LEARNING OBJECTIVESLEARNING OBJECTIVES

• Understand the biologic mechanism of Understand the biologic mechanism of fluoridation fluoridation

• Understand the benefits, possible adverse Understand the benefits, possible adverse effects and fluoride dosingeffects and fluoride dosing

• Understand the community and well water Understand the community and well water fluoride content issues in SCfluoride content issues in SC

COMMUNITY WATER COMMUNITY WATER FLUORIDATIONFLUORIDATION

• Single most effective public health Single most effective public health measure to prevent tooth decaymeasure to prevent tooth decay

• CDC has proclaimed fluoridation as CDC has proclaimed fluoridation as one of the ten great public health one of the ten great public health achievements of the 20achievements of the 20thth century century

• Fluoridation is a powerful strategy in Fluoridation is a powerful strategy in efforts to eliminate health disparities efforts to eliminate health disparities among populationsamong populations

COMMUNITY WATER COMMUNITY WATER FLUORIDATIONFLUORIDATION

• Fluoridated water is accessible to the Fluoridated water is accessible to the entire communityentire community

• Individuals do not need to change Individuals do not need to change their behavior to obtain the benefitstheir behavior to obtain the benefits

• Frequent exposure to small amounts Frequent exposure to small amounts of Fl over time makes Fluoridation of Fl over time makes Fluoridation effective throughout the life spaneffective throughout the life span

Community Water Community Water FluoridationFluoridation

• Community public health measure Community public health measure that is cost effective and saves $that is cost effective and saves $

• The cost of drinking fluoridated water The cost of drinking fluoridated water for a lifetime is about the same as for a lifetime is about the same as the cost of one dental fillingthe cost of one dental filling

• For every $1 invested in water For every $1 invested in water fluoridation, $38 is saved in dental fluoridation, $38 is saved in dental treatment coststreatment costs

Water FluoridationWater Fluoridation

• Reduces decay by 20-40% EVEN in Reduces decay by 20-40% EVEN in conjunction with Fl from other sources conjunction with Fl from other sources (e.g. toothpaste)(e.g. toothpaste)

• 26% fewer cavities in 12 y/o children 26% fewer cavities in 12 y/o children living in a state with >50% community living in a state with >50% community water fluoridationwater fluoridation

• Healthy People 2010 objective is for 75% Healthy People 2010 objective is for 75% public fluoridation; currently @70%public fluoridation; currently @70%

Public Water Fluoridation Stats

• United States as a whole– 72.4%

• South Carolina– 94.4%

• Rank – 9th best!!!

• www.cdc.gov/fluoridation/statistics/2008stats

Caries Prevention and Fluoride-Caries Prevention and Fluoride-mechanism of actionmechanism of action

• Benefit results from (a) uptake of systemic Fl Benefit results from (a) uptake of systemic Fl by enamel crystallites during pre-eruptive by enamel crystallites during pre-eruptive tooth development & (b) uptake of topical Fl tooth development & (b) uptake of topical Fl through repetitive demineralization and through repetitive demineralization and remineralization cycles in the oral cavity after remineralization cycles in the oral cavity after tooth eruptiontooth eruption

• Fl uptake allows formation of Fl uptake allows formation of fluorohydroxyapatite (FHA)fluorohydroxyapatite (FHA)

• FHA less susceptible to acid attack than FHA less susceptible to acid attack than Hydroxyapatite in normal tooth enamelHydroxyapatite in normal tooth enamel

Dental FluorosisDental Fluorosis

• Caused by excess Fl intake; @ risk 0-8y/o; Caused by excess Fl intake; @ risk 0-8y/o; highest risk boys 15-34 mos; girls 21-30 moshighest risk boys 15-34 mos; girls 21-30 mos

• No significant dental risk > 8y/oNo significant dental risk > 8y/o

• MILD: chalk-like lacy marking across enamel MILD: chalk-like lacy marking across enamel surface; not readily apparent to casual observersurface; not readily apparent to casual observer

• MODERATE: >50% of enamel surface is opaque MODERATE: >50% of enamel surface is opaque whitewhite

• SEVERE: enamel is pitted and brittle and may SEVERE: enamel is pitted and brittle and may develop areas of brown staining (think of Dr. develop areas of brown staining (think of Dr. McKay and Colorado Brown Stain)McKay and Colorado Brown Stain)

