Howard Pollick (PowerPoint) Opens a New Window

September 17, 2007

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California Children’s Dental Disease Prevention Program

September 17, 2007 Double Tree Hotel, Sacramento, CA

Current Science on Community Water

Fluoridation

California Children’s Dental Disease Prevention Program

September 17, 2007 Double Tree Hotel, Sacramento, CA

Current Science on Community Water

FluoridationHoward Pollick, BDS, MPH

Health Sciences Clinical ProfessorSchool of Dentistry

University of California San Francisco

Howard Pollick, BDS, MPHHealth Sciences Clinical Professor

School of DentistryUniversity of California San Francisco

September 17, 2007

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Community Water Fluoridation


Safety

Benefits

Safety

Benefits

September 17, 2007

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Safety of Fluoride: all sources

Safety of Fluoride: all sources

• The main safety issue is chronic fluoride intake from all sources during tooth development years (less than 8 years of age) and enamel fluorosis

Recommendations refine fluoridated toothpaste to lower

the risk of fluorosis without significantly reducing its effectiveness in caries prevention.

encourage commencement of toothpaste use in the 19- to 30-month age period

use of 400- to 550-ppm fluoridated toothpaste when toothpaste use starts

encourage spitting after brushing prevent an eating/licking toothpaste

habit in young children.

• The main safety issue is chronic fluoride intake from all sources during tooth development years (less than 8 years of age) and enamel fluorosis

Recommendations refine fluoridated toothpaste to lower

the risk of fluorosis without significantly reducing its effectiveness in caries prevention.

encourage commencement of toothpaste use in the 19- to 30-month age period

use of 400- to 550-ppm fluoridated toothpaste when toothpaste use starts

encourage spitting after brushing prevent an eating/licking toothpaste

habit in young children.

Do LG, Spencer AJRisk-Benefit Balance in the Use of Fluoride among Young Children. J Dent Res. 2007 Aug;86(8):723-8.

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Safety of Water Safety of Water FluoridationFluoridation


National Fluoridation Symposium July, 2005Celebrating 60 Years of Water Fluoridation

Hosted by the American Dental Associationand

U.S. Centers for Disease Control and Prevention

Chicago

National Fluoridation Symposium July, 2005Celebrating 60 Years of Water Fluoridation

Hosted by the American Dental Associationand

U.S. Centers for Disease Control and Prevention

Chicago

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Implementation

Production and delivery of the chemical compounds

Engineering safeguards and regulations

Actions taken in the event of equipment malfunctions

and human error

Continuous Quality Improvement (CQI)

National guidelines on safety

minimum basis for each State’s regulations

applied to each local community, water district

and water wholesaler

Implementation

Production and delivery of the chemical compounds

Engineering safeguards and regulations

Actions taken in the event of equipment malfunctions

and human error

Continuous Quality Improvement (CQI)

National guidelines on safety

minimum basis for each State’s regulations

applied to each local community, water district

and water wholesaler

ISS

UES

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Assurance of periodic review and updating of compliance with new guidelines and regulations

Appropriate funding

The community shares the benefits of CWF

Cost per person receiving fluoridated water is very small

Governmental and voluntary agencies must regularly cooperate and review the science, guidelines and regulations of the safety of CWF.

Assurance of periodic review and updating of compliance with new guidelines and regulations

Appropriate funding

The community shares the benefits of CWF

Cost per person receiving fluoridated water is very small

Governmental and voluntary agencies must regularly cooperate and review the science, guidelines and regulations of the safety of CWF.

ISS

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Definition of Safety

The state of being certain that adverse effects will not be caused by some agent under defined conditions

Water is safe to drink if it meets regulatory standards

Definition of Safety

The state of being certain that adverse effects will not be caused by some agent under defined conditions

Water is safe to drink if it meets regulatory standards

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Regulatory Standards

Scientific Reviews

Health concerns

Cosmetic concerns

Environmental concerns

Total intake


Scientific Reviews

Health concerns

Cosmetic concerns


Total intake

ISS

UES

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Fluoridation Chemicals meet standards

Trace contaminants, such as heavy metals

• Must not exceed the Maximum Allowable Level (MAL)

• one-tenth of the EPA’s regulated MCL

• when added to drinking water at its Maximum Use Level

• No detectable arsenic or lead in the majority of more than 100 samples

of water fluoridated with fluorosilicic acid, tested by NSF International

from 1992 to 2000

• The average concentration of arsenic and lead from all samples was less

than 0.1 ppb (parts per billion)

• Action Level Lead 15 ppb;

• MCL arsenic 10 ppb (January 2006)

Fluoridation Chemicals meet standards

Trace contaminants, such as heavy metals

• Must not exceed the Maximum Allowable Level (MAL)

• one-tenth of the EPA’s regulated MCL

• when added to drinking water at its Maximum Use Level

• No detectable arsenic or lead in the majority of more than 100 samples

of water fluoridated with fluorosilicic acid, tested by NSF International

from 1992 to 2000

• The average concentration of arsenic and lead from all samples was less

than 0.1 ppb (parts per billion)

• Action Level Lead 15 ppb;

• MCL arsenic 10 ppb (January 2006)

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No credible evidence of increased Lead Concerns have been raised about arsenic and lead in fluorosilicic

acid-treated water (Masters and Coplan)

However there is no credible evidence to show that this is of

concern (Urbansky and Schock)

No credible evidence of increased Lead Concerns have been raised about arsenic and lead in fluorosilicic

acid-treated water (Masters and Coplan)

However there is no credible evidence to show that this is of

concern (Urbansky and Schock)

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Masters RD, Coplan MJ, Hone BT, Dykes JE. Association of silicofluoride treated water with elevated blood lead. Neurotoxicology. 2000 Dec;21(6):1091-100. Masters RD and Coplan M. Water Treatment with Silicofluorides and Lead Toxicity. Intern. J. Environmental Studies 1999:56, 435-449.Urbansky ET and Schock MR. Can Fluoridation Affect Lead(II) in Potable Water? Hexafluorosilicate and Fluoride Equilibria in Aqueous Solution. International Journal of Environmental Studies (B), 2000:57:597-637.

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Criticism of studies by Masters and Coplan

Urbansky and Schock conclude:

Criticism of studies by Masters and Coplan

Urbansky and Schock conclude:

Urbansky ET and Schock MR. Can Fluoridation Affect Lead(II) in Potable Water? Hexafluorosilicate and Fluoride Equilibria in Aqueous Solution. International Journal of Environmental Studies (B), 2000:57:597-637.

“the highly-promoted studies asserting enhanced lead uptake from drinking water and increased neurotoxicity still provide no credible evidence to suggest that the common practice of fluoridating drinking water has any untoward health impacts via effects on lead when done properly under established guidelines so as to maintain total water quality.

Our conclusion supports current EPA and PHS/CDC policies on water fluoridation.”

