies when they become availabil continue to monitor other scientific developments related to water fluoridation, and will provid and recommendations about fluoride to the public. CDC continues to strongly support community water fluoridation as a safe and effective publi measure to prevent and control tooth decay and to improve overall health. Water fluoridation people of all ages and socioeconomic groups, including those difficult to reach through other programs and private dental care. CDC has recognized community water fluoridation as one public health achievements of the 20th century. Those wishing to learn more about fluoridatit CDC's Recommendations_for Using_Fit oride_to Prev_entand.Control Dental Care s.in the Uni and other information at www.cdc.gov /oralhealth. References Bassin EB, Wypfj D, Davis RB, Mittleman MA. Age - specific fluoride exposure in drinking watt osteosarcoma (United States). Cancer Causes and Control 2006;17:421 -428. Douglass CW, Joshipura K. Caution needed in fluoride and osteosarcoma study. Cancer Ca. Control 2006;17:481 -482. Packet Page -991 - thttn -Hwvvw r•rir'. env /flrTni- illation /safety /nstensarcoma.htm 3/19/2009 Trends in Children's Oral Health he Surgeon General's Report on Oral Health identifies a "silent epidemic" of dental and oral diseases, and calls for a national effort to improve oral health among Americans.1 Left untreated, the pain and infection caused by dental caries (tooth decay) can lead to problems in eating, speaking, and the ability to learn.2 Access to Children from families with low incomes had five times Oral Health Care more untreated dental caries than children from higher income families. For each child without medical insurance, there are almost three children without dental insurance .3 Only about 50 percent of white children, 39 percent of African - American children, and 32 percent of Mexican - American children have dental insurance .4 9/13/2011 Item 10.C. Serious facial ssvelling from a tooth abscess resulting from decay. Children With Results of the 1994 -95 National Health Interview Survey on access to care and use of ser- vices by children with special health care needs indicate that the most prevalent unmet health Special Health need is dental care. Among the respondents, 8.1 percent reported unmet dental care needs, Care Needs 4.1 percent reported unmet prescription and eyeglass needs, 3.2 percent reported unmet med- ical care needs, and 1.2 percent reported unmet mental health care needs.5 More than half of the dental schools in the United States provide students with less than 5 hours of classroom instruction on patients with special health care needs and devote less than 5 percent of clinical time to this population-6 Early Childhood It is recommended that professional intervention begin at approximately 12 months of age or Caries shortly after the primary teeth begin to erupt. The goal of the first dental visit is to assess the risk for dental disease, initiate a preventive program, provide anticipatory guidance, and decide on the periodicity of subsequent visits.? Children with early childhood caries weigh significantly less than their peers. With compre- hensive dental rehabilitation, these children can experience significant "catch-up" growth.$ The average Medicaid cost for providing restorative dental care for early childhood caries under general anesthesia in the hospital is $2,000 per case .9 Fluoridation Water fluoridation reduces dental caries in perma- nent teeth by 17 to 40 percent.10 However, more than 100 million Americans (38 percent of those on public water systems) do not have access to water that contains enough fluoride to protect their teeth.11 /*N Ul kpakrm 0MA mflimsuft *fla-9;,L5\, fs WkRemcesMaSsrvkesAdmkLtrmba ■� hbier QMchURWhhBweau O Although other fluoride - containing products are available, water remains the most equitable and cost - effective method of delivering fluoride to members of a community, regardless of an individual's age, educational attainment, or income level.12 Nationally, the average per capita cost of water fluoridation is $0.51 per year.1e Over a life- time, this can be ler- "- -- 'L_ --- - "1- -ing one dental filling.11 Packet Page -992- Dental Sealants 9/13/2011 Item 10.C. Over 80 percent of tooth decay in school children is on the chewing surfaces of the teeth; use of dental sealants can prevent this type of decay13 Only 23 percent 'of all children have dental sealants. Further, as few as 3:percent of children from low- income families have dental sealants.14 In 1999 the average cost for placing a dental sealant was $29.09, compared to the average cost of $65.09 for a one - surface dental filling.15 Most dental sealants are placed in private - practice dental offices, but the children at the greatest risk for problems resulting from tooth decay are those least likely to receive dental care in a private practice.13 Injury and By age 16 years, 35 percent of children will have sustained dental trauma at least once,16 Violence Craniofacial, head, face, and neck injuries occur in more than half of the cases of child abuse.17 Dentists and dental hygienists are in a unique position to recognize child abuse and neglect. Used during sports, mouth guards offer a substantial degree of protection to the teeth and oral soft tissues, as well as protecting children and adolescents from.concussion.l$ Tobacco Tobacco use, especially cigarette smoking, is a significant risk factor for periodontal disease.19 Cancer- related signs and symptoms may include sores that do not heal, gingival recession, or difficulty in chewing, swallowing, or moving the tongue or jaw20 Smokeless tobacco can result in advanced gum di §ease that is irreversible. As teeth lose their gum and bone support, they may loosen and eventually have to be removed.21 Among students in grades 9 through 12, 9 percent currently use spit tobacco, and 43 percent use some form of tobacco (cigarettes, spit tobacco, or cigars). In this age group, 29 percent of black orAfrican Americans, 37 percent of Hispanic or Latinos, and 47 percent of whites smoke tobacco.25 References 1. , National Institute of Dental and Craniofacial Research. 2000. The Surgeon General's Report on Oral Health. In National Institute of Dental and Cranio- facial Research [Web site]. Cited December 4, 2000; available at httpJ /wvnv.nidr.nih.gov /sgr /sgr.htm. 2. U.S. General Accounting Office. 2000. Oral Health: Dental Disease cis a Chronic Problem Among Low- Income Populations and Vulnerable Populations. Washington, DC: U.S. General Accounting Office. 3. Vargas CM, Isman RE, Cratl JJ. In press. Comparison of children's medical and dental msur- ance coverage by socioeconomic characteristics, U.S. 1995. [Journal name to come] 4. U.S. Department of Health and Human Services, Public Health Service. 1992. Current Ertimaterfrom the National Healtb Interview Survey, 1991. Hyattsville, MD: US. Department of Health and Human Services. S. Newacheck PW, McManus M, Fox HB, Hung YY, Halton N. 2000. Access to health care for children with special health care needs. Pediatrics 105(4 Pt- 1):760-766. 6. Romer M, Dougherty N, Amores- LaSeur E. 1999. Predoctoral education in special care dentistry: Paving the way to better access? Journal of Dentistry for Children 66(2) :132 ^135. 7. Nowak AJ.1997. Rationale for the timing of the first oral evaluation. Pediatric Dentistry 19(1):6 -11. . 8. Act G, Shulman R, Ng MW, Chussid S. 1999. The effect of dental rehabilitation on the body weight of children with early childhood caries Journal of Pediatric Dentistry 21 (2):109 -113. �M ■ .® ' katbnal Cantu rer Education - Nal7nilAyamJaG.Yd to Hatermt and Vald Health Oral Health GEOrpte Ualrert(t, !!SOURCE CENrEt 9, Kanellis MJ, Da -dano PC, Momany ET. 2000. Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia-Journal of Public Health Dentistry 60(1)28 -32. 10. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2000. Water fluoridation frequently asked questions. In CDC National Center for Chronic Disease Prevention and Health Promotion [Web site]. Cited December 15, 2000; available at bttp-1/vvmv.cdc.gov/nccdphp/oh/fl-faqs-htm- 11. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion 2000. CDC's oral health pro- gram, at- a- glance. In CDC National Center for Chronic Disease Prevention and Health Promotion [Web site]. Cited December 15, 2000; available at httpJ/ www. cde.gov /nccdphp/oh/ataglanc.htm. 12. Centers for Disease Control and Prevention. 2000. Achievements in public health, 1900--1999: Flaorl- dation of drinking water to prevent dental runes. CDC MMWR Weekly [Web site].-Cited October 25,2000; available at httpl /wwwc&gov /mmwr/ preview /mmwrhtm11mm4841a1.h tm. 13. Siegal MD, Farquhar Ci,, Bouchard JM.1997. Dental sealants: Who needs them? Public Health Reports 112(2):98 -106. 14. U.S. Depamnent of Health and Human Services, Office of Disease Prevention and Health Promotion. 2000. Healthy People. In US. Department of Health and Human'Services, Office ofUsease Prevention and Health Promotion [Web site]. Cited December 4, 2000; available at http J /w,,xwhealth-gov/healdg? -ple- 15. Crall J. Faculty member, Department of Pediatric Dentistry. 2000, June 21. Personal communication. Farmington, CT: University of Connecticut Health Center. 16. Slavkin HC. 2000. Compassion, communication and craniofaciel orodental trauma: Opportunities abound Journal oftbeAmerican DentalAssaiation 131(4): 507 -510. 17, American Academy of Pediatrics, Committee on Child Abuse and Neglect, and American Academy of Pediatric Dentistry, Ad Hoc Work Group on Child Abuse and Neglect. 1999. Oral and dental aspects o#' child abuse and neglect Pediatria 1042 Pc 1):348 -350. 18. Sullivan, JA, Anderson SJ, eds. 2000. Care ofibe YoungAtblete. Rosemont, IL: American Academy of Pediatrics and American Academy of Orthopaedic Surgeons. 19. Geaco RJ.1996. Current view of risk factors for periodontal diseases. Journal ofPeriadontalogy 67 (Suppl.l0):1041 -1049. 20. American Dental Association, 1998. ADO Guide to DentalTherapeutiet (1st ed.). Chicago, IL: American Dental Association. 