Frequency of U. S. A. Frequency of U. S. A. Pediatric FluorosisPediatric Fluorosis

• Age 6-11: 40%Age 6-11: 40%

• Age 12-15: 49%Age 12-15: 49%

• Age 16-19: 42%Age 16-19: 42%

RDA for FlRDA for Fl

• 0-6 mos: 0.01mg0-6 mos: 0.01mg

• 7-12 mos: 0.5mg7-12 mos: 0.5mg

• 1-3 yrs: 0.7mg1-3 yrs: 0.7mg

• 4-8 yrs: 1.0mg4-8 yrs: 1.0mg

• 9-13 yrs: 2.0mg9-13 yrs: 2.0mg

• 14-18 yrs: 3.0mg14-18 yrs: 3.0mg

Fluoride dosing that should not Fluoride dosing that should not result in more than mild result in more than mild FluorosisFluorosis• Birth to 6 months: 0.01 mg/dayBirth to 6 months: 0.01 mg/day• 7-12 months: 0.05 mg/kg/day7-12 months: 0.05 mg/kg/day• 12 months to 8 years: 0.1 mg/kg/day12 months to 8 years: 0.1 mg/kg/day

• 1mg=1ppm1mg=1ppm• 0.7 ppm is 2011 current target water fluoridation 0.7 ppm is 2011 current target water fluoridation

dosedose• Community water systems are allowed to provide Community water systems are allowed to provide

water up to 4.0 ppm (MCLG; Maximum water up to 4.0 ppm (MCLG; Maximum Contaminant Level Goal) without taking Contaminant Level Goal) without taking corrective actioncorrective action

FluorosisFluorosis

• True risk not clear re the variables of True risk not clear re the variables of duration, timing, dose, biologic duration, timing, dose, biologic variability, cumulative dosing of variability, cumulative dosing of fluoride from non-water sources fluoride from non-water sources (toothpaste, food, therapeutic Fl (toothpaste, food, therapeutic Fl treatments, etc)treatments, etc)

FluorosisFluorosis

• The most critical ages of The most critical ages of susceptibility are from 0-6 y/o with susceptibility are from 0-6 y/o with the highest risk in boys from 15-24 the highest risk in boys from 15-24 mos and girls from 21-30 months. mos and girls from 21-30 months. After age 7-8, fluorosis does not After age 7-8, fluorosis does not occur because the permanent teeth occur because the permanent teeth are fully developed although not are fully developed although not eruptederupted

Mild FluorosisMild Fluorosis

Moderate FluorosisModerate Fluorosis

Severe FluorosisSevere Fluorosis

Fl in formulaFl in formulaProduct/mean ppm +/- 1SDProduct/mean ppm +/- 1SD

Powdered mild base/0.12 +/- 0.08Powdered mild base/0.12 +/- 0.08

Powdered soy/0.16 +/-0.09Powdered soy/0.16 +/-0.09

Liquid concentrate milk base: 0.27 +/- Liquid concentrate milk base: 0.27 +/- 0.180.18

Liquid concentrate soy base: Liquid concentrate soy base: 0.50 +/-0.50 +/-0.080.08

Ready to feed milk base: 0.15 +/- 0.06Ready to feed milk base: 0.15 +/- 0.06

Ready to feed soy base: 0.21 +/- 0.01Ready to feed soy base: 0.21 +/- 0.01

Fl in FormulaFl in Formula

• Most infants exceed the upper tolerable limit of Fl if Most infants exceed the upper tolerable limit of Fl if formula prepared with 1ppm water @ 0-12 months formula prepared with 1ppm water @ 0-12 months of ageof age

• 6-12 month infants unlikely to reach adequate Fl 6-12 month infants unlikely to reach adequate Fl intake if fed ready to feed, powdered, or liquid intake if fed ready to feed, powdered, or liquid concentrate reconstituted with <0.4 ppm waterconcentrate reconstituted with <0.4 ppm water

• No ready to feed formula will exceed the 0.1 No ready to feed formula will exceed the 0.1 mg/kg/day RDA upper tolerable limit mg/kg/day RDA upper tolerable limit

• True risk of fluorosis not clear re “brief” exposure True risk of fluorosis not clear re “brief” exposure to formula before switching to regular milk @ 1yto formula before switching to regular milk @ 1y

• What impact does Fl in solid food have on this Fl What impact does Fl in solid food have on this Fl dose?dose?