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Scientific Reviews

Health concerns

Cosmetic concerns


Total intake


Scientific Reviews

Health concerns

Cosmetic concerns


Total intake

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National Research Council, U.S.A. (1993, 2006) World Health Organization (1994, 1996, 2006) Agency for Toxic Substances and Disease Registry,

U.S. Public Health Service (2003) International Programme on Chemical Safety, W.H.O. (2002) Forum on Fluoridation. Ireland (2002) Medical Research Council, U.K. (2002) University of York, U.K. (2000) Institute of Medicine, U.S.A. (1999) Locker: Health Canada (1999) City of Calgary,Calgary Regional Health Authority (1998) U.S. Public Health Service (1991) Kaminsky et al. New York State Dept. of Health (1990)

National Research Council, U.S.A. (1993, 2006) World Health Organization (1994, 1996, 2006) Agency for Toxic Substances and Disease Registry,

U.S. Public Health Service (2003) International Programme on Chemical Safety, W.H.O. (2002) Forum on Fluoridation. Ireland (2002) Medical Research Council, U.K. (2002) University of York, U.K. (2000) Institute of Medicine, U.S.A. (1999) Locker: Health Canada (1999) City of Calgary,Calgary Regional Health Authority (1998) U.S. Public Health Service (1991) Kaminsky et al. New York State Dept. of Health (1990)

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A subcommittee of the National Research Council's (NRC) Committee on Toxicology (COT)

reviewed toxicologic, epidemiologic, and clinical data, particularly data published since

1993, and exposure data on orally ingested fluoride from drinking water and other sources

(e.g., food, toothpaste, dental rinses).

The purpose of this report is to provide recommendations to the Environmental Protection Agency

(EPA) on whether the current maximum contaminant level goal (MCLG) of 4 mg/L protects children and

others from adverse health effects.

The NRC committee did not examine health risks or benefits of water at the levels recommended for

fluoridation of water to prevent tooth decay.

The current range for water fluoridation of community water systems is 0.7 to 1.2 ppm (equivalent to

0.7-1.2 mg/L).

Water that has fluoride at these levels is safe and effective for preventing tooth decay.

http://www.cdc.gov/fluoridation/safety/nrc_report.htm

A subcommittee of the National Research Council's (NRC) Committee on Toxicology (COT)

reviewed toxicologic, epidemiologic, and clinical data, particularly data published since

1993, and exposure data on orally ingested fluoride from drinking water and other sources

(e.g., food, toothpaste, dental rinses).

The purpose of this report is to provide recommendations to the Environmental Protection Agency

(EPA) on whether the current maximum contaminant level goal (MCLG) of 4 mg/L protects children and

others from adverse health effects.

The NRC committee did not examine health risks or benefits of water at the levels recommended for

fluoridation of water to prevent tooth decay.

The current range for water fluoridation of community water systems is 0.7 to 1.2 ppm (equivalent to

0.7-1.2 mg/L).

Water that has fluoride at these levels is safe and effective for preventing tooth decay.


National Research Council, U.S.A. (2006) National Research Council, U.S.A. (2006)

Fluoride in Drinking Water: A Scientific Review of EPAFluoride in Drinking Water: A Scientific Review of EPA’s’s Standard Standard





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The NRC Committee evaluated many health effects that have the

potential to be associated with fluoride in drinking water. The NRC concluded that only three adverse health effects warranted

consideration in developing regulatory standards for high levels of

fluoride in drinking water severe enamel fluorosis from exposure to these high levels between birth to

8 years of age, and the potential risk for

bone fractures and the more severe forms of skeletal fluorosis after lifetime exposure.

Severe skeletal fluorosis is a rare condition in the United States.


The NRC Committee evaluated many health effects that have the

potential to be associated with fluoride in drinking water. The NRC concluded that only three adverse health effects warranted

consideration in developing regulatory standards for high levels of

fluoride in drinking water severe enamel fluorosis from exposure to these high levels between birth to

8 years of age, and the potential risk for

bone fractures and the more severe forms of skeletal fluorosis after lifetime exposure.

Severe skeletal fluorosis is a rare condition in the United States.








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Important for people living in areas with natural fluoride greater than 2 ppm (mg/L).

about 0.5% of the U.S. population (1.5 million)

About 220,000 Americans receive water from public water systems with fluoride levels that are equal to or exceed 4 mg/L.

People who consume water with ≥4 mg/L fluoride over a lifetime, when compared to people consuming water with 1 mg/L, are likely to be at increased risk for bone fractures.

Water at ≥2 mg/L fluoride may put children 8 years old and younger at increased risk for severe enamel fluorosis, a condition that causes staining and pitting of the enamel

Where fluoride levels are greater than 2 mg/L, CDC recommends that parents and caregivers of children 8 years and younger should provide children with drinking water from an alternative water source.

At levels less than 2 mg/L, the committee found that the prevalence of severe enamel fluorosis was very low (near zero).


Important for people living in areas with natural fluoride greater than 2 ppm (mg/L).

about 0.5% of the U.S. population (1.5 million)

About 220,000 Americans receive water from public water systems with fluoride levels that are equal to or exceed 4 mg/L.

People who consume water with ≥4 mg/L fluoride over a lifetime, when compared to people consuming water with 1 mg/L, are likely to be at increased risk for bone fractures.

Water at ≥2 mg/L fluoride may put children 8 years old and younger at increased risk for severe enamel fluorosis, a condition that causes staining and pitting of the enamel

Where fluoride levels are greater than 2 mg/L, CDC recommends that parents and caregivers of children 8 years and younger should provide children with drinking water from an alternative water source.

At levels less than 2 mg/L, the committee found that the prevalence of severe enamel fluorosis was very low (near zero).








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CDC Statement on the 2006 National Research Council (NRC) Report on Fluoride in Drinking WaterCDC Statement on the 2006 National Research Council (NRC) Report on Fluoride in Drinking Water

The findings of the NRC report are consistent with CDC’s assessment that water is safe and healthy at the levels used for water fluoridation (0.7 - 1.2 mg/L). CDC reviews the latest scientific literature on an ongoing basis and maintains an active national community water fluoridation quality assurance program. CDC promotes research on the topic of fluoride and its effect on the public’s health. CDC’s recommendation remains the same; that community water fluoridation is safe and effective for preventing tooth decay.

Water fluoridation should be continued in communities currently fluoridating and extended to those without fluoridation.

Prevalence of severe enamel Prevalence of severe enamel fluorosisfluorosis

and water fluoride concentrationand water fluoride concentration

Prevalence of severe enamel Prevalence of severe enamel fluorosisfluorosis

and water fluoride concentrationand water fluoride concentration

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Fluoride Level (mg/L)

Prevalence Severe Fluorosis (%)

MCLG

SMCL

Guideline Value WHO, Canada, EU

Fluoridation

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Trace elements in human nutrition and health. W.H.O. 1996.Trace elements in human nutrition and health. W.H.O. 1996.

An expert consultation of the WHO on trace elements in human nutrition and health categorized fluoride among "potentially toxic elements, some of which may nevertheless have some essential functions at low levels."

Fluoride was regarded as "essential," since the consultation "considered resistance to dental caries to be a physiologically important function."

The consultation indicated that total intakes at 1, 2 and 3 years of age "should, if possible, be limited to 0.5, 1.0 and 1.5 mg/day, respectively," with not more than 75% coming in the form of soluble fluorides from drinking-water.

It was also noted that "adult intakes exceeding 5 mg of fluoride per day from all sources probably pose a significant risk of skeletal fluorosis."

