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HomeMy WebLinkAboutMinutes - September 11, 2001 SSCITY OF LODI INFORMAL INFORMATIONAL MEETING "SHIRTSLEEVE" SESSION CARNEGIE FORUM, 305 WEST PINE STREET TUESDAY, SEPTEMBER 11, 2001 An Informal Informational Meeting ("Shirtsleeve" Session) of the Lodi City Council was held Tuesday, September 11, 2001 commencing at 7:04 a.m. A. ROLL CALL Present: Council Members — Hitchcock (arrived at 7:05 a.m.), Howard, Land, Pennino and Mayor Nakanishi Absent: Council Members — None Also Present: City Manager Flynn, City Attorney Hays, and City Clerk Blackston B. CITY COUNCIL CALENDAR UPDATE City Clerk Blackston reviewed the weekly calendar (filed). C. TOPIC(S) C-1 "Water Fluoridation" Public Works Director Prima reported that a state law was passed a few years ago that required cities to implement water fluoridation if funds were made available. In response, Public Works submitted a cost estimate to the state and they placed Lodi at approximately 65 on a list of cities. To institute water fluoridation, two of the City's wells would need additional property to install the necessary equipment. In addition, it would require more staff, training, and other procedural steps. Doctor Clifford Bradshaw briefly reviewed his background. He stated that Assembly Bill 733 mandates that all cities implement water fluoridation to bring the level of fluoride up to an optimal level, which would decrease the decay rate by 60% and has minimal side effects. The mandate, however, is non -funded, so it is up to each individual community to develop the necessary resources. Funding sources are available through Proposition 10 funds, the California Endowment, and various private grants. Doctor Matthew Stefanac reported that in the 1890s it was noted that people in Texas and southeast Colorado had small white and brown spots on their teeth. The cause was determined to be a high fluoride level of up to 12 parts per million. In the 1920s and 1930s it was also noted that individuals living in these areas had very little tooth decay. With time, it was determined that the correct level of fluoridation was approximately 1 part per million. Approximately 70% of Americans believe that water fluoridation is beneficial, 5% to 10% do not want government to add anything to their water, and 10% to 20% do not have an opinion on the subject. Nearly 70% of the treated water in the United States is fluoridated. In California, only 17% of the treated water is fluoridated. Fluoridation is accepted by the American Dental Association (ADA), American Medical Association, National Academy of Sciences, Center for Disease Control (CDC), and Poison Control. Dr. Stefanac stated that the research done by the anti -fluoridation group does not hold up to the scientific community. The group makes claims that fluoridation causes fractures in hips, cancer, diabetes, and causes fluorosis. Doctor Judee Tippett -Whyte pointed out that fluoride is naturally occurring in water. There is some fluoride in Lodi's water, but it is an insignificant amount. Water fluoridation reduces dental decay by 38% to 60%. Children without access to dental care would benefit the greatest from water fluoridation. Employees who have less dental needs will have less time away from work. Studies have shown that in areas where there is water fluoridation, dental insurance rates are somewhat lower. Annually, it costs approximately Continued September 11, 2001 90 cents per person to fluoridate water. In a recent ADA news article, the CDC reported that approximately 60% (144 million people) of the United States' population have access to the oral health benefits of community water fluoridation. In 1999, the CDC reported that the average water fluoridation cost was 72 cents per person. Ms. Tippett -Whyte read the following quote from the ADA president, "It is our hope that the federal, state, and municipal governments will take their cue from the CDC and increase their efforts to bring water fluoridation to as many communities as possible" Doctor Stefanac reported that it has been estimated that for every dollar put into fluoridation, $80 dollars is returned in terms of lower dental costs. Most of western Europe has fluoridated water, France has fluoridated salt, England is mostly fluoridated, and some of the Scandinavian countries are fluoridated through medication. Doctor Michael Wong, pediatrician, stated that the CDC released a report on August 17 entitled, "Recommendations for using fluoride to prevent and control dental caries for the United States." A panel of 30 specialists stated that all persons should drink water with an optimal amount of fluoride concentration and brush their teeth twice daily with fluoride toothpaste. The ADA, the American Academy of Pediatric Dentistry, and the American Academy of Pediatrics all have guidelines for how much fluoride supplementation should be given to children on a daily basis according to the amount of fluoride in the water. In answer to Mayor Nakanishi, Dr. Wong stated that fluoridating the water will not alter its taste. Doctor Wong reported that in 1992, fluoridated water was reaching 56% of the United States' population. By 2000, 38 states and the District of Columbia were fluoridating their water. California and ten other states provide fluoridated water to less than 49% of their populations. The CDC reported that 80% of the dental caries in the permanent teeth of children ages 5 to 17, were found in 25% of the population. Those at increased risk for dental cavities are those with lower socioeconomic status, low level of parental education, those who do not seek regular dental care, and those without dental insurance or access to dental services. In 1994, an economic analysis reported that water fluoridation saved $39 billion in dental care expenditures in the United States between 1979 and 1989. Dr. Wong stated he was convinced that fluoridation of the community's water is the most equitable and cost effective method of promoting good dental health. In reply to questions by Council Member Howard, Dr. Wong reported that temperature is no longer a determinant of how much fluoride should be put in water. Under that theory, the higher the average temperature of an area, the more water people would consume. If the recommended amount of fluoride were added to the water, fluorosis would be minimal and discoloration of teeth unnoticeable. Fluorosis does not mean that the teeth are weakened. In reference to Ms. Howard's concern about possible fluoride allergies, Dr. Wong pointed out that fluoride is a natural element in rocks and related allergies are unlikely. In regard to individuals on dialysis, tap water is not used, so the fluoridated water would have no effect. The recommended amount of fluoride for water is safe to the body. The salinity of the saliva helps the fluoride bond to the matrix of the teeth. Sherrie Evans, Lodi Unified School District (LUSD), Regional Occupation Program (ROP) dental assisting instructor, reported that since 1997 her students have been teaching oral hygiene instruction at Lawrence and Heritage Elementary Schools, and will begin teaching at Joe Serna Charter School in the near future. Ms. Evans stated that she is the co-chair of the Lodi Area Dental Task Force formed in conjunction with the Healthy Start Program at Lawrence and Heritage Schools. The Task Force has identified that economics, access to dental treatment, language barriers, and lack of community water fluoridation are contributing factors to the poor dental health of many of Lodi's school age children. Ms. Evans presented the following statistics: 9,538 (64%) LUSD elementary students are on free or reduced lunches; 2 Continued September 11, 2001 ➢ A 2000-2001 random survey of school nurses in LUSD's Title I schools indicated that an average of 13 out of 20 students (65%) in each primary grade had obvious, untreated dental disease; ➢ At Joe Serna Charter School, 38 out of 119 Kindergarten to third grade students, required dental referrals; ➢ CDC has reported that 36.8% of poor children ages two to nine years have one or more untreated decayed primary teeth, compared to 17.3% of non -poor children; ➢ 29.2% of LUSD students come from limited English proficient, Hispanic and Asian families. The language barrier presents an obstacle to learning about oral health information. Roberta Willams, LUSD school nurse, stated that for every dollar spent in prevention, $3 is saved in treatment. In 1999-2000 Ms. Williams screened all second graders at Lawrence Elementary School, of which 46% were referred to the dentist. In 2000-2001 she referred 20% of those screened to the dentist. A school nurse assigned to Heritage Elementary School screened two second grade classes and referred 55% and 75% respectively to the dentist. She referred 45% of a fourth grade class to the dentist. Ms. Williams stated that all these percentages average out to a 48% referral rate. School nurses believe that fluoridation of water is not only prevention and good health care, it is also cost effective in getting children to school, getting them to learn, and to eventually be productive citizens. Mike Gilton, member of the California Fluoridation Task Force and American Water Works Fluoride Standards, explained that he was a staff engineer for the City of Modesto and designed its fluoride equipment. He reported that in the valley area, the fluoride level in the water is approximately .8 to 1 part per million. Referencing Ms. Howard's earlier question regarding equipment safety, Mr. Gilton stated that if the equipment is properly installed according to CDC guidelines, the equipment would alarm and automatically shut down if there was a malfunction. The operation and maintenance cost of fluoridating the City of Modesto's system, which has 100 wells and one water treatment plant, is approximately $500,000 a year. This equates to $2.50 per residence. Los Angeles has three water treatment plants, and its cost to fluoridate is 50 cents per capita. Modesto considered providing two liters of bottled water to each of its 30,000 Title 1 students; however, the cost was prohibitive at $3 to $5 million a year. Providing fluoride tablets is less effective. Mr. Gilton spoke with an engineer in Iowa who stated that they have not had a problem in the 50 years that they have been fluoridating their water. Approximately 30% of the water systems in California are fluoridated. Last week the Redding City Council voted to fluoridate its water. Tom Bennett, representing Sierra Health Foundation, stated that they are one of the few private foundations that will fund fluoridation activities. He reported that the City of Redding received money from the County Public Health Department, Proposition 10 Commission. Funds are also available from the California Wellness Foundation, California Endowment, and the California Health Care Foundation. Sierra Health Foundation has set aside $1 million for community water fluoridation. PUBLIC COMMENTS: David Phillips spoke in opposition to fluoridating the water system. He stated that the CDC has recently acknowledged that the mechanism of fluoride benefits are mainly topical and not systemic. According to medical information he had reviewed, when fluoride is ingested it remains in the body and only 50% is excreted. Fluoride is a cumulative poison that remains in the bones, glands, and tissues. It is one of the most toxic substances on earth and if three to five grams are consumed, fluoride is considered deadly. All the fluoride that is added to water systems is a byproduct of fertilizer, pesticide, and aluminum industries. Mr. Phillips asked the Council (if it is considering moving forward) to allow the community to vote on this issue at a regular general election. 3 Continued September 11, 2001 Doctor Stefanac agreed that fluoride has a great topical effect; however, studies have also shown that there is a significant reduction in tooth decay from the ingestion of fluoride. He pointed out that many things are considered poisonous if ingested in large quantities, e.g., caffeine, chlorine. Dr. Stefanac stated that typically 50% of the community will vote against fluoridating water because they are confused about the issue. He encouraged the Council to make the decision for the community. Mayor Pro Tempore Pennino stated that he was unsure of the role of the City Council regarding this issue and believed that more research should be done to bring forward additional information including: Public Works cost estimate and procedural steps to implement water fluoridation, legal and medical issues, equipment safeguards, statistics on dental insurance costs decreasing, and additional input from citizens. Mayor Nakanishi agreed that additional study and information should be sought prior to making a decision. Discussion ensued regarding potential costs for fluoridating Lodi's water system. Council Member Hitchcock noted that a 35 to 45 member Environmental Quality Committee of the League of California Cities has studied the issue of water fluoridation. She agreed that additional information should be obtained regarding research, costs, and potential grants. Addressing City Manager Flynn, she stated that the issue of water fluoridation should be placed on a regular City Council agenda within the next two to three months. Mayor Pro Tempore Pennino and Council Member Howard favored having another Shirtsleeve Session on the topic prior to placing it on a regular City Council agenda. City Manager Flynn believed that the cost to fluoridate the City's water would be minimal compared to the benefits. He agreed with Mr. Prima's estimate of $500,000 for capital costs. D. COMMENTS BY THE PUBLIC ON NON -AGENDA ITEMS None. E. ADJOURNMENT No action was taken by the City Council. The meeting was adjourned at 8:40 a.m. ATTEST: Susan J. Blackston City Clerk 4 Mayor's & Council Member's Weekly Calendar WEEK OF SEPTEMBER 11, 2001 Tuesday, September 11, 2001 7:00 a.m. Shirtsleeve Session 1. Water Fluoridation 8:30 a.m. ADESA Golden Gate's ground breaking ceremony for its new auction site in Tracy, Schulte Road at Stanford Road, Tracy. 11:30 a.m. Nakanishi. United Way Kick -Off Luncheon, Stockton Civic Auditorium. 7:00 p.m. Library Facilities Master Plan Town Hall Meeting II, Lodi Public Library Bud Sullivan Community Room. Wednesday, September 12, 2001 Reminder Hitchcock, Land, and Pennino. LCC Annual Conference, Sacramento, 9/12 - 15. 6:00 - 8:30 p.m. San Joaquin County Superior Court's "Continuing Conversations with the Court: Post, Present, and Critical Issues for the Future of the Justice System," UOP — McCaffery Center Theater. 10:30 a.m. Child Abuse Prevention Council's ground breaking ceremony for the site of the new First Step Childress Center, 540 N. California Street, Stockton. 6:30 p.m. Nakanishi, Hitchcock, Howard, Land, and Pennino. Dinner with LCC Conference attendees, Morgans Central Valley Bistro in the Sheraton Hotel. Thursday, September 13, 2001 Reminder Hitchcock, Land, and Pennino. LCC Annual Conference, Sacramento, 9/12 - 15. Reminder Grope Festival begins and runs through Sunday, 9/16. Friday, September 14, 2001 Reminder Hitchcock, Land, and Pennino. LCC Annual Conference, Sacramento, 9/12 - 15. Saturday, September 15, 2001 Reminder Hitchcock, Land, and Pennino. LCCAnnq0 Co ference, Sacramento, 9/12 - 15. Reminder Kiddie's Parade, Downtown Lodi. Sunday, September 16, 2001 11:00 a.m. Grape Festival Parade Brunch, Odd Fellows Hall, 6 S. Pleasant Avenue. 12:30 p.m. Grape Festival Parade. Monday, September 17, 2001 Disclaimer. This calendar contains only information that was provided to the City Clerk's ofce councillmis6mcalndr.doc City of Lodi Fluoridation Cost Estimate Item (Each Well Site) Cost Fluoride Saturator w/ Metering Pump, Softener $4,000 Fluoride Analyzer $3,500 Subtotal $7,500 Backflow Device $500 Instrumentation $1,000 Level Control $1,000 Safety Facilities $1,000 Subtotal $3,500 Grading/Excay. $1,000 Yard Piping $1,000 Enclosure/Vault $5,000 Sub Total $7,000 Subtotal per Well (1) $18,000 Subtotal 26 Wells $468,000 Design & Construction Management $101,000 Cost Inflation/Contingencies @ 20% (2) $114,000 Total: $ 683,000 Annual Fluoride & Parts $45,000 Annual Labor O&M c1.5 FTE) $89,000 Annual Total: $134,000 Notes: 1. Costs based on State of California Estimates, 1996. 2. Acquisition of additional property will be necessary at Wells 2 and 12. RCP>\NLodints40ent001\wp\COUNCIL\01\ftuoridation Cap Cost.doc 9/10/01 avities used to be a fact of lire. But over the past feu; decades, tooth decay has been reduced dramatically. The key reason: fluoride. Research has shown that it reduces cavities up to 60 percent in baba- teeth and 15-35 percent in adult teeth. It also helps repair the early stages of tooth decay even before the decay becomes visible. Unfortunately, manypeople continue to be misled about fluoride and water fluoridation. To help you learn more about the important oral health benefits offluoride, the American Dental Association (ADA) has prepared this informational brochure. e encourage you to talk toyour dentist about this and other oral health issues. Your health is our first priority a 77 we are pleased to provide you The FACTS ABOUT FLUORIDE. Cbi/rirc;! lir Ill."; ill culurrrr!r!ilies tf iti.tuNt Jlrnrrithilrai rr;uvr rrnr still r-Iljr;I the be uc,?r nJ jlllrrr'i wl TRUE! In such communities, dentists and physicians may prescribe fluoride tablets or drops for children to take daily, or Fluoride may be added to the school Fater supply. Children also may benefit from Fluoride mouthrinses at home or school. or the application of fluoride solutions or gels in the dental office. A/11 b;,lNrri i,:rh'r, u;rirrirr> Iia rvritrl!rrrlr nna;nr,! FALSE! All water contains some fluoride naturally. However, unless the fluoride content is printed on the label, don't assume bottled water contains adequate fluoride to prevent tooth decay. It may be necessary to contact the manufacturer to obtain this information. American Dental Association Division of Communications 211 East Chicago Avenue Chicago, Illinois 60611-2675 01991 American Dental Association \x'102 Facts About w ®; �I TRUE!. Fluoride. when added to community water supplies, is the single most effective public health measure we have to prevent tooth decay and improve oral health for a lifetime. Also. products containing fluoride stop the growth of newly formed cavities AND can prevent formation of cavities on the roots of teeth. Fl;., ...�.' is rrrlii!rtir,';' ,.n1 rr iirlwhr•;'.,i':r,!l;t'4t;_ TRUE! All water contains some fluoride naturally, in amounts greater or lesser than that needed to contribute to oral health benefits. Nater fluoridation is the process of adjusting the natural level of fluoride to the concentration necessary for protection against tooth decay. Another way to receive fluoride is by using oral care products such as toothpastes, mouthrinses and gels. In fact, about 90 percent of toothpastes and many mouthrinses contain fluoride. Both systemic fluoride (fluoride that comes from eating foods and drinking liquids) and topical fluoride (fluoride that is applied to the surfaces of the teeth) work together to keep teeth strong. Firm -We is onh' bcjw/mai to ebild reit FALSE! Fluoride benefits people of all ages. For example, when children are young and their teeth are still forming, fluoride works by making tooth enamel harder and more resistant to the acid that causes tooth decay. In fact, studies indicate that people who drink optimally fluoridated water from birth will experience approximately 35 percent less decay over their lifetimes. For adults, the benefits are just as great. Fluoride helps repair the early stages of tooth decay even before they become visible in the mouth, a process known as remineralization. And for older adults who experience problems with root caries (decay along the gumline), fluoride has been effective in decreasing this condition. {'1 ,11'') it rll,rirlu(i: r., . rrr±ir: FALSE! Not only is fluoridation an oral health benefit, it's also economical! The average cost for a community_ to fluoridate its water is estimated to be less than 50 cents a year, per person. Over a person's lifetime, that's less than the price of having one cavity treated. In light of increasing health care costs, Fluoridation is presently the most cost-effective way we have to prevent tooth decay. W/It';r./itr�u'illtNi;; r t l: .n1; TRUE! Since the 1930s. hundreds of carefully conducted scientific studies have shown that water fluoridation, at the concentrations recommended for good oral health. has no harmful effects. Fluoridation of community water supplies is recognized as a beneficial public health measure by the ADA, the World Health Organization, the U.S. Public Health Service, the American Medical Association and the American Cancer Society. Pitrr'ni:.ib:".10;i.., ;:,; ;i;c'irc'hildre'r1.S 1,x,113 TRUE! The ADA encourages parents to take an active role in their children's oral health and one way to do so is to supervise their brushing habits. Children should be told to use only a small amount of toothpaste and not to swallow, rnnrhnacrPc and mn„rh�incpc FALSE! While it is true that fluoride is instrumental in preventing tooth decay, fluoride alone cannot prevent dental disease. To help, the ADA recommends brushing twice a day, flossing daily and eating well-balanced meals. Regular dental check-ups also are recommended. 0.8""1 ho11"i,, TRUE! Dental Fluorosis is usually a mild cosmetic condition unnoticeable to most people. It is characterized by lacy white lines or specks in the teeth. In fact, teeth with fluorosis are more resistant to decay. mall! iril/ r (Oib, ,G c. ' lblol,„i., ill bilth,vi TRUE! Drinking optimally fluoridated water and properly using products containing fluoride will not cause moderate or severe dental fluorosis. Dental fluorosis occurs when the natural fluoride content is too high and children drink this water when their permanent teeth are forming. Drinking water fluoridated at the recommended level will not cause moderate or severe fluorosis (unsightly stained teeth). Tl),-.;-(.. is In, line, hc•;rv, . !i "'ride Cl /Id coIit vlr TRUE! The U.S. Public Health Service completed an extensive study of the benefits and risks of fluoride. Their report concluded that "optimal fluoridation of drinking water does not pose a detectable cancer risk to humans." The report went on to say that fluoride's "benefits are great and easy to detect." . S -S J* Encominssirrg the Counties of CALAVERAS, SAN )OAQUK AND TUOLUMNE 7849 N. Pershing Ave. - St xl ton, CA 95207 - (209) 951-1311 - FAX (209) 951-321 July 6, 2000 Matthew Stefanac, DDS Chairman Coalition for Healthy Smiles San Joaquin Dental Society 4661 Precissi Lane Stockton, CA 95207 Dear Dr. Stefanac: On behalf of the Board of Directors the San Joaquin Dental Society resoundingly supports community water fluoridation and urges the City of Stockton to bring what the Center for Disease Control has named one of the top ten public health measures of the last century to our community. In 1994 the first ever statewide oral health needs assessment revealed that dental disease is the most prevalent disease plaguing California children, affecting them at twice the rate of the national average. Water fluoridation, in place for more than 50 years in many parts of the country presents the most safe, economical, effective, preventive measure for reducing decay in both adults and children. Decreasing significantly the risk and incidence of decay provides the potential for tremendous savings in both time and treatment costs to public and private sectors. Community fluoridation is estimated to cost about 50 cents per person annually - the California Department of Health Services estimates every dollar invested in fluoridation saves $ 140 in dental care. This is the type of healthcare reform we need most ... prevention. According to the 1994 needs assessment, children in California communities currently providing fluoridated water already have an average of 36-54 percent fewer cavities. Over 60% of the U.S. population benefits from fluoridation, a measure supported by every U.S. Surgeon General since its inception over 50 years ago. With community water fluoridation available to less than 30% of its population, California lags far behind in this process, in spite of the State's 1995 fluoridation mandate. A Component o/ the American Dental Association nrtd the Calihmtia Dnrtal Association Matthew Stefanac, DDS Page 2 As dentists, it's our responsibility to educate our patients and our community on dental health, which includes encouragement and support of water fluoridation. We urge you to help us serve the people of Stockton by bringing this vital public health measure to our community. Sincerely, San Joaquin Dental Society Nick Veaco, DDS President c: Judee Tippett -Whyte, DDS, Coalition for Healthy Smiles Cindy Lyon, DDS, President American Dental Association 211 East Chicago Avenue Chicago. 