Fluoride Content Fluoride Content

• Toothpaste: 0.15% Fl ion (1.5 gm/L); Toothpaste: 0.15% Fl ion (1.5 gm/L);

0.243% NaFl (2.43 mg/L)0.243% NaFl (2.43 mg/L)

• 5% Dental Fluoride Varnish: 50 gm/L 5% Dental Fluoride Varnish: 50 gm/L NaFl or 2.26% Fl ion (22.6 gm/L); NaFl or 2.26% Fl ion (22.6 gm/L); available in 0.4ml and 0.25 ml available in 0.4ml and 0.25 ml volumes in disposable kit form; 9.0 volumes in disposable kit form; 9.0 mg of Fl ion in 0.4 ml dish or 5.6 mg Fl mg of Fl ion in 0.4 ml dish or 5.6 mg Fl ion in 0.25 ml dishion in 0.25 ml dish

Other selected fluoride Other selected fluoride sourcessources• Bottled water not required to label Fl Bottled water not required to label Fl

content; assume sub-optimal content content; assume sub-optimal content unless fluoride content labeled; the unless fluoride content labeled; the distributor can tell the customer on distributor can tell the customer on requestrequest

• Seafood: likely high contentSeafood: likely high content• Foods/Beverages frequently prepared by Foods/Beverages frequently prepared by

manufacturer with community water; may manufacturer with community water; may not be included in labelnot be included in label

• Breast milk: very little fluorideBreast milk: very little fluoride

Fluoride content of selected Fluoride content of selected foods ppmfoods ppm

• 2% milk = 0.042% milk = 0.04

• Wheaties = 0.4Wheaties = 0.4

• Cherrios = 0.9Cherrios = 0.9

• Minute Maid OJ = 0.39Minute Maid OJ = 0.39

• Tea = 0.1-0.6Tea = 0.1-0.6

• Chicken = 0.06-0.1Chicken = 0.06-0.1

• Hunt’s Tomato Paste = 0.27Hunt’s Tomato Paste = 0.27

• Sardines = 0.2-0.4 Sardines = 0.2-0.4

COMMON WATER FILTERSCOMMON WATER FILTERS

• Include carafe filters, faucet filters, under Include carafe filters, faucet filters, under the sink filters, and whole house filtersthe sink filters, and whole house filters

• In general, the amount of Fl filtered In general, the amount of Fl filtered depends on the type of filter, age of filter, depends on the type of filter, age of filter, working condition, and presence of working condition, and presence of activated alumina (up to 80% removal) or activated alumina (up to 80% removal) or carbon in filter (generally little removal)carbon in filter (generally little removal)

• Each type of filter needs to be assessed Each type of filter needs to be assessed individuallyindividually

WATER FILTRATIONWATER FILTRATION

• Reverse osmosis filters remove 65-95% of Reverse osmosis filters remove 65-95% of FlFl

• Steam distillation units remove 100% of FlSteam distillation units remove 100% of Fl

• Water softeners do not remove significant Water softeners do not remove significant amounts of Flamounts of Fl

• Consumers using home water treatment Consumers using home water treatment systems should have their water tested at systems should have their water tested at least annuallyleast annually

WELL WATER SAMPLES WELL WATER SAMPLES

• 1/18/10-6/22/111/18/10-6/22/11

• 339 bottles released339 bottles released

• 170 bottles returned170 bottles returned

WELL WATER SAMPLES ppmWELL WATER SAMPLES ppm

• 1/18/10-6/22/111/18/10-6/22/11

• 0 to 0.69 = 129--76%0 to 0.69 = 129--76%

• 0.7 to 1.20 = 13--8%0.7 to 1.20 = 13--8%

• 1.21 to 2.01 = 17--10%1.21 to 2.01 = 17--10%

• 2.01 to 3.0 = 9--5%2.01 to 3.0 = 9--5%

• 3.1 to 4.0 = 1--<1%3.1 to 4.0 = 1--<1%

• >4.0 = 1--<1%>4.0 = 1--<1%