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September 17, 20071 California Children s Dental Disease Prevention Program September 17, 2007 Double Tree Hotel, Sacramento, CA Current Science on Community Water Fluoridation Howard Pollick, BDS, MPH Health Sciences Clinical Professor School of Dentistry University of California San Francisco Howard Pollick, BDS, MPH Health Sciences Clinical Professor School of Dentistry University of California San Francisco Slide 2 September 17, 20072 Community Water Fluoridation Safety Benefits Safety Benefits Slide 3 September 17, 20073 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 AJ Risk-Benefit Balance in the Use of Fluoride among Young Children. J Dent Res. 2007 Aug;86(8):723-8. Slide 4 September 17, 20074 Safety of Water Fluoridation National Fluoridation Symposium July, 2005 Celebrating 60 Years of Water Fluoridation Hosted by the American Dental Association and U.S. Centers for Disease Control and Prevention Chicago National Fluoridation Symposium July, 2005 Celebrating 60 Years of Water Fluoridation Hosted by the American Dental Association and U.S. Centers for Disease Control and Prevention Chicago Slide 5 September 17, 20075 Safety of Water Fluoridation 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 States 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 States regulations applied to each local community, water district and water wholesaler ISSUES Slide 6 September 17, 20076 Safety of Water Fluoridation 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. ISSUES Slide 7 September 17, 20077 Safety of Water Fluoridation 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 Slide 8 September 17, 20078 Safety of Water Fluoridation Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake ISSUES Slide 9 September 17, 20079 Safety of Water Fluoridation 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) Regulatory Standards Slide 10 September 17, 200710 Safety of Water Fluoridation 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) Regulatory Standards 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. Slide 11 September 17, 200711 Safety of Water Fluoridation 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. Slide 12 September 17, 200712 Safety of Water Fluoridation Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Slide 13 September 17, 200713 Safety of Water Fluoridation 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) Scientific Reviews Slide 14 September 17, 200714 Safety of Water Fluoridation 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. http://www.cdc.gov/fluoridation/safety/nrc_report.htm National Research Council, U.S.A. (2006) Fluoride in Drinking Water: A Scientific Review of EPA s Standard Slide 15 September 17, 200715 Safety of Water Fluoridation 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. http://www.cdc.gov/fluoridation/safety/nrc_report.htm 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. http://www.cdc.gov/fluoridation/safety/nrc_report.htm National Research Council, U.S.A. (2006) Fluoride in Drinking Water: A Scientific Review of EPA s Standard Slide 16 September 17, 200716 Safety of Water Fluoridation 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). http://www.cdc.gov/fluoridation/safety/nrc_report.htm 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). http://www.cdc.gov/fluoridation/safety/nrc_report.htm National Research Council, U.S.A. (2006) Fluoride in Drinking Water: A Scientific Review of EPA s Standard Slide 17 September 17, 200717 Safety of Water Fluoridation CDC 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. Slide 18 Prevalence of severe enamel fluorosis and water fluoride concentration MCLG SMCL Guideline Value WHO, Canada, EU Fluoridation Slide 19 September 17, 200719 Safety of Water Fluoridation 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." Slide 20 September 17, 200720 Safety of Water Fluoridation 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 suggestions Scientific Reviews Medical Research Council (U.K.) working group report: Water fluoridation and health. 2002 Slide 21 September 17, 200721 Total Fluoride Intake 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 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 Scientific Reviews 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. Slide 22 September 17, 200722 Safety of Water Fluoridation Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Slide 23 September 17, 200723 Safety of Water Fluoridation 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) Health concerns No effect on Mortality Agency for Toxic Substances and Disease Registry, U.S. Public Health Service (2003) Slide 24 September 17, 200724 Safety of Water Fluoridation 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 study Health concerns No evidence of Bone Cancer or Osteosarcoma York Review* *NHS Centre for Reviews and Dissemination, University of York. U.K. A Systematic Review of Public Water Fluoridation. 2000. Slide 25 September 17, 200725 Fluoridation: Bassin Study Our exploratory analysis found an association between fluoride exposure in drinking water during childhood and the incidence of osteosarcoma among males but not consistently among females. Further research is required to confirm or refute this observation. Bassin EB, Wypij D, Davis RB, Mittleman MA. Age-specific fluoride exposure in drinking water and osteosarcoma (United States). Cancer Causes Control. 2006 May;17(4):421-8. preliminary findings from the overall analysis of the second set of cases (1993- 2000) do not appear to replicate the overall findings from the first part of the study. Our findings currently being prepared for publication, do not suggest an overall association between fluoride and osteosarcoma. Douglass CW, Joshipura K. Caution needed in fluoride and osteosarcoma study. Cancer Causes Control. 2006 May;17(4):481-2. Our exploratory analysis found an association between fluoride exposure in drinking water during childhood and the incidence of osteosarcoma among males but not consistently among females. Further research is required to confirm or refute this observation. Bassin EB, Wypij D, Davis RB, Mittleman MA. Age-specific fluoride exposure in drinking water and osteosarcoma (United States). Cancer Causes Control. 2006 May;17(4):421-8. preliminary findings from the overall analysis of the second set of cases (1993- 2000) do not appear to replicate the overall findings from the first part of the study. Our findings currently being prepared for publication, do not suggest an overall association between fluoride and osteosarcoma. Douglass CW, Joshipura K. Caution needed in fluoride and osteosarcoma study. Cancer Causes Control. 2006 May;17(4):481-2. Safety: New Study Cancer Causes & Control: Editorial Board at Harvard, Boston, MA Slide 26 September 17, 200726 Fluoridation: Bassin Study After 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 that community water fluoridation is a safe, effective public health measure for preventing tooth decay. The ADA agrees with the papers authors that their work constitutes an exploratory analysis that 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 study by the Harvard School of Dental Medicine scheduled for publication later this summer. 