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• Evidence to date suggests that fluoride has no effect on hip fractures

• There is currently no firm evidence linking water fluoridation to

cancer in general, or to specific cancers

• The group considered suggestions that fluoride may be implicated in

various other health effects and concluded that there was no

evidence for these suggestions

• Evidence to date suggests that fluoride has no effect on hip fractures

• There is currently no firm evidence linking water fluoridation to

cancer in general, or to specific cancers

• The group considered suggestions that fluoride may be implicated in

various other health effects and concluded that there was no

evidence for these suggestionsScie

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ws Medical Research Council (U.K.) working group Medical Research Council (U.K.) working group

report: report: Water fluoridation and health. 2002Water fluoridation and health. 2002

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Total Fluoride IntakeTotal Fluoride IntakeTotal Fluoride IntakeTotal Fluoride IntakeTolerable Upper Intake levels

0.1 mg/kg/day for children (birth - 8 years) 10 mg/day for children over 8 years and adults

LOAEL (lowest-observed-adverse-effect level)

Based on moderate enamel fluorosis for young children Based on skeletal fluorosis for older children and adults

Tolerable Upper Intake levels 0.1 mg/kg/day for children (birth - 8 years) 10 mg/day for children over 8 years and adults

LOAEL (lowest-observed-adverse-effect level)

Based on moderate enamel fluorosis for young children Based on skeletal fluorosis for older children and adults

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Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine.

Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride.

Washington, DC: National Academy Press, 1999.

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Scientific Reviews

Health concerns

Cosmetic concerns


Total intake


Scientific Reviews

Health concerns

Cosmetic concerns


Total intake

September 17, 2007

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Erickson (1978) Residents of 24 cities with fluoridation and 22 cities without Death rates were similar

after adjustment for differences in age, sex, race, education and population density

1,123.9 per 100,000 person-years (fluoridated)

1,137.1 per 100,000 person-years (non-fluoridated)

Erickson (1978) Residents of 24 cities with fluoridation and 22 cities without Death rates were similar

after adjustment for differences in age, sex, race, education and population density

1,123.9 per 100,000 person-years (fluoridated)

1,137.1 per 100,000 person-years (non-fluoridated) Healt

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Agency for Toxic Substances and Disease Registry, U.S. Public Health Service (2003)

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Seven studies of osteosarcoma, presenting 12 analyses were included Of these, the direction of association between water fluoridation and osteosarcoma incidence or mortality was found to be: positive (fewer cancers) in seven, negative (more cancers) in three and no association (two found no relationship)

Of the six studies that presented variance data Only one (Cohn 1992) found a statistically significant association between

fluoridation and increased prevalence of osteosarcoma in males. This study however, also had the lowest validity score, 2.5 out of 8.

Importance of not establishing or changing public policy based on a single study

Seven studies of osteosarcoma, presenting 12 analyses were included Of these, the direction of association between water fluoridation and osteosarcoma incidence or mortality was found to be: positive (fewer cancers) in seven, negative (more cancers) in three and no association (two found no relationship)

Of the six studies that presented variance data Only one (Cohn 1992) found a statistically significant association between

fluoridation and increased prevalence of osteosarcoma in males. This study however, also had the lowest validity score, 2.5 out of 8.

Importance of not establishing or changing public policy based on a single studyH

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No evidence of Bone Cancer or OsteosarcomaNo evidence of Bone Cancer or Osteosarcoma

York Review*York Review*

*NHS Centre for Reviews and Dissemination, University of York. U.K.A Systematic Review of Public Water Fluoridation. 2000.

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Fluoridation: Fluoridation: Bassin StudyBassin StudyFluoridation: Fluoridation: Bassin StudyBassin Study

““Our Our exploratoryexploratory analysis found an association between fluoride exposure in analysis found an association between fluoride exposure in drinking water during childhood and the incidence of osteosarcoma drinking water during childhood and the incidence of osteosarcoma among males but not consistently among females. among males but not consistently among females. Further research is Further research is required to confirm or refute this observationrequired to confirm or refute this observation.”.”

Bassin EB, Wypij D, Davis RB, Mittleman MA.Bassin EB, Wypij D, Davis RB, Mittleman MA. Age-specific fluoride exposure in Age-specific fluoride exposure in drinking water and osteosarcoma (United States). Cancer Causes Control. 2006 drinking water and osteosarcoma (United States). Cancer Causes Control. 2006 May;17(4):421-8. May;17(4):421-8.

“…“…preliminary findings from the overall analysispreliminary findings from the overall analysis of the second set of cases of the second set of cases (1993(1993-2-2000) 000) do not appear to replicatedo not appear to replicate the overall findings from the first the overall findings from the first part of the study. Our findings currently being prepared for publication, part of the study. Our findings currently being prepared for publication, do do not suggest an overall association between fluoride and osteosarcomanot suggest an overall association between fluoride and osteosarcoma.”.”

Douglass CW, Joshipura K.Douglass CW, Joshipura K. Caution needed in fluoride and osteosarcoma study. Caution needed in fluoride and osteosarcoma study. Cancer Causes Control. 2006 May;17(4):481-2.Cancer Causes Control. 2006 May;17(4):481-2.

““Our Our exploratoryexploratory analysis found an association between fluoride exposure in analysis found an association between fluoride exposure in drinking water during childhood and the incidence of osteosarcoma drinking water during childhood and the incidence of osteosarcoma among males but not consistently among females. among males but not consistently among females. Further research is Further research is required to confirm or refute this observationrequired to confirm or refute this observation.”.”

Bassin EB, Wypij D, Davis RB, Mittleman MA.Bassin EB, Wypij D, Davis RB, Mittleman MA. Age-specific fluoride exposure in Age-specific fluoride exposure in drinking water and osteosarcoma (United States). Cancer Causes Control. 2006 drinking water and osteosarcoma (United States). Cancer Causes Control. 2006 May;17(4):421-8. May;17(4):421-8.

“…“…preliminary findings from the overall analysispreliminary findings from the overall analysis of the second set of cases of the second set of cases (1993(1993-2-2000) 000) do not appear to replicatedo not appear to replicate the overall findings from the first the overall findings from the first part of the study. Our findings currently being prepared for publication, part of the study. Our findings currently being prepared for publication, do do not suggest an overall association between fluoride and osteosarcomanot suggest an overall association between fluoride and osteosarcoma.”.”

Douglass CW, Joshipura K.Douglass CW, Joshipura K. Caution needed in fluoride and osteosarcoma study. Caution needed in fluoride and osteosarcoma study. Cancer Causes Control. 2006 May;17(4):481-2.Cancer Causes Control. 2006 May;17(4):481-2.

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Cancer Causes & Control: Cancer Causes & Control: Editorial Board at Harvard, Boston, Editorial Board at Harvard, Boston,

MAMA

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Fluoridation: Fluoridation: Bassin StudyBassin StudyFluoridation: Fluoridation: Bassin StudyBassin Study

AAfter reviewing a recently published paper on a possible association between fluoride in fter reviewing a recently published paper on a possible association between fluoride in water and osteosarcoma (a rare form of bone cancer), the ADA remains confident water and osteosarcoma (a rare form of bone cancer), the ADA remains confident that community water fluoridation is a safe, effective public health measure for that community water fluoridation is a safe, effective public health measure for preventing tooth decay. preventing tooth decay.