21. Brown L, Lewis G, Martin M, Fowler R, Spohn E, Hardison D, eds. 1996. Kentucky Smile Curriculum: An oral Health Education Manual. Louisville, KY: College of Dentistry, University of Kentucky, and Kentucky Cancer Program; Frankfurt, KY. Kentucky Cabinet for Human Resource; and n.p.: Kentucky Oral Health Consortium. This publication has been produced by the National Maternal and Child Oral Health Resource Center sup- ported at the National Center for Education in Maternal and Child Health, Georgetown University, under its cooperative agreement (MCU- 119301) with the Maternal and Child Health Bureau, Health Resources and Services TT q n,- ,t^t "nt of Health and Human Services, with assistance from the National Oral He Packet Page -993- and many colleagues working in oral health. February 2001. GOVERNMENTAL AFFAIRS OFFICE 118 E. Jefferson SL Tallahassee, FL 32301 Phone: 904-224-1089 • Fax: 9042247058 9/13/2011 Item 10.C. I n�n� I - DENTISTRY. HEALTHCARE THAT WORKS fLORIDA DENTAL ASSOCIATION n October 13, 1997 Dr. Harry Davis Department of Health Public Health Dental Program 1323 Winewood Tallahassee, FL 32399-0700 Re: FDA Endorsement of Community Water Fluoridation Projects Dear Dr. Davis: The Florida Dental Association's Board of Trustees and House of Delegates unanimously adopted the following resolution. on August 3, 1991: WHEREAS,. forty -five years of exhaustive study and more than fifty years of community experience have demonstrated community water fluoridation to be the safest and most effective method to prevent dental caries (decay); and, WHEREAS, the health and economic benefits of water fluoridation accrue to individuals of all ages and socioeconomic groups, especially poor children; and WHEREAS, The February, 1991 study released by the U.S. Public Health Service reaffirms.the effectiveness of community water fluoridation and strongly recorimmends that municipalities "Continue the addition of fluorides to water supplies wherever it Is deficient." Therefore be it RESOLVED, that the FDA unequivocally supports the optimal fluoridation of drinking water as a safe; effective and economical way to prevent dental caries. You may assure the Department of Health and others that The Florida Dental Association continues to strongly support the optimal fluoridation of drinking water as a safe, effective, and economical way to prevent dental caries. Sincerely, Q• Carol A. Berkowitz, Esq. Governmental Affairs CB/rr cc: Dr. Thomas P. Floyd, President Dr. Hai Haering, Chairman of Governmental Affairs Dan Buker, Executive Director Packet Page -994 - Debbie Huev. Director of Governmental ATrairs s fJ 9/13/2011 Item 10.C. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Office of the Surgeon General Rockville MD 20857 July 28, 2004 SURGEON GENERAL STATEMENT ON COMMUNITY WATER FLUORIDATION As noted in Oral Health in America: A Report of the Surgeon General, community water fluoridation continues to be the most cost - effective, equitable and safe means to provide protection from tooth decay in a community. Scientific studies have found that people living in communities with fluoridated water have fewer cavities than those living where the water is not fluoridated. For more than 50 years, small amounts of fluoride have been added to drinking water supplies in the United States where naturally- occurring fluoride levels are too low to protect teeth from decay. Over 8,000 communities are currently adjusting the fluoride in their community's water to a level that can protect the oral health of their citizens. Over 170 million people, or 67 percent of the United States population served by public water supplies, drink water with optimal fluoride levels for preventing decay. Of the 50 largest cities in the country, 43 are fluoridated. Although water fluoridation reaches some residents in every state, unfortunately, only 24 states are providing these benefits to 75% or more of their residents. A significant advantage of water fluoridation is that all residents of a community can enjoy its protective benefit —at home, work, school or play— simply by drinking fluoridated water or beverages and foods prepared with it. A person's income level or ability to receive routine dental care is not a barrier to receiving fluoridation's health benefits. Water fluoridation is a powerful strategy in our efforts to eliminate differences in health among people and is consistent with my emphasis on the importance of prevention. The U.S. Centers for Disease Control and Prevention has recognized the fluoridation of drinking water as one of ten great public health achievements of the twentieth century. Water fluoridation has helped improve the quality of life in the United States by reducing pain and suffering related to tooth decay, time lost from school and work, and money spent to restore, remove, or replace decayed teeth, An economic analysis has determined that in most communities, every $1 invested in fluoridation saves $38 or more in treatment costs. Fluoridation is the single most effective public health measure to prevent tooth decay and improve oral• health over a lifetime, for both children and adults. While we can be pleased with what has already been accomplished, it is clear that there is much yet to be done. Policymakers, community leaders, private industry, health professionals, the media, and the public should affirm that oral health is essential to general health and wellbeing and take action to make ourselves, our families, and our communities healthier. I join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing the oral health of all Americans. Acgha"rdH. �Carmona, M.D., M.P.H., F.A.C.S. VADM, USPHS United States Surgeon General Packet Page -995- Fluoridation - Benefits • Background 9/13/2011 Item 10.C. Dater Fluoridation- > '� = `;' Contact info Centers for Disease Control and /�preventlon !vision of Oral Health Mail Stop F -10 4770 Buford Highway NE Atlanta, GA 30341 Contact Us Water fluoridation (fluoride In water) prevents tooth decay two ways: primarily through direct contact with teeth throughout life, and when consumed by children during the tooth forming years. The most Inexpensive way to deliver the benefits of fluoride to all residents of a community is through water fluoridation. All water naturally contains some fluoride. When a community fluoridates Its water, It adjusts the level of fluoride in the water to the optimal level for preventing tooth decay. Currently, more than 170 million people In the United States using public water supplies drink water containing enough fluoride to protect teeth. One of the health objectives contained In Healthy People 2010, the plan that sets health goals for the nation for the year 2010, calls for at feast 75 percent of the population served by community water systems to receive optimal levels of fluoride. The current level Is 67 percent. To reach this goat, approximately 14.3 million more people must gain access to fluoridated water through public water systems. Other sources of fluoride are also available. Fluoride can be applied directly to teeth through toothpaste, mouth rinses, and professionally applied fluoride treatments available In the dental office. Children who have been evaluated by their dentists as being at high risk for tooth decay and whose home water supplies contain low amounts of fluoride can take dietary fluoride supplements. This dally supplement, which can be prescribed by a dentist or a physician, should be taken only by children If the home water supply has been verified to contain a low concentration of fluoride. These methods of delivering fluoride are more expensive than water fluoridation and require a conscious decision to use them. However, the widespread avallabll €ty of fluorides, via water fluoridation, toothpaste, and other sources, has resulted in the steady decline of dental caries throughout the united States. Date last reviewed: 08/03/2006 Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion Home i Policies and Reputations i Disclaimer ( e- Government i FOIA i Contact Us SAVER - HtALMIZrt• P[OPLE' Centers for Disease Control and •Preventiorr 1600 Clifton Rd;.Atiarita,:GA 30333, U S fi � Department•of Health A atilt -Human Services Tel: (404) 839 -3311 /Public lnquities 35347 (13WQ).311 X435 Ys.r7trsF fslsa lr isiv riweF rslc:lll 1 Documents%20and%24SettingsnsaacSP / Desktop / Fluoridation% 20-% 20Benerits %20= /.2oBsckground,htm92 712006 10;27:38 AM Packet Page -996- ........................ l Ts page Printer - friendly version OralHealth Home .......................... ............................... Water Fluoridation Key Resources on Topic Home > Fact Sheets Guidelines & Recommendations, Questions & Answers Benefits > Safety Background information > Statistics August 2005 —Tooth decay, also known as dental caries, Is a health problem that has plagued humankind for centuries. > Until as recently as 60 years ago, the damage caused by caries was an inevitable fact of life for most people. The Enpineerina and Oaeral €ons disease often meant many visits to the dentist to have damage and painful teeth repaired or removed. Today, primarily > as a result of fluoride, damage caused by decay can be reduced and, In many instances, prevented. Oth r Fluoride Products > Fluoride's benefits for teeth were discovered in the 1930s: Dental scientists observed remarkably low decay rates Publications among people whose water supplies contained significant amounts of natural fluoride. Several studies conducted during > the 1940s and 1950s confirmed that when a small amount of fluoride Is added to the community water supply, decay Related Links rates among residents of that community decrease. Although these studies focused primarily on the benefits of water > fluoridation for children, more recent studies demonstrate that decay rates in adults are also reduced as a result of fluoride In the drinking water. Contact info Centers for Disease Control and /�preventlon !vision of Oral Health Mail Stop F -10 4770 Buford Highway NE Atlanta, GA 30341 Contact Us Water fluoridation (fluoride In water) prevents tooth decay two ways: primarily through direct contact with teeth throughout life, and when consumed by children during the tooth forming years. The most Inexpensive way to deliver the benefits of fluoride to all residents of a community is through water fluoridation. All water naturally contains some fluoride. When a community fluoridates Its water, It adjusts the level of fluoride in the water to the optimal level for preventing tooth decay. Currently, more than 170 million people In the United States using public water supplies drink water containing enough fluoride to protect teeth. One of the health objectives contained In Healthy People 2010, the plan that sets health goals for the nation for the year 2010, calls for at feast 75 percent of the population served by community water systems to receive optimal levels of