oral health guide: community water...

Oral Health Guide: Community Water

Fluoridation

community health

Oral Health Guide: Community Water Flouridation

AuthorLaura Dimitrov, MPH, RD

Tobacco Use Prevention and Control Project DirectorNational Association of Local Boards of Health

EditorsL. Fleming Fallon, Jr., MD, DrPH

Director of NW Ohio Consortium for Public HealthProfessor of Public Health – Bowling Green State University

Jennifer M. O’Brien, MPH, MADirector of Education and Training

National Association of Local Boards of Health

©2007 National Association of Local Boards of Health1840 East Gypsy Lane RoadBowling Green, Ohio 43402

www.nalboh.org

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Acknowledgements

This project was made possible by NALBOH staff and members of the Tobacco Use Prevention and Control Subcommittee, Education and Training Committee, and Board of Directors.

Special thanks to:

• TheDivisionofOralHealth,NationalCenterforChronicDiseasePreventionandHealthPromotion,Centers for Disease Control and Prevention, for providing expertise, technical oversight, and financialsupport.

• TheAmericanDentalAssociationforprovidingexpertiseandreviewingthisguide. • The2006and2007TobaccoUsePreventionandControlSubcommitteeforcontributingand

reviewing this guide: Sharon Hampson (Chair), J. Fred Agel, Lee Kyle Allen, Carrie Brainard, Elizabeth Clark, Kerry Cork, Shirley Greene, John Gwinn, Cowboy Ted Hallisey, Marc Hiller, Linda Petersen, Leon Vinci, and Amy Wishner.

• KathleenCuddy,RichardDiPentima,JamesKennedy,andAlanSousieforprovidingboardofhealthexamples for this guide.

Notes

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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Prevalence and Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

What is Fluoride and Where is it Found?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

What about Community Water Fluoridation? . . . . . . . . . . . . . . . . . . . . . . . . . . 2

How Water Fluoridation Prevents Tooth Decay . . . . . . . . . . . . . . . . . . . . . 3

Is Community Water Fluoridation Cost Effective? . . . . . . . . . . . . . . . . . . . . 3

Why Do Some People Oppose Community Water Fluoridation? . . . . . . . . . . . . . 3

Board of Health Opportunities and Best Practices. . . . . . . . . . . . . . . . . . . . . . . . 4

Board of Health Examples

City of Manchester, New Hampshire: The Board of Health in a Supportive Role. . . . 6

City of Burlington, Vermont: The Board of Health Takes the Lead . . . . . . . . . . . 7

Cayuga County, New York: The Board of Health Passes a Resolution . . . . . . . . . 8

Appendix A: Frequently Asked Questions About Community Water Fluoridation. . . . . . . 9

Appendix B: Fluoridation Ordinance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Appendix C: Oral Health Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Table of Contents

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Introduction

Oralhealthisessentialtogeneralhealthandwellbeing.In2000,thefirst-everU.S.SurgeonGeneral’sre-port on oral health reported a “silent epidemic” of dental and oral diseases that burdened some population groups. The report, and its subsequent National Call to Action to Promote Oral Health, call for a national effort to improve oral health among all Americans (U.S. Department of Health and Human Services [HHS], 2000). Findings from this report, and new information linking oral health to overall health, are bringing oral health to the attention of policy makers and the public.

Tooth decay (dental caries) is a common, chronic disease that causes pain and disability across all age groups. If left untreated, tooth decay may lead to pain and infection, and even partial or total tooth loss. As volunteer leaders in public health, local boards of health (BOH) make necessary policy and regulatory changes to introduce or institutionalize oral health programs into local public health agency practices. BOH members serve as advocates and liaisons with neighbors, peers, stakeholders, and other partners. Thus, it is the board of health’s responsibility to continually assure and improve the oral health of the community.

The National Association of Local Boards of Health (NALBOH) has created this guide to provide BOHs with best practices and resources for promoting oral health. This guide provides recommendations for boards toachievemaximumprotectionagainsttoothdecaywhileusingresourcesefficiently.NALBOHrecognizesthat communities vary in the scope and types of oral health programs they offer. Assessing this information andadaptingideasandstrategiesmaybenecessarytomeetacommunity’sspecificneeds.

Thisdocumentspecificallyaddressespreventionoftoothdecaythroughcommunitywaterfluoridation.NALBOH’sgoalistoinformBOHsaboutthisintervention.Communitywaterfluoridationandschool-basedpitandfissuredentalsealantdeliveryprogramswerefoundtobethetwopreventiveinterventionswiththe strongest support in the systematic reviews completed by the Task Force on Community Preventive Services(CentersforDiseaseControlandPrevention[CDC],2001).Similarly,whentheAssociationofState and Territorial Dental Directors (ASTDD) analyzed eight dental public health strategies, the strength of evidence was the strongest for these two interventions (Association of State and Territorial Dental Directors[ASTDD]).NALBOHalsooffersacomplementaryguideaddressingschool-baseddentalsealantdelivery programs.