The ADA agrees with the paper’The ADA agrees with the paper’ss authors that their work constitutes an authors that their work constitutes an eexploratory xploratory analysisanalysis that will require scientific confirmation to confirm or refute the findingsthat will require scientific confirmation to confirm or refute the findings..

The data in this paper is simply one piece of a much more comprehensive 15-year The data in this paper is simply one piece of a much more comprehensive 15-year study by the Harvard School of Dental Medicine scheduled for publication later this study by the Harvard School of Dental Medicine scheduled for publication later this summer. summer.

The principal investigator of the larger Harvard study has advised against drawing The principal investigator of the larger Harvard study has advised against drawing conclusions before seeing the full study, which will not suggest an overall conclusions before seeing the full study, which will not suggest an overall association between fluoride and osteosarcoma, he states. association between fluoride and osteosarcoma, he states.

Further, an Further, an aassociation found in one, limited study, falls far below any scientific ssociation found in one, limited study, falls far below any scientific standard needed to establish a cause-and-effect relationship. In fact, after more standard needed to establish a cause-and-effect relationship. In fact, after more than 60 years of rigorous scientific study of water fluoridation, than 60 years of rigorous scientific study of water fluoridation, the overwhelming the overwhelming weight of scientific evidences does not show an association with osteosarcomaweight of scientific evidences does not show an association with osteosarcoma. .

AAfter reviewing a recently published paper on a possible association between fluoride in fter reviewing a recently published paper on a possible association between fluoride in water and osteosarcoma (a rare form of bone cancer), the ADA remains confident water and osteosarcoma (a rare form of bone cancer), the ADA remains confident that community water fluoridation is a safe, effective public health measure for that community water fluoridation is a safe, effective public health measure for preventing tooth decay. preventing tooth decay.

The ADA agrees with the paper’The ADA agrees with the paper’ss authors that their work constitutes an authors that their work constitutes an eexploratory xploratory analysisanalysis that will require scientific confirmation to confirm or refute the findingsthat will require scientific confirmation to confirm or refute the findings..

The data in this paper is simply one piece of a much more comprehensive 15-year The data in this paper is simply one piece of a much more comprehensive 15-year study by the Harvard School of Dental Medicine scheduled for publication later this study by the Harvard School of Dental Medicine scheduled for publication later this summer. summer.

The principal investigator of the larger Harvard study has advised against drawing The principal investigator of the larger Harvard study has advised against drawing conclusions before seeing the full study, which will not suggest an overall conclusions before seeing the full study, which will not suggest an overall association between fluoride and osteosarcoma, he states. association between fluoride and osteosarcoma, he states.

Further, an Further, an aassociation found in one, limited study, falls far below any scientific ssociation found in one, limited study, falls far below any scientific standard needed to establish a cause-and-effect relationship. In fact, after more standard needed to establish a cause-and-effect relationship. In fact, after more than 60 years of rigorous scientific study of water fluoridation, than 60 years of rigorous scientific study of water fluoridation, the overwhelming the overwhelming weight of scientific evidences does not show an association with osteosarcomaweight of scientific evidences does not show an association with osteosarcoma. .

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http://www.ada.org/public/media/releases/0604_release02.asp

http://www.cdc.gov/fluoridation/safety/osteosarcoma.htm

ADA Reaffirms Support of Water FluoridationADA Reaffirms Support of Water Fluoridation Chicago, April 7, 2006Chicago, April 7, 2006

http://www.ada.org/public/media/releases/0604_release02.asp

http://www.cdc.gov/fluoridation/safety/osteosarcoma.htm

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Fluorine is the most electronegative and reactive of all elements;

fluoride is the ionic form of fluorine.

Fluorine is the most electronegative and reactive of all elements;

fluoride is the ionic form of fluorine.

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Scientific Reviews

Health concerns

Cosmetic concerns


Total intake


Scientific Reviews

Health concerns

Cosmetic concerns


Total intake

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Extensive epidemiological research conducted in the United States during the 1930s and 1940s (Dean, 1942) established, with a high degree of certainty

Chronic fluoride intake of less than 0.10 mg/kg/day by children at

risk of enamel fluorosis (under 8 years of age) associated with a

low prevalence (approximately 10%) of the milder forms of the

condition

Institute of Medicine 1999

Extensive epidemiological research conducted in the United States during the 1930s and 1940s (Dean, 1942) established, with a high degree of certainty

Chronic fluoride intake of less than 0.10 mg/kg/day by children at

risk of enamel fluorosis (under 8 years of age) associated with a

low prevalence (approximately 10%) of the milder forms of the

condition

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Enamel fluorosisEnamel fluorosis

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Fluoride in water: Caries and Fluorosis

Fluoride in water: Caries and Fluorosis

Pre-1945 data; 12-14 year-olds

21 US cities; hundreds of children

Caries Experience

Number of decayed, missing and filled teeth per child (DMFT)

Enamel Fluorosis

Dean’s index: normal, questionable, very mild, mild, moderate, severe

Community Fluorosis Index

0.6 - Public Health Significance

Minimum Caries/ Minimum Fluorosis

1 ppm Fluoride in water

Pre-1945 data; 12-14 year-olds

21 US cities; hundreds of children

Caries Experience

Number of decayed, missing and filled teeth per child (DMFT)

Enamel Fluorosis

Dean’s index: normal, questionable, very mild, mild, moderate, severe

Community Fluorosis Index

0.6 - Public Health Significance

Minimum Caries/ Minimum Fluorosis

1 ppm Fluoride in water

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Dean’s Classification of FluorosisDean’s Classification of Fluorosis

Photographs from Forum on Water Fluoridation in Ireland, 2002

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Moderate and Severe Fluorosis and ‘Moderate/Severe’ CariesModerate and Severe Fluorosis and ‘Moderate/Severe’ Caries

Photographs from Forum on Water Fluoridation in Ireland, 2002“Moderate/Severe Caries” “Moderate/Severe Caries”

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Scientific Reviews

Health concerns

Cosmetic concerns


Total intake


Scientific Reviews

Health concerns

Cosmetic concerns


Total intake

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Environmental concerns have been investigated in literature reviews

Tacoma Pierce County Health Department, Washington State (August 2002)

City of Port Angeles, Washington State (October 2003)

no negative impact of water fluoridation on the environment has been established

Pollick HF. Water fluoridation and the environment: current perspective in the United States. Int J Occup Environ Health. 2004 Jul-Sep;10(3):343-50

Environmental concerns have been investigated in literature reviews

Tacoma Pierce County Health Department, Washington State (August 2002)

City of Port Angeles, Washington State (October 2003)

no negative impact of water fluoridation on the environment has been established


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Fluoridation is safe for the environmentFluoridation is safe for the environment

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There is no negative effect on the health of plants, animals, or humans There is no effect on corrosion of pipes. There is no measurable increase in lead and arsenic. There are no emissions of fluoride into the air outside the well houses. There is no release of toxic or hazardous substances. There is no noise production. There is no measurable increase in the fluoride concentrations in rivers

downstream of the discharges due to adding fluoride to the water supply system.

