Water Fluoridation and Public Health

1. Water Fluoridation and Public Health Janis Winogradsky Walden University

2. Water Fluoridation Fluoridation Basics Benefits Enamel Fluorosis Public Health Measure

3. Intake of Fluoride from… • Soil • Plants • Water • Air Fluoridation Basics

4. Fluoride is Naturally Occurring • Surface water (rivers) -- typically low concentrations, 0.2 mg/L (ppm) or less • Groundwater (wells) --higher concentrations, 0.1 mg/L to over 5.0 mg/L • Ocean water is typically 0.8 to 1.4 mg/L Fluoridation Basics

5. Natural F amount in water 0.7 ppm 1.2 ppm AddedF + = Definition of Fluoridation • Fluoridation is the adjustment of the fluoride in drinking water to a level that is optimal for reduction of tooth decay Fluoridation Basics Optimal Range

6. Adjusted Water Fluoridation • Optimal level varies in the U.S. range from 0.7-1.2 parts per million • Exact level for a given location depends upon ambient air temperature • 1 part per million (ppm) is the same as 1 milligram per liter (mg/L) Fluoridation Basics

7. So How Much is 1 ppm?* • One part per million (ppm) is equivalent to • 1 inch in 16 miles • 1 minute in two years • 1 cent in $10,000 • length of pickup truck on a road between New York and California Fluoridation Basics * 1 mg/L

8. Risk Factors for Caries • Diet • sugars and carbohydrates • Oral hygiene • Xerostomia (Dry Mouth) • fluoride • salivary flow and composition • Bacteria Levels • (especially mutans streptococci) Tooth Fluoridation Basics Decay Bacteria Food Time Saliva Fluoride Plaque

9. Summary - Caries Prevention For the best prevention of tooth decay • frequent exposure to low concentrations of fluoride • water fluoridation and dentifrices Fluoridation Basics

10. Community Water Fluoridation Begins • Grand Rapids, Michigan was the first city to adjust fluoride concentration in public drinking water (1945) • 2005 marked the 60th anniversary of community water fluoridation Historical Background

11. Water Fluoridation Fluoridation Basics Benefits Enamel Fluorosis Public Health Measure

12. Fluoridation in Context • At the time when CWF was initiated: -The typical school child developed 3-4 new cavities each year • Full extractions and complete dentures were the norm for older adults • Recruits into WWII rejected because of poor oral health – 6 opposing teeth -10% rejection rate – 40% needed immediate treatment for relief of pain • Dowries of new brides included dentures • HS graduates sometimes received gift of complete dentures Benefits

13. Early Community Trials • January 25, 1945 • Grand Rapids and Muskegon, MI • 1945-1947 Other early trials • Newburgh and Kingston, New York; • Evanston and Oak Park, Illinois; Benefits

14. Grand Rapids: Results After 15 Years Benefits

15. Newburgh: Results After 10 Years Benefits

16. Evanston: Results After 15 Years Benefits

17. Fluoride For Adults • Many older adults experience dry mouth due to medications and health conditions • Some have problems with dexterity and are unable to brush thoroughly • Fluoride remineralizes demineralized tooth surfaces and helps protect exposed root surfaces Benefits

18. Systematic Reviews Benefits “Based on the evidence of effectiveness, the Task Force strongly recommended community water fluoridation and school-based or school-linked pit and fissure sealant delivery programs…”

19. Summary • Prevention/reduction of coronal and root caries • Benefits all age groups, from children to senior citizens • Benefits everyone, across the socio-economic spectrum • Benefits reach beyond communities with fluoridation • Economical (cost-savings) Benefits

20. Water Fluoridation Fluoridation Basics Benefits Enamel Fluorosis Public Health Measure

21. Enamel Fluorosis • Hypomineralization of enamel characterized by greater surface and subsurface porosity • Occurs when children with developing teeth consume fluoride • Teeth that have erupted are not at risk • Dependent upon dose, duration, and timing of fluoride intake Enamel Fluorosis