In2007,Americanswillspendanestimated$98billionondentalservices(CentersforMedicare&MedicaidServices[CMS],2006).HealthyPeople2010,thenation’sframeworkforpreventionthatsetshealthgoalstoachievebytheyear2010,callsfor75%oftheU.S.populationservedbycommunitywatersystemstohaveaccesstooptimallyfluoridatedwater—thatis,waterwithfluoridelevelsfoundtobeeffectiveinpreventingtoothdecay.In2002,thepercentageoftheU.S.populationreceivingoptimallyfluoridatedwaterwas67.3%.ToreachtheHealthyPeople2010goal,approximately14.3millionadditionalpeoplemustgainaccesstofluoridatedwaterthroughpublicwatersystems(CDC).

Prevalence and Disparities

TheprevalenceandseverityoftoothdecayintheUnitedStateshasdecreasedsignificantlyduringthelast three decades. However, the burden and cost of oral disease is still too high and could be lowered considerably by using proven community prevention measures. The decrease in dental caries has been unevenacrossthegeneralpopulationandisnowmoresevereincertaingroupsandpopulations.Mexican-


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Americanchildrenaged6-11yearshavethehighestlevelsofdecay(31%)inthepermanentteeth,comparedwithnon-Hispanicwhite(19%)orblack(19%)children(Dye,Tan,Smith,Lewis,Barker,Thornton-Evan,etal,2007).

Disparitiesinoralhealthalsoareseenamongadults.Amonghighersocioeconomicstatusadultsaged20-64years,18%haduntreatedtoothdecay,comparedto44%oflowerincomeadults(Dye,etal,2007).Accordingto Oral Health in America: A Report of the Surgeon General, the reasons for this discrepancy are not well understood.Low-incomepopulationsmayhavefeweropportunitiestolearnaboutoraldisease,havelessaccesstodentalcare,belesslikelytofollowrecommendedself-carepractices,orbehardertoreachthroughtraditionalapproaches(HHS,2000).Therefore,groupssufferingfromhigherprevalenceoftoothdecaymayreceivegreaterbenefitfromfluoridatedcommunitywaterthanthosewithlowerprevalenceofdecay(CDC,2001).Lackofdentalcoverageundermanyinsuranceplansandaccesstotreatmenthelpcausedisparitiesin oral health.

What is Fluoride and Where is it Found?

Fluorideistheionicformoftheelementfluorine(CDC,2001).Fluorideisnegativelychargedandcombineswithpositiveionstoformstablecompounds.Smallamountsoffluoridearepresentinsoil,plants,air,andwater.8Whilefluorideispresenttosomeextentinfoodsandbeverages,especiallyiftheyaremadewithfluoridatedwater,theconcentrationsoffluoridevary.Aswatermovesthroughtheearth,itpicksupfluorideionstherebycausingthefluorideconcentrationinbodiesofwatertodiffer.Inhumans,fluorideisassociatedwithcalcifiedtissues(e.g.,bonesandteeth).

Allwaternaturallycontainssomefluoride.Whenacommunitydecidestofluoridateitswater,itadjuststheleveloffluorideinthewatertotheoptimallevelforpreventingtoothdecay.Since1962,theU.S.PublicHealthService(USPHS)hasrecommendedthatcommunitydrinkingwatercontain0.7to1.2partspermillion(ppm),dependingonthecommunity’sclimateandgeographicallocation(CDC,2001).Currently,morethan170millionpeopleintheUnitedStatesdrinkwatercontainingenoughfluoridetoprotectteeth(CDC,2002).

Thewidespreadavailabilityoffluoridesthroughwaterfluoridation,toothpaste,andothersources,hasresulted in the steady decline in the prevalence of tooth decay in children and adults in the United States (Dye,etal,2007).Dietarysupplementsareavailableforchildrenwhohavebeenevaluatedbytheirdentistasbeingathighriskfortoothdecayandwhosehomewatersuppliescontainlowamountsoffluoride.Althoughsuccessful,thesemethodsmaybemoreexpensivethanfluoridatingpublicwatersupplies,because they require the services of an oral health professional and require a conscious decision to use them.

What About Community Water Fluoridation?

Communitywaterfluoridationisthecontrolledadjustmentandmonitoringoffluorideincommunitydrinking water to reach and maintain the optimal concentrations proven to prevent tooth decay (ASTDD, 2003).Whenusedappropriately,fluorideissafeandeffectiveinpreventingtoothdecayboththroughdirectcontact with teeth throughout life and when consumed by children during the tooth forming years (CDC, 2001).MoreinformationregardingthesafetyofcommunitywaterfluoridationisavailableinAppendixA.

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How Water Fluoridation Prevents Dental DecayThefirstuseofadjustedfluorideinwaterbeganin1945and1946intheUnitedStatesandCanada,respectively.TheUSPHSdevelopedrecommendationsinthe1940sand1950sregardingfluorideconcentrationsinpublicwater(CDC,2001).Thesuccessofwaterfluoridation,asnotedbytheresultsofearlycommunitytrialsdemonstratingreductionsintoothdecayamongchildren(by50%ormore),ledtothedevelopmentofotherproductscontainingfluoride.Fluoridehelpstopreventtoothdecaybyprotectingtheteethbothsystemicallyandtopically(CDC,2001).Duringtoothdevelopment,ingestedfluoridesareincorporated into the tooth structures. Fluorides ingested during the time when teeth are developing providelonger-lastingprotectionthanthoseapplieddirectlytothetoothsurface(Newburn,1986).Fluoridethat comes into contact with the teeth becomes incorporated into dental surface enamel and further strengthenstheteeth(Lambrou,Larsen,Fejerskov,&Tachos,1981).