There is no concentration of fluoride in groundwater.

There is no negative effect on the health of plants, animals, or humans There is no effect on corrosion of pipes. There is no measurable increase in lead and arsenic. There are no emissions of fluoride into the air outside the well houses. There is no release of toxic or hazardous substances. There is no noise production. There is no measurable increase in the fluoride concentrations in rivers

downstream of the discharges due to adding fluoride to the water supply system.

There is no concentration of fluoride in groundwater.

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cern

s

Fluoridation is safe for the environmentFluoridation is safe for the environment


September 17, 2007

36




Scientific Reviews

Health concerns

Cosmetic concerns


Total intake


Scientific Reviews

Health concerns

Cosmetic concerns


Total intake

September 17, 2007

37



Extensive reviews of the scientific literature revealed no adverse

effects unless fluoride intakes were greater than 10 mg/day for 10

or more years (Kaminsky et al., 1990; NRC, 1993; USPHS, 1991).

At these high, chronic intake levels, the risk of skeletal changes

consistent with preclinical or stage 1 skeletal fluorosis increases.


Extensive reviews of the scientific literature revealed no adverse

effects unless fluoride intakes were greater than 10 mg/day for 10

or more years (Kaminsky et al., 1990; NRC, 1993; USPHS, 1991).

At these high, chronic intake levels, the risk of skeletal changes

consistent with preclinical or stage 1 skeletal fluorosis increases.


Tota

l In

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Fluoride Intake and Skeletal FluorosisFluoride Intake and Skeletal Fluorosis

September 17, 2007

38



The Tolerable Upper Intake Level for children under 8 years of age (0.1 mg/kg/day) is

exceeded by approximately 1 in 100 children in areas where the water fluoride

concentration is 1.0 mg/liter or slightly higher

In the 1930s and 1940s, no moderate or severe cases of enamel fluorosis were

recorded in these areas

Fluoride intake from water and the diet appears not to have increased since that time

Additional intake by children at risk of enamel fluorosis almost certainly derives from

the use of fluoride-containing dental products (toothpaste, prescription supplements)


The Tolerable Upper Intake Level for children under 8 years of age (0.1 mg/kg/day) is

exceeded by approximately 1 in 100 children in areas where the water fluoride

concentration is 1.0 mg/liter or slightly higher

In the 1930s and 1940s, no moderate or severe cases of enamel fluorosis were

recorded in these areas

Fluoride intake from water and the diet appears not to have increased since that time

Additional intake by children at risk of enamel fluorosis almost certainly derives from

the use of fluoride-containing dental products (toothpaste, prescription supplements)


Tota

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Total Intake and Enamel FluorosisTotal Intake and Enamel Fluorosis

September 17, 2007

39



On November 9, 2006, the ADA issued interim guidance on fluoride intake for infants and young children. Sound science was the driving force behind the release of the guidance. It was issued so parents, caregivers and health care professionals, who may be concerned about a possible increased risk of fluorosis, have some simple and effective advice on ways to reduce fluoride intake from reconstituted infant formula.

For infants who get most of their nutrition from formula during their first 12 months, ready-to-feed formula is preferred to help ensure that they do not exceed the optimal amount of fluoride intake.

If liquid concentrate or powdered infant formula is the primary source of nutrition, it can be mixed with water that is fluoride free or contains low levels of fluoride to reduce the risk of fluorosis. Examples are water that is labeled purified, demineralized, deionized, distilled or reverse osmosis filtered water. Many grocery stores sell these types of drinking water for less than $1 per gallon.

Breast milk is widely acknowledged as the most complete form of nutrition for infants. The American Academy of Pediatrics recommends human milk for all infants (except for the few for whom breastfeeding is determined to be harmful).

http://www.ada.org/public/topics/fluoride/infantsformula.asp

On November 9, 2006, the ADA issued interim guidance on fluoride intake for infants and young children. Sound science was the driving force behind the release of the guidance. It was issued so parents, caregivers and health care professionals, who may be concerned about a possible increased risk of fluorosis, have some simple and effective advice on ways to reduce fluoride intake from reconstituted infant formula.

For infants who get most of their nutrition from formula during their first 12 months, ready-to-feed formula is preferred to help ensure that they do not exceed the optimal amount of fluoride intake.

If liquid concentrate or powdered infant formula is the primary source of nutrition, it can be mixed with water that is fluoride free or contains low levels of fluoride to reduce the risk of fluorosis. Examples are water that is labeled purified, demineralized, deionized, distilled or reverse osmosis filtered water. Many grocery stores sell these types of drinking water for less than $1 per gallon.

Breast milk is widely acknowledged as the most complete form of nutrition for infants. The American Academy of Pediatrics recommends human milk for all infants (except for the few for whom breastfeeding is determined to be harmful).


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Infant Formula and Enamel Fluorosis - ADAInfant Formula and Enamel Fluorosis - ADA



September 17, 2007

40



Recent studies have raised the possibility that mixing infant formula with fluoridated

water, particularly for infants exclusively on a formula diet during the first year of life, may

play a more important role in enamel fluorosis development than was previously

understood.

Ready to feed (no-mix) infant formula typically has little fluoride and may be preferred for

use at least some of the time.

For decades, parents have been mixing infant formula with optimally fluoridated tap water

(a level determined by the U.S. Public Health Service between 0.7 mg/L fluoride and 1.2

mg/L fluoride and maintained by your water utility to maximize decay prevention and limit

fluorosis potential) and no association has been observed between infant formula use and

an increased risk for moderate or severe fluorosis.

http://www.cdc.gov/fluoridation/safety/infant_formula.htm

Recent studies have raised the possibility that mixing infant formula with fluoridated

water, particularly for infants exclusively on a formula diet during the first year of life, may

play a more important role in enamel fluorosis development than was previously

understood.

Ready to feed (no-mix) infant formula typically has little fluoride and may be preferred for

use at least some of the time.

For decades, parents have been mixing infant formula with optimally fluoridated tap water

(a level determined by the U.S. Public Health Service between 0.7 mg/L fluoride and 1.2

mg/L fluoride and maintained by your water utility to maximize decay prevention and limit

fluorosis potential) and no association has been observed between infant formula use and

an increased risk for moderate or severe fluorosis.