'iiinois 60611-2678 312- 4-10.2:00 Fax •312.430-"194 DATE: August 1998 TO: Officers and Memberss off the Board of Trustees FROM: Karen Schaid Wagner`4irector Survey Center SUBJECT: 1998 Consumers ' Opinions Regarding Community Water Fluoridation The Survey Center has just released the 1998 Consumers' Opinions Regarding Communiry Water Fluoridation. The Gallup Organization conducted a national random telephone study of 1003 adults, 18 years of age or older, in lune 1998. Respondents were surveyed on a variety of health and non- health related issues. For the American Dental Association, one specific topic addressed was community water fluoridation. Specifically, respondents were asked: "Do you believe community water should be fluoridated?". A majority of the respondents (70%) indicated yes. Eighteen percent of the respondents said they were opposed to community water fluoridation, while the response for the remaining 12% was don't know. (See the figure below.) This report also summarizes the similarities and/or differences across gender, age, U.S. Census Region, educational attainment, and annual household income regarding this issue. Consumers' Opinions on Whether Community Water Should Be Fluoridated No 18% Don't know 12% Yes 70% Source: ADA. Survey Center. 1998 Consumers' Opinions Regarding Community Water Fluoridation. DEPARTMENT OF HEALTH AND HUMAN SERVICES Timothy R. Collins, D.D.S., Chairman California Fluoridation Task 4340 Redwood Highway -1319 San Rafael, California 94903 Dear Dr. Collins: M.P.H. Office of the Secretary Assistant Secretary for Health Office of Public Health and Science . Washington D.C. 20201 Force RECEIVE OCT 2 6 1998 BY: __.._. . I have just become aware of the -decision by the City of Los Angeles to initiate fluoridation of their drinking water by the end of the year. This is indeed a great public health advancement. As you know, oral diseases and their prevention remain a high priority for the Department, and I am in the process of completing the first Surgeon General's report on oral health. Fluoridation was included in our National Healthy People 2000 objectives and has been proposed for retention in the objectives for 2010. Fluoridation remains an ideal public health measure. based on the scientific evidence of its safety and effectiveness in preventing dental decay and its impressive cost-effectiveness. Further, one of my highest priorities as Surgeon General is reducing disparities in health that persist among our various populations. Fluoridation holds great potential to contribute toward elimination of these disparities. , I am pleased to join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing oral health protection for Americans. Congratulations to you, the task force, and the health organizations that are supporting your efforts. Your success in Los Angeles and other California communities in need of fluoridation will make a significant contribution toward achieving our national goal. Sincerely yours, David Satcher, M.D., Ph.D. Assistant Secretary for Health and Surgeon General American Medical Association Physicians dedicated to the health of America James S. Todd, MD Executive Vice President March 10, 1995 515 North State Street Chicago, Minois 60610 John S. Zapp, D.D.S. Executive Director American Dental Association 211 East Chicago Avenue Chicago, Illinois 60611 Dear Dr. Zapp: This letter is to inform the a resolution adopted in 1994 Association (AMA) regarding drinking water supplies. nUirt 1 3 Ig Ealr 4 > •J. � Q J 312 464-5000 312 464-4184 Fax American Dental Association of by the American Medical the fluoridation of community The continued concern of physicians for improving state drinking water fluoridation programs is indicated in recent AMA policies. In 1986, the AMA adopted as policy: "The AMA urges state health departments to consider the value of requiring statewide fluoridation (preferably a comprehensive program of fluoridation of all public water supplies, where these are fluoride deficient), and to initiate such action as deemed appropriate." (AMA policy no. 440.972) In 1991, the AMA encouraged physicians and medical societies to become involved with this issue: "Local and state medical societies and individual physicians have the opportunity to become involved in correcting the problem of fluoride underfeeding by (1) ascertaining whether municipal water supplies are optimally fluoridated and (2) working with the public health agencies to take corrective action if suboptimal fluoridation is found." (AMA policy no. 440.945) Most recently, at the June 1994 Annual Meeting, the AMA House of Delegates adopted a resolution for improving the operation and maintenance of water fluoridation systems: "The AMA encourages state medical societies to urge state health departments to appoint water fluoridation engineers/specialists as the best protection for assuring optimally fluoridated community water supply programs." (AMA policy no. 440.923) DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service May 1, 1989 Contact: Arent Jaques (301) 496-4261. National Institutes of Health Bethesda, Maryland 20892 NIDR Affirms Effectiveness of Water Fluoridation Claims that water fluoridation does not reduce tooth decay in American children are false, say federal health officials. The claims are being made by anti -fluoridation activist Dr. John Yiamouyiannis, who obtained raw data from a government survey through a Freedom of Information Act request. Officials of the government's National Institute of Dental Research are taking the unusual step of refuting specific anti -fluoridation claims because of fears that in this case the claims could be misinterpreted as having come from the Institute. NIDR conducted a survey during the 1986-87 school year in which dental examinations were performed on almost 40,000 schoolchildren across the country. The results showed a sharp decline --36 percent --in tooth decav since 1980. That decline followed a similar drop during the 1970s. By 1987, half of all Americans aged 5 to 17 had never had a cavity. As part of its survey, NIDR collected information on the residential history of each participant and on the child's use of topical and supplemental fluorides, such as drops, tablets, treatments in the dental office, and school-based fluoride programs. By matching this with information about public water supplies, NIDR epidemiologists were able to determine whether a child had always,'sometimes, or never lived in an area with community water fluoridation. Children who had always lived in fluoridated areas had about 18 percent less tooth decay than children who had never lived in a fluoridated community, they found. When some of the effects of topical fluorides were taken into account, the difference rose to 25 percent. These results were presented at an international scientific symposium in March and have been submitted for publication in a scientific journal. There are many unanswered questions about the reasons for the continued downward trend in tooth decay in American children since the advent of water fluoridation some 40 years ago. But there is little doubt, say NIDR officials, that fluoride -based prevention is necessary to maintain this decline. To ensure optimum delivery of fluoride and to minimize costs, water fluoridation must continue to be the major component of this effort in the United States, they say. L U3*tIVY 01,49CHICUt on Community Water Fluoridation As the dean of a California dental school, I would like to state my personal and professional position on the need to fluoridate California's community water systems. Community water fluoridation, without a doubt, is the greatest public health benefit related to decay prevention. It is a safe, effective and cost effective way to make this preventive measure available to everyone in a community. Quite simply, it is a measure which I would advocate to my family, friends and colleagues without question or concern. The need to fluoridate California's community water systems is obvious. California currently ranks 48th in the nation related to community water system fluoridation. This translates to only 17 percent of Californians benefiting from perhaps the most safe, efficient and cost effective means of preventing tooth decay. Recent studies indicate the decay rate of California school children to be as much as 50 percent higher than the national average. Sixty percent of Californians mistakingly think.that their water is already optimally fluoridated. Fluoride is a naturally occuring element found in trace amounts in most water systems. It has been scientifically proven that by adjusting the concentration of fluoride in community water systems the therapeutic effect for decay prevention will be achieved. Years of studies in communities with naturally occurring optimal levels of fluoride as well as those communities with adjusted levels have proven to be safe and effective. Many communities have voluntarily fluoridated for over forty years with no adverse health effects. With the passage of AB 733 (Speier) in 1995, California was given a tremendous opportunity to act positively regarding this public health measure. This legislation, however, is currently an unfunded mandate. The political will of a community to support fluoridation is important. Community water fluoridation is estimated to cost about 50 cents per person annually. By comparison, a single filling costs between 5504100. This means that for every dollar spent on fluoride a savings of 5100 in dental.care would be realized. This also means that fewer anxiety -provoking visits to the dentist for fillings or other treament would be needed. Many communities across the nation have been studied for the decay -reducing effects of water fluoridation, and it is apparent that this public health measure is beneficial. Studies conducted by the National Institute of Dental Research and the Centers for Disease Control indicate a 30-60 percent reduction in tooth decay after implementation of community water fluoridation. Dental decay (caries) is, in fact, a disease that can be prevented or minimized by consuming drinking water that is fluoridated at an optimal level. This optimal level is monitored by state-of-the-art equipment and highly trained water engineers within a community's water system. Extensive research has been conducted on the safety of community water fluoridation. When present at optimum levels in community water systems, fluoridation is indeed safe. The American Dental Association, the U.S. Public Health Service, the National Institute of Dental Research and independent university research have shown that, although a few individuals continue to object to fluoridation, there is no scientific basis for doubting the medical safety, effectiveness and practicality of community water fluoridation as a public health measure for preventing dental decay. Best wishes for better de=l health, �'darles N. Bertolami, DbS_,D.Med.Sc. Dean, School of Dentistry University of California, San Francisco CSI Charles J. qoodarce, DDS, MSD Dean, School of Dentistry Loma Linda University No -Hee Park, DMD, PhD Dean, School of Dentistry University of California at Los Angeles �.OA41 a -- Arthur A. Dugoni, DDS Dean, School of Dentistry University of the Pacific ; d M. Lade a School bf�-fjj�e ''ts��'try��VN jj .,city of Southern California Great Public Hadtb A&x-vam s — United SCM& 1900-1999 Lap:!/wwM.cdc Dov/epah+,mwr/Drevi� r/aumrr�aoL000i679d.hc R April 02 1999 / 48(12);241-243 Ten Great Public Health Achievements -- United States, 1900-1999 During the 20th century, the health and life expectancy of -persons residing in the United States improved dramatically. Since 1900, the average lifespan of persons in the United States has lengthened by greater than 30 years; 25 years of this gain are attributable to advances in public health (1). To highlight these advances, MMWR will profile 10 public health achievements (see -box) in a series of reports published through December 1999. Many notable public health achievements have occurred during the 1900s, and other accomplishments could have been selected for the list. The choices for topics for this list were based on the opportunity for prevention and the impact on death, illness, and disability in the United States and are not ranked by order of importance. The first report in this series focuses on vaccination, which has resulted in the eradication of smallpox; elimination of poliomyelitis in the Americas; and control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae type b, and other infectious diseases in the United States and other parts of the world. Ten Great Public Health Achievements — United States, 1900-1999 • Vaccination • Motor -vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water • Recognition of tobacco use as a health hazard Future reports that will appear in NOAWR throughout the remainder of 1999 will focus on nine other achievements: • Improvements in motor -vehicle safety have resulted from engineering efforts to make both vehicles and highways safer and from successful efforts to change personal behavior (e.g., increased use of safety belts, child safety seats, and motorcycle helmets and decreased drinking and driving). These efforts have contributed to large reductions in motor -vehicle -related deaths (2). • Work-related health problems, such as coal workers' pneumoconiosis (black lung), and silicosis -- 3 4115199 12:07A N 7C•l rUHIX nCAJUI 1LL1Y•W'd1AWN{Y—%AUNU 1•l+IJ.www,,Yl,yv•Iry,.�url,wl.y,V�r.w�uruw/YWW VVV�V. JYJ�Y common at the beginning of the century -- have come under better control. Severe injuries and deaths related to mining, manufacturing, construction, and transportation also have decreased; since 1980, safer workplaces have resulted in a reduction of approximately 40"/a in the rate of fatal occupational injuries (3). • Control of infectious diseases has resulted from clean water and improved sanitation. Infections such as typhoid and cholera transmitted by contaminated water, a major cause of illness and death early in the 20th century, have been reduced dramatically by improved sanitation. In addition, the discovery of antimicrobial therapy has been critical to successful public health efforts to control infections such as tuberculosis and sexually transmitted diseases (STDs). • Decline in deaths from coronary heart disease and stroke have resulted from risk -factor modification, such as smoking cessation and blood pressure control coupled with improved access to early detection and better treatment. Since 1972, death rates for coronary heart disease have decreased 51% (4). • Since 1900, safer and healthier foods have resulted from decreases in microbial contamination and increases in nutritional content. Identifying essential micronutrients and establishing food -fortification programs have almost eliminated major nutritional deficiency diseases such as rickets, goiter, and pellagra in the United States. • Healthier mothers and babies have resulted from better hygiene and nutrition, availability of antibiotics, greater access to health care, and technologic advances in maternal and neonatal medicine. Since 1900, infant mortality has decreased 90%, and maternal mortality has decreased 99%. • Access to family planning and contraceptive services has altered social and economic roles of women. Family planning has provided health benefits such as smaller family size and longer interval between the birth of children; increased opportunities for preconceptional counseling and screening; fewer infant, child, and maternal deaths; and the use of barrier contraceptives to prevent pregnancy and transmission of human immunodeficiency virus and other STDs. • fluoridation of drinking water began in 1945 and in 1999 reaches an estimated 144 million persons in the United States. fluoridation safely and inexpensively benefits both children and adults by effectively preventing tooth decay, regardless of socioeconomic status or access to care. Fluoridation has played an important role in the reductions in tooth decay (400/o-70% in children) and of tooth loss in adults (400/6-60%) (5). s 1=11'..ecognition of tobacco use as a health hazard and subsequent public health anti-smoking campaigns have resulted in changes in social norms to prevent initiation of tobacco use, promote cessation of use, and reduce exposure to environmental tobacco smoke. Since the 1964 Surgeon General's report on the health risks of smoking, the prevalence of smoking among adults has decreased, and millions of smoking-related deaths have been prevented (6). The list of achievements was developed to highlight the contributions of public health and to describe the impact of these contributions on the health and well being of persons in the United States. A final report in this series will review the national public health system, including.local and state health departments and academic institutions whose activities on research, epidemiology, health education, and program implementation have made these achievements possible. Reported by: CDC. References 1. Bunker JP, Frazier HS, Mosteller F. Improving health: measuring effects of medical care. Milbank Quarterly 1994;72:225-58. 2. Bolen JR, Sleet DA, Chorba T, et al. Overview of efforts to prevent motor vehicle -related injury. In: 4/1569 12:07 E Prevention of motor vehicle -related injuries: a compendium of articles from the Morbidity and Mortality Weekly Report, 1985-1996. Atlanta, Georgia: US Department of Health and.Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 1997. 3_ CDC. Fatal occupational injuries -- United States, 1980-1994. MMWR 1998;47:297-302. 4. Anonymous. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 199'7;157:2413-46. 5. Burt BA, Eklund SA. Dentistry, dental practice, and the community. Philadelphia, Pennsylvania: WB Saunders Company, 1999:204-20. 6. Public Health Service. For a healthy nation: returns on investment in public health. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion and CDC, 1994. Disclaimer All 104" HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML doommm, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Priming Office (GPO), Washington, DC 20402-9371; telephone: (202) $12-1 W. Contact GPO for current prices. • Search Return To: LB414-7? MMWR Home Page CDC Home Page "Questions or messages regarding errors in formatting should be addressed to mmwrg1it?cdc.gov. Page converted; 04/01/99 4/15/99 12:07 A. '3 • \/J Um.241 c• U N a. a� J a1 ar a! .... Ei N C Y c .co,x—.c� eaa _�yyEc"'Wm cwomE.Sg�E 'ice n • O 'd 'p r'7 C •.w�gm"� .:. Cn acimyGoEoi � w�ppamJ..�em'a (/� g " a o •y bar `° m''o cn ... U u u� �b m mar m N O. � L7' • .9j., ^ .D C tl bt la V 7 �'4 �•`',ry a,� 3a� i 7� U 205 a SO N u • �yx�=` 'xodo LE > ggCrr'ar W.0 �• r W .-. y �•, N f , >' 7 a,0c�'u� r� �I J y y O L t0 C 0 _J C 0 O d'O C •� C O O O� C.v N � � •� o F y �� N W S y I `� •'•iiF W "' W C •N C O NN Ira, �/� E d e�� H• L O as C C a'Ci ao. a .�'�::• I' 00 m m •a a. (;o v aur $600,00()- to the that one of them has since left the president. son, he will nut Im culled us u wit - 1996 presidential agency and gone on Tamrazs pay- "Mr. howler culled me," lleslin uass, the lawyers said. Bee Photogreph/Bryan Patrick gher than the assessed value of their homes, an I the agency overseeing the project has denied. 2T er is- o me- reluc- les to if Ute sling, brma over- con - using cr of com- tense under or 8n Agri- tand Eying •and build nose s ex - hose )A to is o.. d tutu lt'uc- ! 1 mayor says Lion of shabbily built homes. '"Phe quality of the work they have put in is a problem and people are paying top dollar for shabby work." De I.a Cruz also said she wants the USDA to investigate charges she heard from some homeowners that their loans were higher than the assessed value of their hones. Keasling bristled at such allegations, call- ing them an outright fabrication and chat - longing De La Cruz to provide proof. As for charges of poor workmanship, he suid,'"I'he homes all have to pass inspection by Cult housing inspectors, so i guess she is saying that her own city is inept." liefare Wednesdays decision in Congress, Call had filed an unsuccessful lawsuit in Federal court challenging Grizzly Hallow. Some new homeowners in the develop- ment accused the city of discriminating against them. "I guess they think we are going to steal front them," said Claudia Espinoza, who, along with her furor worker husband Raul, spends each afternoon and weekend build. ing her "sweat equity' huntc in Galt. Until there are talks between Gult and Kausling's group, Keasling said construction of homes will continue. "People hove a right to own their own home," Keasling said. "And we are going to help people achieve that dream." Dental: Study says 21% of 10th -graders require urgent care Continued from page Al three times as high as for children of comparable age nationally, ac- cording to researchers. A Naliwla! Health and Nutri- tion Examination survey conduct- ed on Lha nation's 5- to 11 -year- olds between 1988 and 1991 found that 26 percent of those children had treated nr untreated tooth de- coy. California's study conducted in the 1993.94 school year found that 73 percent of 6- to 8 -year-olds had treated or untreated decay. "A lot of other states have more preventative programs," said Is - man, adding there are no current statistics on children's dental health on average in the United Stales today and national studios conducted in the past did not break down the data by region. The new California study said that 21 percent of 10th -graders in the slate are in urgent need of dental care for extensive decay, pain or infection. Twenty -mix percent of preschool- ers, 28 percent of kindergarten through third -graders, and 44 percent of high school studentsin s California had no dental inur- ance coverage, researchers found. Thio findings prompted dental health officials to form an advise- ry committee of public health ex- perts and children's groups to push for better dental health among the stales schoolchildren. The group hopgs to develop a plan to increase the use of dental seal- ants on children, having them ap- plied to kids at school by mobile dental units. Sealants are plastic coatings that are applied to the chewing surfaces of the back teeth to pro- tect against decay. Isman said the committee will look at ways to counsel communi- ties against -baby bottle Laoth de- cay — the rotting of children's teeth due to overuse of feeding bottles — andrto increase the use of fluoride toothpastes and flossing. The committee also hopes to en- courage more health insurers to offer dental coverage. "Oral diseases affect, not only the teeth, jams and the rest of the Mouth," said Jared Fine, a dentist and chairman of the Dental Health Foundation, "they can also lead to more serious general health problems." Health care officials working to improve the dental health of Cali- fornia's kids also hope to raise money to pay for the fluoridation Of the states public drinking wa- ter systems and to lobby for such fluoridation. The study found that only 16 California children and dental care Dental Health Foundation study conducted during the 1993.94 school year. Tooth decay. Percentage of California children experiencing tooth decay: 78 4 Preschool Kindergarten- 101h grade third grads California 10th -graders in need of dental care In need of W Urgent No care denial care;: ; Not urgent needed .e' Steps to improve children's dental health ■ Don't put children to bed with a botlle. ■ Have children visit the dentist . by age 1; and every slx months ' after that. ■ Use 1louride toothpaste and mouth rinses. ■ Floss and brush teeth regularly. Cul down on candies and sweets. ■ Ask dentist to apply dental sealants. ■ Encourage children to use mouthguards during sports. Source: Dental Health Foundation .. eau graphic percent of the slate's population drinks fluoridated water, which has been found to decrease tooth decay. That 116ptre ranks Califor- nia 47th among the 50 states in the percentage of its population drinking fluoridated water. Isman said the law rate of fluo- i ridutiot and a luck of public den- tal programs pluce California's kids at risk fordenlal disease. :on: Devastated by TV show's cancellation tpage A] week to $7,500," lie said. Sciences at the Emmy Awards once said: "I don't want to be linrennpe. Ind.. nn 11.. n., r".1i� -d ..,, chn,.. hr. t„Irl thn m,rlinnrn• "T ,..,n,.a art... ..I I .