A Tennessee Perspective A Tennessee Perspective on Community Water on Community Water

FluoridationFluoridation

David E. Brumley, DDS, MPHDavid E. Brumley, DDS, MPHSouth Central RegionSouth Central RegionNovember 16, 2006November 16, 2006

Community Water FluoridationCommunity Water Fluoridation

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

Community water fluoridation is one of Community water fluoridation is one of

ten great public health achievements ten great public health achievements

of the 20of the 20thth century. century.

MMWRMMWR April 2, 1999, Vol. 48 (12) April 2, 1999, Vol. 48 (12)

Community Water FluoridationCommunity Water FluoridationWhat is water fluoridation?What is water fluoridation?

• Small amounts of fluoride are present naturally in Small amounts of fluoride are present naturally in all water sources.all water sources.

• Water fluoridation is the precise adjustment of Water fluoridation is the precise adjustment of the natural fluoride concentration in a public the natural fluoride concentration in a public water supply up to the level recommended for water supply up to the level recommended for preventing tooth decay.preventing tooth decay.

• The USPHS has established the optimal The USPHS has established the optimal concentration for fluoride in water supplies in a concentration for fluoride in water supplies in a range of 0.7 to 1.2 parts per million.range of 0.7 to 1.2 parts per million.

• At the turn of the 20At the turn of the 20thth century, Dr. Fredrick S. McKay century, Dr. Fredrick S. McKay moved from Philadelphia to Colorado Springs, Colorado moved from Philadelphia to Colorado Springs, Colorado and opened a dental practice.and opened a dental practice.

• He noticed that many of his patients exhibited a peculiar He noticed that many of his patients exhibited a peculiar condition referred to along the Continental Divide as condition referred to along the Continental Divide as ‘Colorado Brown Stain.’ ‘Colorado Brown Stain.’

• In 1908, he initiated a study and found that this condition In 1908, he initiated a study and found that this condition was prevalent among long-term residents who were was prevalent among long-term residents who were born in the area. It was also endemic to other born in the area. It was also endemic to other communities along the Continental Divide. communities along the Continental Divide.

• Dr. McKay and Dr. G.V. Black wrote the first detailed Dr. McKay and Dr. G.V. Black wrote the first detailed clinical description of mottled enamel which is now clinical description of mottled enamel which is now termed fluorosis.termed fluorosis.

Historical PerspectiveHistorical Perspective

• In 1928, Dr. McKay discovered the agent in the drinking water that In 1928, Dr. McKay discovered the agent in the drinking water that caused mottled enamel also inhibited dental caries.caused mottled enamel also inhibited dental caries.

• In 1931, Dr. McKay sent samples of this water to an Alcoa chemist In 1931, Dr. McKay sent samples of this water to an Alcoa chemist named H.V. Churchill who identified the causative agent as named H.V. Churchill who identified the causative agent as fluoride.fluoride.

• In the 1930s, Dr. McKay and Dr. H. Trendley Dean of the USPHS In the 1930s, Dr. McKay and Dr. H. Trendley Dean of the USPHS collaborated to explore the possibility of adjusting the level of collaborated to explore the possibility of adjusting the level of fluoride in drinking water to reduce dental caries. fluoride in drinking water to reduce dental caries.

• In the 1940s, four classic studies were begun which proved the In the 1940s, four classic studies were begun which proved the benefits of adding fluoride to community water supplies. benefits of adding fluoride to community water supplies.

Grand Rapids, MI – Muskegon, MIGrand Rapids, MI – Muskegon, MI Newburgh, NY – Kingston, NYNewburgh, NY – Kingston, NY Evanston, IL – Oak Park, ILEvanston, IL – Oak Park, IL Brantford, Ontario – Sarnia, OntarioBrantford, Ontario – Sarnia, Ontario

Historical PerspectiveHistorical Perspective

When Fluoridation is DiscontinuedWhen Fluoridation is Discontinued

City or Town

Initiated

Fluoridation

Discontinued Fluoridation

Number of

Years without Fluoridation

Percent

Increase in Caries Rates

Antigo, Wisconsin

1949

1960

5.5

70%-200%

Wick,

Scotland

1971

1979

5.0

Primary 40% Permanent 27%

Galesburg, Illinois

Naturally Fl

water source

1959

switched to non-Fl

water source

2.0

38%

BristolBristol

CrossvilleCrossville

CookevilleCookeville

ClevelandCleveland

ChattanoogaChattanooga

CowanCowan

LawrenceburgLawrenceburg

NashvilleNashville

ParisParis

Milan, TennesseeMilan, Tennessee

• In March 1951, Milan became the first city in Tennessee In March 1951, Milan became the first city in Tennessee and the second city in the Southeast to adjust the level and the second city in the Southeast to adjust the level of fluoride in its community water supply for the of fluoride in its community water supply for the prevention of dental caries.prevention of dental caries.