Is Community Water Fluoridation Cost Effective?Thecostperpersonoffluoridationvariesbythesizeofthecommunitypopulation.Theaveragecostforacommunitytofluoridateitswaterisestimatedtorangefromabout$0.50ayearperpersoninalargecommunity(populationgreaterthan20,000)toabout$3.00ayearperpersoninasmallercommunity(populationslessthan5,000)(Griffin,Jones,&Tomer,2001).Waterfluoridationistheleastexpensivewaytodeliverthebenefitsoffluoridetoallresidentsofacommunitygiventheminimalcosttofluoridatewatersystemsservingmostpeople(HHS,2000).

Apeer-reviewedCDCstudyfoundthat,incommunitieswithmorethan20,000residents,every$1thatisinvestedincommunitywaterfluoridationyieldsabout$38insavingseachyearfromfewercavitiestreated(Griffin,etal,2001).TheTaskForceonCommunityPreventiveServicesconcludedthattoothdecayamongchildrenintheUnitedStateshasdecreasedby30-50%becauseoffluoridation(CDC,2001).Althoughthecostofwaterfluoridationoveraperson’slifetimeislessthanthecostofonedentalfilling,morethan100millionAmericansstilldonothaveaccesstowaterthatcontainsenoughfluoridetoprotecttheirteeth(CMS,2006).

Why Do Some People Oppose Community Water Fluoridation?Fluoridationisconsideredbeneficialbytheoverwhelmingmajorityofthehealthandscientificcommunitiesaswellasthegeneralpublic(CDC,2002).Inarecentsurvey,92%ofhouseholdswereconnectedtopublicwatersuppliesandofthese63%wereinfavoroffluoridation(seeFigure1)(WesternResearchInstitute,

Figure 1 Western Researh Institute, Household fluoridation study.

March 2006

Connected to the Public Water Supply

0 20 40 60 80

In favor of fluoride

don't Know

Not in favor offluoride

Percent

2006).Althoughwaterfluoridationisbeneficial,in some communities opposition may occur. Some individualsmayviewfluoridationofpublicwateras limiting their freedom of choice. Some believe technicalissuesandthecostsoffluoridatingsmall water systems are too high, while others misinterpret or inappropriately represent the sciencebehindthesubjectoffluoridation(AmericanDentalAssociation[ADA],2005).Antifluoridationwebsites often contain outdated studies and statements. NALBOH encourages BOH members to keep this in mind when reviewing opposition arguments.


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NALBOH and the American Dental Association (ADA) urge community leaders and politicians to become educatedonthisissue.Antifluoridationwebsitescontaindraftletterstobesenttonewspaperpublishers,waterdepartments,andcommunitypublicofficialsfalselywarningthemoftheir“liability”shouldtheysupportorendorsewaterfluoridation(ADA,2005).

Thesesitesurgeleaderstoremain“neutral”andallowfluoridationdecisionstobeputtoapublicvote(ADA,2005),whilethosewhoopposefluoridationusethistimetoconductpublicreferendumsto“educate”thepublicwithinformationdesignedtoturnpublicopinionagainstfluoridation.Unfortunately,theirefforts never direct people to reliable information sources such as the American Dental Association or other recognized health and science organizations and government agencies, including the U.S. Centers for Disease Control and Prevention, the Institute of Medicine, and the World Health Organization.

Board of Health Opportunities and Best Practices

Boards of health have a unique opportunity to protect the oral health of their communities and support communitywaterfluoridation.Thefollowingsectionincludessomeresponsibilitiesofboardsofhealthdepending upon their legal authority.

Oral health should be part of a community needs assessment process. Following are some best practices for boards of health to protect the community from tooth decay. (Adapted from Best Practice Approaches for State and Community Oral Health Programs—Use of Fluoride: Community Water Fluoridation, the AssociationofStateandTerritorialDentalDirectors,2003.)

Education

Educate yourself, other board of health members, and community leaders.

• Knowthebestpracticeapproachesfororalhealth.TheAssociationofStateandTerritorialDental Directors developed Best Practice Approaches for State and Community Oral Health Programs—Use of Fluoride: Community Water Fluoridation. Available at: http://www.astdd.org/docs/BPAFluoridation.pdf

• Learnthefluoridationstatusofyourjurisdictionandprovidesupport.Youmayfindthisinformationfrom your local water supplier, state health department, or from the CDC My Water’s Fluoride website (http://apps.nccd.cdc.gov/MWF/Index.asp).

• Educatefellowboardmembersbyprovidingsessionsandtrainingatlocal,state,andregionalmeetings.

• Knowwheretogoforreliable,science-basedinformationaboutwaterfluoridation(e.g.,theU.S.Centers for Disease Control, the American Dental Association, etc.)

Support Policy

Implement and enforce or support laws, regulations, and resolutions to continue or implement community waterfluoridation.

• TheADAFluoridationOrdinance-SuggestedProvisionsisprovidedasaresourceforBOHtouseasa model ordinance in Appendix B.