• - I i California Fluoridation Implementation Project r-.-CAAP)_, C� Prepared by the California Department of Health Services Office of Oral Health In Cooperation with the California Dental Association, California Fluoridation Taskforce, and The Dental Health Foundation ' • • • •• • •„ T• / FLUORIDATION PREVENTS TOOTH DECAY v Baby teeth have 60% less tooth decay ✓ Adult teeth have 35% less tooth decay 1 Recent survey data shows Californians want this inexpensive, medically proven to be safe means of preventing tooth decay Fluoride is SAFE 'Fluoride SAVES ✓ Current scientific research shows fluoride ✓ Every dollar invested in fluoridation is safe saves S 140 in dental bills ✓ Fluoride does not cause cancer, bone of By preventing just one cavity in each disease, kidney disease, genetic diseases, child, California's taxpayers would save impaired intelligence more than 5385 million within five years ✓ Fluoride from water, food, and tooth- paste combined does not create health risks ✓ The cost to provide fluoridated water to one person for a lifetime, at 54 cents a year, is less than the cost of a single denial filling Fluoridated Water is One of the 10 Great Public Health Achievements of the 20th Century California Department of Health Services MAJOR HEALTH ORGANIZATIONS SUPPORT FLUORIDATION: /$� a The National Cancer Institute, Centers for Disease Control and Prevention, American Academy of Pediatrics, California Department of Health Services, s� American Pharmacological Association, National Academy of Sciences, Institute of Medicine, World Health Organization, American Public Health Association, American Hospital Association, American Medical Association, American Dental Association, California Dental Association, Califomia Dental Health Foundation, (just a partial list) Fluoridated Water is One of the 10 Great Public Health Achievements of the 20th Century California Department of Health Services What is Dental Fluorosis? ♦ Dental fluorosis is defined as challcy white spots on the teeth Dental fluorosis is a minor cosmetic effect and is not considered to be harmful to health. It may occur when chil- dren drink water, which is high in natural fluoride content as the enamel of their pemra- nent teeth, is forming. If children exhibit fluorosis, it is usually a very mild form and often unnoticeable. In most cases, only a trained dentist can detect dental fluorosis. The benefits received from community water fluoridation far outweigh the risk of mild den- tal fluorosis. ♦ Fluorosis can be prevented through appropriate use of fluoride -containing products. Children take dietary fluoride supplements only when the home water supply is known to be deficient in fluoride and the children are not consuming fluoridated water from other sources (e.g., school, daycare). Children under the age of six should be supervised when using fluoride toothpastes to avoid excessive swallowing. It is recommended that a pea -size amount of tooth- paste be used when brushing. Who Supports Water Fluoridation? ♦ The National Cancer Institute, American AcadeM of Pediatrics, National Academy of Sciences, Institute of Medici nc, World Health Organization, Amen can Dental Associa- tion, American Medical Amoaation aue just some organizations supporting fluoridation Of community water supplies. ♦ Over 100 major, slate, national, and udernational health related organizations support fluoridation The MMWR published by CDC just listed the fluoridation of drinking water as one of the 2e Century's "Ter Gnat Public Health Achievements" ♦ Every Surgeon General of the U. S., for the past 50 years, has supported community waterfluoridation For further information and for more copies, please call the California Department of Health Services, Office of Oral Health, at (916) 323.0852 ' mn 4,ll Community Water Fluoridation One of the 20th Century's Ten Great Public Health Achievements The benefits of public water fluoridation are well known Since its introduction over 50 years ago, fluoridation has been primarily responsible for i 4wong the public's oral health status. No other issue in public health has been as widely studied as community ivater fluoridation, and has been proven to be safe and effective. The amazing results from its use confit W. What is Fluoride? Fluoride is a naturally occurring element. Fluoride is nature's cavity fighter. It is abundani in the earth's mist and is found in manuals that are in rocks and soil everywhere. Small amounts of fluoride are pre- sent naturally in all water sour= and varying amounts of fluoride are found in all foods and beverages. tj What is Water Fluoridation? ♦ Water fluoridation is the process of adjusting the natural level of fluoride to a sufficient concentration for protection against tooth decay, a range of from 0.7 parts per million to 1.2 parts per million depending on average air temperature. ♦ Fluoridation of community water supplies is the single most effective measure for preventing tooth decay and improving dental health. ♦ Over 144 million U.S, residents in more than 10,000 commu- nities are now served by water supplies in which the fluoride concentration has been adjusted to an optimal level (134.6 million residents). Is Water Fluoridation Effective? ♦ The average cost to the consumer for the protection of fluoridated water is estimated at 51 cents a year per person. Over a lifetime, that is less than the cost of having one cavity treated. Studies show that water fluoridation can reduce the amount of cavities children get in their baby teeth by as much as 60 percent; and can reduce tooth decay in permanent adult teeth by nearly 35 percent. ♦ For optimal protection against decay, children and adults need both systemic and topical fluoride sources. Systemic fluoride is obtained by drinking fluoridated water or by the use of fluoride supplements such as drops or tab- lets for children. Topical fluoride is applied to the surfaces of teeth using toothpaste, mouthrinse and gels. ♦ Fluoride reduces tooth decay in many ways. It is incorporated into the enamel of developing teeth, making them more resistant to decay. Fluo- ride also markedly decreases decay that forms along the gum line which is seen in older people. Why Should California Fluoridate? ♦ Community wwafluondation benefits the entire community regardless of education or income, especially people without access to regular dental care. ♦ There are 152 cities in the U. S. with a population over 50,000 that are not fluoridated Of these, 87 are in California. These include Los Angeles, San Diego, San Jose, Sacramento, Santa Ana, Anaheim, and Staidon A national health objective for the year 2000 is to increase to at least 75 percent the proportion of persons served by community water systems providing optimal levels offluoride. To achieve this objective, an additional 30millionpersonsmust receive optimally fluoridated water from public water supplies. In California, only 17.0 percent of the population is served by fluoridated water, giving California a ranking of 48`s in the country in terms of the proportion of people served by fluoridated water. ♦ California taxpayers could save as much as $385 million in dental care costs after five years of community water fluoridation. Is Water Fluoridation Safe? ♦ Studies over the past 50 years have repeatedly confirmed the mfcty of water &mda- tion at optimal levels and its effectiveness in preventing dental decay. ♦ There is no cancer risk associated with drinking water. A National Academy of Sci- ences study concluded "the weight of the evidence from more than 50 epWemiologi- cal studies does not support the hypothesis of an association baween fluoride expo- sure and increased cancer risk in knnians" ♦ The National Carter Institute has stated repeatedly that "Water fluoridation applied for the purpose of dental caries prevention does not pose a detectable risk cf cancer to hm-ans" ♦ Consumption of optimally fluoridated water along with proper use of topical fluoride products is not hamM because most of the fluoride is excreted from the body. IFN aaas D a 0 ■aa. iL 0 CL 0 ILO mti Lob �, 'T (M T-- dr N e-- T- N t' O co Public Support for Water Fluoridation in 16% California, 1991-94 14% Source: California Behavioral Risk Factor Surveillance System California Department of Health Services ■ Yes • No 0 Don't Know Consumers' Opinions on Whether Community Water Should Be Fluoridated When asked "Do you believe community water should be fluoridated? a majority of the respondents (70%) indicated `yes' LI 12%-` 4M I' M ® Yes i No ■ Don't Know Source: American Dental Association Survey Center 1998 Consumers' Opinions' Regarding Water Fluoridation WHY COMMUNITY WATER FLUORIDAT"10N 1. GOOD FORCALIFORNIA'SCHILDREN ✓ Children with poor dental health suffer from pain, discornfort and the social embarrassment ofhaving unsightly or missing teeth Community wafter fluoridation will substantially reduce ill effects on children's emotional and physical well being. ✓ Since water fluoridation began in the U. S. 50 years ago, continuous scientific research shows a reduction of 20 percent to 40 percent in tooth decay for children growing up in communities with fluoridated water. A reduction of up to 60 percent is seen in clnldren with all their deciduous (`baby') teeth ✓ Despite the commercial availability of topical fluorides and fluoride toothpaste, a huge number of Califomia children do not have access to regular dental care and/or carurot afford to buy these products. The only way millions of Cal forma children wig receive the benefit of fluoride is through commuridy water fluoridation. ✓ Even for children who have access to a dentist or to fluoride products, `Inoncompliance' is a big problem Oust as it is regular flossing and brushing). Research shows that even when parents are educated and highly motivated in the use of fluoride supplements, most are unable to maintain the daily schedule needed to achieve effectiveness comparable with water fluoridation. The best way to assure the benefits of fluoride is through community water fluoridation ✓ Fluoridation plays a Vetime protective role as children become adults, by reducing root cavities. This is a benefit to older citizens even when exposure to fluoridated water begins in adulthood. ✓ Marry thousands of scientific studies have carefully eararnined fluoridation and found it to be safe and effective. Enamel fluorosis can be controlled by appropriate use offluoridated toothpaste and fluoride supplements during early childhood. ✓ Compared to the national average, twice as many six -to -eight year old children in California have tooth decay. ✓ A 1994 California statewide survey found that children m norAuondated areas, grades K-3, had 43 percent more tooth decay, and loth graders had 53 percent more tooth decay, than children living in fluoridated areas ✓ Preventing just one cavity in each school-age child in California will save taxpayers an estimated $385 million over the first five years of statewide fluoridation CEIILDREN SHOULD NOT HAVE TO SUFFER FROM PREVENTABLE DENTAL, DISEASE ti � a a� b 2 0 a 5 0 California Children's Oral Health Needs Assessment Preschool Children: Dental Decay El Fluoridated Urban ® Non -fluoridated Urban O Non -fluoridated Rural Head Start Non -Head Start The California Oral Health Needs Assessment Survey, 1993-94, found that children in fluoridated urban areas had less tooth decay than those in non -fluoridated urban and rural areas. Source: California Oral Health Needs Assessment Survey, 1993-1994 Research Project of the Dental Health Foundation, December 1994 1 W' u 167 m m, M N V. -O v ppga aad glaa; pai[g puelauissnu 1pascaap jo ,iagwnu a2e.zaAV M 0 5 bo lb �. C� H cd a cs U '17 O O Y O � O A vi O wcc a� 00,0 b too CALIFORNIA CONSUMERS' GUIDE TO COMMUNITY WATER FLUORIDATION: A QUESTION AND ANSWER GUIDE FOR CITIZENS, PUBLIC OFFICIALS, AND THE MEDIA © Michael W. Easley, D.D.S, M.P.H., President & Chief Executive Officer, International Health Management & Research Associates; and Director, National Center for Fluoridation Policy & Research Publication Prepared for: School of Dentistry, University of California - San Francisco; & California Department of Health Services, Sacramento This publication was made possible by grant number 1999-B1-CA-PRVS-01 from the Centers for Disease Control and Prevention. TABLE OF CONTENTS Introduction..................................................................................................................... 4 What is Fluoride and Why is it Necessary ?................................................................ 5 What is Community Water Fluoridation and Why is it Important ? ........................... 5 Why Use the Public Water System to Provide Fluoride ?.......................................... 5 Don't We Have Other Ways of Getting Fluoride ?....................................................... 6 (1) Systemic Benefits of Fluoride..................................................................... 6 (2) Topical Benefits of Fluoride........................................................................ 6 How Much Fluoride is Added to the Drinking Water ?............................................... 7 Is the Amount of Fluoride in Fluoridated Water Systems Safe ? .............................. 8 How Widespread is the Practice of Community Water Fluoridation inthe United States ?....................................................................................... 9 California Recently Passed Legislation Requiring Fluoridation of Some Community Water Systems. Do Any Other States Require Fluoridation?........................................................................... 9 Who Benefits from the Cost Savings that Result from Fluoridation ? ..................... 10 What Other Impact is Water Fluoridation Having on Consumer orTaxpayer Costs ?......................................................................................... 11 Who Supports Community Water Fluoridation ?....................................................... 11 Who Opposes Community Water Fluoridation ?....................................................... 12 What are Some of the Claims Against Fluoridation that are being Made By Antifluoridationists ?........................................................... 13 BoneHealth...................................................................................................... 13 AdultDental Health.......................................................................................... 13 Total Fluoride Intake in Children and Adults ................................................. 13 DentalFluorosis............................................................................................... 14 SkeletalFiuorosis............................................................................................ 15 Reproduction, Infertility, Birth Rates, Genetics, and Sudden Infant Death Syndrome (SIDS) ...................................... 15 Cancer, Heart Disease, Kidney Disease, AIDS, Mental Deficit, and Alzheimers' Disease ........................................... 15 2 FluorideStatus in Europe............................................................................... 15 U. S. Environmental Protection Agency........................................................ 16 ToothpasteWarning Label.............................................................................. 16 Summary and Conclusions......................................................................................... 17 References.................................................................................................................... 18 Appendix I: National & International Organizations that Recognize the Public Health Benefits of Community Water Fluoridation for PreventingDental Decay............................................................................................. 25 Appendix II: Partial List of California Organizations and Agencies that Recognize the Public Health Benefits of Community Water Fluoridation forPreventing Dental Decav......................................................................................... 27 AppendixIII: Bibliography........................................................................................... 28 Appendix IV: Selected World Wide Websites with Scientifically Accepted Fluoridation Information............................................................................ 29 Appendix V: Statement from the California Poison Control System ..................... 31 Appendix VI: Statement from Dr. David Satcher, Assistant Secretary for Health and Surgeon General of the United States Regarding the Fluoridation of Los Angeles....................................................................................... 32 Appendix VII: Position Statement on Community Water Fluoridation from the Deans of California's Five Dental Schools ................................................ 33 3 INTRODUCTION Community water fluoridation has been utilized for more than half a century as the principle public health measure to prevent the ravages of a common disease known as dental decay. Also known as dental caries, dental decay is a disease that ultimately results in the formation of dental cavities and can lead to dental infections (abscesses), loss of teeth, massive general (systemic) infections, and occasionally death. The treatment of dental decay also results in substantial direct and indirect costs to individuals, employers, insurance companies, consumers, and taxpayers. Community water fluoridation is one of the safest, most effective, and most economical programs that public officials can provide for their constituents in order to prevent the pain, suffering, and costs of dental decay. Community water fluoridation is generally easy and inexpensive to implement - costing public water systems, on average, about 50 cents per person per year to operate1-2. The return on investment is tremendous - more than $80 in dental treatment costs being avoided for each dollar invested in community water fluoridation 2. Few health activities, and even fewer publicly financed programs, result in such a large amount of savings to consumers, taxpayers, insurance companies, and employers. Moreover, fluoridation has proven to be a safe, effective, efficient, economical, and environmentally sound means to prevent dental decay in children and adults. The implementation of community water fluoridation by public and private water systems serves as an excellent example of good public policy at work. Former U. S. Surgeon General C. Everett Koop has frequently stated that, "Fluoridation is the single most important commitment a community can make to the oral health of its children and to future generations." 4 Why would dentists, who earn their livelihood fixing decayed teeth be recommending fluoridation of local water supplies? The answer is simple. Adding fluoride to the water supply is the right thing to do for our patients and our community. Many communities throughout the United States have been fluoridating their water for over 50 years. Currently, 62% of Americans with access to community water systems benefit from fluoridation's continuous protection against dental decay. "Data consistently has indicated that water fluoridation is the most cost effective, practical and safe means for reducing tooth decay in a community" states the Surgeon General of the United States. In the May 2000, Oral Health of America. Report of the Surgeon General, David Satcher MD, PhD, says "Community water fluoridation remains one of the greatest achievements of public health in the twentieth century -an inexpensive means of improving oral health that benefits all residents of a community, young and old, rich and poor alike." Studies conducted by the National Institute of Dental Research and the Center of Disease Control indicate a 30-60% reduction in tooth decay after implementing community water fluoridation. >- Water fluoridation is the process of adjusting the natural level of fluoride to a sufficient concentration for the prevention of tooth decay. Community water fluoridation is estimated to cost about 50 cents per person annually! Over a lifetime this amounts to about $42.00, less than 1/2 the cost of a filling. The benefits reach to all people of our '4 community, but especially the poor and under served. it has been estimated the California taxpayers will save as much as $385 million in the Denti-Cal program alone after only 5 years of water fluoridation. We vaccinate our children to prevent diseases such as chickenpox and measles, however, only 17% of California water sources are fluoridated, ' nature's cavity- fighter! The water in the City of Stockton and outlying areas is not fluoridated. Despite the commercial availability of topical fluorides and fluoride toothpaste, a significant number of children and adults do not have access to regular dental care and/or cannot afford to buy these products. It is estimated that 35% of the population of our community do not have access to dental care. Daily, children miss school and adults work due to toothache pain. Recent research findings have pointed to possible links between oral infection and diabetes, heart and lung disease, stroke and low -birth -weight and premature infants. Through water fluoridation, we can provide the single most effective public health measure to prevent tooth decay and improve TOTAL health for a lifetime. Through a collaborative campaign, the San Joaquin Dental Society, San Joaquin County Health Care Services -Family Preservation of Oral Health Initiative, San Joaquin County Public Health Services and community members are working toward the goal of fluoridating the drinking water of the City of Stockton. In 1995, The California Fluoridation Act, AB 733, was passed that directed cities with 10,000 water connections or more to supplement the water to optimal fluoride levels. Since this is a non -funded mandate, it is up to each community to develop resources for funding and implementation of water fluoridation. Funding resources are now available and potential sources include Prop 10 funds, the California Endowment and various private grants. It is most apparent that everyone wins with fluoridation. Fluoridation ultimately promotes: lower health care costs; lower insurance costs; lower tax supported costs for public service programs; decreases costs for employers; and lowers costs for consumer goods and services..Most importantly, all individuals, young or old, wealthy or poor, will benefit through their lifetime from improved oral health. Ultimately, optimizing the public's oral health through community water fluoridation