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 summer. The principal investigator of the larger Harvard study has advised against drawing conclusions before seeing the full study, which will not suggest an overall association between fluoride and osteosarcoma, he states. Further, an association found in one, limited study, falls far below any scientific standard needed to establish a cause-and-effect relationship. In fact, after more than 60 years of rigorous scientific study of water fluoridation, the overwhelming weight of scientific evidences does not show an association with osteosarcoma. After 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 that community water fluoridation is a safe, effective public health measure for preventing tooth decay. The ADA agrees with the papers authors that their work constitutes an exploratory analysis that 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 study by the Harvard School of Dental Medicine scheduled for publication later this summer. 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 summer. The principal investigator of the larger Harvard study has advised against drawing conclusions before seeing the full study, which will not suggest an overall association between fluoride and osteosarcoma, he states. Further, an association found in one, limited study, falls far below any scientific standard needed to establish a cause-and-effect relationship. In fact, after more than 60 years of rigorous scientific study of water fluoridation, the overwhelming weight of scientific evidences does not show an association with osteosarcoma. Safety: New Study http://www.ada.org/public/media/releases/0604_release02.asp http://www.cdc.gov/fluoridation/safety/osteosarcoma.htm ADA Reaffirms Support of Water Fluoridation Chicago, April 7, 2006 Slide 27 September 17, 200727 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. Slide 28 September 17, 200728 Safety of Water Fluoridation Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Slide 29 September 17, 200729 Safety of Water Fluoridation 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 Institute of Medicine 1999 Cosmetic Concerns Enamel fluorosis Slide 30 September 17, 200730 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 Slide 31 September 17, 200731 Deans Classification of Fluorosis Photographs from Forum on Water Fluoridation in Ireland, 2002 Slide 32 September 17, 200732 Moderate and Severe Fluorosis and Moderate/Severe Caries Photographs from Forum on Water Fluoridation in Ireland, 2002 Moderate/Severe Caries Slide 33 September 17, 200733 Safety of Water Fluoridation Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Slide 34 September 17, 200734 Safety of Water Fluoridation 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 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 Fluoridation is safe for the environment Slide 35 September 17, 200735 Safety of Water Fluoridation 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. Environmental concerns Fluoridation is safe for the environment 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 Slide 36 September 17, 200736 Safety of Water Fluoridation Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Regulatory Standards Scientific Reviews Health concerns Cosmetic concerns Environmental concerns Total intake Slide 37 September 17, 200737 Safety of Water Fluoridation 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. Institute of Medicine 1999 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. Institute of Medicine 1999 Total Intake Fluoride Intake and Skeletal Fluorosis Slide 38 September 17, 200738 Safety of Water Fluoridation 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) Institute of Medicine 1999 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) Institute of Medicine 1999 Total Intake Total Intake and Enamel Fluorosis Slide 39 September 17, 200739 Safety of Water Fluoridation 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 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). http://www.ada.org/public/topics/fluoride/infantsformula.asp http://www.ada.org/public/topics/fluoride/infantsformula.asp Total Intake Infant Formula and Enamel Fluorosis - ADA Slide 40 September 17, 200740 Safety of Water Fluoridation 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 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. http://www.cdc.gov/fluoridation/safety/infant_formula.htm http://www.cdc.gov/fluoridation/safety/infant_formula.htm Total Intake Infant Formula and Enamel Fluorosis - CDC Slide 41 September 17, 200741 Safety of Water Fluoridation 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 Institute of Medicine 1999 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 Institute of Medicine 1999 Total Intake Dietary fluoride intakes by adults from food, water and beverages Slide 42 September 17, 200742 Total Fluoride Intake Institute of Medicine, 1999 Table from http://www.ada.org - Dietary Reference Intakes for Fluoride Slide 43 September 17, 200743 Safety of Water Fluoridation Regulatory StandardsMeets the standards Scientific Reviews15 reviews in past 17 years Health concernsNo health concerns Cosmetic concerns Cosmetic benefit Caries / Enamel fluorosis * Environmental concernsNo negative effect Total intakeWater fluoridation: OK * *Concerns with compliance with Rx F Supplements, Toothpaste supervision for children under 8 years of age, mixing infant formula Slide 44 September 17, 200744 Community Water Fluoridation Safety Benefits Safety Benefits Slide 45 September 17, 200745 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 CDCs MMWR Recommendations and Reports (RR-21) November 30, 2001 Slide 46 September 17, 200746 Recommendations 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) Slide 47 September 17, 200747 Community Water Fluoridation 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 Slide 48 September 17, 200748 Fluoride in water: Caries and Fluorosis: Pre-1945 data The Scientific Foundation for fluoridation Historical Background 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 Slide 49 September 17, 200749 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 Slide 50 September 17, 200750 Systemic and Topical Effects: or pre- and post-eruptive effects of fluoridation on caries prevention Slide 51 September 17, 200751 Experiment to determine topical and systemic effects 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 systemic effects 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 Group Number of animals All Molars: Mean number of carious areas SmoothSulcal Control - No F2430.227.4 F - Stomach Tube24 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 September 17, 200752 Experiment to determine pre- and post-eruptive effects of fluoride on caries prevention Effect of fluoride administered by stomach tube or orally on smooth surface & sulcal (fissure) caries in rat: 3 rd molars only (>2 weeks pre-eruptive effect) Experiment to determine pre- and post-eruptive effects of fluoride on caries prevention Effect of fluoride administered by stomach tube or orally on smooth surface & sulcal (fissure) caries in rat: 3 rd molars only (>2 weeks pre-eruptive effect) Group Caries score Smooth surfaces % Reduction Caries score Sulcal surfaces % Reduction Control: no F 7.02.3 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