22. Risk Factors for Enamel Fluorosis • Total Intake • Fluoride supplements • 26% of kids in fluoridated area received inappropriate supplements • Fluoride toothpaste • excess swallowing by young children Enamel Fluorosis

23. Water Fluoridation Fluoridation Basics Benefits Enamel Fluorosis Public Health Measure

24. Fluoridation Public Health Issues Fluoridation has resulted in a remarkable decline in the prevalence and severity of dental caries (tooth decay). Despite this reduction, dental caries is still the most common preventable chronic disease in the U.S. • 1 in 5 elementary schoolchildren • 2 out of 3 adolescents • 9 out of 10 adults Public Health Measure

25. Fluoride Public Health Issues • Decline in tooth decay has been uneven across the general population • 80% of decay found in 25% of children aged 5-17 years old • Populations with increased risk • Low level of parental education • Little, if any, access to dental care • Low socioeconomic status Public Health Measure

26. Ideal Public Health Measure • No compliance required – do not have to DO anything – just drink and use the water • Benefits everyone • Safe • Benefits spread beyond immediate area (halo effect) • No access to care issues • Inexpensive • True cost savings Public Health Measure

27. Public Policy on Fluoridation Endorsed by every major public health organization • American Dental Association • U.S. Public Health Service • American Medical Association • World Health Organization • American Water Works Association • And virtually every other scientific and professional organization in the health field Public Health Measure

28. Community Water Fluoridation CDC named water fluoridation as one of 10 great public health achievements of the 20th Century Public Health Measure

29. 2006 National Fluoridation Report Over 69% of people on public water systems have fluoridated water • Up from 62% in 1992 • Greater increase from 2000-2006 than from 1992-2000 • Still underutilized – 25 states have not reached HP 2010 objective Status at 60+

30. References • American Dental Association (2005) Fluoridation Facts. • Retrieved from: http://www.ada.org/public/topics/fluoride/facts/index.asp • Ast, D.B., Fitzgerald, B. (1962). Effectiveness of water fluoridation. Journal of the American Dental Association, 65:581-7. • Bailey, W., Duchon, K., Barker, L., Maas, W. (2008). Populations receiving optimally fluoridated public drinking water – United States, 1992–2006. MMWR 2008; 57(27):737–741. • Beltrán-Aguilar, E.D., Griffin S.O., and Lockwood, S.A., (2002) Prevalence and trends in enamel fluorosis in the United States from the 1930s to the 1980s. Journal of the American Dental Association, 133:157–165. • Blayney, J.R., Hill, I. N. (1967). Fluorine and dental caries: findings by age group. Journal of the American Dental Association, 74 (2): 246-52. • Centers for Disease Control (2001). Promoting oral health: interventions for preventing dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries: a report on the recommendations of the Task Force on Community Preventive Services. MMWR, 50(RR-21):1–13.

31. References (con’t) • Centers for Disease Control (2001. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR, 50 (No.RR-14). • Centers for Disease Control and Prevention (1999). Ten great public health achievements – United States. 1990-1999. MMWR 1999; 48(12):241-3 • Hayes, R.L., Littleton, N.W., White, C. (1957). Posteruptive effects of fluoridation on first permanent molars of children in Grand Rapids, Michigan. American Journal of Public Health, 47(2):192 • Levy, S.M., Kiristy, M.C., Warren, J.J. (1995) Sources of fluoride intake in children. Journal of Public Health Dentistry, 55(1):39-52 • National Health and Nutrition Examination Survey (NHANES) 1999-2001. Retrieved from: • http://www.cdc.gov/nchs/nhanes.htm . • U.S. Department of Health and Human Services (2009). Guide to Community Preventative Services. • http://www.thecommunityguide.org/oral/supportingmaterials/RRfluoridation.html