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Compliance

Assure that your jurisdiction is in compliance with current engineering and administrative recommendationsforwaterfluoridation.TheCDCwebsitehasavailabletheEngineeringandAdministrationRecommendationsforWaterFluoridation,1995(www.cdc.gov/fluoridation/engineering.htm).

Reporting

TheBOHshouldensurethatwaterfluoridationprogramsparticipateinCDC’sWaterFluoridationReportingSystem(WFRS),providingupdatesonchangesinthewaterfluoridationstatusofwatersystems.ThestatemayalsoparticipateintheCDCWaterFluorideLaboratoryProficiencyTestingProgram,describedat:http://www.cdc.gov/fluoridation/fact_sheets/engineering/pt_factsheet.htm.

Collaboration

Collaborate with water quality and other partners to organize and mobilize community resources (both publicandprivate).Thisincludesparticipatingincoalitionsthatsupportwaterfluoridationasameansofimproving oral health.

Financial Resources

Supportfinancialresourcestoincreaseormaintaincommunitywaterfluoridationefforts.


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Board of Health Example –City of Manchester, New Hampshire: The Board of Health in a Supportive Role

Richard DiPentimaPublic Health Director (retired January 2006)Manchester Health Department

Fluoridation had been maintained in Manchester, New Hampshire, without interruption since December 19,2000.However,in2002,theNHSuperiorCourtandSupremeCourtagreedthata1999referendumtofluoridatewaterinManchesterwasfaultysinceitdidnotaddressresidentslivingintownsoutsideofManchester who purchase water from the town. The Supreme Court upheld a ruling that the residents of towns purchasing water from Manchester should have voted in the referendum, but the town of Derry wasexcludedbecauseitpurchaseswateronawholesalebasis.ThecitywasgivenuntilJune2005toholdanotherreferendumorhavethelegislaturechangetheexistinglawgoverningfluoridation.

In2004,theManchesterHealthDepartmentrequestedlegislationbefiledtocorrectthesituation.Legislationwaspassedthatrequiredanytownwith100ormoreconnectionstotheManchesterwatersystemtoconductavoteonfluoridation.Manchesterwasalsorequiredtoputthefluoridationreferendumontheballotagainduringthe2004primaryelection.ThislawwassignedbythegovernorinJune2004.

The Healthy Manchester Leadership Council (HMLC)* began to prepare for the referendum. The board ofhealthsupporteditsstaff’sinvolvementintheHMLCfluoridationinitiative.Publichearingswereheld in all the towns. Dr. Paul Connett, a professor of Chemistry at St. Lawrence University, and Dr. WilliamHirzy,SeniorVicePresidentinLocalChapter280oftheNationalTreasuryEmployeesUnion,spokeagainstfluoridationwhileformerU.S.SurgeonGeneralDr.C.EverettKoopspokeinsupportoffluoridation.Allthetowns,includingManchester,passedthereferendum.Animportantaspectofthelawwasthatthevotewasanaggregate,soifonetowndidnotvoteinfavoroffluoridationitcouldnotvetotheresultsifthemajorityofthetotalvotewasinfavoroffluoridation.

Afterthevote,thoseagainstfluoridationfiledsuitchargingthatthelegislationandsecondvotewereillegalbecause the community of Auburn was excluded. They wanted the language of the referendum changed from“allowsfluoridestobeaddedtothewater”to“addsarsenic,lead,fluorideandothercontainmentstothe water.” They suggested that Derry have a vote. The Superior Court ruled that Auburn should have a referendum, that Derry should not, and that the language was appropriate. In the end, Auburn voted in the September2006primarytoapprovefluoridation.

Individual members of the board of health assisted in the campaign by obtaining signatures for the referendum and gaining votes for the referendum. This was truly a community initiative, with the Health Department completing most of the “behind the scenes” work with assistance from the HMLC membership. Theboardofhealthwasverysupportiveofthefluoridationinitiativeandgavethepublichealthdirectorauthority to support this activity, support staff to work on the initiative, and made the mayor and aldermen aware of their stance.* Healthy Manchester Leadership Council (HMLC) consisted of the following: CatholicCharities,ChildandFamilyServices,ChildHealthServices,Dartmouth-HitchcockClinic,ElliotHospital

Catholic Medical Center, Greater Manchester Mental Health, Manchester Community Health Center, Manchester HealthDepartment,ManchesterOfficeofYouthServices,ManchesterPoliceDepartment,SalvationArmy,UnitedWay of Greater Manchester, and YWCA.

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Board of Health Example –City of Burlington, Vermont: The Board of Health Takes the Lead

Alan Sousie, BSNChair, Burlington Board of Health

Burlington,thelargestcityinVermont,hasfluoridateditswaterfor53years.Theboardofhealth(BOH)begananopen,publicinvestigationoftheissueonMarch9,2005.TheboardreceivedinformationfromMichaelConnett,ProjectDirectorofFluorideActionNetwork,whichisopposedtowaterfluoridation,and Dr. Donald Swartz, Director of Oral Health Improvement at the Vermont Department of Health, representing the perspective of proponents. Dr. Swartz has since been replaced as director by Dr. Steve Arthur who has contributed to subsequent discussions and testimonies. Attendees at this meeting included about40membersofthepublicandcitycouncilors.