will require a concerted effort by public officials, health professionals and the public. It's time to fluoridate Stockton's water now! We hope your organization will support our efforts. Enclosed are some fluoridation fact sheets and literature from the American Dental Association that will answer question you may have regarding this important community benefit: Also included for your convenience is a sample letter of support that can be transferred to your letterhead, signed and mailed in the postage paid envelope provided. For more information you may contact: Dr. Matt Stefanac 478-2252 Dr. Judee Tippett -Whyte 957-8940 Thank you in advance for your support! Sincerely, Dr. Judee Tippett -Whyte Dr. Matt Stafanac Coalition for Healthy Smiles IJ Retum Address Coalition for Healthy Smiles c/o San Joaquin Dental Society 7849 North Pershing Ave. Stockton, CA 95207-1749 PLACE STAMP HERE To Whom It May Concern: Yes, we realize the significance of water fluoridation and endorse the efforts of the Coalition for Healthy Smiles to bring water fluoridation to the Stockton community water supply. Studies conducted by the Center for Disease Control and the National Institute for Health indicate a 30-60 percent reduction in tooth decay after implementation of water fluoridation. We feel confident in the medical safety, effectiveness and practicality of community water fluoridation as a public health measure for preventing dental decay. Please add our endorsement of this proposal for community water supply. Sincerely, What Is Fluoride And Why Is It Necessary? Fluoride is a naturally occurring substance that is present in virtually all sources of drinking water in the United States. It serves as an essential trace element necessary for the proper development of teeth and bones, and for the protection of teeth once they have erupted into the mouth. Therefore, fluoride not only benefits children before their teeth have come in, but it also protects the teeth of children and adults after all of their teeth are present in the mouth. Those fortunate enough to have had access to community water fluoridation experience 40-60% fewer dental cavities3. What Is Community Water Fluoridation And Why Is It Important? Community water fluoridation is the precise adjustment of the existing naturally occurring fluoride levels in drinking water to a safe level that has been determined to be ideal for the prevention of dental cavities in children and adults. As previously mentioned, virtually all sources of drinking water in the United States contain some fluoride naturally. There are even some locations in the United States where naturally occurring fluoride levels are adequate for the prevention of dental cavities - these communities do not have to fluoridate their drinking water. However, most communities in the U. S. have insufficient levels of fluoride for effective prevention of dental decay. Therefore, these communities with insufficient naturally -occurring fluoride in their water require the addition of very small amounts of fluoride to achieve the optimal level for good health. Community water fluoridation mimics a naturally occurring process and can be considered to be a form of enrichment or supplementation of the drinking water. Moreover, the concept of fluoridation as a measure to prevent dental decay is very similar to the supplementation of: milk and breads with Vitamin D to prevent rickets; fruit drinks with Vitamin C to prevent scurvy; table salt with iodine to prevent goiter; breads and pastas with folic acid to prevent certain birth defects; and cereals with many different vitamins and minerals in order to provide for proper human development and to promote good health. Why Use The Public Water System To Provide Fluoride? First of all, public water systems have been used for the purpose of preventing diseases in the United States since the 1840's. The original reason for the establishment and widespread use of community water systems by cities and villages was to prevent the outbreak of serious diseases like cholera, hepatitis A, and typhoid fever. Many other diseases, including dental cavities, are prevented through the treatment of drinking water. Water treatment for disease prevention is considered to be a primary public health activity and is essential for the control of many diseases that would otherwise plague modern society. 5 Don't We Have Other Ways Of Getting Fluoride? There are other ways to provide fluoride, but none are as effective as community water fluoridation for the prevention of dental decay in children and adults4"9. Fluoride benefits Teeth in two general ways - there are (1) systemic benefits and (2) topical benefits. (1) Systemic Benefits of Fluoride: Systemic benefits are gained when one drinks water and eats foods that contain fluoride. Systemic benefits can also be obtained by taking fluoride tablets or vitamins with fluoride that have been prescribed by a family's physician or dentist. More permanent in nature, the fluoride obtained from systemic sources actually becomes part of the tooth structure as baby teeth and permanent teeth develop under the gums of infants and children °. These teeth are then considerably stronger and resist dental decay much better once they have erupted into the mouth. This protection, gained from getting fluoride from systemic sources, generally stays with the teeth throughout life. Systemic sources of fluoride also benefit older children and adultsa-s Fluoride from food and drink eventually ends up in a person's saliva. The fluoride in the saliva constantly bathes the teeth so that the teeth are protected continuously with low amounts of fluoride. For those older children and adults fortunate enough to live in fluoridated communities, this constant Protection of the teeth by saliva containing small amounts of fluoride is substantial . The fluoride from saliva not only prevents some cavities from ever starting, but it also repairs early dental decay through a process called remineralization . With remineralization, some very small cavities are not only prevented from getting larger, they actually can "heal" or repair themselves because of the action of low levels of fluoride present in the salivas. It should be noted that community water fluoridation is much more effective, much safer, and much more economical than the use of prescribed fluoride supplements (fluoride tablets or fluoride vitamins)4-9. Community water fluoridation is always the best choice to prevent dental decay in children and adults, not only because it is safer, more effective, and more economical, but because it benefits all people using the public water system, regardless of age, race, ethnic background, or socioeconomic status4 9. Fluoride tablets or vitamins with fluoride can and should be used in the absence of community water fluoridation, but are meant only as a temporary substitute until a community's water system can be fluoridated. Because they must be prescribed by a physician or a dentist, fluoride tablets or vitamins with fluoride often are only available to people fortunate enough to be able to afford regular visits to a family dentist or physician. (2) Topical Benefits of Fluoride: Topical benefits, on the other hand, are temporary benefits that are gained when fluoride from external sources comes into direct contact with the surfaces of the teeth 48. Topical benefits can be H obtained through use of such things as fluoride toothpaste, fluoride mouthrinses, and fluoride treatments that are provided in dentists' offices. Fluoride toothpaste do a great job in helping to prevent dental decay, but only provide a temporary topical benefit to the tooth surfaces. Fluoride toothpaste, by themselves, also do not prevent decay as well as fluoride from the previously mentioned systemic sources -4,6'8. Readily available from grocery stores, drug stores, and other commercial establishments, fluoride toothpaste are safe and should be used according to directions on their labels. Fluoride toothpaste can be used by children and adults in areas served by fluoridated community water systems and do provide additional protection to teeth. Fluoride mouthrinses are effective in preventing dental decay, but also only provide a temporary benefit and are not as effective as fluoride from systemic sources3-4.6-8. They are available over the counter (grocery stores, drug stores, etc.) or by prescription from dentists and physicians. Fluoride mouthrinses may be used at the same time that people are getting fluoride from systemic sources (community water fluoridation or fluoride tablets/vitamins with fluoride), however fluoride mouthrinses should only be used in these situations after consulting with the family's dentist or physician. Fluoride treatments from a family's dentist also provide a temporary topical benefit to the tooth surface 4.6-8. These topical fluoride treatments may be used at the same time that an individual is receiving fluoride from systemic sources, but only if the dentist has determined that there is a need for a fluoride treatment because of the level of decay present in that individual. It is important to remember that fluoride from topical sources, while effective in preventing dental decay, is not nearly as effective as fluoride from systemic sources4•8. Moreover, fluoride from topical sources should never be considered to serve as an adequate substitute for fluoride from systemic sources. The gold standard for dental disease prevention is community water fluoridation4 8. Community water fluoridation should be implemented whenever it is technically feasible. Fluoride tablets are meant to be used as a temporary substitute for community water fluoridation only until a community water system can be fluoridated. Topical sources of fluoride (fluoride toothpaste, fluoride mouthrinses, and fluoride treatments provided in dental offices) are only meant to be used as adjuncts to systemic sources of fluoride. How Much Fluoride Is Added To The Drinking Water? Only a very small amount of fluoride is added to the drinking water to achieve the desired maximum benefits. The existing natural fluoride levels in drinking water supplies are adjusted slightly in order to raise them to between 0.7 and 1.2 parts per million10. This very small amount of fluoride being added is considered to be a trace amount. The precise level of fluoride calculated to be appropriate for each individual community is determined based on that 7 community's annual average daily temperature". Depending on the precise calculation, each community's water fluoride levels will be adjusted to either 0.7, 0.8, 0.9, 1.0, 1.1, or 1.2 parts per million depending on where the community is located and what type of climate it has". Whichever level of fluoride is determined to be the correct level for an individual community, it bears repeating that only a very small amount of fluoride is ultimately added to the drinking water. It also is important to remember that the optimal amount of fluoride in fluoridated drinking water has been calculated to take into account the fluoride the people get from other sources, like food and drink. Fluoridated drinking water provides only about one-third to one-half the amount of fluoride that an individual should be getting on a daily basis12. Is The Amount Of Fluoride In Fluoridated Water Systems Safe? The amount of fluoride present in fluoridated community water systems is miniscule and has been determined to be safe for all individuals, regardless of age, race, gender, or health status13. In other words, community water fluoridation is safe for infants, children, teenagers, young adults, mature adults, and senior citizenst3. It is safe for everyone, even those with chronic diseases 13. Community water fluoridation harms no one and it is also effective in preventing dental decay in people of all ages, races, ethnic groups, or socioeconomic backgrounds18 Fluoride is like many substances that are required to sustain life and promote health; it is beneficial in small amounts and harmful in large amounts. Such common substances as vitamins, minerals, table salt, food, even water, are helpful in the correct amounts and harmful in excessive amounts. For example, fluoride levels in fluoridated water are so low that an adult would have to consume 660 gallons of fluoridated water in a 2 to 4 hour period in order to get a toxic level of fluoride that would cause death14. It is physically impossible for an adult to ever consume that amount of water - the adult would die of other causes long before they were able to accumulate enough fluoride to cause a problem14. Likewise, a 12-18 month old child would have to drink 85 gallons of fluoridated water in a 2 to 4 hour period in order to get a toxic level of fluoride that would cause death, again a physical impossibility14. In order to suffer chronic skeletal effects of too much fluoride, an adult would have to consume roughly 6 to 14 gallons of fluoridated water every day for 10 to 20 years - again physically impossible for virtually all adults14. Most adults drink far less than 1 gallon of water or other liquids a day. Children consume even much lower amounts of liquids than do adults on a daily basis. A lifetime of drinking water fluoridated at the optimum level (0.7 to 1.2 parts per million) results in NO adverse effects to any individual or group of individuals13. Thousands of scientific studies have been completed which looked at individuals and groups who used water with optimum levels of fluoride their H entire lives 13. Lifetime exposure to fluoridated water caused no diseases, no disabilities, nor any other adverse conditions for any group or individuals13. Lifetime exposure to fluoridated water only resulted in benefits - lower rates of dental decay and lower health care bills13. How Widespread Is The Practice Of Community Water Fluoridation In the United States? Currently 135 million Americans are benefiting from community water fluoridation15. Another 10 million Americans are fortunate enough to live in communities with adequate levels of naturally occurring fluoride 5. That means that over 62 percent of Americans with access to community water systems currently benefit from fluoridation's continuous protection against dental decay15 Unfortunately, only 17 percent of Californians currently enjoy the same decay - preventive benefits of fluoridation, ranking California 47th of 50 states'S. The 145 million Americans benefiting from fluoridation live in more than 10,500 communities that are served by over 14,300 water systems15. In addition, 43 of the 50 largest cities in the United States are currently fluoridating their water systems' . With Los Angeles and Sacramento planning to begin fluoridation in 1999, that means that 45 of the 50 largest cities in the U. S. will be fluoridated by year's end. It also means that California, a state whose fluoridation efforts have lagged considerably behind the rest of the nation, will begin to move up in the rankings. It is also important to remember that communities in the United States have been fluoridating their public water systems since 1945, many since the 1950's and 1960's. We have over 54 years experience adjusting fluoride levels in community water systems. California Recently Passed Legislation Requiring Fluoridation of Some Community Water Systems. Do Any Other States Require Fluoridation? Many states have passed legislation requiring community water systems to provide the benefits of water fluoridation for their customers. In addition to California, the states of Connecticut, Delaware, Georgia, Illinois, Minnesota, Nebraska, Nevada, Ohio, and South Dakota require certain communities to fluoridate their public water systems16 ". Several other states are currently considering legislation similar to that enacted in California. Both the Commonwealth of Puerto Rico and the District of Columbia have also legislatively mandated fluoridation16. Additionally, Kentucky requires statewide fluoridation by administrative regulation18. Moreover, many local governments have required fluoridation through laws, regulations, and ordinances. 9 Who Benefits From The Cost Savings That Result From Fluoridation? The total cost to the nation for dental treatment services reported in 1997 was $50.6 billion - a substantial amount usually paid for by individuals, employers, government agencies, and insurance companies19. California's Denti-Cal program, just one taxpayer supported program that provides dental services to indigent Californians, regularly costs almost $700 million per year. There are a number of ways in which individuals and groups benefit from the costs savings brought on by community water fluoridation, costs which are avoided because of the need for less dental treatment. For example, taxpayers benefit because public programs paying for dental care for disadvantaged populations require fewer local, state, and federal tax dollars for each person covered by the program20. It has been estimated that California taxpayers will save as much as $385 million in the Denti-Cal program alone after only 5 years of fluoridation. Employers benefit because their costs for prepaid dental care fringe benefits for their employees are lower20. Employers also avoid the extra costs required when their employees are absent from work due to personal or family visits for dental care20. Consumers benefit because they pay lower costs for consumer goods since employers costs for insurance and employee absences is lowerz . In other words, the cost of doing business in a fluoridated community is lower for employers. Additionally, all patients benefit in several ways. First, their overall health care bills and insurance premiums are lower in fluoridated communities because there are fewer expensive hospital emergency room visits for dental emergencies, costs of which are usually passed on to everyone able to pay through their health care bills and insurance premiums20. Secondly, patients in fluoridated communities avoid having to pay higher health care bills, dental bills, and insurance premiums that often result from the need for physicians, dentists, and hospitals to pass on their extra costs for uncompensated care to those who can pay20 It is most apparent that everyone wins with fluoridation. Not only do individuals benefit because of their improved oral health, but they benefit greatly because cost savings resulting directly and indirectly from a community's decision to fluoridate. Fluoridation ultimately promotes. lower health care costs; lower insurance costs; lower tax -supported costs for public programs; lower business costs for employers; and lower costs for consumer goods and services20. 10 What Other Impact Is Water Fluoridation Having On Consumer Or Taxpayer Costs? The extensive use of community water fluoridation in the United States has contributed substantially to decreasing consumer and taxpayer costs for supporting dental education. Because of lower levels of dental decay in the U. S. population, fewer dentists are needed to care for those currently in the health care ystem. As a result, seven dental schools have ceased operations since 19852 . In addition since 1980, enrollment reductions in the remaining dental schools have been equivalent to the closure of another 20 average size dental schools21. Community water fluoridation has also had an impact on the costs of dentists' malpractice insurance. Dentists practicing in fluoridated communities pay significantly lower malpractice insurance premiums than dentists practicing in non -fluoridated communities22. These lower malpractice insurance rates occur for several reasons. First, since the population suffers from much less decay in fluoridated communities, dentists do not spend as much time providing complicated procedures and therefore are less likely to run into complications. Secondly, dentists also do less general anesthesia and other forms of premedication in fluoridated communities because there are fewer cases of rampant decay in young children. Who Supports Community Water Fluoridation? Most legitimate organizations of health professionals and scientists strongly support community water fluoridation. Table 1 provides a list of just a few of the hundreds of organizations that support fluoridation, their year of establishment, and the number of members they represent23. Table 1: Examples of Scientific, Technical, and Professional Organizations that Support Community Water Fluo{idation23 Professional Organization Established Membershi American Medical Association 1847 296,000 American Dental Association 1859 141,000 American Dental Hygienists' Association 1923 100,000 American Osteopathic Association 1897 43,000 American Dietetic Association 1917 70,000 American Academy of Pediatrics 1930 49,000 American Academy of Family Physicians 1947 84,000 American Public Health Association 1872 50,000 American Nurses Association 1893 180,000 National Academy of Sciences 1863 2,200'`* American Water Works Association 1881 52,000 •' The 2,200 Members of the National Academy of Sciences include more than 160 Nobel Prize Winners. 