• As a result, five years later in 1956, the six-year-old As a result, five years later in 1956, the six-year-old Milan children had a 57 percent reduction in dental Milan children had a 57 percent reduction in dental caries in their permanent teeth compared to the 1951 caries in their permanent teeth compared to the 1951 same-age cohort.same-age cohort.

• In addition, when compared to their counterparts in In addition, when compared to their counterparts in Humboldt and Trenton – two neighboring nonfluoridated Humboldt and Trenton – two neighboring nonfluoridated cities – the 1956 Milan six-year-olds had a 62 percent cities – the 1956 Milan six-year-olds had a 62 percent and 70 percent reduction in dental caries, respectively.and 70 percent reduction in dental caries, respectively.

• 97 percent of tooth enamel is composed of hydroxyapatite.97 percent of tooth enamel is composed of hydroxyapatite.

• When fluoridated water is ingested, the fluoride ion (FWhen fluoridated water is ingested, the fluoride ion (F--) ) readily replaces the hydroxyl ion (OHreadily replaces the hydroxyl ion (OH--) during enamel ) during enamel formation of the tooth. formation of the tooth.

• Hydroxyapatite CaHydroxyapatite Ca55(PO(PO44))55OH then becomes a compound OH then becomes a compound

called fluorapatite Cacalled fluorapatite Ca55(PO(PO44))33F.F.

• Fluorapatite at the enamel surface is less soluble and more Fluorapatite at the enamel surface is less soluble and more resistant to acids produced by cariogenic bacteria. resistant to acids produced by cariogenic bacteria.

Systemic Effect of Drinking Fluoridated WaterSystemic Effect of Drinking Fluoridated Water

Community Water SystemsCommunity Water Systems

>50 water treatment chemicals used for:>50 water treatment chemicals used for:

• DisinfectionDisinfection• AbsorptionAbsorption• DechlorinationDechlorination• Algae controlAlgae control• Oxidation Oxidation • Metal coagulationMetal coagulation• Water softeningWater softening

• FiltrationFiltration• pH controlpH control• Iron controlIron control• CoagulationCoagulation• Corrosion controlCorrosion control• DecolorizationDecolorization• FluoridationFluoridation

Water Fluoridation ChemicalsWater Fluoridation Chemicals• Sodium Fluoride (NaF)Sodium Fluoride (NaF)

– Crystalline powderCrystalline powder– Relatively constant (low) solubilityRelatively constant (low) solubility– pH 7.6pH 7.6– Saturator SystemsSaturator Systems

• Sodium Fluorosilicate (NaSodium Fluorosilicate (Na22SiFSiF66))– Crystalline powderCrystalline powder– Solubility varies with water temperatureSolubility varies with water temperature– pH 3.5pH 3.5– Dry-feed SystemsDry-feed Systems

• Fluorosilicic Acid (HFluorosilicic Acid (H22SiFSiF66))– LiquidLiquid– Infinite solubilityInfinite solubility– pH 1.2pH 1.2– Venturi SystemsVenturi Systems

Community Water FluoridationCommunity Water FluoridationIs it safe?Is it safe?

• Acute fatal poisoning (CLD) in adults requires the Acute fatal poisoning (CLD) in adults requires the ingestion of 2.5 - 5.0 grams of fluoride in a 2 - 4 hour ingestion of 2.5 - 5.0 grams of fluoride in a 2 - 4 hour time frame. time frame.

• In drinking fluoridated water at 1.0 ppm, an adult would In drinking fluoridated water at 1.0 ppm, an adult would have to drink 660 gallons in 2 - 4 hours to reach the have to drink 660 gallons in 2 - 4 hours to reach the lower limit of a fatal dose.lower limit of a fatal dose.

• A 10kg child (12 - 18 months of age) would have to drink A 10kg child (12 - 18 months of age) would have to drink 85 gallons of fluoridated water (1.0 ppm) in 2 - 4 hours to 85 gallons of fluoridated water (1.0 ppm) in 2 - 4 hours to reach the lower limit of a fatal dose.reach the lower limit of a fatal dose.

Community Water FluoridationCommunity Water FluoridationWhat are the costs?What are the costs?

$0.50 per person$0.50 per personAverage annual cost of water fluoridation in the U.S.Average annual cost of water fluoridation in the U.S.