TheBOHsubsequentlydecidedtoconductapublicdebateonfluoridation.ItalsodecidedtoholdasecondhearingwhenalltestimonieswouldbeacceptedbytheBOHwithoutdiscussion.OnJune15,aninformationaldebatewasheldbeforeanaudienceofapproximately100citizens.Thefollow-upopinionhearingwasconductedonJune23,inthepresenceofabout85citizens.

Followingthesepublicforums,duringapublicmeetingonJune29,theBOHchose(byavoteof3to2)torecommendcontinuingthefluoridationofBurlington’swater.Somemembershadconcernaboutpublicharmandwereadvocatesforremovingfluoridefromthecity’spublicwatersupplies.Thedisputeresultedfromindividualdifferencesofopinionaboutthevalidityofbenefit-to-harmratiosdeterminedbyresearchandstudies.However,theydidagreethattheeffectsoffluorideoninfantsbetweenbirthand6monthsofage poses a “public health risk.” It was decided that the BOH would develop and distribute public education materials about the use of tap water when reconstituting infant formula.

InAugust2005,theBOHsentanInterimReporttotheCityCouncil.Thereportstatedthat“theBoardof Health has limited statutory responsibility for the prevention, removal, or destruction of public health hazardsandthemitigationofpublichealthrisks.”In2005,theboard’smostimportantprojectwastheevaluationofBurlington’sneedtocontinuefluoridationofitspublicwatersupply.Theyspentmanyhoursof personal and mutual time studying and discussing this subject. They endeavored to “address concerns of citizens,legislators,cityofficials,andthepublichealthcommunity.”

InSeptember2005,actingontheInterimReport,theCityCouncilvotedtolowerthefluorideusedinBurlington’swaterfrom1.2ppmto1.0ppm.OnMarch7,2006,71.4%ofBurlingtonvotersconfirmedcontinuingfluoridation.Inviewofthesedecisions,theBOHcontinuestoevaluateboththeamountandtypeoffluoridebeingaddedtothecity’swater.Asnewresearchisreported,theBOHexpectstoupdatethesystem accordingly. In the end, the Board of Health unanimously agreed that progress toward improvement has been made.


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Board of Health Example –Cayuga County, New York: The Board of Health Passes a Resolution

Kathleen Cuddy, MPH James X. Kennedy, MS, LCSWDeputy Director, Health Services Cayuga Community Health NetworkCayuga County Health and Human Services

CayugaCountydoesnotcurrentlyprovidefluoridatedwater;itisoneofonlysixcountiesincentralNewYorkwithoutfluoridatedpublicwatersupplies.About150watersystemsinNewYorkaddfluoridetotheirwaterandanother800watersystemsreceivefluoridatedwaterbypurchasingwaterfromthose150originalsystems.ThedebateoncommunitywaterfluoridationbeganinCayugaCountymorethan20yearsagoandfrequentlyresurfaces.InordertoimplementwaterfluoridationinCayuga,thecityofAuburnwillbe required to change the city charter.

In2005,acommunityhealthassessmentwascompletedanddentalhealthwasshowntobeamajorpublichealthprobleminthecommunity.Cayugaalsohasthehighestpercentageofchildrenwithcavities(72%ofCayugaCountythird-gradershaveatleastonecavity).InOnondagaCountywhere93%ofthepopulationhasfluoridatedwater,only42%ofthird-gradershadcavities.

In2005,theCayugaCommunityHealthNetwork,aRuralHealthNetwork(theNetwork)ledbyJamesX.Kennedywasinstrumentalinmovingcommunitywaterfluoridationtotheforefrontonceagain.TheNetworksponsoredaForumonWaterFluoridation,heldonJanuary24,featuringalocalpro-fluoridedental hygienist, Julie Reuther, NYS Department of Health, Bureau of Dental Health, and nationally known expert Michael Easley, DDS, MPH. This forum provided information that: “Fluoridation is safe,effective,efficient,economical,sociallyequitable,environmentallysound,andgoodpublicpolicy.Communitywaterfluoridationistheperfectpublichealthinterventionbecauseitdoesnotdiscriminateagainstanygroup;largegroupsareprotectedcontinuouslywithoutanyconsciouseffortontheirparttoparticipate;workswithoutrequiringindividualstogatherinacentrallocation;doesnotrequirethecostlyservicesofexpensivehealthprofessionalstodeliveritsbenefits;therearenodailydosageschedulestoremember;andtherearenofoultastingoralmedicationstoendureorpainfulinoculationstoexperience.All the public has to do is go about their normal daily routine to be protected.”

In2006,theCayugaCountyBoardofHealth(BOH)unanimouslypassedaresolutioninsupportofthefluoridationofthecounty’spublicwatersystem,statingfluoridatedpublicwaterisasafeandeffectivewayto prevent tooth decay. The resolution was heard by the city council although it declined to pass community waterfluoridationatthattime.