fluoride. The current level Is 67 percent. To reach this goat, approximately 14.3 million more people must gain access to fluoridated water through public water systems. Other sources of fluoride are also available. Fluoride can be applied directly to teeth through toothpaste, mouth rinses, and professionally applied fluoride treatments available In the dental office. Children who have been evaluated by their dentists as being at high risk for tooth decay and whose home water supplies contain low amounts of fluoride can take dietary fluoride supplements. This dally supplement, which can be prescribed by a dentist or a physician, should be taken only by children If the home water supply has been verified to contain a low concentration of fluoride. These methods of delivering fluoride are more expensive than water fluoridation and require a conscious decision to use them. However, the widespread avallabll €ty of fluorides, via water fluoridation, toothpaste, and other sources, has resulted in the steady decline of dental caries throughout the united States. Date last reviewed: 08/03/2006 Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion Home i Policies and Reputations i Disclaimer ( e- Government i FOIA i Contact Us SAVER - HtALMIZrt• P[OPLE' Centers for Disease Control and •Preventiorr 1600 Clifton Rd;.Atiarita,:GA 30333, U S fi � Department•of Health A atilt -Human Services Tel: (404) 839 -3311 /Public lnquities 35347 (13WQ).311 X435 Ys.r7trsF fslsa lr isiv riweF rslc:lll 1 Documents%20and%24SettingsnsaacSP / Desktop / Fluoridation% 20-% 20Benerits %20= /.2oBsckground,htm92 712006 10;27:38 AM Packet Page -996- 9/13/2011 Item 10.C. VLORIDA DEPART T HEALT Chariic Crist Ana M. Viamontc Ros, M.D., M.P.H. Governor State Surgeon General January 2008 POLICY STATEMENT ON COMMUNITY WATER FLUORIDATION The Florida Department of Health Is strongly committed.to the fluoridation of community water systems. Fluoridation began nationally over sixty years ago and the Florida State Board of Health officially endorsed fluoridation in 1949. Strong support and active promotion of the measure as a safe, economical and effective means of reducing tooth decay has continued. Today, fluoridation is still the most cost-effective way to prevent dental cavities. It Is an Ideal public health measure where everyone benefits, whether rich or poor, no matter the age, without requiring any conscious effort of the Individual. Beginning in Gainesville in 1949, Florida cities have embraced the concept of fluoridation for their citizens. At present, approximately 12.9 million people are benefiting from fluoridation in Florida. Nationally, over 170 million people benefit from water containing fluoride at the recommended level for controlling dental_decay. National surveys of oral health dating back several decades document the continued benefit of fluoride in decreasing tooth decay in children and adults. It is doubtful that any other public health procedure has undergone more research, epidemiological study and intense public scrutiny than water fluoridation. The federal Centers for Disease Control and Prevention (CDC) in 1999 recognized fluoridation as one of the ten great public health achievements of the twentieth century. In the last few years, systematic reviews of community water fluoridation studies through the Surgeon's General's Report on Oral Health, CDC's Recommendations for Using Fluoride to Prevent and Control Dental Caries In the United States, and the Oral Health Report Issued by the Task Force on Community Preventive Services have all .reinforced the safety and efficacy of fluoridation in preventing dental decay in both children and adults. Along with. the overwhelming majority of the world's health care organizations and leaders within the scientific community, the Florida Department of Health firmly supports and continues to recommend water fluoridation as the most economical and effective means to control the major public health problem of dental caries. Ana M. Vlamonte Ras, M.D., M.P.H. State Surgeon General Office of tiie state surgcon General 405213aid Cypress "` " "- '' " - -ee, FL 32399.1701 Packet Page -997- . . 9/13/2011 Item 10.C. Partial list of national and international organizations that endorse or support fluoridation of drinking water for preventive dental health: American Hospital Association American Medical Association American Psychiatric Association Florida Medical Association American Academy of Pediatrics American Association of Dental Research American Association of Dental Schools American Association of Public Health Dentistry American College of Dentists American Dental Association American Dental Hygienists Association Florida Dental Association Florida Dental Hygiene Association Federation of Dentaire international National Institute of Dental Research State and Territorial Dental Directors Association American Water Works Association Conference of State Sanitary Engineers American Association for the Advancement of Science American Pharmaceutical Association American Public Health Association ^ American Public Welfare Association American School Health Association National Cancer Institute National Research Council State Territorial Health Officer Association Department of Defense U.S. Public Health Service World Health Organization Florida Public Health Association Florida Department of Health State of Florida Department of Health Department of Health Public Health Dental Program 4052 Bald Cypress Way Bin # A -14 Tallahassee, Florida 32399 -1724 Packet Page -998- 9/13/2011 Item 10.C. Achievements in Public Health, 1900 -1999; Fluoridation of Drinking Water to Prevent D... Page 1 of 8 Weekly October 22,1999 /48(41);933 -940 Achievements in Public Health, 1900 -1999: Fluoridation of Drinking 'water to Prevent Dental Caries Fluoridation of community drinking water is a major factor responsible for the decline in dental caries (tooth decay) during the second half of the 20th century. The history of water fluoridation is a classic example of clinical observation leading to epidemiologic investigation and community -based public health intervention. Although other fluoride- containing products are available, water fluoridation remains the most equitable and cost - effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level. Dental; Caries Dental caries is an infectious, communicable, multifactorial disease in which bacteria dissolve the enamel surface of a tooth (1). Unchecked, the bacteria then may penetrate the underlying dentin and progress into the soft pulp tissue. Dental caries can result in loss of tooth structure and discomfort. Untreated caries can lead to incapacitating pain, a bacterial infection that leads to pulpal necrosis, tooth extraction and loss of dental function, and may progress to an acute systemic infection. The major etiologic factors for this disease are specific bacteria in dental plaque (particularly Sh•eptococcus nrutans and lactobacilli) on susceptible tooth surfaces andthe availability of fermentable carbohydrates. At the beginning of the 20th century, extensive dental caries was common in the United States and in most developed countries (2). No effective measures existed for preventing this disease, and the most frequent treatment was tooth extraction. Failure to meet the minimum standard of having six opposing teeth was a leading cause of rejection from military service in both world wars (3,4). Pioneering oral epidemiologists developed an index to measure the prevalence of dental caries using the number of decayed, missing, or filled teeth (DMFT) or decayed, missing, or filled tooth surfaces (DMFS) (5) rather than merely presence of dental caries, in part because nearly all persons in most age groups in the United States had evidence of the disease. Application of the DMFT index in epidemiologic surveys throughout the United States in the 1930s and 1940s allowed quantitative distinctions in dental caries experience among communities - -an innovation that proved critical in identifying a preventive agent and evaluating its effects. History of Water Fluoridation Packet Page -999- 9/13/2011 Item 10.C. Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent D... Page 2 of 8 Soon after establishing his dental practice in Colorado Springs, Colorado; in 1901, Dr. Frederick S. McKay noted an unusual permanent stain or "mottled enamel" (termed " Colorado. brown stain" by area residents) on the teeth of many of his patients (6). After years of personal field investigations, McKay concluded that an agent in the public water supply probably was responsible for mottled enamel. McKay also observed that teeth affected by this condition seemed less susceptible to dental caries (7). Dr. F. L. Robertson, a dentist in Bauxite, Arkansas, noted the presence of mottled enamel among children after a deep well was dug in 1909 to provide a local water supply. A hypothesis that something in the water was responsible for mottled enamel led local officials to abandon the well in 1927. In 1930, H. V. Churchill, a chemist with Aluminum Company of America, an aluminum manufacturing.company that had bauxite mines in the town, used a newly available method of spectrographic analysis that identified high concentrations of fluoride (13.7 parts per million [ppm]) in the water of the abandoned well (8). Fluoride, the ion of the element fluorine, almost universally is found in soil and water but generally in very low concentrations (less than 1.0 ppm). On hearing of the new analytic method, McKay sent water samples to Churchill from areas where mottled enamel was endemic; these samples contained. high Ievels of fluoride (2.0- 12.0 ppm). The identification of a possible etiologic agent for mottled enamel led to the establishment in 1931 of the Dental Hygiene Unit at the National Institute of Health headed by Dr. H. Trendley Dean. Dean's primary responsibility was to investigate the association between fluoride and mottled enamel (see box). Adopting the term "fluorosis" to replace "mottled enamel," Dean conducted extensive observational epidemiologic surveys and by 1942 had documented the prevalence of dental fluorosis for much of the United States (9). Dean developed the ordinally scaled Fuuorosis Index to classify this condition. Very mild fluorosis was characterized by small, opaque "paper white" areas affecting less than or equal to 25% of the tooth surface; in mild fluorosis, 26 % -50% of the tooth surface was affected. In moderate dental fluorosis, all enamel surfaces