Tota

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Infant Formula and Enamel Fluorosis - CDCInfant Formula and Enamel Fluorosis - CDC



September 17, 2007

41



where concentration is 1.0 ppm F in water range from 1.4 to 3.4 mg fluoride per

day

where concentration is less than 0.3 ppm F range from 0.3 to 1.0 mg/day


where concentration is 1.0 ppm F in water range from 1.4 to 3.4 mg fluoride per

day

where concentration is less than 0.3 ppm F range from 0.3 to 1.0 mg/day


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Dietary fluoride intakes by adultsDietary fluoride intakes by adultsfrom food, water and beveragesfrom food, water and beverages

September 17, 2007

42

Total Fluoride IntakeTotal Fluoride Intake

Institute of Medicine, 1999Table from http://www.ada.org - Dietary Reference Intakes for Fluoride

September 17, 2007

43



Regulatory Standards Meets the standards

Scientific Reviews 15 reviews in past 17 years

Health concerns No health concerns

Cosmetic concernsCosmetic benefitCaries / Enamel fluorosis *

Environmental concerns No negative effect

Total intake Water fluoridation: OK *

*Concerns with compliance with Rx F Supplements, Toothpaste supervisionfor children under 8 years of age, mixing infant formula

September 17, 2007

44



Safety

Benefits

Safety

Benefits

September 17, 2007

45

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

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

CDC’s MMWR Recommendations and Reports (RR-21) November

30, 2001

CDC’s MMWR Recommendations and Reports (RR-21) November

30, 2001

September 17, 2007

46

RecommendationsRecommendations

Preventing dental caries

Community water fluoridation (strongly recommended)

School-based sealant programs (strongly recommended)

Preventing dental caries

Community water fluoridation (strongly recommended)

School-based sealant programs (strongly recommended)

September 17, 2007

47



21 studies (good to fair quality) Median decrease in dental caries:

29.1% (before-and-after measures) 50.7% (after measures only)

Children (4-17 years) of varying levels of baseline caries and socioeconomic status

Evidence of effectiveness: strong

21 studies (good to fair quality) Median decrease in dental caries:

29.1% (before-and-after measures) 50.7% (after measures only)

Children (4-17 years) of varying levels of baseline caries and socioeconomic status

Evidence of effectiveness: strong

September 17, 2007

48

Fluoride in water: Caries and Fluorosis: Pre-1945 dataThe Scientific Foundation for fluoridation

Fluoride in water: Caries and Fluorosis: Pre-1945 dataThe Scientific Foundation for fluoridation

His

tori

cal B

ackg

rou

nd

• 12-14-year-olds• Midwest US• 21 cities

Dean,H.T. in Dental caries and Fluorine, Washington, American Association Advancement Science, pp. 5-31, 1946

September 17, 2007

49

CDC: Fluoridation protects teeth in two ways

CDC: Fluoridation protects teeth in two ways

When delivered through the water supply to children during the tooth forming years.

Through direct contact with teeth throughout life.

When delivered through the water supply to children during the tooth forming years.

Through direct contact with teeth throughout life.

http://www.cdc.gov/fluoridation/benefits.htm

September 17, 2007

50

Systemic and Topical Effects: or pre- and post-eruptive effects of fluoridation on caries prevention

Systemic and Topical Effects: or pre- and post-eruptive effects of fluoridation on caries prevention

September 17, 2007

51

Experiment to determine topical and systemiceffects of fluoride on caries prevention

Effect of fluoride administered by stomach tube or orally (5 ppm) on smooth surface & sulcal (fissure) caries in rat molars

Experiment to determine topical and systemiceffects of fluoride on caries prevention

Effect of fluoride administered by stomach tube or orally (5 ppm) on smooth surface & sulcal (fissure) caries in rat molars

GroupNumber

of animals

All Molars: Mean number of carious

areas

Smooth Sulcal

Control - No F 24 30.2 27.4

F - Stomach Tube 24 9.0 * 23.1

F - orally (water) 22 0.6 * 10.6 *

Larson RH, Mellberg JR, Senning R. Experiments on local and systemic action of fluoride in caries inhibition in the rat. Archives of Oral Biology. 1977;22(7):437-9

* p <0.01

September 17, 2007

52

Experiment to determine pre- and post-eruptiveeffects of fluoride on caries prevention

Effect of fluoride administered by stomach tube or orally on smooth surface & sulcal (fissure) caries in rat:

3rd molars only (>2 weeks pre-eruptive effect)

Experiment to determine pre- and post-eruptiveeffects of fluoride on caries prevention

Effect of fluoride administered by stomach tube or orally on smooth surface & sulcal (fissure) caries in rat:

3rd molars only (>2 weeks pre-eruptive effect)

GroupCaries score

Smooth surfaces

% Reductio

n

Caries score Sulcal

surfaces

% Reductio

n

Control: no F 7.0 2.3

F - stomach tube

0.5 * 93 % 1.6 * 30 %

F - orally (water)

0.0 * 100 % 0.8 * 65 %

Larson RH, Mellberg JR, Senning R. Experiments on local and systemic action of fluoride in caries inhibition in the rat. Archives of Oral Biology. 1977;22(7):437-9

* p <0.01

September 17, 2007

53

Tiel-CulemborgNetherlands

Tiel-CulemborgNetherlands

Cross-sectional study of dentinal caries based on standardized bite-wing x-rays of permanent teeth

Tiel, Netherlands, began fluoridating water at 1 ppm in 1953 and stopped Dec 1973 under court order. Culemborg served as non-fluoridated control

Data collected in 1961, 1973, and 1979-86

In all categories of surfaces (proximal, smooth, pit & fissure) the use of fluoridated water only post-eruptively shows less effect than the use only pre-eruptively.

“In order to obtain maximal reduction in all surfaces the use of fluoridated water must be started at onset of calcification of a tooth.”

Cross-sectional study of dentinal caries based on standardized bite-wing x-rays of permanent teeth

Tiel, Netherlands, began fluoridating water at 1 ppm in 1953 and stopped Dec 1973 under court order. Culemborg served as non-fluoridated control

Data collected in 1961, 1973, and 1979-86

In all categories of surfaces (proximal, smooth, pit & fissure) the use of fluoridated water only post-eruptively shows less effect than the use only pre-eruptively.

“In order to obtain maximal reduction in all surfaces the use of fluoridated water must be started at onset of calcification of a tooth.”

Groeneveld A, Van Eck AA, Backer Dirks O. Fluoride in caries prevention: is the effect pre- or post-eruptive? J Dent Res. 1990 Feb;69 Spec No:751-5; discussion 820-3

September 17, 2007

54

Fluoride effect: Pre- and Post-eruptive

Fluoride effect: Pre- and Post-eruptive

Site Pre- Post-

Pit & Fissure 66% 33%

Approximal 50% 50%

Smooth surfaces 25% 75%

Fluoride has an important pre-eruptive effect

on subsequent caries experience; % reduction depends on site

Groeneveld A, Van Eck AA, Backer Dirks O. Fluoride in caries prevention: is the effect pre- or post-eruptive?J Dent Res. 1990 Feb;69 Spec No:751-5; discussion 820-3

September 17, 2007

55

Conclusions from recent Conclusions from recent Australian studiesAustralian studies

Confirm earlier findings: higher pre- than post-eruptive exposure more beneficial for

overall caries experience and for pit & fissure surfaces caries reduction

Children with optimum exposure to fluoridated water both pre- & post-eruption had

lowest caries in all surface types

There was an exposure-response relationship between pre-eruptive exposure and caries.

Singh KA, Spencer AJ, Brennan DS. Effects of water fluoride exposure at crown completion and maturation on caries of permanent first molars.Caries Res. 2007;41(1):34-42.Singh KA, Spencer AJ. Relative effects of pre- and post-eruption water fluoride on caries experience by surface type of permanent first molars.Community Dent Oral Epidemiol. 2004 Dec;32(6):435-46 Singh KA, Spencer AJ, Armfield JM. Relative effects of pre- and posteruption water fluoride on caries experience of permanent first molars.J Public Health Dent. 2003 Winter;63(1):11-9.