Along with many other strong advocates, the BOH was involved in the effort to pass community water fluoridationandwillcontinuetoworkonthisissueinthefuture.TheNetworkcontinuestopromotetheuseoffluorideaspartofitsHealthyCayugahealthpromotioncampaign(www.cayugahealthnetwork.org).TheNetworkconductedasurveyinSeptember2006atacommunityeventwheretheoverwhelmingmajorityofrespondentsindicatedtheirsupportforpublicwaterfluoridation.

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Appendix A: Frequently Asked Questions

Thefollowingquestionsoftenareaskedbythoseinquiringaboutthesafetyofwaterfluoridation.Foranswers to additional questions, please visit the American Dental Association’s Web site for Fluoridation Facts(www.ada.org)andtheCDC’sFrequentlyAskedQuestionsWebpage(www.cdc.gov/fluoridation/faqs.htm).

Is fluoride in the water supply, at the levels recommended for the prevention of dental decay, safe?Theoverwhelmingweightofscientificevidenceindicatesthatfluoridationofcommunitywatersuppliesissafe(CDC.2001).

TheoverallvalueandsafetyofcommunitywaterfluoridationhasbeenendorsedbytheU.S.CentersforDiseaseControlandPrevention;bythelastfiveU.S.SurgeonsGeneral—see,Oral Health in America: A Report of the Surgeon General(2000);bytheU.S.TaskForceonCommunityPreventiveServices(2001);and by numerous public health and professional organizations, including the American Dental Association, the American Medical Association, the American Association of Public Health, U.S. Public Health Service, andtheWorldHealthOrganization(ADA,2005).

Are additional studies being conducted to determine the effects of fluorides on humans?Yes,studiesontheadverseeffectsoffluoridesinhumansarecontinuallybeingconducted(ADA,2005).Overthelast60years,thousandsofreportshavebeenpublishedonallaspectsoffluoridation.Thecollectivedental,medical,andpublichealthevidenceconcerningfluoridationhasbeenreviewedandevaluated by committees of experts, academics, special councils of government, and most of the world’s major national and international health organizations.

RecentreviewsofwaterfluoridationsafetyincludeacomprehensivereviewofthescientificliteraturebytheU.S.PublicHealthServicein1996andtheUniversityofYorkin2000(CentresforReviewandDissemination,UniversityofYork,2000).Thereport,FluorideinDrinkingWater:AScientificReviewofEPA’sStandards,wasissuedin2006bytheNationalResearchCouncil(NRC).Thereportaddressesthesafetyofhighlevelsoffluorideinwaterthatoccurnaturally,anddoesnotquestiontheuseoflowerlevelsofadditionalfluoridetopreventtoothdecay.TheNRCCommitteeonFluorideinDrinkingWaterconcludedthat the current maximum contaminant level goal (MCLG) of 4 mg/L should be lowered to better protect peoplefromthehealthrisksassociatedwithhighnaturalfluoridelevels(NRC,2006).Thecommittee’sconclusionsconcerningthepotentialforadversehealtheffectswerefocusedonexposuretofluorideatlevelsof2mg/Landhigher.ThefindingsareconsistentwithCDC’sassessmentthatwaterissafeandhealthyatthelevelsusedforwaterfluoridation(0.7mg/L–1.2mg/L)(HHS,1991).

Whileresearchcontinues,theweightoftheevidenceindicatesthatwaterfluoridationissafeandeffectivein preventing dental decay in humans.

What are some of the health claims made against water fluoridation?FromsourcessuchastheInternet,newsletters,andpersonalanecdotes,communitywaterfluoridationisfrequently blamed for causing adverse health effects such as low IQ, AIDS, Alzheimer’s disease, cancer, behavior problems, bone disease, thyroid disease, kidney disease, and even tooth decay. Such allegations may raise doubts with some members of the public. However, as stated throughout this document, the overwhelmingscientificevidencehasconsistentlyindicatedthatfluoridationofcommunitywatersuppliesis safe and effective.


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Appendix B: Fluoridation OrdinanceAmerican Dental Association, reprinted with permission

Suggested Provisions

1. Findings of fact: • Fluoridationofcommunitywatersuppliesisthesinglemosteffectivepublichealthmeasureto

prevent tooth decay and to improve oral health for a lifetime.

• TheCentersforDiseaseControlandPreventionhasproclaimedcommunitywaterfluoridationoneof10greatpublichealthachievementsofthe20thcentury.

• FluoridationofcommunitywatersuppliesissupportedbytheAmericanDentalAssociation,theU.S. Public Health Service (USPHS), the American Medical Association and the World Health Organization.

• Studiesoverthepast60yearshaverepeatedlyconfirmedthesafetyofwaterfluoridationanditseffectiveness in preventing dental decay.

• AUnitedStatesnationalhealthobjectivefortheyear2010istoincreasetoatleast75%theportionofthepopulationservedbycommunitywatersystemsprovidingoptimallevelsoffluoride.AccordingtotheCentersforDiseaseControlandPrevention,approximately67%ofthepopulationreceivedfluoridatedwaterin2002.

• Communitywaterfluoridationisapublichealthmeasurethatbenefitsindividualsofallagesandsocioeconomic groups, especially those without access to regular dental care.

2. Authorization,DirectionandResponsibilityThe city [insert title of appropriate person or entity, given the state and local regulatory scheme, e.g., directorofhealth/boardofhealth](the“ResponsibleParty”)isauthorizedanddirectedtofluoridatethecity’swatersupplyby[date]andisthereafterresponsibleforthefluoridationofthatsupply.