were involved and susceptible to frequent brown staining. Severe fluorosis was characterized by pitting of the enamel, widespread brown stains, and a "corroded". appearance (g)• Dean compared the prevalence of fluorosis with data collected by others on dental caries prevalence among children in 26 states (as measured by DMFT) and noted a strong inverse relation (10). This cross - sectional relation was confirmed in a study of 21 cities in Colorado, Illinois, Indiana, and Ohio (I1). Caries among children was lower in cities with more fluoride in their community water supplies; at concentrations greater than 1.0 ppm, this association began to level off. At 1.0 ppm, the prevalence of dental fluorosis was low and mostly very mild. The hypothesis that dental caries could be prevented by adjusting the fluoride level of community water supplies from negligible levels to 1.0 -1.2 ppm was tested in a prospective field study conducted in four pairs of cities (intervention and control) starting in 1945: Grand Rapids and Muskegon, Michigan; Newburgh and Kingston, New York; Evanston and Oak Park, Illinois; and Brantford and Sarnia, Ontario, Canada. After conducting sequential cross - sectional ^surveys in these communities over 13 -15 years, caries was reduced 50 % -70% among children in he communities with fluoridated water (12). The prevalence of dental fluorosis in the intervention communities was comparable with what had been observed in cities where drinking water contained natural fluoride at 1.0 ppm. Epidemiologic investigations of patterns of water consumption and caries experience across different climates and geographic regions in the United States led in 1962 to the development of a recommended optimum range of fluoride concentration of 0.7 -1.2 ppm, with the lower t Packet Page -1000- vended for warmer climates 9/13/2011 Item 10.C. Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent D... Page 3 of 8 (where water consumption was higher) and the higher concentration for colder climates (13). The effectiveness of community water fluoridation in preventing dental caries prompted rapid adoption of this public health measure in cities throughout the United States. As a result, dental caries declined precipitously during the second half of the 20th century. For example, the mean DMFT among persons aged 12 years in the United States declined 68 %, from 4.0 in 1966 -1970 (14) to 1.3 in 1988 -1994 (CDC, unpublished data, 1999) (Fig4ue 1). The American Dental Association, the American Medical Association, the World Health Organization, and other professional and scientific organizations quickly endorsed water fluoridation. Knowledge about the benefits of water fluoridation led to the development of other modalities for delivery of fluoride, such as toothpastes, gels, mouth rinses, tablets, and drops. Several countries in Europe and Latin America have added fluoride to table salt. Effectiveness of Water Fluoridation Early studies reported that caries reduction attributable to fluoridation ranged from 50% to 70 %, but by the mid -1980s the mean DMFS scores in the permanent dentition of children who lived in communities with fluoridated water were-only 18% lower than among those living in communities without fluoridated water (15). A review of studies on the effectiveness of water fluoridation conducted in the United States during 1979 -1989 found that caries reduction was 8 % -37% among adolescents (mean: 26.5 %) (16), Since the early days of community water fluoridation, the prevalence of dental caries has declined in both communities with and communities without fluoridated water in the United n States. This trend has been attributed largely to the diffusion of fluoridated water to areas without fluoridated water through bottling and processing of foods and beverages in areas with fluoridated water and widespread use of fluoride toothpaste (17). Fluoride toothpaste is efficacious in preventing dental caries, but its effectiveness depends on frequency of use by persons or their caregivers. In contrast, water fluoridation reaches all residents of communities and generally is not dependent on individual behavior. Although early studies focused mostly on children, water fluoridation also is effective in preventing dental caries among adults. Fluoridation reduces enamel caries in adults by 20 %- 40% (16) and prevents caries on the exposed root surfaces of teeth, a condition that particularly affects older adults. Water fluoridation is especially beneficial for communities of low socioeconomic status (18). These communities have a disproportionate burden of dental caries and have less access than higher income communities to dental -care services and other sources of fluoride. Water fluoridation may help reduce such dental health disparities. Biologic Mechanism FIuoride's caries - preventive properties initially were attributed to changes in enamel during tooth development because of the association between fluoride and cosmetic changes in enamel and a belief that fluoride incorporated into enamel during tooth development would result in a more acid - resistant mineral. However, laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children (1). These mechanisms include 1) inhibition of demineralization, 2) enhancement of remineralization, and 3) inhibition of bacterial Packet Page -1001- 9/13/2011 Item 10.C. Achievements in Public Health, 1900 -1999, Fluoridation of Drinking Water to Prevent D... Page 4 of 8 activity in dental plaque (1). Enamel and dentin are composed of mineral crystals (primarily calcium and phosphate) embedded in an organic protein /lipid matrix. Dental mineral is dissolved readily by acid produced by cariogenic bacteria when they metabolize fermentable carbohydrates. Fluoride present in solution at low levels, which becomes concentrated in dental plaque, can substantially inhibit dissolution of tooth mineral by -acid. Fluoride enhances remineralization by adsorbing to the tooth surface and attracting calcium ions present in saliva. Fluoride also acts to bring the calcium and phosphate ions together and is included in the chemical reaction that takes place, producing a crystal surface that is much less soluble in acid than the original tooth mineral (1). Fluoride from topical sources such as fluoridated drinking water is taken up by cariogenic bacteria when they produce acid. Once inside the cells, fluoride interferes with enzyme activity of the bacteria and the control of intracellular pH. This reduces bacterial acid production, which directly reduces the dissolution rate of tooth mineral (19). Population Served by Water Fluoridation By the end of 1992, 10,567 public water systems serving 135 million persons in 8573 U.S. communities had instituted water fluoridation (20). Approximately 70% of all U.S. cities with populations of greater than 100,000 used fluoridated water: In addition, 3784 public water systems serving 10 million persons in 1924 communities had natural fluoride levels greater than or equal to-0.7 ppm. In total, 144 million persons in the United States (56% of the population) were receiving-fluoridated water in 1992, including 62% of those served by public water systems. However, approximately 42,000 public water systems and 153 U.S. cities with populations greater than or equal to 50,000 have not instituted fluoridation. Cost Effectiveness and Cost Savings of Fluoridation Water fluoridation costs range from a mean of 31 cents per person per year in U.S. communities of greater than 50,000 persons to a mean of $2.12 per person in communities of less than 10,000 (1988 dollars) (21).-Compared with other methods of community -based dental caries, prevention, water fluoridation is the most cost effective for most areas of the United States in terms of cost per saved tooth surface (22). Water fluoridation reduces direct health -care expenditures through primary prevention of dental caries and avoidance of restorative care. Per capita cost savings from 1 year of fluoridation may range from negligible amounts among very small communities with very low incidence of caries to $53 among large communities with a high incidence of disease (CDC, unpublished data, 1999). One economic analysis estimated that prevention of dental caries, largely attributed to fluoridation and fluoride - containing products, saved $39 billion (1990 dollars) in dental -care expenditures in the United States during 1979 -1989 (23). aafety of Water Fluoridation Early_ investigations into the physiologic effects of fluoride in drinking water predated the first community field trials. Since 1950, opponents of water fluoridation have claimed it increased the risk for cancer, Down syndrome, heart diseQ ^&A ^n^rncic and bone fracture, acquired Packet Page -1002- - 9/13/2011 Item 10.C. Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent 1)... Page 5 of 8 immunodeficiency syndrome, low intelligence, Alzheimer disease, allergic reactions, and other health conditions (24). The safety and effectiveness of water fluoridation have been re- evaluated frequently, and no credible evidence supports an association between fluoridation and any of these conditions (25). 