September 17, 2007

56

Exposure to fluoridated water Exposure to fluoridated water since birth produces the since birth produces the

maximum benefit.maximum benefit. The strongest caries-preventive

effect was produced by a high exposure to fluoridated water at crown completion

supplemented by a high exposure at maturation and/or post-eruption

but the latter two phases could not produce a significant caries-preventive effect on their own.

findings relate mainly to pit and fissure surfaces

Singh KA, Spencer AJ, Brennan DS. Effects of water fluoride exposure at crown completion and maturation on caries of permanent first molars. Caries Res. 2007;41(1):34-42

September 17, 2007

57

Effectiveness of water fluoridation Difference in Caries Prevalence by U. S. Region according to

% on fluoridated water. (1987-88) Children 5-17 year-olds

Effectiveness of water fluoridation Difference in Caries Prevalence by U. S. Region according to

% on fluoridated water. (1987-88) Children 5-17 year-olds

Newbrun E. Current regulations and recommendations concerning water fluoridation, fluoride supplements, and topical fluoride agents. J Dent Res. 1992 May;71(5):1255-65(data from: Brunelle JA, Carlos JP Recent Trends in Dental Caries in U.S. Children and the Effect of Water Fluoridation Journal of Dental Research. 1990 Feb; 69 (Special Issue); 723-727.

Explained by

• Halo or diffusion effect

• The more fluoridation in a region, the less difference between fluoridated and non-fluoridated areas

Explained by

• Halo or diffusion effect

• The more fluoridation in a region, the less difference between fluoridated and non-fluoridated areas

September 17, 2007

58

HALO (or diffusion) EffectHALO (or diffusion) Effect

12-year-old children living in

states where more than half

of the communities have

fluoridated water will have

26% fewer decayed tooth

surfaces per year than 12-

year-old children living in

states where less than one-

quarter of the communities

are fluoridated.

12-year-old children living in

states where more than half

of the communities have

fluoridated water will have

26% fewer decayed tooth

surfaces per year than 12-

year-old children living in

states where less than one-

quarter of the communities

are fluoridated.

A 12-year-old child who has lived in

a non-fluoridated community in a

highly fluoridated state would

typically have one fewer cavity than

a child in a low-fluoridated stateGriffin SO, Gooch BF, Lockwood SA, Tomar SL. Quantifying the diffused benefit from water fluoridation in the United States. Community Dent Oral Epidemiol 2001. Apr;29(2):120-9.

September 17, 2007

59

The Percentage of the U.S. Population on Public Water Supply Systems Receiving Fluoridated

Water is 67.3%, but varies from State to State

The Percentage of the U.S. Population on Public Water Supply Systems Receiving Fluoridated

Water is 67.3%, but varies from State to State

http://www.cdc.gov/fluoridation/fact_sheets/us_stats2002.htm

California:27.6%

September 17, 2007

60

Caries Status in California:Caries Status in California:High School Students

in fluoridated areas have far fewer urgent treatment needs

Caries Status in California:Caries Status in California:High School Students

in fluoridated areas have far fewer urgent treatment needs

URGENT TREATMENT NEEDS

per

cent

0

10

20

30

40

Asian African-American Latino/Hispanic White/Caucasian All

2.73.4

5.8

2.53.8

19.2

22.2

36.5

18

24.8

3.5

10.8

16.7

18.6

30.5

15

20.8

14.7

Fluoridated Urban Rural All

REGULAR HIGH

SCHOOLS

I.D.I.D.

I.D.: Insufficient Data for Asians and Blacks in Rural Areas

Pollick HF, Isman R, Fine JI, Wellman J, Kipnis P, Ellison J. Report of the California Oral Health Needs Assessment of Children, 1993-94: Background, Methodology, Findings. The Dental Health Foundation, Oakland, California. 1999

September 17, 2007

61

Fluoride is cost-effective Fluoride is cost-effective

Every dollar spent on community water fluoridation saves from $7 to $42 in treatment costs depending on the size of the community. Savings are greatest in large communities.

At least 60% of the U.S. population on public water systems has received fluoridated water since 1990, translating to savings in dental treatment costs of over $25.7 billion in the past decade.

Every dollar spent on community water fluoridation saves from $7 to $42 in treatment costs depending on the size of the community. Savings are greatest in large communities.

At least 60% of the U.S. population on public water systems has received fluoridated water since 1990, translating to savings in dental treatment costs of over $25.7 billion in the past decade.

http://www.cdc.gov/oralhealth/factsheets/dental_caries.htm

September 17, 2007

62

Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation.

Journal Public Health Dentistry 2001;61(2):78-86

Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation.

Journal Public Health Dentistry 2001;61(2):78-86

Annual per person cost savings resulting from fluoridation ranged from $15.95 in very small communities to $18.62 in large communities

On the basis of the most current data available on the effectiveness and cost of fluoridation, caries increment, and the cost and longevity of dental restorations, we find that water fluoridation offers significant cost savings.

Annual per person cost savings resulting from fluoridation ranged from $15.95 in very small communities to $18.62 in large communities

On the basis of the most current data available on the effectiveness and cost of fluoridation, caries increment, and the cost and longevity of dental restorations, we find that water fluoridation offers significant cost savings.

September 17, 2007

63

Fluoridation: Recent Fluoridation: Recent EvidenceEvidence

Fluoridation: Recent Fluoridation: Recent EvidenceEvidence

Mean number of teeth affected by dental caries Mean number of teeth affected by dental caries

Fluoridated Fluoridated Republic of IrelandRepublic of Ireland; Non-fluoridated ; Non-fluoridated Northern IrelandNorthern IrelandMean number of teeth affected by dental caries Mean number of teeth affected by dental caries

Fluoridated Fluoridated Republic of IrelandRepublic of Ireland; Non-fluoridated ; Non-fluoridated Northern IrelandNorthern Ireland

5-year-olds5-year-olds 15-year-olds15-year-olds

FluoridatedFluoridated 1.01.0 2.12.1

Non-FluoridatedNon-Fluoridated 1.81.8 3.63.6

AustraliaAustralia

Subjects with a lifetime exposure to fluoridated drinking water had a Subjects with a lifetime exposure to fluoridated drinking water had a lower level of caries experience than those with no exposure to lower level of caries experience than those with no exposure to fluoridated drinking water, and this was more noticeable in approximal fluoridated drinking water, and this was more noticeable in approximal surfaces than occlusal surfaces.surfaces than occlusal surfaces.

Hopcraft MS, Morgan MV. Pattern of dental caries experience on tooth surfaces in an adult population. Hopcraft MS, Morgan MV. Pattern of dental caries experience on tooth surfaces in an adult population.

Community Dent Oral Epidemiol. 2006 Jun;34(3):174-83.Community Dent Oral Epidemiol. 2006 Jun;34(3):174-83.