(Rationale:Identifiesindividual/entitytomaintainauthorityoverthefluoridationprocess.)

3. FundingFundingshallbeprovided[describefundingmechanism].[Modifyasneededtoreflectfundingmechanism.](Rationale: Need money to get the job done.)

4. Introduction of FluorideUponthedirectionoftheResponsibleParty,the[insertnameofpublicworksentitythatwillfluoridate](the“Agency”)shalltakethestepsnecessarytofluoridatethecity’swatersupply,andshallintroduceafluoridecompoundmeetingAmericanWaterWorksAssociation(AWWA)standardsintothecitywatersupplyinsuchquantitiesasrequiredtomaintainthroughoutthedistributionsystemafluorideconcentration at levels recommended by the USPHS, or otherwise required by the state health department.

(Rationale:Helpsassureoptimalfluoridationofthewater.Allowsthestatetoprovidenecessaryguidance.)

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5. RecordsTheAgencyshallkeepanaccuraterecordofthetypeandamountoffluoridecompoundintroducedandthequantities of water treated.

TheAgencyshallconductandkeeprecordsoftestsforfluoridecompoundinthetreatedanduntreatedwatersinaccordancewithCDCengineeringandadministrativerecommendationsforwaterfluoridation,orotherwise required by the state health department.

The Agency shall make copies of the records required above to the Responsible Party every [set time frame for predetermined intervals, if desired] and/or as otherwise requested by the Responsible Party.

(Rationale:Providestoolstoassistinaccountingforthemanagementoftheprocess;providesmethodtomonitor quality and accountability.)

NOTE:Thisdocumentidentifiesselectelementsforpossibleinclusioninalocalwaterfluoridationordinance. Exactly what elements will be needed in a particular community, and how they will need to be worded, will depend upon existing state and local laws. The document is especially designed to provide helpfulinformationtodentistsanddentalsocietiespromotingfluoridationintheircommunities,butisnotintended or offered as legal or other professional advice. Readers must consult their own legal counsel for such advice.February2007©2007AmericanDentalAssociation


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Appendix C: Oral Health Resources

American Association for Community Dental Programs (AACDP)Supports the efforts of those with an interest in serving the oral health needs of vulnerable populations at thecommunitylevel.Membersincludestaffofcity,county,andcommunity-basedhealthprogramswithan interest in oral health issues and access to care. AACDP publishes a newsletter and sponsors an annual meeting. Website: www.aacdp.com

American Dental Association (ADA)Theworld’slargest(155,000+members)andoldestnationaldentalorganization,theADAistheprofessional association of dentists committed to the public’s oral health, ethics, science, and professional advancement. Website: www.ada.org

Association of State and Territorial Dental Directors (ASTDD)ASTDD provides leadership to advocate for a governmental oral health presence in each state and territory, to formulate and promote sound oral health policies, to increase awareness of oral health issues, and to assist in the development of initiatives for prevention and control of oral diseases. Website: www.astdd.org

Center for Disease Control and Prevention (CDC) Division of Oral HealthThe Centers for Disease Control and Prevention is the federal agency with primary responsibility for supportingstateandcommunity-basedprogramstopreventoraldisease,promotingoralhealthnationwide,and fostering applied research to enhance oral disease prevention in community settings. Guidelines, fact sheets,reports,surveillanceinformation,stateandcountyfluoridationinformation,andstateoralhealthprograms are found here. Website: www.cdc.gov/OralHealth

In1995,CDCpublishedEngineeringandAdministrativeRecommendationsforWaterFluoridation,whichprovidesspecificrecommendationsontheengineeringaspectsofwaterfluoridation,includingadministration, monitoring and surveillance, technical requirements, and safety procedures for community publicwatersupplysystems.Availableat:www.cdc.gov/fluoridation/engineering.htm

Council of State Governments (CSG)Amulti-branchorganizationforecastingpolicytrendsforthecommunityofstates,commonwealths,andterritoriesonanationalandregionalbasis.In2006,CSGissuedapolicyresolutiontoencouragestatestosupportoradoptcommunitywaterfluoridation.Theresolutionisavailableat:http://www.csg.org/policy/documents/CommunityWaterFluoridation.pdf

Guide to Community Preventive Services, Oral HealthThisguidesystematicallyreviewstheeffectivenessofselectedpopulation-basedinterventionsaddressingoral health focused on three strategic areas: preventing or controlling dental caries (tooth decay), preventingorcontrollingoralandpharyngealcancers,andpreventingorcontrollingsports-relatedcraniofacial injuries. Website: www.thecommunityguide.org/oral/default.htm

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National Center for FluoridationDevelopedin1996,withawebsiteestablishedin1998toserveasacentralrepositoryforinformationregardingallaspectsofcommunitywaterfluoridation.TheCenterbecameaprogramofOralHealthAmericain2004.Website:www.fluoridationcenter.org