21st Century Challenges Despite the substantial decline in the prevalence and severity of dental caries in the United States during the 20th century, this Iargely preventable disease is still common, National data indicate that 67% of persons aged 12 -17 years (26) and 94% of persons aged greater than or equal to 18 years (27) have experienced caries in their permanent teeth. Among the most striking results of water fluoridation is the change in public attitudes and expectations regarding dental health. Tooth loss is no longer considered inevitable, and increasingly adults in the United States are retaining most of their teeth for a Iifetime (12). For example, the percentage of persons aged 45 -54 years who had lost all their permanent teeth decreased from 20.0% in 1960 -1962 (28) to 9.1% in 1988 -1994 (CDC, unpublished data, 1999). The oldest post -World War II "baby boomers" will reach age 60 years in the first decade of the 21 st century, and more of that birth cohort will have a relatively intact dentition at that age than any generation in history. Thus, more teeth than ever will be at risk for caries among persons aged greater than or equal to 60 years. In the next century, water fluoridation will continue to help prevent caries among these older persons in the United States. Most persons in the United States support community water fluoridation (29). Although the proportion of the U.S. population drinking fluoridated water increased fairly quickly from 1945 into the 1970s, the rate of increase has been much lower in recent years. This slowing in the expansion of fluoridation is attributable to several factors: 1) the public, some scientists,.and policymakers may perceive that dental caries is no longer a public health problem or that fluoridation is no longer necessary or effective; 2) adoption of water fluoridation can require political processes that make institution of this public health measure difficult; 3) opponents of water fluoridation often make unsubstantiated claims about adverselealth effects of fluoridation in attempts to influence public opinion (24); and 4) many of the U.S. public water - systems that are not fluoridated tend to serve small populations, which increases the per capita cost of fluoridation. These barriers present serious challenges to expanding fluoridation in the United States in the 21st century. To overcome the challenges facing this preventive measure, public health professionals at the national, state, and local Ievel will need to enhance their promotion of fluoridation and commit the necessary resources for equipment, personnel, and training. Reported by Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. References I . Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31 -40. 2. Burt BA. Influences for change in the dental health status of populations: an historical perspective. J Public Health Dent 1978;38:272 -88. 3. Britten RH, Perron GSJ. Summary of physical findings on men drafted in world war. Pub Health Rep 1941;56 :41 -62. Packet Page -1003- 9/13/2011 Item 10.C. Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent D... Page 6 of 8 n 4. Klein H. Dental status and dental needs of young adult males, rejectable, or acceptable for military service, according to Selective Service dental requirements. Pub Health Rep 1941; 56:1369 -87. 5. Klein H, Palmer CE, Knutson JW. Studies on dental caries. 1. Dental status and dental needs of elementary school children. Pub Health Rep 1938;53 :751 -65. 6.' McKay FS, Black GV. An investigation of mottled teeth: an endemic developmental imperfection of the enamel of the teeth, heretofore unknown in. the literature of dentistry. Dental Cosmos 1916;58:477 -84. 7. McKay FS. Relation of mottled enamel to caries. J Am Dent A 1928;15 :1429 -37. 8. Churchill HV. Occurrence of fluorides in some waters of the United States, J Ind Eng Chem 1931;23:996 -8. 9. Dean HT. The investigation of physiological effects by the epidemiological method. In: Moulton FR, ed. Fluorine and dental health. Washington, DC: American Association for the Advancement of Science 1942:23 -31. ' 10. Dean HT. Endemic fluorosis and its relation to dental caries. Public Health Rep 1938;53:1443 -52. 11. Dean HT. On the epidemiology of fluorine and dental caries. In: Gies WJ, ed. Fluorine in dental`public health. New York, New York: New York Institute of.Clinical Oral Pathology, 1945;19 -30, 12. Burt BA, Eklund SA. Dentistry; dental practice, and the community. 5th ed. Philadelphia, Pennsylvania: WB Saunders, 1999. 13. Public Health Service.. Public Health Service drinking water standards -- revised 1962.. Washington, DC: US Department of Health, Education, and Welfare, 1962. PHS publication no. 956. 14. National Center for Health Statistics. Decayed, missing, and filled teeth among youth -12- 1,7 years -- United States. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service; Health Resources Administration; 1974. Vital and health statistics, vol 11, no. 144. DHEW publication no. (HRA)75 -1626. 15. Brunelle JA, Carlos JP. Recent trends in dental caries in US children and the effect of . water fluoridation. J Dent Res 1990;69:723 -7. 16. Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49:279 -89. 17. Horowitz HS. The effectiveness of community water fluoridation in the United States. J. Public Health Dent 1996;56:253 -8. 18. Riley JC, Lennon MA, Ellwood R.P. The effect of water fluoridation and social inequalities on dental caries in 5- year -old children. Int J Epidemiol 1999;28:300 -5. 19. Shellis RP, Duckworth RM. Studies on the cariostatic mechanisms of fluoride. Int Dent J 1994;44(3 suppl 1):263 -73. . 20. CDC. Fluoridation census 1992. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Prevention Services, Division of Oral Health, 1993. 21. Ringelberg ML, Allen SJ, Brown LJ. Cost of fluoridation: 44 Florida communities. J Public Health Dent 1992;52:75 -80. 22. Burt BA, ed. Proceedings for the workshop: cost effectiveness of caries prevention in dental public health. J Public Health Dent 1989;49(5, special issue):251 -344. 23. Brown LJ, Beazoglou T, Heffley D. Estimated savings in U.S. dental expenditures, 1979 - 89. Public Health Rep 1994;109:195 -203. 24. Hodge HC. Evaluation of some objections to water fluoridation. In: Newbrun E, ed. FIuorides and dental caries. 3rd ed. Springfield, Illinois: Charles C. Thomas, 1986:221- 55. 25. National Research Council. Health effects of ingested fluoride. Washington, DC: National Academy Press, 1993. Packet Page -1004- 9/13/2011 Item 10.C. Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent u.. Page % of S 26. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1 -17 years of age: United States, 1985 -1991. J Dent Res 1996;75:631 -41. 27. Winn DM, Brunelle JA, Selwitz RH, et al. Coronal and root caries in the dentition of adults in the United States, 1988 -1991. J Dent Res 1996;75 :642 -51. 28. National Center for Health Statistics. Decayed, missing, and filled teeth in adults -- United States, 1960 -1962. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, 1973. Vital and health statistics vol 11, no. 23. DREW publication no. (HRA)74 -1278. 29. American Dental Association Survey Center. 1998 consumers' opinions regarding community water fluoridation. Chicago, Illinois: American Dental Association, 1998. Figure 1 FIGURE 1. Percentage of population residing in areas with fluoridated community water systems and mean number of decayed, missing (because of caries), or filled permanent teeth (DlbMFT) among children aged 12 years --- United States, 1967 --1992 L 100 5 90 so Mean DMFT M 70 a - � 60 Percentage prinking U. 3 m 50 Fluoridated Water... r................ _...... �........_ ...� ......................... .. � ...».....,. t7 lie 40 2 . 30 M, z0- 1 � 10- U 1957 1977 1887 Year Sources: 1. CDC. Fluoridation census 1992, Atlanta, Georgia. US Department of Health and Human Serv- ices, Public Health Service, CDC, National Center for Prevention Services, Division of Oral Health, 1993. 2. National Center for Health Statistics, Decayed, missing, and filled teeth among youth 12- 17 years — United States. Rockville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, Health Resources Administration, 1974. Vital and health statistics, vol 11, no. 144. DREW publication no. (HRA)75 -1526. 3. National Center for Health Statistics. Decayed, missing, and filled teeth among persons i- 74 years --- United States. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, Office of stealth Research, Statistics, And Technology, 1981, Vital and health statistics, vol 11, no. 223. DHHS publication no. (PHS)81 -1673. 4. National Institut4 of Dental Research. Oral health of United States children: the national Survoy of Dental Caries in U.S. School Children, 1986 -1987. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1989. NIH publication no. 89 -2247. 5. CDC, unpublished data, third National Health and Nutrition Examination Survey, 1988 -1994. Return to top. Packet Page -1005- 9/13/2011 Item 10.C. Achievements in Public Health, 1900 -1999: Fluoridation of Drinking Water to Prevent D... 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Contact GPO for current prices. * *Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov, Page converted: 10/2111999 HOME l ABOUT MMWR j MMWR SEARCH l DOWNLOADS I RSS I CONTAC POLICY j DISCLAIMER' l ACCESSIBILITY SArKit•WEAL7}fIMPCOPLK" � i4 Morbidity and Mortality Weekly Report � Departmnt e of Health Centers for Disease Control and Prevention '$ ..'and Human Services 1600 Clifton Rd, MallStop E -90, Atlanta, GA aamnmwirt ad «�aar• . 39333, U.S.A This page last reviewed 512101 Packet Page -1006- 9/13/2011 Item 10.C. An. Ounce-of Prevention... . What Are the Returns?' Second-Edition 1999 (EXCERPTS) JUVIC". I'll I,■.J! // U.S. DEPARTMENT OF HEALTH &HUMAN SERVICES Centers for Disease Control and Prevention Atlanta, Georgia 30333 Packet Page -1007- 9/13/2011 Item 10.C. the United States, 1988 -1991. J Dent Res 1996;75 :642 -51. 28. National Center for Health Statistics. Decayed, missing, and filled teeth in•adults -- United States, 1960 -1962. Rockville, Maryland: US Department of Heal th' Education, and Welfare; Public Health Service, Health Resources Administration, 1973. Vital and health statistics yol 1 I, no.'23. DREW publication no. (HRA)74- 1278, 29. American Dental Association Survey Center. 1998 consumers' opinions regarding community water fluoridation. Chicago, Illinois. American Dental Association. 1998.. - Figure 1 FIGURE 1. Percentage of population residing in areas with fluoridated community Water systems and mean number of decayed, missing (because of caries), or tilled permanent teeth (PM. FT) among. children aged 12 years — United States, 1967_1992 ' °: i 00• 90 b 80 ra 70 b u. 50 50 - .`. 40 30 as ?o J.7 nCi 10 � p CL Mean DMFT Percentage. Drinking Fluoridated Water- 1957 1977 ' 1847 5 a ' -3CD M 1 - o ' Sources: Year 1. CDC. Fluoridation census 1992. Atlanta, Georgia: US Department of Health and Harman Serv- ices, Public Health Service, CDC, National center for Prevention Services, Division of Oral Health, 1993. ' 2, National Center for Health Statistics. Decayed, missing, and filled teeth among youth 12- 17 years— United Smies. Rockville:, Maryland: US Deportment of Health, Education, and Welfare, Public Health Service, Healili Resources -Administration, 1974. Vital and Health statistics, vol 11, no. 144. DREW publication no. (HRA175.1626. 3. National tenter for Health Statistics. Decayed, missing, and filled.teeth 2mong persons 1- 74 years — United States. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, office of Health Research, Statistics, and Technology, 1981. Vital and health statistics, Vol 11, no. 223. DHHS publication no. (PHS)81 -1573. 