Whelton H, Crowley E, O'Mullane D, Donaldson M, Cronin M, Kelleher V. Dental caries and enamel fluorosis Whelton H, Crowley E, O'Mullane D, Donaldson M, Cronin M, Kelleher V. Dental caries and enamel fluorosis among the fluoridated population in the Republic of Ireland and non fluoridated population in Northern Ireland in among the fluoridated population in the Republic of Ireland and non fluoridated population in Northern Ireland in 2002. Community Dent Health. 2006 Mar;23(1):37-432002. Community Dent Health. 2006 Mar;23(1):37-43

Benefits

- N

ew

Stu

die

sB

enefits

- N

ew

Stu

die

s

September 17, 2007

64

Water fluoridation and SealantsWater fluoridation and Sealants

Prospective (mean 2 years) cohort study of children in Australia

789 children (mean age = 10.5 years) with one sealed permanent first molar at baseline, while the paired surface was diagnosed as sound.

The caries incidence of the fissure sealed occlusal surfaces was 5.6% compared to 11.1% for sound surfaces (p < 0.001); a 50% reduction in caries incidence for sealed vs non-sealed surfaces.

Prospective (mean 2 years) cohort study of children in Australia

789 children (mean age = 10.5 years) with one sealed permanent first molar at baseline, while the paired surface was diagnosed as sound.

The caries incidence of the fissure sealed occlusal surfaces was 5.6% compared to 11.1% for sound surfaces (p < 0.001); a 50% reduction in caries incidence for sealed vs non-sealed surfaces.

The reduction in caries increment attributable to sealants increased across fluoridated water exposure categories

36.4% reduction was found for children with 0% exposure (p > 0.05)

55.0% reduction for children with intermediate exposure (p < 0.01)

82.4% reduction for children with 100% lifetime exposure to fluoridated water (p < 0.001).

The reduction in caries increment attributable to sealants increased across fluoridated water exposure categories

36.4% reduction was found for children with 0% exposure (p > 0.05)

55.0% reduction for children with intermediate exposure (p < 0.01)

82.4% reduction for children with 100% lifetime exposure to fluoridated water (p < 0.001).

Armfield JM, Spencer AJ. Community effectiveness of fissure sealants and the effect of fluoridated water consumption.Community Dent Health. 2007 Mar;24(1):4-11

September 17, 2007

65

Water fluoridation and SealantsWater fluoridation and Sealants

ConclusionThe effectiveness of fissure sealants in community-based

programs may be further improved when coupled with increased lifetime exposure to optimally fluoridated water.

ConclusionThe effectiveness of fissure sealants in community-based

programs may be further improved when coupled with increased lifetime exposure to optimally fluoridated water.

Armfield JM, Spencer AJ. Community effectiveness of fissure sealants and the effect of fluoridated water consumption.Community Dent Health. 2007 Mar;24(1):4-11

September 17, 2007

66

Annual incremental benefit of water fluoridationAnnual incremental benefit of water fluoridation

An annual incremental benefit of fluoridation of 0.19 tooth surfaces (range 0.04 to 0.34). This equates to 1.9 tooth surfaces every decade, or 9.5 tooth surfaces over 50 years.

Griffin SO, Jones K, Tomar SL. Economic Evaluation of Community Water Fluoridation. J Publ Health Dent 2001;61(2):78-86

An annual incremental benefit of fluoridation of 0.19 tooth surfaces (range 0.04 to 0.34). This equates to 1.9 tooth surfaces every decade, or 9.5 tooth surfaces over 50 years.

Griffin SO, Jones K, Tomar SL. Economic Evaluation of Community Water Fluoridation. J Publ Health Dent 2001;61(2):78-86

Brunelle & Carlos data: Differences between Non-F and F: DMFS

y = 0.0081x2 + 0.0092x

R2 = 0.8465

0

0.6

1.2

1.8

5 6 7 8 9 10 11 12 13 14 15 16 17

Age

Mean DMFS difference

Difference in mean Decayed, Missing due to caries and Filled Permanent Tooth Surfaces (DMFS) between children with continuous exposure to water fluoridation and those with no such exposure.

Data from Table 6 of Brunelle & Carlos. Brunelle JA, Carlos JP. Recent trends in dental caries in U.S. children and the effect of water fluoridation. J Dent Res. 1990;69 Spec No:723-7; discussion 820-3. Pollick HF. Scientific evidence continues to support fluoridation of public water supplies. Int J Occup Environ Health. 2005 Jul-Sep;11(3):322-6.

September 17, 2007

67

Benefit for adults from water fluoridationBenefit for adults from water fluoridation

Review of adult studies after 1980 Any fluoride, whether self-applied,

professionally applied or water fluoridation, or combination

averted 0.29 (95%CI: 0.16-0.42) carious coronal tooth surfaces per year

and averted 0.22 (95%CI: 0.08-0.37) carious root surfaces per year.

Total averted 0.51 carious surfaces /year

Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res. 2007 May;86(5):410-5.

Review of adult studies after 1980 Any fluoride, whether self-applied,

professionally applied or water fluoridation, or combination

averted 0.29 (95%CI: 0.16-0.42) carious coronal tooth surfaces per year

and averted 0.22 (95%CI: 0.08-0.37) carious root surfaces per year.

Total averted 0.51 carious surfaces /year


The prevented fraction for water fluoridation was 27% (95%CI: 19%-34%)

Prevents 0.14 carious surfaces / year

Slightly less than 0.19 for all ages from the 2001 review

The prevented fraction for water fluoridation was 27% (95%CI: 19%-34%)



September 17, 2007

68

Benefit for adults from water fluoridationBenefit for adults from water fluoridation

Water fluoridation, all adults, coronal caries

Including only lifelong residents of control or fluoridated-water communities

7 studies 5409 participants


Water fluoridation, all adults, coronal caries

Including only lifelong residents of control or fluoridated-water communities

7 studies 5409 participants


equivalent to a prevented fraction of 34.6% (95%CI: 12.6%-51.0%).



equivalent to a prevented fraction of 34.6% (95%CI: 12.6%-51.0%).



September 17, 2007

69

Although adults are as likely to experience new caries as children, certain segments of the U.S. adult population - those with low incomes and the elderly - may have little or no access to restorative or preventive clinical care.

At present, approximately 15% of state Medicaid programs provide no adult dental benefits at all, and approximately 45% cover only tooth extraction and emergency services (Oral Health America, 2003). Routine dental care is one of the few health areas not covered by Medicare.

Limited access to restorative care increases the need for effective prevention; complications and pain and suffering are more likely if caries remains untreated.

The proportion of the U.S. population comprised of older adults is increasing, most of these persons are likely to be dentate and at risk for dental caries, and many lower-income adults lack access to timely restorative care.

Our finding that fluoride is effective among all adults supports the development and implementation of fluoride programs to serve this population.

Although adults are as likely to experience new caries as children, certain segments of the U.S. adult population - those with low incomes and the elderly - may have little or no access to restorative or preventive clinical care.

At present, approximately 15% of state Medicaid programs provide no adult dental benefits at all, and approximately 45% cover only tooth extraction and emergency services (Oral Health America, 2003). Routine dental care is one of the few health areas not covered by Medicare.

Limited access to restorative care increases the need for effective prevention; complications and pain and suffering are more likely if caries remains untreated.

The proportion of the U.S. population comprised of older adults is increasing, most of these persons are likely to be dentate and at risk for dental caries, and many lower-income adults lack access to timely restorative care.

Our finding that fluoride is effective among all adults supports the development and implementation of fluoride programs to serve this population.


CONCLUSION

September 17, 2007

70

Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?Questions?

[email protected]

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