National Oral Health Surveillance System (NOHSS)NOHSS is a collaborative effort between CDC’s Division of Oral Health and the Association of State and Territorial Dental Directors (ASTDD). NOHSS is designed to monitor the burden of oral disease, use of the oralhealthcaredeliverysystem,andthestatusofcommunitywaterfluoridationonbothnationalandstatelevels. Website: www.cdc.gov/nohss

Oral Health AmericaDevelops, implements, and facilitates educational and service programs designed to raise awareness of oral health’s importance to total health. They also provide assistance to oral health coalitions. Website: www.oralhealthamerica.org

Synopses of State and Territorial Dental ProgramsTheSynopsescontaininformationusefulintrackingprogresstowardHealthyPeople2010oralhealthobjectives in states, U.S. associated jurisdictions, and the nation. Website: http://apps.nccd.cdc.gov/synopses/index.asp

Surgeon General’s Report: Oral Health in America (May 2000)Thisreport,thefirsteverbytheU.S.SurgeonGeneraldiscussingoralhealth,focusedontherelationshipbetween oral health and overall good health throughout life. Oral problems may include tooth decay and periodontal or gum disease, oral infections such as cold sores, birth defects, chronic facial pain conditions, and oral cancers. In this report, the U.S. Surgeon General calls for a national partnership to provide opportunities for individuals, communities, and the health professions to work together to maintain and improvethenation’soralhealth.Inconjunctionwiththisreport,in2003,theSurgeonGeneralissuedANational Call To Action to Promote Oral Health. Website: www.surgeongeneral.gov/library/oralhealth


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References

AmericanDentalAssociation.(2005).Fluoridation facts. Available at: http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf

Association of State and Territorial Dental Directors. A message from the ASTDD Best Practices Committee to policy and government agencies. Available at: www.astdd.org

AssociationofStateandTerritorialDentalDirectors.(2003).Best practice approaches for state and community oral health programs—Use of fluoride: Community water fluoridation. Available at: http://www.astdd.org/docs/BPAFluoridation.pdf

Centers for Disease Control and Prevention. Fluoridation statistics 2002: Status of water fluoridation in the United States. Availableat:www.cdc/gov/fluoridation/fact_sheets/us_stats2002.htm

Centers for Disease Control and Prevention. Oral health: Water fluoridation. Available at: www.cdc/gov/fluoridation/benefits/background.htm

Centers for Disease Control and Prevention. Oral health: Water fluoridation, frequently asked questions. Availableat:www.cdc/gov/fluoridation/faqs.htm

CentersforDiseaseControlandPrevention.(2001).Promotingoralhealth:Interventionsforpreventingdentalcaries,oralandpharyngealcancers,andsports-relatedcraniofacialinjuries.Morbidity and Mortality Weekly Report, 50,1-13.Availableat:www.cdc.gov/mmwr/preview/mmwrhtml/rr5021a1.htm

CentersforDiseaseControlandPrevention.(2001).Recommendationsforusingfluoridetopreventandcontrol dental caries in the United States. Morbidity and Mortality Weekly Report, 50,1-42.Availableat:www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm

CentersforMedicare&MedicaidServices.(2006).National health care expenditure projections: 2006-2016. Availableat:www.cms.hhs.gov/Nationalhealthexpenddata/downloads/proj2006.pdf

CentreforReviewsandDissemination,UniversityofYork.(2000).A systematic review of community water fluouridation.York:UK.Availableat:http://www.york.ac.uk/inst/crd/fluores.htm

Dye,B.A.,Tan,S.,Smith,V.,Lewis,B.G.,Barker,L.K.,Thornton-Evan,G.,etal.(2007).Trends in oral health status: United States, 1988-1994 and 1999-2004. Washington, DC: National Center for Health Statistics.Availableat:www.cdc.gov/nchs/data/series/sr_11/sr11_248.pdf

Griffin,S.O.,Jones,K.,&Tomer,S.L.(2001).Aneconomicevaluationofcommunitywaterfluoridation.Journal of Public Health Dentistry, 61(2),78-86.

Lambrou,D.,Larsen,M.J.,Fejerskov,O.,&Tachos,B.(1981).Theeffectoffluorideinsalivaandremineralization of dental enamel in humans. Caries Research, 15,341-345.

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NationalResearchCouncil,CommitteeonFluorideinDrinkingWater.(2006).Fluoride in drinking water: A scientific review of EPA’s Standards. Washington, DC: The National Academies Press. Available at: http://www.nap.edu/catalog.php?record_id=11571#toc

Newburn,E.(1986).Fluorides and dental caries(3rded.).Springfield,IL:CharlesC.Thomas.

U.S.DepartmentofHealthandHumanServices.(2000).Oral health in America: A report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services. National Institute of Dental and Craniofacial Research, National Institutes of Health. Available at: http://silk.nih.gov/public/[email protected]

U.S. Department of Health and Human Services, Public Health Service. (1991). Review of fluoride: Benefits and risks. Available at: http://health.gov/environment/ReviewofFluoride/default.htm

WesternResearchInstitute.(2006).Household Fluoridation Survey. Available at: http://www.ada.org.au/app_cmslib/media/lib/0703/m50765_v1_householdfluoridationsurvey.pdf


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The National Association of Local Boards of Health has publications available in the following public health programs:

For a complete listing of all available NALBOH publications, please visit www.nalboh.org.

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