Systems serving 2,000 or less =Systems serving 2,000 or less =$0.77 - $1.16 per person per year$0.77 - $1.16 per person per year

Systems serving 2,000 - 20,000 =Systems serving 2,000 - 20,000 =$0.21 - $0.95 per person per year$0.21 - $0.95 per person per year

Systems serving Systems serving 100,000 = 100,000 =$0.12 - $0.21 per person per year$0.12 - $0.21 per person per year

In most communities, In most communities, everyevery $1$1 invested in fluoridation invested in fluoridation saves $38 to saves $38 to $80 $80 in dental treatment costs.in dental treatment costs.

Healthy People 2010 GoalHealthy People 2010 Goal75%75%

States Currently Meeting Goal = 24States Currently Meeting Goal = 24

States range from:States range from:2.3% (Utah) to 100% (Kentucky, Rhode Island, South 2.3% (Utah) to 100% (Kentucky, Rhode Island, South

Dakota, & the District of Columbia)Dakota, & the District of Columbia)

CDC Fluoridation Status, 2002CDC Fluoridation Status, 2002

Community Water FluoridationCommunity Water Fluoridation

StatusStatus

Community Water FluoridationCommunity Water Fluoridation

StatusStatus• 10 states, Puerto Rico, and the District of Columbia 10 states, Puerto Rico, and the District of Columbia

mandate statewide fluoridation through legislation.mandate statewide fluoridation through legislation.

– California, Connecticut, Delaware, Georgia, Illinois, California, Connecticut, Delaware, Georgia, Illinois, Minnesota, Nebraska, Nevada, Ohio, South DakotaMinnesota, Nebraska, Nevada, Ohio, South Dakota

• Kentucky mandates statewide fluoridation through Kentucky mandates statewide fluoridation through administrative regulation.administrative regulation.

• Tennessee has a voluntary process with an emphasis Tennessee has a voluntary process with an emphasis on education rather than legislative mandate.on education rather than legislative mandate.

TennesseeTennessee(2005)(2005)

United StatesUnited States(2002)(2002)

Percentage of total Percentage of total population receiving population receiving fluoridated waterfluoridated water

89.7%89.7% 60.5%60.5%

Percentage of Percentage of population on public population on public water system receiving water system receiving fluoridated waterfluoridated water

96.0%96.0% 67.3%67.3%

Community Water FluoridationCommunity Water Fluoridation

StatusStatus

Healthy People 2010 Goal 75.0%

Public Water SystemPublic Water System

Source: http://apps.nccd.cdc.gov/gisdoh/waterfluor.aspx

Total PopulationTotal Population

Source: http://apps.nccd.cdc.gov/gisdoh/waterfluor.aspx

Number of water systems starting fluoridation, by year, Tennessee, 1950-2005

0

2

4

6

8

10

12

14

16

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Numb

er of

Wate

r Sys

tems

Tennessee’s Water Systems

532

Approved Systems

214

Fluoridating Systems

118

Consecutive Systems

332

Fluoridated Systems

Tennessee’s 50-Year Fluoridated CitiesTennessee’s 50-Year Fluoridated Cities

MilanMilan CookevilleCookeville NashvilleNashville KingsportKingsport

BrownsvilleBrownsville CowanCowan MurfreesboroMurfreesboro LindenLinden

ClevelandCleveland LawrenceburgLawrenceburg WoodburyWoodbury LebanonLebanon

GermantownGermantown CrossvilleCrossville LewisburgLewisburg RipleyRipley

BristolBristol Union CityUnion City SpringfieldSpringfield HartsvilleHartsville

ChattanoogaChattanooga Oak RidgeOak Ridge ShelbyvilleShelbyville

ParisParis WinchesterWinchester DresdenDresden

Tennessee’s Largest Tennessee’s Largest Non-Fluoridating SystemsNon-Fluoridating Systems

SystemSystem CountyCounty PopulationPopulation

South BlountSouth Blount BlountBlount 30,72530,725

Lincoln County #1Lincoln County #1 LincolnLincoln 16,64316,643

Poplar GrovePoplar Grove TiptonTipton 16,04316,043

OcoeeOcoee BradleyBradley 13,31313,313

Pleasant ViewPleasant View CheathamCheatham 11,84611,846

Watts BarWatts Bar RheaRhea 9,0019,001

First Utility DistrictFirst Utility District TiptonTipton 8,4798,479

County WideCounty Wide CrockettCrockett 8,2588,258

First Utility DistrictFirst Utility District CarterCarter 6,9516,951

Mount PleasantMount Pleasant MauryMaury 6,2206,220

1996-97 East Tennessee Dental

Health Survey

15 ETR counties

62 communities

65 schools

17,256 children

http://apps.nccd.cdc.gov/MWF/Index.asp

http://www.ada.org/public/topics/fluoride/facts/