11 Some other well-known organizations and agencies supporting community water fluoridation include the National Academy of Sciences (established 1863), the U. S. Public Health Service (established 1798), the National Institutes of Health (established 1891), the U. S. Centers for Disease Control (established 1946), and the World Health Organization (established 1946)23. These and many additional scientific and professional organizations that recognize the public health benefits of community water fluoridation are listed in the Appendix. It is important to note that these broadly based organizations represent millions of health practitioners, scientists and other professionals. These credible and respected organizations have also been working to improve the lives of Americans for many years. They are organizations and agencies with established administrative offices, some with state and local chapters, and many whom publish peer-reviewed scientific journals. Community water fluoridation has also been repeatedly shown to have wide support of the American public24-25. Most recently, a national scientific poll taken by the prestigious Gallup Organization documented that 70% of Americans thought community water systems should be fluoridated, 12% did not know, and only 18% thought that community water systems should not be fluoridated24. Who Opposes Community Water Fluoridation? While there is a small, very vocal, minority of the population that opposes the implementation of community water fluoridation, no credible national scientific or professional organization opposes the practice16,26. Individuals whom oppose fluoridation are often called 'antifluoridationists.' Most groups that claim to oppose fluoridation have few members, have no history because they have been organized for relatively short periods of time, have no established offices because they often operate out of individuals' homes, and have unfamiliar names and spokespersons' 6,266 These groups have been granted no professional credibility or scientific standing by the scientific or health care communities, publish no accepted scientific journals, and frequently use multiple names in order to appear to have more support for their position than actually exists'6 ,26-31. Most of the groups lack any stability, disbanding and reforming periodically as interest in their movement periodically increases or subsides' 26-31. The antifluoride groups often publish pseudoscientific propaganda pieces which, when vigorously reviewed and investigated, lack any basis in science's, 26-31 Many of these organizations operate exclusively though the Internet where there is little in place to protect consumers from their scientifically invalid claims and their extensive propaganda21-31 12 What Are Some of the Claims Against Fluoridation that are Being Made by Antifluoridationists? Bone Health: Antifluoridationists often claim that the fluoride from community water systems is bad for bones, that it causes osteoporosis, that it is responsible for increased hip fractures in senior citizens, and that it causes bone cancer. Not only have such claims never been demonstrated in legitimate scientific studies, just the opposite has been shown to be true. Most studies show no differences in the prevalence of osteoporosis or hip fractures for those people living in fluoridated communities when compared to those living in non -fluoridated communities32-37. A recent study actually demonstrated that populations living in fluoridated communities had fewer hip fractures than those living in non -fluoridated communities37. An additional study even demonstrated the significant benefits of using fluoride to treat osteoporosis of the spinal column in post -menopausal women 38. Regarding the allegation that fluoridation causes bone cancer, studies indicate otherwise - that fluoridation is not related to bone cancer13.3940 Adult Dental Health: Antifluoridationists repeatedly claim that community water fluoridation is only effective in preventing decay in young children. Thankfully, this antifluoridationists' claim is incorrect. Fluoridation benefits people of all ages, whether they are infants, children, adolescents, young adults, middle- aged adults, or the elderly. It is quite clear that adults exposed to fluoridated water experience much less tooth decay than their counterparts who do not have access to fluoridated water41. Moreover, substantial benefits to older persons have been documented repeatedly in studies that show a significant decrease in root decay in older Americans41-45. Root decay occurs in adults for two reasons. First as people age, the gum tissue recedes so that soft root surfaces become exposed to decay -causing foods in the mouth41-45. Secondly as people age or as they become dependent on certain types of medications used to manage chronic health conditions, the flow of saliva tends to become diminished, resulting in what has been termed "dry mouth i46. Dry mouth can result in a substantial increase in the likelihood that teeth will decay46. Root decay is a serious problem in older Americans and has been shown to be a significant reason for loss of teeth after age 5547. Total Fluoride Intake in Children and Adults: Antifluoridationists make a number of bogus claims about total fluoride intake in children and adults. Those few individuals opposed to fluoridation often try to claim that children and adults in the United States routinely get too much fluoride or that fluoride intake for children and adults is somehow increasing. Nothing could be further from the truth. Fluoridation levels for communities have been calculated so as to factor in the amount of fluoride that children and adults get from other sources4,'2,48-52 Moreover, fluoride consumption for both children and adults in the United States has repeatedly been demonstrated to fall well within a wide margin of safety '2.48- 53 13 Dental Fluorosis: Antifluoridationists frequently claim that children and adults living in fluoridated communities suffer from an increased amount of dental fluorosis. Again, there are a number of significant problems with these allegations by the antifluoride minority. Firstly, dental fluorosis is a relatively rare occurrence and describes a range of conditions which mostly do not occur in the United States13. Fluorosis occurs when children consume more than optimal amounts of fluoride during tooth developmenti3•54. Antifluoridationists often exhibit photographs of children living in other countries where serious industrial pollution causes teeth to have permanent brown stains. These brown stains are examples of moderate and severe fluorosis, a condition directly related to industrial pollution and almost never seen in the United States 3,5a-55 The types of fluorosis seen occasionally in the United States are the questionable, very mild, and mild forms13.55. Questionable and very mild fluorosis result in changes in teeth so subtle that only trained dental examiners are likely to discover them13.55 Mild fluorosis is characterized by a subtle white lacy appearance of the teeth, barely discernable by someone looking closely at the teeth 13,55 None of these minor forms of fluorosis (questionable, very mild, or mild fluorosis) are considered abnormal or of any health consequence'2-13,55 Questionable, very mild, and mild fluorosis usually result from very young children swallowing too much fluoride toothpaste or from the inappropriate supplementation with prescription fluoride products (such as (1) when physicians and dentists independently prescribe fluoride supplements or (2) when physicians and dentists prescribe fluoride supplements without checking the fluoride content of the child's water supply so that, in either case, a child gets a "double" dose of fluoride on a daily basis) 12.5"2 . Dental fluorosis also can occur when children consume water with high levels of naturally -occurring fluoride from private wells or community water systems with higher than optimum natural fluoride levels. Community water fluoridation plays almost no role in the development of any of the forms of fluorosis and certainly plays no role in the development of moderate or severe fluorosis. Secondly, adults cannot get fluorosis 13,56,663 Fluorosis is caused when high levels of fluoride are consumed during the time that children's teeth are developing under the gums13.56. Once all of the permanent teeth have fully formed in children and erupted into the mouth (usually between ages 14-18), fluorosis cannot occur13 56. 3 Thirdly, the various forms of fluorosis that occasionally occur in the United States are not considered to be any sort of adverse health effeCt13. They are not precursors to any diseases, despite the claims by antifluoridationists, nor are they of any concern other than as a minor issue of esthetics13. Moreover, because of the additional fluoride incorporated into the enamel of teeth with questionable, very mild, or mild fluorosis, they are likely to be much more resistant to decay. 14 Skeletal Fluorosis: Allegations by antifluoridationists that long term consumption of fluoridated water causes skeletal fluorosis are untrue. Skeletal fluorosis occurs after long term consumption (10 years or more) of very high levels of fluoride, amounts which far exceed what one would consume with 'lifetime exposure to community water fluoridation 12"13. Extensive studies looking at thousands of lifetime residents who routinely drank water with natural fluoride levels of 4-8 parts per million yielded only 23 cases of an extremely mild condition known as osteosclerosis and no cases of skeletal fluorosis53,64 Advanced skeletal fluorosis has not been demonstrated to occur even when people spend their entire lives drinking water with naturally occurring fluoride levels of as much as 20 parts per million 12-13,53.64-65 Advanced skeletal fluorosis is so rare in the United States that only 5 cases have been confirmed in the last 35 years' 2"13. These 5 cases of advanced skeletal fluorosis were related to industrial exposures of extremely high amounts of fluoride chemicals that occurred over a lontq period of time and in no way was related to community water fluoridation12" 3 Reproduction, Infertility, Birth Rates, Genetics, and Sudden Infant Death Syndrome (SIDS): Using the laundry list approach, antifluoridationists allege that fluoride from fluoridated water systems interferes with reproduction, lowers birth rates, causes genetic damage, and is responsible for sudden infant death syndrome (SIDS). Researchers have looked at each of these allegations in depth and have concluded that the allegations are not true 13,53.57.64-85 Despite scientific evidence to the contrary, antifluoride zealots persist in repeating these false allegations. Cancer, Heart Disease, Kidney Disease, AIDS, Mental Deficit, and Alzheimers' Disease: Using the same laundry list approach, antifluoride activists also attempt to induce panic in the public by claiming that fluoride from fluoridated water causes such dreaded diseases as cancer, heart disease, kidney disease, AIDS, and Alzheimers' Disease. These claims have resulted in the conduction of a substantial amount of scientific research, all of which demonstrates that the antifluoridationists' claims are without substancet2"13.53,84-97. Again, as with the previously mentioned laundry list of alleged diseases attributed to community water fluoridation, scientific evidence counters the false allegations of the antifluoride minority. Fluoride Status in Europe: Antifluoridationists often claim that "only the United States fluoridates its community water supplies," or that "98% of Europe is fluoride free," or even that "Europe has banned fluoride." All three of these claims are false. The World Health Organization strongly recommends the use of community water fluoridation where ever it is technologically feasible 2398. The phrase "technologically feasible" means that the country has one or more public water systems: (1) that are capable of adding fluoride to the drinking water; (2) has drinking water systems that are usable, safe, and dependable; and (3) that the country's water systems employ qualified water plant operators who can ensure that optimum levels of fluoride will continue to be maintained. 15 Currently approximately 60 countries practice community water fluoridation, providing the benefits of optimally fluoridated drinking water to more than 360 million people9S"99 . While many of these countries which fluoridate their community water systems are in Europe, some European countries provide their populations. with fluoride through alternative means. For example, France and Switzerland add fluoride to table salt to ensure that adequate amounts of fluoride are made available to all of their populations, although one community water system in Switzerland is fluoridated. Salt fluoridation was chosen because of inherent difficulties in using water fluoridation in communities with extremely complex water distribution systems. Other countries, especially Norway, Sweden, Finland, Denmark, and the Netherlands utilize their extensive national health care systems to deliver fluoride supplements to all children, as well as to provide routine topical fluoride applications in their public clinics. Many Eastern European community water systems have stopped fluoridation (some have even shut down their water treatment plants altogether) only because of their current financial difficulties and will likely be resuming fluoridation once their economies permit upgrading of worn out and outdated facilities. Not a single European country has "banned" fluoridation as alleged by America's antifluoride minority. U. S. Environmental Protection Agency:. Some antifluoridationists have claimed that the U. S. Environmental Protection Agency (USEPA) has banned fluoridation in the United States. This allegation serves as yet another example of the use of false and misleading statements by the antifluoride minority. First of all, the USEPA continues to support the use of community water fluoridation in public water systems in the United States, all of which fall under the Agency's regulations. As recently as 1997, a USEPA spokesperson reconfirmed that "recent reviews of the available toxicity data by the Department of Health and Human Services (1991) and the National Research Council (1993) support EPA's policy and the use of optimal fluoridation"100. An official letter from the USEPA that is included in the current Code of Federal Regulations further emphasizes that "fluoride in children's drinking water at levels of approximately 1 mg/I [1 part per million) reduces the number of dental cavities"101. Toothpaste Warning Label: Recently, warning labels have been showing up on fluoride -containing toothpastes. Although unrelated in any way to community water fluoridation, there are several reasons why this has happened. First of all, most toothpastes sold in the United States contain fluoride at levels that are between 1,100 and 1,600 parts per million. Since toothpaste fluoride levels are more than 1,000 times higher than fluoride levels in community water systems, very young children swallowing substantial amounts of toothpaste could end up with mild to moderate fluorosis58. Mild to moderate fluorosis, while not being an adverse health effect, could result in some slightly stained permanent teeth 58. As discussed previously, older children and adults can not get fluorosis, although they are less likely to swallow large amounts of toothpaste anyway13.566 While there is the hypothetical possibility that a very small child EZ could intentionally swallow enough fluoride toothpaste to become acutely ill, there are other chemical constituents in toothpaste that would likely cause the child to vomit long before they swallowed enough fluoride to be harmful102. In the U. S., any consumer products companies making health claims for their products, even if their products are sold over the counter, come under the regulatory authority of the U. S. Food and Drug Administration (FDA)102. The FDA requires that all over-the-counter products include warning labels for every such product to explain to the public what might happen if the product is consumed in larger quantities than recommended by the manufacturer'02. While the FDA began enforcing this requirement a number of years ago by selectively imposing the regulation on various categories of consumer products, they only recently began enforcing the requirement on toothpastes102. It is important to note that there never has been a documented case of serious injury or death from children swallowing toothpaste' 02. Furthermore, the statewide California Poison Control System confirms that NO child has ever been referred to a hospital for toothpaste related illness as a result of a call to one of California's regional poison control centers' 02. The Director of the San Diego Division, California Poison Control System, himself a board certified applied toxicologist, stated: Equally convincing are the numerous studies that have shown that fluoridation of drinking water is safe. From a toxicological perspective, many epidemiologic studies have been performed that show convincingly that fluoridation of drinking water produces no harmful effects.' 03 SUMMARY AND CONCLUSIONS Community water fluoridation has served the American public extremely well as the cornerstone of dental caries prevention activities for more than 54 years. The dental health and general health benefits associated with the consumption of water -borne fluorides have been documented for over 100 years. Ongoing research, often conducted in response to the repeated allegations by those opposed to fluoridation, continues to confirm the safety, effectiveness, efficiency, cost-effectiveness, and environmental compatibility of community water fluoridation. Fluoridation also continues to be acclaimed as an important contributor to the health of the nation, most recently being named as one of the 20th Century's ten greatest public health achievements' 04. Dr. David Satcher (currently the Assistant Secretary for Health and the Surgeon General of the United States) recently reconfirmed the support of his office for community water fluoridation'05. Dr. Satcher's comments were included in a congratulatory letter to the chair of California's Fluoridation Task Force regarding the positive decision of the City of Los Angeles to initiate fluoridation' 05. Moreover, the deans of California's five 17 dental schools recently issued a signed Position Statement on Community Water Fluoridation (1999) that stated in part: As the dean of a California dental school, I would like to state my personal and professional position on the need to fluoridate California's Community water systems. Community water fluoridation, without a doubt, is the greatest public health benefit related to decay prevention. It is a safe, effective and cost effective way to make this preventive measure available to everyone in a community. Quite simply, it is a measure which I would advocate to my family, friends and colleagues without question or concern. "106 The adoption of community water fluoridation by local communities and state legislatures represents an excellent example of good public policy. Communities throughout the United States continue to exhibit sound decision- making and evidence their continued trust and faith in science and the health professions by adopting fluoridation. The acceptance of community water fluoridation by public officials ensures that all citizens of a community, regardless of age, race, ethnic background, religion, gender, educational status, or socioeconomic level, receive the same substantial dental disease prevention benefits currently available to the 145 million Americans on fluoridated water systems. REFERENCES: 1. Garcia Al. Caries incidence and costs of prevention programs. J Public Health Dent 1989; 49(5):259-71. 2. U. S. Centers for Disease Control & Prevention. Public health focus: fluoridation of community water systems. MMWR: Update 1992; 41(21):372-5. 3. Murray JJ. Efficacy of preventive agents for dental caries. Caries Res 1993; 27(Suppl 1):2-8. 4, Newbrun E. Fluorides and dental caries, 3id ed. Springfield, IL; Charles C. Thomas, publisher, 1986. 5. Lambrou D, Larsen MJ, Fejerskov O, & Tachos G. The effect of fluoride in saliva on remineralization of dental enamel in humans. Caries Res 1981; 15:341-5. 6. Burt BA (ed.). The relative efficiency of methods of caries prevention in dental public health: proceedings of a workshop at the University of Michigan, Jun 5-8, 1978. Ann Arbor, Ml; University of Michigan Press, 1978. Burt BA (ed.). Proceedings for the workshop: cost effectiveness of caries prevention in dental public health, held at Ann Arbor, MI, May 17-19, 1989, J Public Health Dent 1989; 56(5, Spec Issue):249-344. 8. Murray JJ, Rugg -Gunn AJ, & Jenkins GN. Fluoride in caries prevention, Yd ed. Oxford, England, UK; Wright, publisher, 1991. 18 Levy SM, Kiritsy MC, & Warren JJ. Sources of fluoride intake in children. J Public Health Dent 1995; 55(1):39-52. 10. U. S. Centers for Disease Control & Prevention. Water fluoridation: a manual for water plant operators. Atlanta, GA; The Agency, Apr 1994. 11. Galagan DJ & Vermillion JR. Determining optimum fluoride concentrations. Public Health Rep 1957; 72:491-93. 12. National Academy of Sciences, Institute of Medicine (Food & Nutrition Board). Dietary reference intakes for calcium, phosphorous, magnesium, vitamin D, & fluoride, report of the standing committee on scientific evaluation of dietary reference intakes. Washington, DC; National Academy Press; 1998 (Advance Prepublication Copy). (In Press). 13. U. S. Department of Health & Human Services, Public Health Service. Review of fluoride benefits and risks: report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs. Washington, DC; The Agency; Feb 1991. 14_ Burt BA & Eklund SA. Dentistry, dental practice, & the community, 4", ed. Philadelphia, PA; W. B. Saunders Company, publisher, 1992. pp.146-147. 15. U. S. Centers for Disease Control. Fluoridation Census, 1992. Atlanta, GA; The Agency; 1993. 16. Easley, MW. The status of community water fluoridation in the United States. Public Health Rep 1990; 105(4):348-353. 17. Delaware State Senate, 1391" General Assembly. Senate Bill No. 173 - An act to amend title 16 of the Delaware Code relating to fluoridation of water supplies. Delaware Online Legislative Information Service at htto://www.state.de. us/govern/agencies/leo is/lis/139/bills/107796. htm. 18. Kentucky Administrative Regulations. Title 401, Chap. 8 - Public Water Supply; 401 KAR 8:650 - Supplemental Fluoridation. 19. Palmer C. Dental spending exceeds $50 billion. Am Dent Assoc News, 1998; 29(22):1,30. 20. White BA, Antczak-Bouckoms AA, Milton C, & Weinstein MC. 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The tooth robbers: a pro -fluoridation handbook. Philadelphia, PA; George F. Stickley Company, 1980. 28. Wulf CA, Hughes KF, Smith KG, & Easley MW. Abuse of the scientific literature in an antifluoridation pamphlet (2ntl ed.). Baltimore, MD; American Oral Health Institute Press; 1988. 29. Easley MW. Celebrating 50 years of fluoridation: a public health success story. British Dent J 1995; 178(2):72-5. 30. Easley MW. Fluoridation: a triumph of science over propaganda. Priorities (J American Council on Science & Health) 1996; 8(4):35-39. 31. Easley MW. Community water fluoridation, p.48-49, in American Council on Science & Health. Facts versus fears, special report: a review of the greatest unfounded health scares of recent times. New York, NY; The Organization, 1998. 32. Gordon SL & Corbin SB. Summary of workshop on drinking water fluoridation influence on hip fracture and bone health. Osteoporosis Int J 1992; 2:109-117. 33. 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Pak CY, Sakhaee K, Adams-Huet G, Piziak V, Peterson RD, & Poindexter JR. Treatment of post -menopausal osteoporosis with slow-release sodium fluoride: final report of a randomized controlled trial. Ann Intern Med 1995; 123(6):401-408. 39. Bucher JR, Hejtmancik MR, Taft JD II, Persing RL, Eustis SL, & Haseman JK. Results and conclusions of the National Toxicology Program's rodent carcinogenicity studies with sodium fluoride. Int J Cancer 1991; 48:733-737. 20 40. Maurer JK, Cheng MC, Boysen BG, & Anderson RL. Two-year carcinogenicity study of sodium fluoride in rats. J Natl Cancer Inst 1990; 82:1118-1126. 41. McGuire S. A review of the impact of fluoride on adult caries. J Clin Dent 1993; 4(1):11-13. 42. Melbert JR & Ripa LW. Fluoride in preventive dentistry: theory and clinical applications. Chicago, IL; Quintessence; 1983:41-80. 43. Grembowski D, Fiset L & Spadafora A. How fluoridation affects adult dental caries: systemic and topical effects are explored. J Am Dent Assoc 1992; 123:49-54. 44. Stamm JW, Banting DW & Imrey PB. Adult root caries survey of two similar communities with contrasting natural water fluoride levels. J Am Dent Assoc 1990; 120:143-149. 45. Newbrun E. Prevention of root caries. Gerodont 1986; 5(1):33-41. 46. American Dental Association (Council on Access, Prevention, & Interprofessional Relations). Caries diagnosis and risk assessment: a review of preventive strategies and management. J Am Dent Assoc 1995; 126(Suppl). 47. Brown LJ, Winn DM, & White BA. Dental caries restoration and tooth conditions in U. S. adults, 1988-1991. J Am Dent Assoc 1996; 127:1315-1325. 48. Rugg -Gunn AJ. Nutrition and dental health. New York, NY; Oxford University Press; 1993. 49. Kaminsky LS, Mahoney MC, Leach J, Melius J, & Miller MJ. Fluoride: benefits and risks of exposure. Crit Rev Oral Biol Med 1990; 1:261-281. 50. National Academy of Sciences (Committee on Animal Nutrition and the Subcommittee on Fluorosis). Effects of fluorides in animals. Washington, DC; The Organization; 1974. 51. Pendrys DG & Stamm JW. Relationship of total fluoride intake to beneficial effects and enamel fluorosis. J Dent Res 1990; 69(Spec Issue):529-538. 52. Olson RE (ed.). Fluoride in food and water. Nutr Rev 1986; 44(7):233-235. 53. Leone NC, Shimkin MB & Arnold FA, et al. Medical aspects of excessive fluoride in a water supply. Public Health Rep 1954; 69(10):925-936. 54. Whitford GM. The metabolism and toxicity of fluoride (2"0 rev. ed.) in Monographs in oral science. Basel, Switzerland; Karger; 1996. (Vol. 16). 55. Dean HT. The investigation of physiological effects by the epidemiological method in Moulton FR (ed.). Fluorine and dental health. Washington, DC; Am Assoc Advancement Sci Publ. No. 19; 1942:23-31. 56. Lewis DW & Banting DW. Water fluoridation: current effectiveness and dental fluorosis. Community Dent Oral Epidemiol 1994; 22:153-158. 57. National Research Council. Health effects of ingested fluoride: report of the Subcommittee on Health Effects of Ingested Fluoride. Washington, DC; National Academy Press; 1993. 21 58. Levy SM. A review of fluoride intake from fluoride dentifrice. J Dent Child 1993;60(2):115-124. 