4. Nntional institute of Dental Research, oral health of United States child ran:the NaflonAl Survey D1 Dental Caries in U.S, School Children, 1986 -1987. Bethesda; Maryland; US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1989. NIH publication no. 89.2247. 5. CDC, unpublished data, third•Naiional Health and Nutrition Examination •Survcy. 1988 -1994. Retu to tots. Packet Page -1008- 9/13/2011 Item 10.C. September 03,1999 / 4$(34);753 -757 Water Fluoridation and Costs of Medicaid Treatment for Dental Decay — Louisiana, 1995 -1996 Treatment costs for dental decay in young children can be substantial, especially if extensive dental procedures and general anesthesia in a hospital operating room (OR) are needed. Because caries in the primary dentition disproportionately affect children from low - income households (1,2 ), the cost for care frequently is reimbursed by state Medicaid programs. To determine whether the average treatment cost for Medicaid - eligible children In Louisiana differed by community fluoridation status, the Louisiana Department of Health,and Hospitals (LDHH) and CDC analyzed Medicaid dental reim- bursements and Medicaid eligibility records from July 1995 through June 1996 for children aged 1 -5 years. Findings suggest that Medicaid - eligible children in communi- ties without fluoridated water were three times more likely than Medicaid - eligible chil- dren in communities with fluoridated water to receive dental treatment In a hospital OR, and the cost of dental treatment per eligible child was approximately twice as high. tal reim- bursements and Medicaid eligibility from July 1995 through June 1996 for children aged 1-5 years and the number of dentists practicing in each parish (county) in 1995. Demographic data for each parish were obtained from the Bureau of the Census (3). The proportion of the population that received optimally fluoridated water in each parish was estimated based on CD C's 1992 fluoridation census (4) and a study by LDHH (LDHH, unpublished data, 1996). A parish was designated as optimally fluorl- dated (F) if 100% of its population received fluoridated water (optimal level: X0.7 ppm) In both 1992 and 1996, and nonfluoridated (NF) if 0% received fluoridated water in both.years. Of 64 parishes, five F parishes with 38,162 Medicaid - eligible preschoolers and 14 NF parishes with 16,444 Medicaid - eligible preschoolers were included in this analysis.,All analyses were conducted at the parish level. , For each F and NF parish, the percentage of Medicaid - eligible children aged 1 -5 years who, during the study period, received one or more of the following types of services was calculated: 1) caries - related services (e.g., fillings, crowns, and puipp- tomies); 2) 'examinations or preventive care (topical fluoride or prophylaxis) but no caries - related services; 3) topical fluoride application (with or without caries - related care); and 4) dental care In a hospital OR. The mean value for each of these measures was calculated for F and NF parishes for each of the five ages. Medicaid reimbursements for dental procedures likely to be associated with treat- ment for dental caries were totaled for each parish for each age group. If dental care was provided in a hospital, a payment of $650 (based on estimates from the.Louislana Bureau of Health Financing) was adder4 { ^r na isea anti nAneral anesthesia. The aver - age'caries- related cost per Medicaid -e Packet Page - 1009 - garish was obtained by di- 9/13/2011 Item 10.C. 754 MMWR September 3,1999 Dental Decay = Continued viding parish Medicaid reimbursements by the number of Medicaid- eligible children in the parish in each age group. For each age group, linear regression was used to examine the association be- tween parish average caries - related cost per- Medicaid - eligible child and fluoridation status of the parish. In addition to'fluoridation status, per capita income, population, and dentists per 1000 residents were included in the model as dichotomous variables. Independent variables that added no explanatory -power were eliminated through backward elimination to obtain the reduced model (5). Children residing in F parishes were slightly more likely to have received only ex- aminations or preventive services (Table 1). The proportions of children who received topical fluoride were similar, with younger children in F and older children in NF slightly more likely to have received the procedure. For all age groups, the percentage of Medicaid - eligible children who received one or more caries - related procedures was higher in NF parishes. The difference in treatment costs per Medicaid - eligible child residing in F parishes compared with those residing'in NF parishes ranged from $14.68 for 1- year -olds to $58.91 for 3- year -olds (Table 2); at all ages, costs were higher in NF than in F parishes. Louisiana Medicaid - eligible children were distributed uniformly by age; the mean dif- ference in treatment costs per eligible preschooler was $36.28 (95% confidence inter- val= $9.69 -- $62,87)• - Reported by: R Barsley, DDS, Louisiana State Univ, New Orleans; J • Sutherland, DDS; L McFarland, DrPH, State Epidemiologist, Office of Public Health, Louisiana Dept Public Health and Hospitals. Surveillance, -investigations, and Research Br, Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: In this analysis of Medicaid claims, more Medicaid - eligible children in NF parishes received caries- related dental treatment and OR -based care at greater cost than did Medicaid - eligible children in F parishes. In 1998, 1.3 million Louisianans received nonfluoridated water from public water systems that served approximately 10,000 customers (S. Hoffman, Office of Public Health Engineering Services, personal communication, 1999), and 3% of the state population were Medicaid - eligible children aged 1 -5 years (3). These data suggest that at least 39,000 preschoolers in Louisiana could potentially benefit from water fluoridation; the expected annual reduction in their dental treatment costs is $1.4 million. The findings in this report are subject to at least four limitations. First; although the analysis showed an association between lower caries - related costs and residence.in one of the five F parishes, the analysis did not measure the length or magnitude of the children's exposure to fluoride, Some children classified as residing in NF parishes once may have resided in F parishes and vice versa. It also did not verify that the water systems serving the five F parishes maintained fluoride concentration 'at the optimal level. However, misclassification of exposure status would be more likely to reduce the observed effect of fluoridation. Second, if access to dental care were better in NF than in F parishes, children with decay who resided in F parishes would be less.likely to seek restorative care, resulting in an underestimate of treatment costs in F parishes and an overstatement of water fluoridation's benefits. The observed rates for preven- tive care in F and NF parishes suggest similar rather than- differential access. Further- more, this analysis controlled for differences in access to dental care. Third, the ---1 - : `on would be overstated ' +f difference in treatment costs attributat Packet Page -1010- Vol. 48 / No. 34 Dental Decay - Continued w 0 �p{rN�D �; C Mai NUio rN NM fH�lvb969 �,i C w �•L ✓ RI CL tL mula>(no UI C w 2° wnr%aNi►� O 7 h s R 'C s: QOp Ot�O 0 y N {n ao `" N o R 040 y o d aD to (I r a? I�MM(VM mlalnM O 017 4+ rnoic(n� ONNNr' 0 .L (/1 Z o 000vrr � rVISiMr GF IM m .> 0 .. d O v � .a i% r Ui C; (4 r >= Q �' u1 (7; Oq (8 l{i ro r G{ O 9 d c E M N .= in d UrLn a) to C • InNN(O 00 L v O W \ r.M -MCI V �+ w F- � .O L 0 O) r d CL jy 3° MMC�MOR (L�MMN = � 0 O O z 'a a d C p ' =OO (n ryN O O a A a (a (0 '� a N000 NO O.r MMN w 4 ` - O C a m et Cq m y cue G1 Ri W j y N In O M 0 tt lO N r Gtr C C LL V O MMM Gl C N r ' ZL R o a � rn 0 SM O M (O M�(n N N tti V d 0� � y CI M F-; !'� i Q —,N M tt to MMWR cI c� O �y r r N 3 a r aZ LL. cc My '0. d � LO ? roN 7•r Lm � R IT C 16 C'O L1 f, •p U U9 m 'ts � 2 O a o:n s. E � 7 . C O FO m C NOa Q O) > rod) 0:2,0 +a20 v =9 zoo MZw Packet Page -1011- 9/13/2011 Item 10.C. 755 Irm- OIL 9/13/2011 Item 10.C. 756 MMWR September 3,1999 Dental Decay — Continued TABLE 2. Results of multivariate regression' analysis; adjusted R2 and estimated treatment cost savings associated with water fluoridation for Medicaid - eligible children aged 1 -5 years residing in fluoridated and nonfluoridated parishes, by age --- Louisiana, July 19954une 1996 *Controlling for the parish variables of per capita income, population, and number of dentists per-1000 population.. tAssumes children are distributed uniformly by age. §Confidence interval. children in F parishes had.more exposure to other sources of fluoride (e.g., toothpaste or topical application in a dental office). Although fluoride toothpaste use could not be determined, toothpastes containing fluoride accounted for >94% of the market in 1984 (6). Different uses of topical applications was probably not a substantial factor be- cause children in F and NF parishes received topical fluoride in the dental office at similar rates. Finally, lower treatment costs associated with water fluoridation should not be generalized to preschoolers from high- and middle- income families because of their lower prevalence of dental caries in primary teeth, (1,2 ). The lower treatment costs associated with- residence in F parishes is a conservative estimate of benefits because the analysis did not consider benefits that accrue to populations other than Medicaid - eligible preschoolers. For this group, however, treat- ment cost savings associated with fluoridating the 39 NF water systems that serve populations of 210,000 could be substantial In 1996, approximately 50% of Louisiana's population using public water supplies received fluoridated water, a percentage well below the 2000 objective of 75% (objec- tive 13.9) (7). The 1996 assessment of community water fluoridation in Louisiana also found that of 73 water systems adjusting fluoride content in 1986, only 45 were. still doing so in 1996 (8). This decline prompted passage of state legislation in 1997 that 1} established a water fluoridation program within LDHH; 2) encouraged fluoridation of public water systems serving at least 5000 households (because the average number of persons per U.S, household in 1996 was 2.66, this equals approximately 13,000 persons 13 j); and 3) created a Fluoride Advisory Board to assist in locating public and private funding to cover the costs of initiating