COMMUNITY WATER FLUORIDATION IN

NEW YORK STATE

MAY 7, 2013

Jay Kumar, DDS, MPH

June 22, 2012

Why Do Cavities Matter?

Dental Caries Facial Cellulitis Dental Caries

Dental Extraction Dental Caries

Teeth problems caused by cavities

Source: Pew Children’s Dental Campaign

Goal #5: Reduce the prevalence of dental caries among NYS children. Prevention Agenda Target 2017.

Preva-lence

Un-treated

Sealant Dental Visit

05

101520253035404550 45.4

24

42 40.840

21.6

46 45

Third-grade children Medicaid (2-20)

Fluoridation: Increase from 71.4% to 78.5%

Why water fluoridation?

Reduces cavities by up to 40% — for both children and adults

Helps Americans keep their teeth Saves millions in treatment costs and

eliminates pain and suffering Nearly every large city and more than

204 million Americans benefit CDC: One of the 10 great public health

achievements of the 20th century

Source: Pew Children’s Dental Campaign

A Public Health Achievement“Fluoridation is the single most important commitment a

community can make to the oral health of its children and to future generations.”

Dr. C. Everett KoopSurgeon General (1982-1989)

“Fluoridation is the single most effective public health measure to prevent tooth decay and improve oral health over a lifetime, for

both children and adults.”

David Satcher, MD, PhDSurgeon General (1998-2002)

One of water fluoridation’s biggest advantages is that it benefits all residents of a community—at home, work, school, or play—

through the simple act of drinking fluoridated water.

Regina M. Benjamin, MD, MBA Surgeon General

Source: Pew Children’s Dental Campaign

Fluoridation in New York State

Fluoridation efforts started in 1942 Newburgh initiated fluoridation in 1945 Focus on research and evaluation Approximately 12.5 million residents or

approximately 72% on public water supplies receives fluoridated water

June 22, 2012

The Weight of Science

Opposition to Fluoridation

Mean claim per recipient for caries related procedures was correlated with county fluoridation status

Spearman Correlation Coefficient -0.53 (p < 0.01).Each bubble denotes the size of the Medicaid population.

1.66 1.33 1.23

Savings from Water Fluoridation:What the Evidence Shows

Louisiana: A statewide analysis of Louisiana Medicaid reimbursements for caries-related procedures delivered to children, aged 1 to 5 years - Savings $66.8 per child

A Texas study confirmed that the state saved $24 per child, per year in Medicaid expenditures.

A 2010 study in New York State - $23.65. Researchers estimated that in 2003 Colorado saved

nearly $149 million in unnecessary treatment costs by fluoridating public water supplies—average savings of roughly $61 per person.

Scientific Review

National Research Council Report – Fluoride in Drinking Water (2006)

Griffin SO et al. Effectiveness of fluoride in preventing caries in adults. Journal of Dental Research 2007;86(5):410–414.

Scientific Committee on Health and Environmental Risks of the European Commission (SCHER 2011)

EPA Reports

Fluoride in Drinking Water: Proposal to Change Standards EPA Drinking Water Standards

Maximum Contaminant Level Goal (MCLG) – 4 mg/L

Maximum Contaminant Level (MCL) Secondary Maximum Contaminant

Level (SMCL) – 2 mg/L CDC Recommendations for Fluoridation

(0.7 -1.2 mg/L) New York State Standards

Fluoridation Target is 1 mg/L ( Range 0.8 -1.2)

State MCL is 2.2 mg/L

2.01.6

2.42.8

1.2

3.23.64.0

0.80.40.0

News ReleaseFOR IMMEDIATE RELEASE

January 7, 2011 Contact: OASH ashmedia@hhs.gov 202-205-0143 EPA isa.jalil@epa.gov or 202-564-3226

HHS and EPA announce new scientific assessments and actions on fluoride

Agencies working together to maintain benefits of preventing tooth decaywhile preventing excessive exposure

WASHINGTON – The U.S. Department of Health and Human Services (HHS) and the U.S. Environmental Protection Agency (EPA) today are announcing important steps to ensure that standards and guidelines on fluoride in drinking water continue to provide the maximum protection to the American people to support good dental health, especially in children. HHS is proposing that the recommended level of fluoride in drinking water can be set at the lowest end of the current optimal range to prevent tooth decay, and EPA is initiating review of the maximum amount of fluoride allowed in drinking water.************************************************************************HHS’ proposed recommendation of 0.7 milligrams of fluoride per liter of water replaces the current recommended range of 0.7 to 1.2 milligrams.

Reasons

Americans have access to more sources of fluoride than they did when water fluoridation was first introduced in the United States in the 1940s.

The prevalence of dental fluorosis has increased. Severe enamel fluorosis is the clinical end point for setting EPA standards.

EPA and HHS scientific assessments to balance the benefits of preventing tooth decay while limiting any unwanted health effects show that this can be achieved at 0.7 mg/L.

Lack of association between daily temperature and children’s water intake in the United States.

Tooth Decay Dental Fluorosis

National Research Council Report – Fluoride in Drinking Water (2006)

The Committee considered three toxicity end points for which there were sufficient relevant data for assessing the adequacy of the MCLG for fluoride to protect public health:

severe enamel fluorosis,

skeletal fluorosis, and

bone fractures.

Prevalence of Severe Enamel Fluorosis below 2 mg/L F, NRC Report 2006

Strong evidence exists that the prevalence of severe enamel fluorosis is nearly zero at water fluoride concentrations below 2 mg/L.

0

5

10

15

20

25

30

0 1 2 3 4Fluoride Level (ppm)

Prev

alen

ce S

ever

e Fl

uoro

sis

2006 National Research Council Report – page 294

EPA’s Point of DepartureEPA ASSESSMENT The data in Table 8-2 indicate that some children drinking water at the 90th percentile intakelevel up to about age 7 are being exposed to fluoride on a daily basis at levels at or higher thanestimated acceptable intake levels when the concentration of fluoride in their drinking water is at or above 0.87 mg/L.

Reduce the MCLG of 4 mg/L

Conclusion that the MCLG should protect against severe enamel fluorosis is consistent with recommendations of Institute of Medicine (IOM).

IOM (1997) Age-specific tolerable upper intake levels (UL) Set to reduce moderate enamel fluorosis

Water fluoride Prevalence 4 mg/L ~10% <2 mg/L ~0%

Strategies to promote fluoridation

Build support - Internal & External Engage partners and stakeholders

State Oral Health Coalition Rural Water Association Local Health Departments State Dental Association Foundations

Develop resources Provide training Explore financing options

Resources

New York State Department of Health (NYSDOH) website CDC and ADA

Technical Assistance Center in Rochester ILikeMyTeeth.org - NewYork.ILikeMyTeeth.org Fluoride Science.org

Rural Water Association Local Health Department

Water Fluoridation Manual

Fluoridation Manual

AddressesBenefitsSafety concernsCostOperations and

Engineering Contains:

ArticlesFact sheets and official

statementsNew York specific

information

NewYork.ILikeMyTeeth.org

Component website on ILMT

Features information specific to NYS including: NYS laws and regulations Electronic copy of

fluoridation manual New York fluoridation maps Links to other fluoridation

websites Fact sheets and resources

FluorideScience.org

Topic summaries Critical appraisals Videos featuring

fluoride researchers

Training

New York Rural Water Association (NYRWA)Operations and EngineeringBenefitsSafety concernsTechnical Assistance

jvk01@health.state.ny.us

Thank you