59. Stookey GK. Review of fluorosis risk of self -applied topical fluorides: dentifrice, mouthrinses, and gels. Community Dent Oral Epidemiol 1994; 22(3):181-186. 60. Pendrys DG, Katz RV, & Morse DE. Risk factors for enamel fluorosis in a nonfluoridated population. Am J Epidemic) 1996; 143(8):808-815. 61. Pendrys DG. Risk of fluorosis in a fluoridated population: implications for the dentist and hygienist. J Am Dent Assoc 1995; 126:1617-1624. 62. Margolis FJ, Reames HR, Freshman E, Macauley CD & Mehaffey H. Fluoride: ten-year prospective study of deciduous and permanent dentition. Am J Dis Child 1975; 129:794-800. 63. Horowitz HS. Indices for measuring dental fluorosis. J Public Health Dent 1986; 46(4):179-183. 64. Stevenson CA & Watson AR. Fluoride osteosclerosis. Am. J Roentgenology, Radium Therapy and Nuclear Med 1957; 78(1):12-18. 65. Hodge HC. The safety of fluoride tablets or drops, in Johansen E, Taves DR, & Olsen TO (eds.). Continuing evaluation of the use of fluorides. Boulder, CO; Westview Press: 1979:253-275. 66. Kram D, Schneider EL, Singer L, & Martin GR. The effects of high and low fluoride diets on the frequencies of sister chromatid exchanges. Mutat Res 1978; 57:51-55. 67. Li Y, Dunipace AJ & Stookey GK. Lack of genotoxic effects of fluoride in the mouse bone -marrow micronucleus test. J Dent Res 1987; 66(11):1687-1690. 68. Li Y, Dunipace AJ & Stookey GK. Effects of fluoride on the mouse sperm morphology test. J Dent Res 1987; 66(9):1509-1511. 69. Zeiger E, Gulati DK, Kaur P, Mohamed AH, Razova J, & Deaton TG. Cytogenetic studies of sodium fluoride in mice. Mutagenesis 1994; 9(5):467471. 70. Li Y, Heerema NA, Dunipace AJ, & Stookey GK. Genotoxic effects of fluoride evaluated by sister -chromatid exchange. Mutat Res 1987; 192:191-201. 71. Dunipace AJ, Zhang W, Noblitt TW, Li Y, & Stookey GK. Genotoxic evaluation of chronic fluoride exposure: micronucleus and sperm morphology studies. J Dent Res 1989; 68(11):1525-1528. 72. Li Y, Xhang W, Noblitt TW, Dunipace AJ, & Stookey GK. Genotoxic evaluation of chronic fluoride exposure: sister -chromatid exchange study. Mut Res 1989; 227:159-165. 73. Obe G & Slacik-Erben R. Suppressive activity by fluoride on the induction of chromosome aberrations in human cells and alkylating agents in vitro. Mutat Res 1973; 19:369-371. 74. Slacik-Erben R & Obe G. The effect of sodium fluoride on DNA synthesis, mitotic indices and chromosomal aberrations in human leukocytes treated with Tremnimon in vitro. Mutat Res 1976; 37:253-266. 22 75. Martin GR, Brown KS, Singer L, Ophaug R, & Jacobson -Kram D. Cytogenic and mutagenic assays on fluoride, in Schupe JL, Peterson HB & Leone NC (eds.). Fluorides, effects on vegetation, animals and humans. Salt Lake City, UT; Paragon Press; 1983:271-280. 76. Martin GR, Brown KS, Matheson DW, Lebowitz H, Singer L, & Ophaug R. Lack of cytogenetic effects in mice or mutations in salmonella receiving sodium fluoride. Mutat Res 1979; 66:159-167. 77. Li Y, Dunipace AJ, & Stookey GK. Absence of mutagenic and antimutagenic activities of fluoride in Ames salmonella assays. Mutat Res 1987; 120:229-236. 78. Tong CC, McQueen CA, Brat SV & Williams GM. The lack of genotoxicity of sodium fluoride in a battery of cellular tests. Cell Biol Toxicol 1988; 4(2):173-186. 79. Erickson JD, Oakley GP Jr., Flynt JW Jr. & Hay S. Water fluoridation and congenital malformations: no association. J Am Dent Assoc 1976; 93:981-984. 80. Knox EG, Armstrong E & Lancashire R. Fluoridation and the prevalence of congenital malformations. Comm Medd 1980; 2:190-194, 81. Berry WT. Study of the incidence of mongolism in relation to the fluoride content of water. Am J Ment Def 1958; 62:634-636. 82. Needleman BL, Pueschel SM & Rothman KJ. Fluoridation and the occurrence of Down Syndrome. New Eng J Med 1974; 291:821-823. 83. Erickson JD. Down syndrome, water fluoridation, and maternal age. Teratol 1980; 21:177-180. 84. Hoover RN, McKay FW & Fraumeni JF. Fluoridated drinking water and the occurrence of cancer. J Natl Cancer Inst 1976; 57(4):757-768. 85. Erickson JD. Mortality in selected cities with fluoridated and, non -fluoridated water supplies. New Eng J Med 1978; 298(20):1112-1116, 86. Rogot E, Sharrett AR, Feinleib M & Gabsitz RR. Trends in urban mortality in relation to fluoridation status. Am J Epidemiol 1978; 107(2):104-112. 87. Chilvers C. Cancer mortality and fluoridation of water supplies in 35 US cities. Int J Epidemiol 1983; 12(4):397-404. 88. Mahoney MC, Nasca PC, Burnett WS & Melius JM. Bone cancer incidence rates in New York State: time trends and fluoridated drinking water. Am J Public Health 1991; 81(4):475-479. 89. Cohn PD. An epidemiologic report on drinking water and fluoridation. Trenton, NJ; New Jersey Department of Environmental Protection and Energy; 1992. 90. Knox EG. Fluoridation of water and cancer: a review of the epidemiological evidence (Report of the Working Party). London, UK; Her Majesty's Stationary Office; 1985. 91. International Agency for Research on Cancer. IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans. Switzerland; IARC Monograph, Volume 27; 1982. 23 92. U. S. Department of Health & Human Services, Centers for Disease Control, Dental Disease Prevention Activity. Update of fluoride/acquired immunodeficiency syndrome (AIDS) allegation. Atlanta, GA; Pub No. FL-133; June 1987. 93. Shannon FT, Fergusson DM & Horwood LJ. Exposure to fluoridated public water supplies and child health and behaviour. N Z Med J 1986; 99(803):416-418. 94. Kraus AS & Forbes WF. Aluminum, fluoride and the prevention of Alzheimer's Disease. Can J Public Health 1992; 83(2):97-100, 95_ U. S. Department of Health, Education, & Welfare, National Institutes of Health, Division of Dental Health. Misrepresentation of statistics on heart deaths in Antigo, Wisconsin. Bethesda, MD; Publ. No. PPB-47; November 1972. 96. Geever EF, Leone NC, Geiser P & Lieberman J. Pathologic studies in man after prolonged ingestion of fluoride in drinking water I: necropsy findings in a community with a water fluoride level of 2.5 ppm. J Am Dent Assoc 1958; 56:499-507. 97. Schlesinger ER, Overton DE, Chase HC & Cantwell KT. Newburgh-Kingston caries-fluorine study XIII: pediatric findings after ten years. J Am Dent Assoc 1956;52:296-306. 98. World Health Organization. Fluorides and oral health: Report of the W.H.O. Expert Committee on Oral Health Status and Fluoride Use. Geneva, Switzerland; W.H.O. Technical Report Series 846; 1994. 99. British Fluoridation Society. Optimal water fluoridation: status worldwide. Liverpool, England; The Organization; May, 1998. 100. Barles B. (Chief, Prevention & Support Branch, USEPA). Memorandum to Drinking Water Branch Chiefs, Regions I-X: Fluoridation. Washington, D.C.; U. S. Environmental Protection Agency (Office of Water); August 28, 1997. 101, U. S. Code of Federal Regulations, 40 CFR 143.5. 102. Manoguerra AS. Review of the Toxicological Profile of Fluorides. Apr 16, 1999 at California Environmental Health Association's 48`" Annual Educational Symposium: Environmental Health in the New Millennium, Consequences of Our Actions. San Diego, California; Handlery Hotel & Resort; April 12-16, 1999. 103, Manoguerra AS. Letter to Whom it May Concern, from the Director, San Diego Division, California Poison Control System. March 30, 1999. 104. U. S. Centers for Disease Control & Prevention. Ten great public health achievements: United States, 1900-1999. Morbidity & Mortality Weekly Report; 48(12):241-243. April 2, 1999. 105. Satcher D. (U.S. Surgeon General). Letter to Collins, TR (Chairman, California Fluoridation Task Force). October 19, 1998. 106. Bertolami CN, Dugoni AA, Goodarce CJ, Landesman HM, & Park N-H. Position statement on community water fluoridation. 1999. 24 APPENDIX I: National & International Organizations that Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay* *[From: Fluoridation Facts, © 1999, American Dental Association] Academy of Dentistry International Academy of General Dentistry Academy of Sports Dentistry Alzheimer's Association American Academy of Allergy, Asthma & Immunology American Academy of Family Physicians American Academy of Oral & Maxillofacial Pathology American Academy of Pediatrics American Academy of Pediatric Dentistry American Academy of Periodontology American Association for the Advancement of Science American Association for Dental Research American Association of Community Dental Programs American Association of Dental Schools American Association of Endodontists American Association of Oral & Maxillofacial Surgeons American Association of Orthodontists American Association of Public Health Dentistry American Cancer Society American College of Dentists American College of Physicians American Society of Internal Medicine American College of Prosthodontists American Council on Science & Health American Dental Assistants Association American Dental Association American Dental Hygienists' Association American Dietetic Association American Federation of Labor / Congress of Industrial Organizations American Hospital Association American Medical Association American Nurses Association American Osteopathic Association American Pharmaceutical Association American Public Health Association American School Health Association American Society of Clinical Nutrition American Society of Dentistry for Children American Society for Nutritional Sciences American Student Dental Association American Veterinary Medical Association American Water Works Association Association for Academic Health Centers Association of Maternal & Child Health Programs Association of State & Territorial Dental Directors Association of State & Territorial Health Officials British Dental Association 25 British Fluoridation Society British Medical Association Canadian Dental Association Canadian Dental Hygienists Association Canadian Medical Association Canadian Nurses Association Canadian Paediatric Society Canadian Public Health Association Chocolate Manufacturers Association Consumer Federation of American Delta Dental Plans Association European Organization for Caries Research FDI World Dental Federation Federation of Special Care Organizations in Dentistry Academy of Dentistry for Persons with Disabilities American Association of Hospital Dentists American Society for Geriatric Dentistry Health Insurance Association of America Hispanic Dental Association International Association for Dental Research International Association for Orthodontics International College of Dentists Institute of Medicine National Academy of Sciences National Alliance for Oral Health National Association of County & City Health Officials National Association of Dental Assistants National Confectioners Association National Council Against Health Fraud National Dental Assistants Association National Dental Association National Dental Hygienists' Association National Down Syndrome Congress . National Down Syndrome Society National Foundation of Dentistry for the Handicapped National Kidney Foundation National PTA National Research Council Society of American Indian Dentists The Dental Health Foundation (of California) U.S. Department of Defense U.S. Department of Veterans Affairs U.S. Public Health Service U.S. Centers for Disease & Prevention (CDC) U.S. Health Resources & Services Administration (HRSA) U.S. Indian Health Service (IHS) National Institute of Dental & Craniofacial Research (NIDCR) World Federation of Orthodontists World Health Organization 26 APPENDIX II: Partial List of California Organizations and Agencies that Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay" "[From California Dental Association and California Department of Health Services] American Academy of Pediatrics - California Division California Chamber of Commerce California Children NOW California Conference of Local Health Officers California Department of Health Services California Dental Association California Dental Hygienists' Association California Fluoridation NOW California Fluoridation Task Force California Medical Association California Public Health Association - North California Rural Indian Health Board California Schools of Dentistry University of California, San Francisco Dr. Charles N. Bertolami, Dean University of the Pacific Dr. Arthur A. Dugoni, Dean Loma Linda University Dr. Charles J. Goodarce, Dean University of Southern California Dr. Howard M. Landesman, Dean University of California at Los Angeles Dr. No -Hee Park, Dean Delta Dental Plan of California Dental Health Foundation (of California) Los Angeles Citizens for Better Dental Health Older Women's League Sacramento District Dental Society Southern California Public Health Association 27 APPENDIX III: BIBLIOGRAPHY (Suggested Readings) American Council on Science & Health. Fluoridation. New York, NY; The Organization, 1990. iii+13p. American Dental Association (Council on Access, Prevention, & Interprofessional Relations). Fluoridation Facts. Chicago, IL; 1999. 57p. Barrett S & Rovin S (eds.). The tooth robbers: a pro -fluoridation handbook. Philadelphia, PA; George F. Stickley Company, 1980. xii+130p. Burt BA (ed.). Proceedings for the workshop: cost effectiveness of caries prevention in dental public health, held at Ann Arbor, M!, May 97-19, 1989. J Public Health Dent 1989; 56(5, Spec Issue):249-344. Consumers Union. A two-part report on fluoridation. Consumers Reports; 1978 (Reprint); (July -Aug). Easley MW, Wulf CA, Brayton KJ, & Striffler DF (eds ). Fluoridation: litigation and changing public policy; proceedings of a workshop at the University of Michigan, August 9-10, 9983. Ann Arbor, MI; The University of Michigan Press, 1983. vi+129p. Murray JJ, Rugg -Gunn AJ, & Jenkins GN. Fluoride in caries prevention, 3`d ed. Oxford, England, UK; Wright, publisher, 1991. x+396p. Newbrun E. Cariology, 2nd ed. Baltimore, MD; Williams & Wilkins, 1983. xvi+344p. U. S. Centers for Disease Control & Prevention. Water fluoridation: a manual for water plant operators. Atlanta, GA; The Agency, Apr 1994. xii+99p. U. S. Department of Health & Human Services, Public Health Service. Review of fluoride benefits and risks: report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs. Washington, DC; The Agency; Feb 1991. xii+134+81 p. R1: APPENDIX IV: SELECTED WORLD WIDE WEBSITES WITH SCIENTIFICALLY VALID FLUORIDATION INFORMATION CALIFORNIA SITES: California Dental Association http://www.cda.org/public/index.html California Fluoridation Now http:l/www.deltadentaica.org/flo/flo spr98.html Delta Dental Plans of California http://www.deltadentalca.org/subJsub fluor.html Dental Health Foundation (of California) http://www.dentalhealthfoundation.om Los Angeles Citizens for Better Dental Health htti)://www.dhs.co.1a.ca.us/phps/phwpost/watrflrd.htm Sacramento District Dental Society http://www.sdds.orqffiuorida,htm OTHER STATES' SITES: Washington State Children's Alliance htti)://www.childrensalliance.org/teeth/fluorida.htm Washington State Dental Association http:/Iwww.wsda.orci/public/consumers/factsheets2.cfm?id=34 Washington State Oral Health Coalition http://www.childrensailiance.org/teeth/Washinqt.htm NATIONAL SITES: American Academy of Family Physicians httr)://www.aafp.org/policy/50.htmi American Dental Association hftp://www.ada.org/consumer/fluoride/fi-menu.html American Society for Nutritional Sciences and the American Society for Clinical Nutrition hftp://www.faseb.org/ain/fluoridation.html National Center for Fluoridation Policy & Research hftp://fluoride.oralhealth.org/ 29 U. S. Centers for Disease Control, Division of Oral Health http://www.cdc.gov/nccdphpioh U. S. National Institutes of Health, National Center for Dental & Craniofacial Research hftr)://www.cyberdentist.com/fluoride.htm#Ql hftp://www.nidr.nih.gov/flouride.htm U. S. Public Health Service (Report on Fluoride Benefits & Risks) hftr)://www.cda.orq/;)ublic/pubhsrvc.htmi INTERNATIONAL SITES: British Fluoridation Society hftr)://www.derweb.ac.uk/bfs/index.html Calgary (Alberta, Canada) Regional Health Authority htti)://www.crha-health.ab.ca/t)ophlth/hp/fluoride/ 30 APPENDIX V: STATEMENT FROM THE CALIFORNIA POISON CONTROL SYSTEM From: California Poison Control System Anthony S. Manoguerra, Pharm:D., ABAT Director, San Diego Division, California Poison Control System Professor of Clinical Pharmacy & Pediatrics Diplomate, American Board of Applied Toxicology To: To Whom It May Concern Date: March 30, 1989 What Follows is the Transcribed Contents of Dr. Manoguerra's Letter: As with nearly all substances, fluoride is toxic in large doses and safe and therapeutic in small doses. / have reviewed the evidence for the safety of fluoridation of water along with poison center data relative to fluoride ingestions in children. The California Poison Control System has established a threshold of 10 mg/kg of fluoride as the acute dose that a child must ingest before a referral to a health care facility is necessary. This amounts to approximately 100 sodium fluoride tablets (1 mg fluoride per tablet), 90 to 100 grams (3 ounces or more) of fluoride -containing toothpaste or 100 liters of fluoridated water. These amounts are so large that they are rarely, if ever, ingested. Chronic ingestion of fluoride in the quantities found in fluoridated water plus typical food and beverage sources and toothpaste are not associated with adverse health effects. There is no evidence that fluoride ingestion is related to an increased incidence of cancer. There is strong and convincing evidence that fluoridation decreases the incidence of dental caries in children. Recent studies have shown that California children suffer an excess of dental caries because of inadequate fluoridation programs. This results in substantial and unnecessary dental work and the resultant costs associated with the repair of children's teeth. Equally convincing are the numerous studies that have shown that fluoridation of drinking water is safe. From a toxicologic perspective, many epidemiologic studies have been performed that show convincingly that fluoridation of drinking water produces no harmful effects. l appreciate the opportunity to provide this input and ask that if you have any questions, please contact me. Sincerely, sl Anthony S. Manoguerra, Pharm. D., ABA 31 APPENDIX VI: STATEMENT FROM DR. DAVID SATCHER, ASSISTANT SECRETARY FOR HEALTH AND SURGEON GENERAL OF THE UNITED STATES REGARDING THE FLUORIDATION OF LOS ANGELES From: David Satcher, M.D., Ph.D., Assistant Secretary for Health and Surgeon General of the United States To: Timothy R. Collins, D.D.S., M.P.H., Chairman, California Fluoridation Task Force Date: October 19, 1998 What Follows is the Transcribed Contents of Dr. Satcher's Letter: I have just become aware of the decision by the City of Los Angeles to initiate fluoridation of their drinking water by the end of the year. This is indeed a great public health advancement. As you know, oral diseases and their prevention remain a high priority for the Department, and I am in the process of completing the first Surgeon General's report on oral health. Fluoridation was included in our National Healthy People 2000 objectives and has been proposed for retention in the objectives for 2010. Fluoridation remains an ideal public health measure based on the scientific evidence of its safety and effectiveness in preventing dental decay and its impressive cost-effectiveness. Further, one of my highest priorities as Surgeon general is reducing disparities in health that persist among our various populations. Fluoridation holds great potential to contribute toward elimination of these disparities. 1 am pleased to join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing oral health protection for Americans. Congratulations to you, the task force, and the health organizations that are supporting your efforts. Your success in Los Angeles and other California communities in need of fluoridation will make a significant contribution toward achieving our national goal. Sincerely yours, sl David Satcher, M.D., Ph.D. 32 APPENDIX VII: POSITION STATEMENT ON COMMUNITY WATER FLUORIDATION (FROM THE DEANS OF CALIFORNIA'S FIVE DENTAL SCHOOLS) From: Charles N. Bertolami, D.D.S., D.Med.Sc. Dean, School of Dentistry; University of California, San Francisco Arthur A. Dugoni, D.D.S. Dean, School of Dentistry; University of the Pacific Charles J. Goodarce, D.D.S., M.S.D. Dean, School of Dentistry; Loma Linda University Howard M. Landesman, D.D.S. Dean, School of Dentistry; University of Southern California No -Hee Park, D.M.D., Ph.D. Dean, School of Dentistry; University of California at Los Angeles What Follows is the Transcribed Contents of the Deans' Position Statement: As the dean of a California dental school, I would like to state my personal and professional position on the need to fluoridate California's community water systems. Community water fluoridation, without a doubt, is the greatest public health benefit related to decay prevention. It is a safe, effective and cost effective way to make this preventive measure available to everyone in a community. Quite simply, it is a measure which I would Advocate to my family, friends and colleagues without question or concern. The need to fluoridate California's community water systems is obvious. California currently ranks 4e in the nation related to community water system fluoridation. This translates to only 17 percent of Californians benefiting from perhaps the most safe, efficient and cost effective means of preventing tooth decay. Recent studies indicate the decay rate of California school children to be as much as 50 percent higher than the national average. Sixty percent of Californians mistakingly (Sic) think that their water is already optimally fluoridated. Fluoride is a naturally occurring element found in trace amounts in most water systems. /t has been scientifically proven that by adjusting the concentration of fluoride in community water systems the therapeutic effect for decay prevention will be achieved. Years of studies in communities with naturally occurring optimal levels of fluoride as well as those communities with adjusted levels have proven to be safe and effective. Many communities have voluntarily fluoridated for over forty years with no adverse health effects. 33 With the passage of AB 733 (Speier) in 1995, California was given a tremendous opportunity to act positively regarding this public health measure. This legislation, however, is currently an unfunded mandate. The political will of a community to support fluoridation is important. Community water fluoridation is estimated to cost about 50 cents per person annually. By comparison, a single filling costs between $504100. This means that for every dollar spent on fluoride a savings of $100 in dental care would be realized. This also means that fewer anxiety - provoking visits to the dentist for fillings or other treatment would be needed. Many communities across the nation have been studied for the decay - reducing effects of water fluoridation, and it is apparent that this public health measure is beneficial. Studies conducted by the National Institute of Dental Research and the Centers for Disease Control indicate a 30-60 percent reduction in tooth decay after implementation of community water fluoridation. Dental decay (caries) is, in fact, a disease that can be prevented or minimized by consuming drinking water that is" fluoridated at an optimal level. This optimal level is monitored by state-of-the-art equipment and highly trained water engineers within a community's water system. Extensive research has been conducted on the safety of community water fluoridation. When present at optimum levels in community water systems, fluoridation is indeed safe. The American Dental Association, the U. S. Public Health Service, the National Institute of Dental Research and independent university research have shown that, although a few individuals continue to object to fluoridation, there is no scientific basis for doubting the medical safety, effectiveness and practicality of community water fluoridation as a public health measure for preventing dental decay, Best wishes for better dental health, s/ Charles N. Bertolami, D.D.S., D.Med.Sc. s/Arthur A. Dugoni, D.D.S. s/ Charles J. Goodarce, D.D.S., M.S.D. sl Howard M. Landesman, D.D.S. s/ No -Hee Park, D.M.D., Ph.D. 34 Conducted by the Charlton Research Company, March 23-27,1995 600 interviews statewide with a margin of error of 4 percent 1. Do you agree or disagree that fluoride is an effective tool in the fight against tooth decay? Agree 80% Disagree 8% Unsure 12% 2. Do you agree or disagree that having fluoride in your local water supply is a good way to help fight tooth decay? Agree 69% Disagree 15% Unsure 16% 3. Do you believe that your local water supply contains fluoride? Agree 48% Disagree 22% Unsure 30% 4. Would you be more or less likely to favor a state law requiring fluoride be put in all communities' water supplies if you knew that the cost of providing fluoridated water over one's lifetime is usually less than the cost to repair just one cavity? More likely 62% Less likely 18% Unsure 20% S. Would you be willing to accept a ten -cent to fifty -cent increase in your monthly water bill to fluoridate your local water supply? Yes 589 No 34% Unsure 8% �/ CDA. _. v c.........w n,,,. c,.....,....., ra.