water fluoridation in these locations. In addition, LDHH is planning an early intervention program to ensure that infants and to oddlers at high risk for early childhood caries are screened and referred for clinical preventive services (e.g., topical fluoride application), prompt treatment of incipient disease, and education of the parent or caregiver. Packet Page -1012- Estimated treatment cost savings associated with water Age (yrs) Adjusted R2 fluoridation (95% CIS)' 1 0.59 $14.68 $ 5.58- $23.77 2 0.27 $40.17 $ 9.81-$70.53 3 0.42 $58.91. $19.45 - $98.37 4 0.47 $36.08 $11.81- $60.35 5 0.18 $31.55 $ 1.79 - $6,1.31 All age groupst $36.28 $ 9.69- $62.87 *Controlling for the parish variables of per capita income, population, and number of dentists per-1000 population.. tAssumes children are distributed uniformly by age. §Confidence interval. children in F parishes had.more exposure to other sources of fluoride (e.g., toothpaste or topical application in a dental office). Although fluoride toothpaste use could not be determined, toothpastes containing fluoride accounted for >94% of the market in 1984 (6). Different uses of topical applications was probably not a substantial factor be- cause children in F and NF parishes received topical fluoride in the dental office at similar rates. Finally, lower treatment costs associated with water fluoridation should not be generalized to preschoolers from high- and middle- income families because of their lower prevalence of dental caries in primary teeth, (1,2 ). The lower treatment costs associated with- residence in F parishes is a conservative estimate of benefits because the analysis did not consider benefits that accrue to populations other than Medicaid - eligible preschoolers. For this group, however, treat- ment cost savings associated with fluoridating the 39 NF water systems that serve populations of 210,000 could be substantial In 1996, approximately 50% of Louisiana's population using public water supplies received fluoridated water, a percentage well below the 2000 objective of 75% (objec- tive 13.9) (7). The 1996 assessment of community water fluoridation in Louisiana also found that of 73 water systems adjusting fluoride content in 1986, only 45 were. still doing so in 1996 (8). This decline prompted passage of state legislation in 1997 that 1} established a water fluoridation program within LDHH; 2) encouraged fluoridation of public water systems serving at least 5000 households (because the average number of persons per U.S, household in 1996 was 2.66, this equals approximately 13,000 persons 13 j); and 3) created a Fluoride Advisory Board to assist in locating public and private funding to cover the costs of initiating water fluoridation in these locations. In addition, LDHH is planning an early intervention program to ensure that infants and to oddlers at high risk for early childhood caries are screened and referred for clinical preventive services (e.g., topical fluoride application), prompt treatment of incipient disease, and education of the parent or caregiver. Packet Page -1012- 9/13/2011 Item 10.C. Vol. 48 / No. 34 MMWR 757 Dental Decay — Continued References 1. Kaste LM, Drury TF, Horowitz AM, Beltran E. An evaluation of NHANES III estimates of early childhood caries. J Public Health Dent 1999 (in press). 2. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988 -1994. J Am Dent Assoc 1998;129:1229 -38. 3. Bureau of the Census. USA counties 1996. Atlanta, Georgia: Bureau of the Census, US De- partment of Commerce, Economics and Statistics Administration, Bureau of the Census, 1996. 4. CDC. Fluoridation census 1992. Atlanta, Georgia: US Department of Health and Human Ser- vices, Public Health Service, CDC, 1993. 5. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemioiogic research principles and quantitative methods. Belmont, California: Life -Time Learning Publications, 1982, 6. Bohannan HM, Graves RC, Disney JA, at al. Effect of secular decline in caries on the evaluation of preventive dentistry demonstrations. J Public Health Dent 1985;45:83 -9. 7. US Department of Health and Human Services. Developing objectives for healthy people 2010. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, September 1997. 8. Sutherland J, Ray TJ. Community water fluoridation in Louisiana: an update: LDA J 1996; 55:16 -7. Congenital Syphilis — United States, 1998 Congenital syphilis (CS) occurs when the spirochete Treponema pallidum is trans- mitted from a pregnant woman with syphilis to her fetus. A multiorgan infection, CS may result in a neurologic or musculoskeietal handicap or death in the fetus when not properly treated. Trends in CS rates in women of childbearing age follow by approxi- mately 1 year the rates of primary and secondary syphilis (1). The last national syphi- lis epidemic, which was followed by a CS epidemic, occurred during the late 1980s and early 1990s. The syphilis rate began to decline in 1991(2); the CS rate began to declihe in 1992 (1). To evaluate CS epidemiology since this decline, CDC analyzed 1998 CS notifiable disease data and assessed rate changes during 1992 -1998. This report summarizes the results, which indicate that the CS rate declined 78.2% from 1992 to 1998, and that rates remained disproportionately high in the southeastern United States and among minority racial /ethnic populations. CS surveillance data were reported to CDC from the 50 states and District of Colum- bia. For the purpose of public health surveillance, CS is defined as 1) infants manifest- ing typical signs of CS or in whom T. pallidum is identified from lesions, placenta, umbilical cord, or autopsy specimens; 2) infants whose mothers have a syphilitic le- sion at delivery; 3) infants born to women with untreated or inadequately treated syphilis before or during pregnancy, and to women whose serologic response to peni- cillin therapy was not documented, and either a) no examination of the infant was performed radiographically and by cerebrospinal fluid (CSF), or b) one or more radi- ologic or CSF tests were consistent with CS.* CS rates per 100,000 live births were determined from state natality data.t *Congenital Syphilis Case Investigation and Report Form 73.126. tFrom the National Center for Health Statistics, Vital Statistics: Natality Tapes 1989 -1996. 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' m� W o O 2 W w 6�U � QCU L,0MCL tnmJUV 2 � d wC/)0 Qm_U U z U a 1 U Q'tp L) PacketPage- 1019 -a Q mm CO to mUU S Z z }w W O� zQ�Q U U 9 n.♦ W LL Q y J C' 2 00 ♦ 1 S j 0 � 0 Lr 4) C O a CL N IL L O N 41 ^ � c N d L V Y a -,r�„ h ° ♦ w W t 4 4� m 0 m d W 0 m CO b m m W ro 17 v E �0 v r O� e E L T p2 m m pe c�m°s Lo o m o2 l�V O V 8 U m d O m C m ♦♦ O .° _m® vo 'ro � °c 2w w m W y F}�mm - ca c o r`mS �c � ° �_ 2 c m � c!�?cmWW m Y o`•c ' -c- %oc"o . m ♦.CC c z Q- c z Cro �m °m o m o V m W m m E no °E - cm2rlC0 o m c � W ♦ rom 5 am m c80 EN "m r - m �° E E C � v°0, h mO U c u E a m ° C, �Y ° O Cd m aoO E N —, a u x Om m c »o o o a o O o Q2 Zmc - 0Xui �EU xanU 0- LL V)NU U 0C c ° a o of _ O Q < U z ' 2 p Z p K OF z w z Oa p re z w U W h z� g U. U J LL 0 ° Yz z ? W ut LLI O ♦O O a (L a v v •� m o m m m m nm'e c io '0 e ♦ c ♦roo° 'o � c ♦mo ro oco 'S ♦ss o g o ♦n ° aa °c m m y c m o E rm E ♦ m o t W m h — o-(-*- m� O s� , m cr E% _ = � c ° mB tn� oc� n r 5 $ E °Vm E ° O vmm ct � vcc� ° o — ti o8 d a azU rnc a �. ' m� W o O 2 W w 6�U � QCU L,0MCL tnmJUV 2 � d wC/)0 Qm_U U z U a 1 U Q'tp L) PacketPage- 1019 -a Q mm CO to mUU S Z z }w W O� zQ�Q U U 9 n.♦ W LL Q y J C' 2 00 ♦ 1 S ?O�*N k N �2 O\ ■ 2 g 2 m 0 �$ �L■ <_ S2 k� � q g3 U /U. CD J $C) � 0 � 7 v 2 ƒ a � £ CO 2 J ƒ 2 2 O \ LLJ � G E a q 0 I 0 $ � w Q 0 J � < � 3 O U m / r < < 2 20 m = \ LL � LL P 0 zn 0 � $ V- (7) Co ( C R � a : S k � Co \ � 3 2 _\ \ \ % \ � % ƒ Q Q 2 2 ¥-C) C, Z, Co 2 $ 2 2 LO ƒ� � / � 2 o / kk�k � � � ■ � Packet Page -1020 9/13/2011 I m 1O.C. It k � to � 9 § k � Q) S � 2 § \ / f 2 \ � � § � k ?k \2? 3 *ems * \ ) k ) ) \ f f § k to CO /\ 2 g \ d \ \ 3 / � 2 o / kk�k � � � ■ � Packet Page -1020 9/13/2011 I m 1O.C. It k � to � 9 § k � Q) S � 2 § \ / f 2 \ � � § � k ?k \2? 3 *ems * \ ) k ) ) \ f f § k to CO U) V, \ @ % k 2 °° 2 DO $� . G& ƒM § w \ \ \\o�\ 0 CO Co L 5 % n Cu %.2 % R S = Q Z3 f C) Q) \ / f \ » \k ok o° Packet Page -1021- / f ) \�\ m m \ y 2{$2 7k$[ 9/13/2011 Item 1O.C. � § ) k k \ \ � .c §� \ 0. / \ � v0 »0 . � \ ƒ .� a ƒ CL � . �9 mf 0 \ L ' $ 2 . 2 . @ e w q . n F \ CM > + C � / $ .. E / I 2\ @ 7 n n L7 . - F- o \> /� \ R _ J2 0 q 0 $/ \ \ e/ \0 C) / / 3. U. . _ .j ¢ 0 7 . � / U�\� \� . . w ©(4 ®\ g 11 / ?k //• . o< )Je8QA \ U ƒ A \ u 0 e \ 2k2 2 © ®� - � 2 $ / / /�£ U) V, \ @ % k 2 °° 2 DO $� . G& ƒM § w \ \ \\o�\ 0 CO Co L 5 % n Cu %.2 % R S = Q Z3 f C) Q) \ / f \ » \k ok o° Packet Page -1021- / f ) \�\ m m \ y 2{$2 7k$[ 9/13/2011 Item 1O.C. � § ) k k \ \ � .c §� \ \ »0 . � \ ƒ .� U) V, \ @ % k 2 °° 2 DO $� . G& ƒM § w \ \ \\o�\ 0 CO Co L 5 % n Cu %.2 % R S = Q Z3 f C) Q) \ / f \ » \k ok o° Packet Page -1021- / f ) \�\ m m \ y 2{$2 7k$[ 9/13/2011 Item 1O.C. � § ) k k \ \ � .c §� \ ti 0 o� �y U. G z� E y ^� v w fQ L4! 0 r, o 0� 0 0z J �3 LL. J 0 CL O a ro U `0 0 LL CL 0 0 3 LL e 0 Z 20 0 w CL O C. 0 w U) O Co Q O U 9/13/2011 Item 10.C. V M Co tiS Q Q J (`D o U W o3 oL 4�t Z) N p QTY U � N 0 U U U y �Q �Q m c4 O Ei 0 0 o m ro .Q a� Mcoo! cu ca Q Q Eli cc) OQ yN Ti t3 n� a� _2 ��(',�3 �j j j U v ) w oo Z Q C 0 M U .+ Packet Page -1022- CO M e 'o Co o Q Q Q J (`D ° CL W o3 oL 4�t Z) j a Qo � 0 0 U U U y �Q �Q m c4 O CO .Q Fw 0 w Eli OQ f7_ m w4 E a� U v ) w oo v W O a��°o ° o `0 0 �N �'M °1 a D U) w o �ai� , Z3 o woa w.m t (2)L �Co Co Z Q C 0 M U .+ Packet Page -1022- CO M e Co L' Co o Q Q Q J (`D ° CL W o3 oL 4�t Z) j a Qo � 0 0 U U U y .i 0 a 0 M c 0 v 0 Ll N Co E M L N M 0 0 � W 4�t Z) j b Z g U U U y �Q �Q m c4 .i 0 a 0 M c 0 v 0 Ll N Co E M L 9/13/2011 Item 10.C. 0 o. N CL m U 0 o Lt Cl. O I]. •Zy T � Z LL. Packet Page -1023- ti Z, O D 00 `r° a rn m rn °o 0 F a F N to CO O N F^ 113 ? M V Nt F � M Ii f�j O a z LJL. z� E 1�LS Lu M w CO CO m Q C a tL' so IQ" � 2 ayi •c � b J Q-a ?t p Qbj Q) `�° a' �' N t7 01) �° o ro o CO n °Q 8 o W a Q 2 C fba v�w� o O � 3 ' LL U CL Q U C o O w o o ro auj �,o� rJ boo � Z¢ U 4m�'W�ca, o � o o c fi cv �-♦ U Z LL V �' bI ♦C� v O F Q CO R N �m. `. p �' CO Q> n% O b o ,a> t O> o c o� 0) Q) 00 Vj 1 1 ti .