(,....,....t�. >`louride LA Times Jan. 26, 1995 Fluoridation: a shining public health success Unfounded qualms aside, the pioneering 1945 test and later studies confirm that cavities decline when drinking water is treated. By MARLENE CIMONS TIMES STAFF WRITER tfty years ago this week, public health history was made in Grand Rapids. Mich. On Jan. 25. 1945. Grand Rapids became the first city in the world to fluoridate its water. In doing so, it launched a program des- tined to become what dental professionals and others have called one of the most successful public health experiments ever. "One of the most exciting ex- periences of my career was ob- serving firsthand the benefits of fluoridation in the people of Grand Rapids." said Dr. David Scott, former director of the National Institute of Dental Re- search and one of the research- ers. The study was sponsored by the Public Health Service, the University of Michigan and the city of Grand Rapids. Results Came early: After 11 years of what was a planned 15 -year study of tooth decay among.the city's 30.000 school- children, scientists announced that the rate of cavities had plunged by 60%. Subsequent studies have solid- ly confirmed fluoride's benefits. From 1971 through the mid- 1980s. three national surveys of children's oral health showed a continued decline in cavities at- tributed to the use of fluoride. Nrb,W I-— D..W lia. h Dr. David Scott examines one of the 30,000 children in the Grand Rapids, Mich., fluoridation study of the late '40s and '50s. according to the dental institute. which is part of the National Institutes of Health- The ealthThe most recent survey, taken in 1986-97, found that American children had 36% fewer cavities than they did at the beginning of the 1980x, a decline similar to one shown during the 1970s. Today, half of the children entering first grade have never had a cavity thanks to fluorida- tion, according to the American Dental Assn. Moreover, fluoride also can reduce cavities by 15% to 35% In adults, the ADA said- More aidMore than 144 million Ameri- cans in about 10.500 communities drink fluoridated water. Put an- other way, about 70% of U.S. cities with populations of more than 100,000 add the mineral to their water, according to the federal Centers for Disease Con- trol and Prevention. About 26 million Americans live in areas without central water systems. such as those who drink water from private wells. In California. the cities of Los Angeles. San Diego and San Jose do not fluoridate their water; San Francisco. Long Beach. Oakland and Fresno do. Experts give several reasons why the number of cities partici. pating isn't greater. These in - elude costs and inertia on the part of some local govern- ments—which run the water systems—to make the decision to fluoridate. Perhaps more signtft- canUy. there has been a lingering public unease in some quarters about adding anything to the community water supply. The latter attitude has been fueled over the years by isolated anti -fluoridation drives, where opponents have attacked fluori- dation as a Communist plot and a violation of civil liberties, or claimed that the substance pro- motes everything from cancer. birth defects and sickle cell ane- mia to heart disease and AIDS. Several studies in recent years have shown no evidence that fluoride poses any health risks. Despite its critics, the practice has been endorsed by the Ameri- can Dental Assn.. the American Medical Assn.. the World Health Organization, the American Can- cer Institute, the CDC and the Public Health Service. In recent years. fluoride also has been added to toothpaste and mouth rinse. Other sources in. clude drinks made with fluori- dated water. fluoride drops or tablets and topical application in the dentist's office. In addition to preventing de- cay. water fluoridation has been shown to "remineralize." or re- build, enamel layers in teeth at spots affected by early stages of decay. the ADA said. Scientists are also examining other possible therapeutic uses of fluoride. A study published in the April, 1994. Annals of Internal Medicine by researchers at the Texas Southwestern Medical Center showed that a regimen of fluoride and calcium supple- ments appeared to prevent new spinal fractures and hel' ed to rebuild bone loss in post -meno- pausal women suffering from a major form of osteoporosis - Experts call fluoridation a real bargain. It costs an average of 51 cents per person per year, and about 238.25 over a lifetime—less than the average cost of about $42 for one denial filling, the dental institute said Every dollar in- vested in community fluoridation programs saves about $80 in dental bills, the ADA says. Research on fluoride and its effects on tooth enamel be- gan in the early 1930s under Dr. H. Trendley Dean, a dentist at what was then the National In- stitute of Health. after scientists observed low decay rates among people- whose drinking water contained high levels of natural- ly occurring fluoride. By the. early 1940s. dental scientists concluded that water containing 1 part per million of fluoride would protect teeth from decay, and decided to test their theory by adding the mineral to the almost fluoride -tree Grand Rapids water supply. "The most important historical feature of water fluoridation was that this public health measure simply replicated what had al- ready been demonstrated in na- ture," Scott said. Exactly how fluoride prevents cavities is not fully understood. but scientists do know that fluo- ridated water most helps those who drink it from birth "and the protection holds throughout life for persons who continue to live in fluoridated communities." the dental institute said. CDC BRIEFS CENTERS FOR DISEASE CONTROL "Current Issues in Preventive Health" SEPTEMBER 1992 Fluoride: It's in the Water Tooth decay (also known as dental caries) was a virtually inevitable fact of life for most persons, until the middle of this cemury. The disease often meant many visits to the dentist to have painful or damaged teeth repaired. Stili, a few persons escaped this condition, and a small number of these ezperi- enced dental fluorosis, "mottled teeth," because of exposure to fluoride, naturally present in the drink- ing water. fluorosis is a change in the color of teeth in persons exposed during o,„ the developmental phase of life while adult teeth are forming. These people also seemed to retain their teeth for longer than average, however. Studies in the 1930s curt - fumed a reduced rate of tooth decay in persons whose drinking water contained a threshold level of fluoride. Since almost all water contains some fluoride, Other methods of delivering fluoride have been developed over the last half century, including toothpastes, mouth rinses, and dietary supplements. These require a conscious decision to use, however, and are more expensive than water fluoridation. The nationwide distribution of fluoride containing products and fluoridation of drinking water has resulted in a reduction of dental caries throughout the population of the United States. pcmaaw of Sana' papukd= oft nraridawd dry .'aa - U. s., IM - adjusting the fluoride level of the water supply is an inexpensive and easy way to improve public oral health. Based on observations in communities, an optimal fluoride concentration was established, whereby teeth remained white and incidence of dental caries decreased. A new prevention strategy was realized. Studies in the 1950s conclusively showed that when fluoride was added to drinking water, a marked decline of dental caries followed among consumers. Currently, over 126 trillion U.S. residents are supplied with water containing added or adjusted fluoride, provided by over 9,400 community water systems. 0-2s 26.90 51-7S 76.100 No evidence of adverse effects resulting from deliberate water fluorida- tion has been confuted since this prevention ; strategy was first initi- ated. Some studies have examined the relation- ship between fluoride consumption and bora/ 0 PR teeth development; cost/ benefits ratio in provid- �• r wwr rfmms who MMM ing public fluoridation; Div. CDC. .. aJ o d boa* the increase in local dental caries after a community ceases to add fluoride to drinking water, and effects of overconsumption of fluoridated water and products. Healthy People 2000 is the U.S. Department of Health and Human Services plan which sets health objectives for the nation. The objective in the area of fluoridation calls for 75 percent of those served by community water systems to receive optimal levels of fluoride in their dririlcing water, by the Year 2000. (The current level is 62 percent.) To reach this goal, approximately 30 trillion more people need to be added to the roster of fluoridated `'eater consumers. Prepared by: John P. Anderson CDC, Office of Public Affairs rr a nCDA DT1L'%Fr'nr urArTC Aun Lrrri/AN CrDtJT/"rC/D..4I.- u_..#A C_..:__ V..1 't Mn 9 Questions and Answers about... mater Fluoridation Q. Is public water fluoridation safe? A. Yes. Extensive research conducted over the past 45 years has shown time and time again that fluoridation of public water supplies is a safe and effective way to reduce the incidence of dental caries. A recent, comprehensive Public Health Service review of the benefits and potential risks confirmed the value and safety of water fluoridation. Q. Are there alternative methods of fluoride delivery? A- Yes. Available with a prescription are dietary supplemems for children during the years teeth are forming. In addition, non- prescription tooth pastes and mouth rinses containing fluoride are available for topical USC. Q. What does it cost to fluoridate the water? A. Nationally, the average cost to provide fluoridated water to an individual for one year is $0.51. Q. Is public water fluoridation cost effective? A. Yes. It is estimated that $34 billion (5 percent of 1990 U.S. expenditures for health care) is spent for dental services. The national average cost to restore one cavity with dental amalgam is $40; that amount is the same as the cost of water fluoridation for a person's life- time. For more information contact: Dr. Kim Cowles Division of Oral Health National Center for Prevention Services Centres for Disease Co=ol 404/488-4451 Q. Has incidence of dental caries decreased, since public water fluoridation began? A. Yes. In 1945 and 1946, independent studies followed four communities experimentally testing water fluoridation. Aber 15 years, dental caries in these communities declined an average of 56 percent, compared to demo- graphicaliy similar communities whose water did not contain additional fluoride. In a more recent study, concluding in 1987, caries levels were 26 to 30 percent lower in fluoridated communities because of wide use of fluoride in other forms. In communities which at one time fluoridated their water supplies and then ceased to do so, cases of dental caries increased, further substantiating the findings of other studies. Q. What is the current prevalence of dental caries in the United States? A. The most recent national study, in 1987, showed that 50 percent of persons between 5 and 17 years of age had experienced caries in pennanent teeth. By age 17, 84 percent of persons had experienced some dental decay in permanent teeth. CDC BRIEFS are distributed to state and territorial health departments, from material submitted by Centers, Insdtute% and Offices at CDC. //• .0 _nFPAAPTA./FAIT nJr FAtTsI AAM John P. Anderton, Editor CDC, Office of Public Affairs 1600 Clifton Road, NE, Msilstop D-25, Atlanta. GA 30333 4041639.3286 VaL 56, No. 5, Speaal issue 19% ZSs The Effectiveness -of Community Water Fluoridation in the United States Herschel S. hcrowiiz, DDS, MPH p.bs=ct Grand Rapids. the first cry in the world to bmplemem corttrofied water fluorida- tron, has served as a model for thcx=aands of other cwxn&Wes Fluoridation is oris of the greatestpub6c hearth and diseaseprevenov e measures of au mma Its advantages induds effectiveness for aff, ease of deNviery, saAW, equity, and low cost Today. nearly 56 percent of the CAS population &w in fluordared commu- nines (62% of those on central water supplies). Previously observed caries raapductions of one-half to two-thirds are no longer attainable in the CAnimd Stains because other fluoride methods and products have reduced the caries prevalence in afl areas, thus diluting the measurenww of effectiveness, and because benehns of fluoridation are dispersed in marry ways to persons in nonfluondawd areas Water fluoridation itself, however, rwriairrs *as eilectim as it evtar was among groups at high risk to dermal caries Contrary 0 early beliefs Mat Stressed the viporrance! of preemptive Ruotide exposures, fluoridation also provides an irrrpor- tarn source of toil fluoride and faaTitates remineralization. Although data on sfftchmerress aid safety are comp+eOv. Anurte progress of water fluoridation wX be affix-mof by economic po6Cta4 and ptbffc perception fates jJ Public Health )rent 1996a5(5)253-81 Kay Words: water duaridabon, lfuorfdation sktics, dil/usran and dilution oft cs of fluoridation, preertrpwie andposx+enlptiw effects olflr�oradatiart, Atiorosis, future of water fluoddadam Although the subject of my presest- tation is the ttFf, ativeness of wm=- nity water fluoridation in the United States. I tannar Mist az ignore the Op- portunity osis forum provides to Con- gratulate Grazed Rapids, b6chigan, for its innovative unplemae to tion of com- imunity water fluoridation in 1945, and to extol the attibutes and benefits of the procedure. By adjusting the fluo- ride concerttration of its water supply to one part fluoride to I million parts of water (I opm),Grand Rapidsted the way to developing a public health cmethod for the prevention of dental caries, a disease tint was a scourge at the time among Americans. Grand Rapids, by being the first city in the worid to fluoridate its water supply, ocovided an —rn le for many outer it ies in the tinted States to fluoridate :heir own waver supplies Approxd- asately 10,000 communities in the United States now are adjusting the concentrations of fluoride in their drinking water (I)_ Another 3x'00 US communities have drinking water sources that naturally contain suffi- cient concentrations of fluoride (1). Controlled water fluoridation is prac- ticed in some 40 other countries as well, some of which use this health promotional method foressentiallyall of their populations--eg., the city- states of Hong Kong and Singa- pore—or for major proportions of their populations—e-g., Australia, Canada, Ireland, Malaysia, and New Zealand tZk Although abundant epidemiologic evidence exdsted from studies done in the I930s and 1940s showing thatehil- dren who consumed water with ap- proximately I ppm fluoride had re- -orkably fewer cavities than did chil- dren who consumed water with negligible concentrations of fluoride 0-6), it nevertheless required courage and foresight for decision makers in Grand Rapids more thart 50 years ago to agree to participate in a venture_ some investigation that would deter- nsine the effectiveness and safety of a brand new intervention for healttr— community water fluoridation. This is not my fust chance to con- gratulate Grand Rapids for its major contribution to public health. On April 21, IM, I took part in a symposium here in Grand Rapids to honor the 43rd anniversary of the drys fluorida- tion, sponsored by the National Insti- tute of Dental Research.. I quote from my remarks at that time M. Grand Rapids started something remazinble in 1945. The city has served for many years as a mode[ for public health workers. Cer- tainty,all dentalpublic hen lth per- son nel in tate world and most den- tim in t heUnitedStases kaww dw Grand Rapids was the pioneer in cxnm=ity water fluoridation. Advan=ges of Water Fluoridation, Wait respect to qty water fluoridation itself, it is difficult to re- strain myself Elam delivering a paean of praise and exultation for this great public health procedure, which was characterized by Dr. William H. Ste- wart; surgeon general of the Public Health Service from L%S-a, as one of the great disease prevention measures of all tame, along with the pasWZiZa- tion of milk the punr=tioa of water, and imatnniration against diseases There are campeiling advantages to a public health approach to disease prevention. The characteristics that make com=unity water fluoridation a great public health and disease pre- vention measure are its safety, effec- tiveness ffectiveness in preventing dental decay. Base of administration, low cost, and its equity (9). The entire community benefits from the procedure regard - les of age. socioeconomic status, edu- cational artz nznent, or other sodas Dr. Horawi tz s r•...,.umn t for dental r m sheet and tubtic healtts Ere narmdy resides at 6307 K=i= Ca=t Beti,�a, MD 20Sl7. RePd= will not be- available is o &e aukhor. 254 Jour sal of Public Health Dendstry variables. With community water that dental decay in permanent teeth gin to fluoridate its drinking water, a: fluoridation in place, automatic bene- of children who grew up drinking reduction in dental pies in a range of fits accue to everytme who consumes fluoridated water declined by about50 3D to 65 percent would accrue to fumm the water directly, who consumes percent to 70 percent compared with generations compared with the east foods and beverages cooked or pre- children in the same mtzemunities be- ing status of dental decay. Although pared with the water, or who con-. fore fluoridation was initiated or in there already were i wli a dons by that sumer manuhicsured foods andbever- si.-�silar control, masmunities without time that the prevalence of dental Gar- ages processed with the water. A con- fluoridated water (18.19). Car iesgco- iespithildsen was declining d=ugh- scious, cooperative effort or direct tem* n of primary teeth in studies re- . out the country in fluoridated and action on the part of the population is parted between 1956 and i979 were nonfluotidated arms =, review arti- not required for belief is to be derived- only slightly less substantial than for des of fluoridation and hem edtua- Benefrts do not depend on the avail- permanent taeeft the majority of re- tioaal and proms doaal materials de - ability of professional dental services duction ranged from 40 percent to 60 veloped by tmalth agencies aid pro. or the ability to afford them. The bene- percent (18,19). Other comparisons fessiowl acgaaazatiam owned to fits continue for a lifetime if cntssump- showed that more than six timer as promise reductions of d aai decay tion of the water mntawes. Lifetime many school -aged children were car- that ranged from one-half to two - consumption of fhuoridatred drinking ies free in fluoridated communities, thinks of their present cries preva- waterhas been associated withalower that: benefits were particularly pro- lent prevalence of root surface caries in found in approximal and smooth sur- With publication of reports frons elle older adults (IOL Thr unique atmb- faces of teeth (as great as 95 percmtin NiDrs 1986-87 survey of dental car- utres of wanes fluoridation maioe it the sppcouaral surfaces of maxMarytad- ies prevale= am4rtg US.schoolydu� fundamental base for community car- sors) and that the number of fim mo- dreg it became appaxe= that not only ies pmve:stion. lars requiring extractions was reduced had the prevalence of dental Caries in Water fluoridation is eminently by 73 pwcew 02021). permanent tree& deduced nadozi2 ty safe. Bemuse opponents have comas- Seta use many larger cities in the by about 36 percent in the few years ued a barrage of allegations against United States began to fluoridate their bet"= 1980 and 1987, but that the water fluoridation, no other idbm se- water supplies within a few years of difference in mean caries scores be - preventive method has been studied the publication of early reports of tweet children who lived in fluuori- as extensively for safety. Fluoridation benefits observed in communities that dated communities and those who has received dose and continuing pioneered water fluuondatioa, by 1955 lived in ruonfluoridataci wmmu=tim - seutiny (II,=Aide from direct ba- more than 15 percent of the US pope- was only 18 pm%xmt in permanestr sic research on safety considerations, latwa had access to drinking water teeth and 23 percent in primary teeth diseasehncidenceand prevalercefind- with optimal or greater concentrations C73). Could it be passible that commu- ings and dzta on morbidity and mor- of Quoride CIL By 1963 this percentage city water fluoridation was no longer tal,hty have been assessed and r+eas- had increased to greater than 30 per- es effec've in preventing deatal decay sessed- FAch newstudyaranalysis has cert and by -1975 tis'nearl'y 49 pesaent as it once was? reaffirmed the safety of community (I). Despite persistent opposition by a Let me assure you brat water au m- waterfluoridadon QI,I2). - few vocal opponents and groups„ it cation per se is just as effewve as it The far. that a conscious effort or looked as if the US was weI1 on its way ever was in being able to prevent den - action is not reaudred to -benefit from to achieving universal water fluoddar tal caries in poRlations at high risk to fluoridation its led to a certain osm- tic-_ dental caries who do not have ready placency in the population. For exam- Singe 1973, however, progress in access to other sources of fluoride_ ple, most of my nondeatal friends as- implementing the procedure has Two factors primarily explain the ap- s ,me that the entire United States is siowed. The most recent esdatates in- parent decline in observed benefits fluoridates and has been for many dicate that about I442 million per- fmax drinking fluoridated water d f - years. The nubUc must be kept aware sass, or nesiiy 56 percent of the US fusion. effects of fluoridated drinkin of the benefits a: fluoridation so brat a po?uiation, live in communities with water, and dilution effects franc other constituency of eablic support for the sufficient concentrations of fluoride in sources of fluoride on the measure - measure is maintained or, in some taesdrinkmgwaterforogtimaldental ment of effectiveness of community geographic areas, is "eared. health (I). Nearly all of these wmmu- water fluoridation C19). rates adjust the natural fluoride of - Effectiveness of Water Finouidation their water to concentratimns that Diffnaiea Effects of Wates in Preventing Dental Caries range from 0.7 to 12 parts per mullion Fluaridatina Newburgh, NY, and Brantford, On- of fluoride, depending on their mean The implementation of water fluori- tario, also beets to fiuoridaw their artnuual maxil uum dally temperatures. dation has been more successful in water supniies in 2945, and Evanson, Because areas odstin the United States larger than in smaller mmuxttunid= IL. is 1947 (I3). Farcy findings of w;�out central water supglies, lite agproramately 70 percent of all U5 cit- dueed densl decay in children were pmulation with fluoridated water as ies with populations of more than so profound 0 4 17) that water auori- a oercerntage of those who live in area 100,000 --inducting 42 of the 50 largest dation grew rapidly as a public health orae central water su=lies is approxi- cities fluoridate their water (1). measure. The :=dings of most of the manly 62 percent (I ). Many of these large cities are likely to evaluations_.o water fluoridation re- Well into the .l980s._ie sail was _1 - *- -.c.