� 1 N 1 C fi Q E O. O } Q Q ��v�Q oo o LL � �y�oouv o 0 C d f0 h td ` Q R '4 L R O fi v U m� Packet Page -1023- ti O O N D � O o U z� Co E uw y ro w }„ o O� LL c J 3 � U F- iL O Q. ro U o o UL a O (L b Jy. �Or 4; .O Z li. z 00 jto D W O M �v- � O OOJ) N Co h N N ti Cl (0 0) N N M n 9/13/2011 Item 10.C. N W) Co ro m Cu tD -1, Q 92 1 O b m U b b m b C O O J QQ W O 0 m Q, aroiZ �mC�o m uO bo 0 `0 0- a> ro o 3 mp a° � B x- m m 4 O V U CZ b C Co O 0 Co m +: m O ro C —,M 3 `O C � m O C m cp N Co Z Z Z� J O Z Z U .ti; y 0 Q Q O w z 0 w U v _� Q U a W m U �' U coo v Q' O a� t°co acv o° ! � � ai�wu� oco qN 0 �b �crn ~ 2 C9N N _h v m t �' O cfia U mZ2 C$ d C O 0 Packet Page -1024- Oa O 0 0 0 E C. 0 3 M C N R N f0 N W L °. o CL m U 0 o Li 06 O 0. V o m Z LL 0- 0 z o� cV O N C> O n r. C) O LLJ Co rn CO M � cn co Q? 00 <. eF- N N N e- to ti E2 .N Q O 7. L z waEi y y W a� af Co I Co IT) L�) Wca � -0 N O � C - N� O O O O O U U Q F- Q ro C ro O o Co a 0 o a C C C �, �a O w � 3 U. w a� a. w Z3 _ Q O O C O C \ Co ^ O U U r V U U r C31 0 W v U a N m to 0 Q sts tq @ to � N ro O QQ� C' O 1 i , U u CO tL �o> �° �o 0 CZ � CL Q � ° mom 3 "`U�v�`�t 0 � a z 0 � O W v Packet Page -1025- 9/13/2011 Item 10.C. � 1, !h 0 Q Co ' V C t td W U L Ia O m � � v O > U th d O N p V ti o e> Co C a c y p o. a 0 10 c 0 0 0 0 0 0 0 Co U7 to M v L7% 0 N � N O o LL c _z E FN >- N U) L wr+ `l 7 W O in O� J N !L O } .. J � J O O � U Q O CL M ELM U o �LL 0 a O CL C m a; �a z LL 0 z O [] a w O IL a W Q � O U w 0 W o oa Z a Q � O w Co J � a Z D 0 U O N CS Q to QI 0 Uo U C�7 j to Ei 6 aLi IT UM Q> � O N � � � N � to rn CF) 0 o� n> Cu nOi v 00 Q 00 (tv 00 C O 0 0 o 2 0 Q� Cu ILI 0 U m QL U p 0 Z� to rn CF) 0 o� n> Cu nOi v 00 Q 00 (tv 00 C O 0 0 o to rn CF) 0 o� 4- 0 n> QS vj m 4- v 00 Q U C- o co o� ° -C o 0 Rs M M O i o .k Q Q) M 21 m Cu ai C: 0 v W as q q T 4- 0 QS vj m 4- v 00 Q U C- o co o� ° -C o 0 Rs M M O i o Packet Page -1026- 9/13/2011 Item 10.C. m a 0 n C 0 0 5 a 0 ro N 0 T R 'D D1 a / 0 v / LL CL m 3 . kk \ 7 LL $ w 0 9 R CO Cl) q q $ q 7. o R m Cl) m 9 c o Cl q m q � r a B U Cl) / © % w . <a it / �$ a. O0 . . U. ■ ( . . k r- § w ^ \ \ \ m a m % E \ J \ % �. / ° -o / e < 2 • 2 S ° \ \ Co £ o f \ / R\ O LL 2 Zill . . - �\ / ° . ° � a m _\ o % � ? % 0SCo w n e § it � wm� n� «�o m Gw ® < e e > * tz 'R § ƒ Z Q f \k§$Kfk�\/ 7•aQaoAQ■geQ 7 0 R q k 2 f// 2 2/ 2 k I\ _ . q # / @ % 2 LLI � k/ \2 §\ \8:8®8 \ w . § .\ /� . \ Packet Page -1027- 9/13/2011 Item 1O.C. N O H _0 N N Q O L C Z ui Gl } 7 (n L t0 M tLLJ O Q � O u. aNi c _ o o U F= tL O 0 CL (L ro U o 0 o LL Cl O a -0 >, a; 'C ZLL; 0 Z 00 D w CL w O� a- 0 Lij N� W ui CO fl:� O Q � O U w Q O 0 w QZ Q a w O F- O I :i O U Lo N M N v a a U ro � 0 a Q j t U 0 �v Q L " 2 to W C: Cc Packet Page -1028- 9/13/2011 Item 10.C. T C) L Q a 0 O C R 4i ,c I rn. 0 p 0 s E a 0 c d �o N 16 d ftf n o� a ro X.pj V c o C C tq ti La CL O m 0- a 0 N � O a ?; o t� 2 LL. 0 z 0 N D _N iL N O Z 0 1 O L4 z N LLt Y to � t,1^- ^� VJ o Q� O 0 0-5 �xj 3 U. >- d O � U F- a O w o w O Q Q w O F- D J r LL F- 1 Z O i U I e It CO N N w ,e C: 7 0 � o a� o � � v.. U N CO t t I` ti IN 08 o O n! N N � n O CO 0 U �i CO O C mCO Ila0 M N LO L O � � M a � o � Q � a. a+ o � 06 U w N tA � X" � PN X.pj N� p c C, C C tq ti La C m o 0 N � O v C: 7 0 � o a� o � � v.. U N CO t t I` ti IN 08 o O n! N N � n O CO 0 U �i CO O C mCO Ila0 M N LO L O � � M a � o � Q � a. a+ o � 06 U w N tA � X" � PN X.pj N� p c C, C C tq ti La C CO o y j 3 � a CO EL o � T o o 0 43 0 Q U�U, 3iv�Q �O Packet Page -1030- 9/13/2011 Item 10.C. a 0 0 R ;o 0 3 IM m J a 0 r c 51 R a a c`o v t in N Cu z O c g N La C m o Q U ,C CO o y j 3 � a CO EL o � T o o 0 43 0 Q U�U, 3iv�Q �O Packet Page -1030- 9/13/2011 Item 10.C. a 0 0 R ;o 0 3 IM m J a 0 r c 51 R a a c`o v t in N z O c g N C CO o y j 3 � a CO EL o � T o o 0 43 0 Q U�U, 3iv�Q �O Packet Page -1030- 9/13/2011 Item 10.C. a 0 0 R ;o 0 3 IM m J a 0 r c 51 R a a c`o v t in \ E ƒ CL %3ƒ3 Dui C) §LT / m ;\ ] ° : mot Z E \ ) � ) \72//0/3 ® °taco v ±� ® 2k4 o®a A #6)$2 / 0 \ \ \ k \ r LL- I o ` D O CL _ \ � / d 0 U) \ L . 2 O E m k w • m m \ R Q 2 2 / aa) CL / ~ �/ / O/ Z E. \ . 0 & $ . 2 w $ Cu o \ f O2 §� / uj § < 3 t ® ƒ �\ o O 'M o 0 o .� / . �0 k B � � . % e 0 9 � / \ E ƒ q 2 / © � q . 2 t � \ k / S e 2 ƒ � /s \ \ƒ \ &§ ±e bozo® \k /22 0) � \ \ \ �± f \ \ \ \ \ § ` 2 4) CO q \ ®k� Packet Page -1031- 9/13/2011 Item 1O.C. \ v. N I- 4 § \ / � \ f . \ Q % k � Um \» a & \\ u k � to \ u C \ 2 f \ I c / } � m k £ %3ƒ3 Dui C) §LT QF- z c m ;\ ] ° : mot Z E \ ) � ) \72//0/3 ® °taco ±� ® 2k4 o®a A #6)$2 / Z / \ \ \ k \ I o ` D O 0� \ � / d 0 q 2 / © � q . 2 t � \ k / S e 2 ƒ � /s \ \ƒ \ &§ ±e bozo® \k /22 0) � \ \ \ �± f \ \ \ \ \ § ` 2 4) CO q \ ®k� Packet Page -1031- 9/13/2011 Item 1O.C. \ v. N I- 4 § \ / � \ f . \ Q % k � Um \» a & \\ u k � to \ u C \ 2 f \ I c / } � m � k q d$ i U c LLIx � g § � # � n & � ■ . � �$ M 0 �\ 0 o/ j \ � 0 kC) � 0 CL k 0 a ƒ CL a -a �z± q � LL a O n m % \ $ b + a- CO, 0 R O $ � LLI « of O _ J D < § 0 O \ I u ± < k / /LL k� q \ � $ 2 9 k - % N z N & N w 'N f 2 OR 2 ~ o 2 � 2 k � k k ƒ k \ � 2 Co 2 $ k 2 L" f m / \ $ $ $ k / / k S k R / it \ \ \ \ Packet Page -1032- 9/13/2011 Item 1O.C. \ k Co CO \ Co t o � \ ƒ \ m � o CL 0 § G m _2 > / ®R/ L��wf9 /R° d / � 2 $ ® t � / ■ § $ ®■ $ * 2 S ~ $ ~ S, /ƒq/ o\ / / \LLlz— Packet Page -1032- 9/13/2011 Item 1O.C. \ k Co CO �� Co � 2 $ a s .Q) f %lob- \ Q) Co \� /0 § $ 2 P, @ 2 0 to 2 Co � � Co Lil o °w a� O ui U) J LL i Z 0 `r a w 0 N to a M a o r to J h N o 0 o ol LL ni n. 0 c c t o,0 3 0 a 'a oci a 0 P M c c ) vm i r � � Z _O ! 4 CD N F- w n a a can �y O M O -j 0 U- 0 z2 _M �N E LU Co can CO LLJ 3 a � fu 0 ~O Z) Lu 2 Q n � O o U O 3 .j L1. N N � Q U � 77 CL O Lil o °w a� O ui U) J LL i Z 0 `r N to a M tt L to J h N o 4 Co n � v 0 to Co T- Q m 0 o co ca O 0 o O 4 oUi° C Q � O 7 VO N 1p- . io Packet Page -1033- R a 0 U O 0 c U 3 a a� a Q a Y b � 9/13/2011 Item 10.C. Do a 0 Y o mM ZCo ID o 0 o � ni c c t o,0 3 0 oci a 0 P M c c 4 Co n � v 0 to Co T- Q m 0 o co ca O 0 o O 4 oUi° C Q � O 7 VO N 1p- . io Packet Page -1033- R a 0 U O 0 c U 3 a a� a Q a Y b � 9/13/2011 Item 10.C. Do a 0 ID 0 0 o � c c t o,0 3 0 4 Co n � v 0 to Co T- Q m 0 o co ca O 0 o O 4 oUi° C Q � O 7 VO N 1p- . io Packet Page -1033- R a 0 U O 0 c U 3 a a� a Q a Y b � 9/13/2011 Item 10.C. Do a 0 O O N _Q r N O a Li- c Z N w m � N (n L w 3 c� w 0 D� �0 O JO ...1 O < O F- 0. O CL 0 U `o e 2 C. O a � >M � M v L � O LL O z Oa Q d' CL !U O (L a LLJ LLJ U) of O Q � O U UJ 0 W Q Q Z 0 20 LL] :3 } LL } Z U 9/13/2011 Item 10.C. W V- di O O W Co O O ti t` Obi M +O N nt X - M Co M Q 0 ¢ to 2 QL Q " o c Q) c S U` p W O v-. 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Thomas +1.703.299,8084 or ithomas cDiadr.orQ July 28, 2011 Study Shows Bone Fluoride Levels Not Associated with Osteosarcoma Alexandria, VA, USA — The International and American Associations for Dental Research have released in its Journal of Dental Research a study that investigated bone fluoride levels in individuals with osteosarcoma, which is a rare, primary malignant bone tumor that is more prevalent in males. Since there has been controversy as to whether there is an association between fluoride and risk for osteosarcoma, the purpose of this study, titled "An Assessment of Bone Fluoride and Osteosarcoma," was to determine if bone fluoride levels were higher in individuals with osteosarcoma. No significant association between bone fluoride levels and osteosarcoma risk was detected in this case - control study, based on controls with other tumor diagnoses. In the case - control study, by lead researcher Chester Douglass of Harvard University, patients were identified by physicians in the orthopedic departments from nine hospitals across the U.S. between 1993 and 2000. in this report, the study sample included Incident cases of primary osteosarcoma and a control group of patients with newly- diagnosed malignant bone tumors. Specimens of tumor - adjacent bone and iliac crest bone were analyzed for fluoride content. The study was approved by the Institutional Review Boards of the respective hospitals, Harvard Medical School and the Medical College of Georgia. Logistic regression of the incident cases of osteosarcoma (N =137) and tumor controls (N =51), adjusting for age and sex and potential confounders of osteosarcoma, was used to estimate odds ratios (OR) and 95% confidence intervals (CI). There was no significant difference in bone fluoride levels between cases and controls. The OR adjusted for age, gender, a history of broken bones was 1.33 (95% Cl: 0.56 - 3.15). "The controversy over whether there is an association between fluoride and risk for osteosarcoma has existed since an Inconclusive animal study 20 years ago," said IADR Vice-president Helen Vdhelton. "Numerous human descriptive and case - control studies have attempted to address the controversy, but this study of using actual bone fluoride concentrations as a direct indicator of fluoride exposure represents our best science to date and shows no association between fluoride in bone and osteosarcoma risk." The study design was approved by the National Institutes of Health's National Cancer institute (NCI), with funding provided by the National Institute of Environmental Health Sciences, National Institute of Dental and Craniofacial Research and NCI. Visit http://idr,sageRub.com/contentlearl /recent for a link to the complete article or contact Ingrid L. Thomas at ithomasaa iadr.org to request the PDF. About the Journal of Dental Research The IADR/AADR Journal of Dental Research is a multidisciplinary journal dedicated to the dissemination of new knowledge in all sciences relevant to dentistry and the oral cavity and associated structures In health and disease. At .0226 1, the JDR holds the highest Eigenfactor Score of all dental journals publishing original research and continues to be ranked number one in Article Influence Score, reflecting the influential nature of the Journal's content. About the International Association for Dental Research The international Association for Dental Research (IADR) is a nonprofit organization with nearly 11,000 individual members worldwide, dedicated to: (1) advancing research and increasing knowledge to improve oral health, (2) supporting the oral health research community, and (3) facilitating the communication and application of research findings for the improvement of oral health worldwide. To learn more, visit www,ladr.orsr. The American Association for Dental Research (AADR) is the largest Division of IADR, with nearly 4,000 members in the United States. To learn more, visit www.a2dronline.org. 1619 Duke Street, Alexandria,\/A 22314 -3406, USA Packet Page -1044- T +1.703.548.0066 . F A- 1.703.548.1883 www.iadror8