�__,.L_.... 'roL 56; tvo. Z, 5peau [,sue 1996 a=y of the processed food products contain varying, functional concentra- a.ons of fluoride because they are pre - razed with fluoridated water. These foods and beverages are consumed notonlyinthedtyofmanul cwn'but pzovide a windfall by being distrtb- uied for sale in areas with fluoride-de- frQent water supplies. Regular con- sumption of these products in non- fI uorfdated areas provides a disseminated or diffusion effect of fluoridated drinking water (19). The cogency of this phenomenon is validated by a comparison of regional taxies scores in fluoridated and tm- fluoridated areas from the 1986-97 NMIZ survey of the dental health status of US schoolchildren (23). In re- gions of the country in which a tela- tiwvly low percffitags of the popula- tion lives in coca rities with suffi- cient fluoride in water--p-g, Region VQ [Pacific), with 19 perces t --the dff- fere ce in scores between fluoridated areas and noniluoridated areas is sub- stantial (61961. Children in nonfluori- dated eoties in those regions ire less lilady to benefit vicariously oro fluoridation by consuming foods _. r beverages processed in nearby amoridated comarunidesorby visiting or attending schools or eagagin in other activities in such communities In regions of the United States with a relatively high percentage of the population livingincommunities with fimmidated dzhldng water -e g., Re- gion III (Midwest) with 74 per- cent—the difference in caries scores between fluoridated and ruonfluori- dated areas is nzinfnsat or nonexistent (6%) (19:13,241. OthetSources of Flucrade and Their Dilation Effects on Observed fluoridation Effectiveness Since water fluoridation fust was iarplemented as a public health caries preventive measure in the United States, the development and use of other fluoride agents have expanded gready (21= Dietary fluoride sup- plemuents, with or without viburins, have been available by prescription for many years as alternative sources of steric (and topical) fluoride for ar- s with fluoride -deficient drinking water. Several fluoride solutions, gels, and varnishes have been developed for professional application during dental visits Other fluoride gels are available by prescription for use at home by persons at high risk to dental caries. Fluoride -containing tooth- pastes have been marketed in the United States since the 1950s, and now comprise well over 90 percent of total toothpaste sales. Fluoride mouthrin- ses are used in school-based programs (as are fluoride tablets, where appro- priate). Fluoride mouthrinses with di- lute concentrations of fluoride Are sold over the counter. The use of each of these fluoride delivery systems is sup- ported by a large body of research findings (ZI,25,26). Evidence indicates that various logical aombinadons of use of these fluoride agents and meth- ods produce additive benefits in re- ducing tete incidence of caries Q7). Dietary fluoride supplements are designated for use in areas with insnf- &cent coucentrat ns of fluoride in water. The otherprodu>rtsand preven- tive services that incorporate fluoride are intended for use by people in non - fluoridated and ftuaridated cmmmtuni- hes, whirr has served to provide pro- tection from dental deny throughout the country and diasiaish the diSer- ence in the levels of dental decay be- -tween fluoridated and nonfiunridatad comnmrides This phenomenon has been termed a dilution eSea on the mmsareatemt of effectiveness of com- munity water fluoridation (19). The concomitant dispersion and dilution effects have served to equalize dental cries experience between fluoridated and nonf3uoridated communities; es- pecially in regions of the oma"th high proportions of the population us- ing fluoridated water. As Ripa has pointed out; although communities salt may be classified as being opti- mally fluoridated or fluoride-defhdent based on the fluoride concentration of their drinking water. the distinction may be spurious because of the differ- - - Sion effects of fluoridated water (19) - With respect to dilution -FF -s, Ripa staves - _ because fluoride fs ubigui:- toes in food and dental health prod- ucts. practicaJly no American today is unexposed to fluoride- (19). Variations in Fluoride Exposure Not all segments of the US popula- tion have benefited uniformly from re- duced dental decay (28,29). Inner-city schoolchildren in Empoverished neighborhoods, [dative Amerimnchil- dren, and children from migrant bmi- lies have been observed in surveys to have much higher prevalences of den - 25 tal decay than the average_ Caries re mains a public health problem fo these groups fn Texas, for maatpie black and Hispanic children have much more deny than Anglo-Ameri. can children. Buck schoolchildren it South Carolina were shown to have approximately 45 percent more DMF -- It is MF-- Itis Empos sibke t'o ascribe with cerraarty the e reasons for etre disparity, but they may includedifferences; in dietary practices and other behaviors that can affect dental decay. Moreover, many poor children do not have fluoride tooth- pastes at their homes, do not receive professional preventive services, and are not likely to take dietary fluoride supplements. Many might not have tnothbrushes'ot must share them with other faasi.fy members. In contrast accumulating evidence indietes that some ciuldren who live inmoreeomfortableeconomic orrnat- stastces may be receiving too much fluoride during the first six years of life, inannur$ as several,", have indicated iaaeasing prevalences and, to a lesser exist; intensities of dental fluorosis in both fluoridated and un - fluoridated mmmQnities f30M). The early epidemiologic studies of the re- lation between fluoride in water and dental fluorosis showed that about 16 percent of persons born and reared in optimally fluoridated communities would have signs of mild Eotms of fluorosis G321- The recent auaeases are not surprising when one cuasders all, the additional sources of fluoride available today that were notavarlable- in the I930s and IMs, prior to the introduction of water ftuoridation. Factors that have been shown to be associated with increased fiumrosis ton day are the early use of fluoride tooth- pastes 033,34), tine use and misuse of —dietary iluoride supplements 0,36), and prolonged consumption of infant formula (33,36). These factors prmcl- pally aro ale for increases in the prevalence of fluorosis. Lewis and Ranting (37) reo - r, y estimated that more than 60 percent of fluorosis to- day is caused by sources of fluoride other than in drkddng water they con- tend that removing fluoride from all water supplies would reduce fluorosis by only 13 peraertt MK arils w of Action of Fluorides When comatunity water fluorida- tion was first implemented and for 4=PmQ Tq aF3 m_tgnd;o TmmO[ 9SZ ;a aouairnaad alp u) sasra�Toptlod pur ::itacuo. ;M'an= -ne? nnoq sauaPrt;s ag VwS s Aepcn oq -u1 moq e u rw= $utnao4 aigissod . -um vopdope s uoprpuong m amu= aq=sap (a 2u'4 m srq aq 4rr gM r 'uogrpuoni; pur sapuoni;-;o =9 -sari pazzurSsosaopSIucION '(6);inn aqq znoge m=L% srq u00asaz;r -REP Si al2q^t-s? 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Lures icy S=ax v=w ut scams stp i0 maj r OnOrigiY 'ir q gg2=. -aha VT r uogsasm aga pannbas apu P64N4n azp iq (isuv=oua posraa Let{; Moq )o sswMztgw `saocrg xpT -Ong jo uogh;0 =.mrq:-ara'Lluo ayq -in aarq ssavtrr► PaAgOeT ;O Barrs asci iN`+grga 8utg3due aMap uaa IOU 3i Pa^atl An= i911O?;nTlod TEauarsrssnanvaanoge ao pautput st Lepa1 �tigrsd agg aryl si -uaS sgsgrr+os 'saq;aazap ssYaL Luna 4=PmQ Tq aF3 m_tgnd;o TmmO[ 9SZ VoL Sb, No. S. Special Issue 1996 Grand Rapids.' achievement an initiat- �ng ooatmtmity water fluoridation 50 years ago and for wntmuiag to serve as a model for other communities and for what public health promotional ef- forts can aaomplish. The develop- rr-umt and widespread use of fluoride pzoduas aroaad lite world are based largely on the strildag batefits pro- dv.ced by the t>xcauaptioa of fiuori- dated dri d&q water, which means th=at the whole world owes a deist of gratitude for Qand Rapids' mncva- t0 ve attic in 1945. You have reached a sigriffcartMalestone is the history of pmblic health and preventive den- h-IaY- R_eferences L Us Deparmn ut of Health and H- --Sevier: Fluoridation caucus Atlanta. GA: Public Hudth Saevooe. Cansas for Dlseise C =ul and Prevmdon. Na- baoal CentrforPrevenb= Swviae%. Di- visum of Oral Health. sept 1993. L Fbdiradon Dacaite Intenatieoale: FDI basic hues 1990--dmestry xswmd the world. Laedaa F-yi--4 FedEration Dentadm Iamenarim a 1990. 3. Dean HT. A deer➢- f}noross and its Me - tion to dMMI ouie. Public Hsllh Rep I938;53.1443 -3L 4. Dem HT, jay P. Arnold FA Jr. McClure FI- Domestic water and dent miss. fa - e+2 . gxdeaor4ogial =specs of oral L amdapfoius. Public Head& Rep 1939;=� S. Dean Est Jay P. Arnold FA Jr, ilvove E Domestic wrier and Anal esti- IL A study of 2J2 wbite cnidren aged 12-14 yeas of ei&suburban Chug* ommenta- nitles l L aot&p�cba stadia of 1761 -6Q-!6- Public: Health Rep 1941; S&M-92. 6. Deas M Arnold FA 14 Elveve E. Do - tack water and dental arses V. AA&- tbsal etudes of tha relic- of Eumide dameadc waeo to dsatal ou=t r_oqMM- oae in 4= wiQte children. aged 12 to 14 years of 13 dries in fat states Public Health Rap 194Z-57-.ILSS-79. 7. Han7witz M Gr=ad Rapids the public bslth s=T. I PW*c H.alth Deist 1984; 49A2a L swwast WH; Matmmt on water &wd- AettianJ Its: Md3mc FI- Water flttor;do- dom.-the sang and the vtaary. $e ttneda. MM US Depaammt of Health. EgthCatann. and Weifart, Nar-al Iasa- tsrta-anfFieLdL,Natioaallof Dea- tal RRIMINIrb.19 USL 9. Horowitz Hs. The future of water f h iod- daticn and other sysaemic Arland- j Dent Ra 1990*95pee Lsk76D-4. M Stauam JW, 3 -ting DW, fancy PB. Adult toot carie survey of two similar casttnu- nitles with =Mastmg nattaal @u xide levels I Am Dent Assoc 1990;MI43-9. 12. U5 Pubhc Health service; Report of the ad hoc subm®ittee m fluoride of the --Ph- to coordinate mvitvnawaual 6alth and reianed aroerams- Review of DC US Departtnau of Health and Hu- man Services. 1991- M National Research ConmdL The he a 19, eZ%as of lagesaea duoride. Report of true subcs=mittee on health a 6, -ft of in - Sewed Suoridc. Board on ExAromamtai Studies and To4cology, Camaoam on Life Sdmori Washingcoa. DC t49-1 Academy Pam. 1993. a Mccure FT. Water fluoridation -the seamb and d victarf- 8ahesd;.ddl} US Department Cf Health. Edratatim and Welfare, NadonaR Institutes of Health National Ivxw=e of Dental Research, . I97tk109.42. I& Dean HT. A -%-IA FA Jr. Jay P, Kcattson jW. so-dfe an ams aontrd of Asara! aria tlt:ougl fhtoadation of the public water ply. Public Health Rep 1950; is. Aso DB, Fiera 58, Cbax HC Newburgh - Kingston atie flnonne sandy. IL Fha- the analysis of dental fi-h- mduding the permaamt and dedrhm dentitiom aha 4 years of finewidatfaa J Am Dent Assoc 1951;!2168-95_ 16. HM IN, Bhyney JR. Wolf W Thi Evan- stondmnl� study. VILTheeffeeof azilEciaRy Suo>;dated water on dsatal cries experience of 12-,13-, and I4 -year- old schooliduldren I Dent Ras MUM 00-3- 17. Hattan WL- Lacon BW, WMiams DB. The Hrantfard fluorine e ; immt in - hr" -fm report after five years of water a,,.,.id-dam CanjPublicHealthtM.4L- 61-7. I8- Nhwray Ij, Rugg -Cama Aj. Wates S=e- dation and child Asatal health, water fivanxiation and adult dental health. cotrununity fluoridation scheaes taut the world 1= R=ddas in esti a prrveetioa. Decal pnoitioaet e handbook no 201 2nd ed. Basion, MA. Wright PSG.19MM's. 19. Rb a LW. A bag -century of ninth inner water &=d:Aon in the United Stags review and aaatmauary- J Public Health Dent 1993;3-17.44. 20_ Anmld FA Jr. The po@dWity of radtr�g dental aries by ino:asmg fluoride in - g su= Is Dental aria and Anaddc Watahinstem. DC A-- Aaodaoaa for the Advanc tment of Science 194L"991- 107. 3. Horowitz HE Fiumides to prevestt dm- tald-qr. an apda- Iw- Dental b-ollh is a aornasmity affairs Proandtngs of the Minnesota Canf rmom an Dental Catera Prevention is Public Health Programs, b4la>aeapotis. WIL UnivesityofMittaa- polia. IN226-47. 22. Man RL.. The fait ew�.t confer- ence onfere ce on the decSaing prevalence of da+- taleMAM Theevidammavdtheitnpaaan dental education. dental research and dental practice. I Dent Res 1962; 610upp►Y-M-8L 23_ Brvndk JA. Carlo- JP. Recent trends in dstatal cries is US cbildren and tha cheer of weer fluoridation. ) Dent Res 1990; 69c5pee lesi:723-7. 24. Newbrun E Effeciiveness of wager Buoridaun. I Public Health Dent 1989; 49.27949. Z3. Horowitz HS. Coutmentary m and ree- tL-A @"chide. I Public Hsalttl Det 199SM;57- 6L 26. Ripa Lw A critique of topical fhsoods methods (dentif em moulbxi=a aP Gator-, and wU-p*-d Vds) in in as of duaeased arses and W"ea ed fluwosu presale rice_ j Public Health Dent LWUI; 2341. 27. Horowitz H5. Catsnbinanons of omm preventiveagentsandproa tueslDent - -Rm 19 9.2163-9. 26. Stan en TEM. Brown IP, adz Public Health Service worlahop on mal health of mothers and rduldim--background issue papas. Washington. DC Nati-al Curter far Eduction in Mat=-' and Child Health.1989. 29. US Deparmtiett of Hdth and H=on Srvtcek Public Mesh, Savita Healthy people 2000- national health promotion and disease prevention objectives Wash- ington. DC US Government Psmting Of - &P -1991350.64. 30 Laverett DH. Prevalence of dental 9uocoss in fht®daaed and nonfinan- dated ommnunitias-a preliminary in- ve ption. j Public Health Deet 1986; 46A84-7 3L Szpu= SM, Brat BA. Trends in the prevalence of dental flunross in the United stater a review. I Public Health Dent 1987;47:71-9- 32 Dean hM The investigation of phyg ologicat eft by the epidaxtiobgyal method hr Moaiiton FR, ad. Ruatide and chiral health- Waahiagton. DC: A=Axian Aaaomtiaa for the Advance- ment of 5dence 19123^ 3L - 33 Ong! = -caber It+ mapmaa ML Ntid- forvk G, Loco D. Levine N. Risk fsaors fm dental iluceosis in a flea ndatedcom- ttn=astY j Daft Ra 1986371468-97- 34. Husain K, Mitropolos C%C F.natstd da- fes=s is 8-year-o4i cltt7drm is fiu�aodated and nonBuoridated parts of Cheshire. Caries Ra 1990'24236.9. 35. Thylstrup A. F*mknv O, Brtam G Kara I- Fat®d change and derail rade in 7-yeerddchikkat giv= @uaodetablets frost sbortly after birth. Caae Ras MY% 1326576. 36. Pe whys DG. Katz RV, Meese DE Rbic fat tots for esaaul fhtorms in a f umi- dated pea ulaeioa. Am I Epidemict 1994;140:1--7L 37. Lawis DW, Baarimg DW. watts fivatida- tioo--arrant effective== and dental flatus: Cosmm=ity Daft Or.l Epids- tniol 19902--M& 38. Atmold FA Jr E hxnde is d-kiv g water- ins eSeeo an dental aria f Art Deat As- soc 194836c284& 39. Koulourides T. Phaatumvanit EC, Mamksgaard EC, Hcusch T. An immoral model mrd farsetdi of fivcrida iamr- poration to enamel. I Oral Pathal 19743: 185-96. 40. Feathesrnte JDB. OTmUy MM, Shahati M, Brugle S. Echancesnent of remine- aliation in Vitro and in vivo. Ia: I M+ SA. Factors tdatin to dt®aeaUatim and rrminaraliation of the met - 0 - ford. Eagiand: IRL pis, L%6:l91.8. 41. Savesuine LM, Weld Is, Mm= -- 3F. Clariaw mi. Feat MT. Re- mineraliation of natural tad ardfiaal 259 r- ciao Rs I9BI ISO&57. 42. Zero Ur, Fu L EgmWd MA. Fadow- st= ]DR. C:oaq atism of duacide aoa- onatrztiaosia utfstiatutated Whokulva 6ouowmg for we of a &w dds doodkioe and a fluoride rima J Dent Ras IMP: 1257-Q 43. Iiatbtou D, fsmm MI Fyessioov O, Taus L The dfic of fh od in saliva on reasnetahmian of dental enamd is huasani Grin Ras I96195:M-5. 44. Toumba A Levy S. Cu=n MM. The 8uondt embtm at bouW daakft wo- baa. Br DmtJ M4;I76C74d&& t5. Fiaitz CM, EM Nr— RcIm K. A wavey of bodW .rater usage by pediatae den- tal patio= Implicatiom for dental 6esleh. Qubown tom int 290.1moa.62. 4& tffeys I.I0dtvfmC, War. Xsmncm of duodde latah In ehs7drom J Public Haft Owt I995a3942. 47. Camel m Ac=6 PrrmwA oat and h*w- prdesoonai Madays, Anuri,= Dam' Aaodxdm Ropat ofreomt hmms cmo- adered by dw m m il, &saibutad .to m®hems. ADA'i I+ IatiooaCFbm=dahm Journal of Public Health Dend=y Advomy Ccosatttmat fort mmn of July ZI, I"f pV-A-IOD. 48. Anumvioa 4 Treatment rvg=wns is pee"mdve and reatmttve deatiserf j Am Dent Am= I99592b-=4& 49. Homwit{ M& Ramarls by Haxhel s. Horowitz upon r oaving e� John W_ rimboa Dishugutshed Award ba DmW Public Ftealt J Pub EfisJth Dent I99SAmS IM -4. M Btasiu totheayaspamt%= iiGbdde--bow num t of a good WiW J Public iie;lth Deaf I995;5z-37$ Ttuzpdo cu ape sent Imp apumg S=n=m mmm 2=rmp Aq pansas a=^--sgddm sagem �qqnd uo mm ;o z=.Od tZ9 Puv u=gndod av;o mad 6-ES —suessaay uau¢ SEI gE1P P�c3'1J?Q a3 s=uaD a,* Aq m,oda,`sm aaa4P!=tg 6861 --RU IS =1-14 Pump -uong Au== put Pm=dpe &wn =P== tiz =. q snnmaimtu put sapiimsa = sn o00`Ot Avm qpjw Arp s44 co saminum uaptpuang amm Aummam;o A= -sq amp uz p=ad pmtp aT3.'(£) P=Puaa6 sent'swumM '==M&3Lt6I Amugaima pxr,"61 u<PatePuort8 azaM ' IvvTlPmput'usa=.m uc&ogam-vumup 'Tuqpu=fi;a ATdam =v- ag} (A Is"i v amf uo PUT '0'611 ATA uO'410,t ,%aN 2=q -%a I)o Alddns =v— MP cg Pam sent apumIg um Pas 'giw4 Tamp aam -°d m p=ad= 1AaI Y as uoge === apuonU :aaE sn wwpe ca ptsom ato m 44C =zg a47 aaca? '-ae2npryq 'SP'aE2i Puw7 um; --k 'scw 'sz famuri uo =-iaa '{g} .zn=--"A %TrR-13 Aq ..S= i u=,rp=V ui == jo z=n -oto_ag3s-tpaotusaa'Pauaaasnp>g1.' M APep im =ncmn;o 4WZAe at{a u0 Pasta's mdd PuT LO um-4N;w amm uoq puonU nnupdo;o =n=q ag3'sssoaonrd;c v=ap nut apuon3 Aq P - E zgaa4 aAl�tiaAaid-5;RM --I;p =d1l mmTeq Aq -Imri -saum jm -=0 Pue'sis =jj Tagnetra'atens 3uquup agP %q uogest -ilaO'tiW ap730n$ �+**,"•T+�, ��pEBat{� �uo�IIE SQIL1S1IaC -Iqw atp u0 POMDC4 vwc AaTPu;u1. -H;o saga= =3olo -!Wap!da IMnsup -W) Pouad Puo305 au1 .qsmonU Tam= ==pm otuaiva `AU= -;caas am=-20'raneua PaRuxu se P6vlP== sant azap SrgL -'op=ts vnt(sq c pr qc:L. you P= 'Av;pyj -ate ,Sq nT�na saat3S P�f 1 � ut pact.^saP '�asag TA== Iesu mndop Aepr;oam=aut UwA pa L-=uco SMM {SE-I06I -M} isa3 ate- -{I) sflouad =zgstp "zut salq QagtpuonU zmvm ,=taatoo ;o A=s-tq atu, -P= cm an saL� ag3o luoq SZiodw 'sums P°q?uR agg ui --uEt. t4nlYu=cz 30 malAaS r sz SAS 42nolmy ML=ft ASCUS i%Vl zmrd;,a-M Aa f=l=-l�� .3 .im1I�..iY'- � SIML 3=N -ud Ja�to cv pazra;az aq as Wt.,% kyl p =xp zTwm oz Poau TLS SaF= pm I. -a rsdozdde =M ft pate u=q aaeq saomws kepucm Apgvdw; a as r. mn= AjrQ* M -P saatsisuoumP 3SzI fou A aq Prwm 1; Pm'Lw� zatM -/uizsaco;o kaastq Javel P'� �a � 3c sa"a'� n>atpmm Austin maq aAEq =P41 'aaaa mcH -swmm ktmrsd qx% a -.Imm jo ado sM kM=H ' 3 s mmvpu=m dmuttp ao; aaascraz r se a&.= a3 Put ash s,uoqiPuanU ;o a&qmxl9o= e aq az =wm st #--qew sem. M O.Q aAasd sa!=jo pogpu iATwq =pod sup ;a am ;o wmL4 o5 Av ou a{a 5=tp pwnac= =q anq 3tp uMppoag 3o =O&v zMo St U2A St 'uaaeauaa$ Zarin A(4===CO ;o qsu Par sc}acaq aaz3 du�zaa aaursas?I Asx W�?I� � ;o MMAM It st g'Asauaa %meaH mgna ;o UMXERUFi W -P ;o am===0 tPTeai-i IWO --qz Pn LSO aeg� aP 3a �aeiaa z ava ae pa:aaaid sent sadtd sem, �ua��:uo�nyaue saue�iotu 'a��++e+war'Seu�lt�tta -J= 'ucouanaid Saute 'UOMWCX j _WUO g -SWaM 4931 .. x7pQ1Sla0Un 1832aq . aq ai Peau uOtti uom x ssrz= M=go=. = aw -,uat -E=JLAM Jamin =000 whey Suoq Poe ucwsfi ! aPwm uoa&uSQ d+ysua of aw :S:VmE ut PUB wo uo Sap=ja ej ars amw sptm 'vargnP jo ta"i x mtu jad OW UO UOMMJOrV JMM ja sseuaA4=W OW DWn -ntLj = al SaA.UVJJSIM A« veyvunu1u = jo uc7QE=om 1njSS8.:: m am --vAM =a sen=1a5w Pup 'meds = PUP P=utPM '=Dajje GA. druelsod ptm em -druawd Vo ununrx= auo =MW uca -gyp MV 40 uorsr4fiD SM *$0 20= apuorW JOW jo GWW -umv ow esnweq su)euoq uc awuojv oigzmmsw io LCR�a12iJSlPOQE StJ16�pr?irt9 pa�s8p 05JPL -auaq aw u0 si =imus i0imu am tom Pame.jAw S? uqt� -uoiV Jazem .(iga==;o Ammy m*A-QS 42au m j P=KV IrU L L AN 'YPQ9 AUMS mows AuciszExiok*aN ;a &Pmmuri =* auppaw tmaa m,omm Lasnuaa 5711 Sac '2ti ',Y1 strio7 br uaun�a� Pte= MalAa-a :sa4vq5 pa4rjfi al:p uz uoz;rPTzonL X;nrnu=off �o Azr4uao- 'V SNOII:Ill'd L NOS i'YI:)3dS LI E6o1 M'1 °l'i IGA IS TABU- I Pzinc:b%aI Secondary Sources Used in the Preparation of this Review BOOKS McQure K. Watt aucridasicn. The search tett' the vi®ry. Wasmft5=an. DC Us C,ovttrtu nent Miming Ofnee. Isla. MdtheM M Rina LW. Fluoride in preventive der=stry. Taeory and cliairal applicadons. Chicago, M.: Q rte« Publishing Co_ 19M. Murray JJ, Rugg -Goan AJ. Fluorides m caries preveacon- Dental pracrmpnes handbook no 20.2nd ed. lsosmr., MA.: P5G Wngl—,- 29EL World Heakh Organiatior Appmpriam use of fluorides for hrtaua health. jJ WA:rray, ed. Geneva: Worid Health Orgy n iza d oz `.1986.. PURLLLSHM PROC =-INGS Proceedings fir time woriaaop: Coat effezivettfts of cazizs Fte- ver=n m dermt rubik healthheld at Ann Arbor, MI. May is -I4. I9N. Burt &k ed. J Public Health Ment I9sq omoec Lss)SI-344. Proceedings of a joint lADR/ORCA kn=nabonal symposium on fluorides mechards s of actim and for use, acid at Callaway Carstens Confeserim Cm=, Pine Mouresia, GA, Mar 21-24.1989. J Dent Res 1990 Feb;69 pec Ins). P . , Report of the ad toe svbmmni on fluoride of the Cmmatit- m_ to Coordma: a Env=—errat Health and Reiasnd PwFawm- Review of fluoridebesndm and rissla Bethesda, MD: US Public Fm" Service, Deparmumt of Health and Human Services. Feb IWI. National Health and Medial Research Caudal Report of working Pam on ftuoriaes in the mrt:roI of denat caries. Aust Dept j 296;a:4ir 42- Natioaal Health and Medical Research Cbtmal The effective - rims of wars fluoridation. AtutraLm C vcm==t Publishing semcr.1991- Rl vIESVARnC= Y.aminskp IS, Mainoney MC, Leach I. Medius j, Mier K. Fkw ondc berm and risks of cgmvam Crit Rev Oral Cytol Med levels or that had fluoride aheady prtsmt to a level considered at or above optimal (4). Table 2 preeerus the 2989 fluoridation figures by geographic area. Region III Oofidwest) had the highest propordort of the population with access to fluoridated water and Region VII alac w the lowest. Of the 235 anOm people whose drinking water is fluoridated, 93 percent have had their water supply adristed to the re=zm=ertded fluoride mntxntza- Journal of Public ie = I'rmstry tion. This figure mvreients the fluoridation of 9,411 pub. tic water systetas is 801 coauatanfties (4). The mrai ing 7 parsm reside in 1.369 uni ties drat are serve, by 3,403 water Systmm with nattnai fluonllation (4•,. Most of the tides with populatiors greater titan 250= have adjusted or naturaliv optimal fluoride Levels (3). Four of tiC five ImLmst L.tS cities New York Chicago, Philimd , and De=oit) were fluoridated at the 1950s and I%CG (5). Los Angeies, with a population of3 million, is the e:orepdon (6). Eight std=, the District of Cohmtbia, ant ti- Com- monwealth of Puerto Rico have mandated the addition of fiuoride to the public- water stwDlies (5,7), a lthou# in Puerto Rico the:' has not been vigorous a =anon o: the mandate. The Minnesota and Mirtcis legislacoa has tate g rmmst scope, reranririiag that all public waterstroplies be fluor umed. Soars of the other staves have retrimms in titer taws brat limit the scope of tate *lira*_- Fou,- states--Georgia. ou;states--Georgsa, 3tichig m Nevrasim, and Ohio --allow a mataumity to ewmtat itself f = coatalian, if it.does not wish to asstitatie fmaridatiou. Two of time smttL---- Michigaa and Ohiio—placed a time limit winch has al- ready a pu on the period allowed fur a reietenc t on fluoridation. Four Ohio, Corm cit, and South Dakota --set towerhalite on the size of the coauruauty dw trust c=Tiy. Tame 3 dean m=ates the satires of water fluoadatfon iia those states where it mardated. All eight rank m the clop half of states, base on the peoetuage of the populadmt with public water - sappLies who are served by fluoridated ware- Moreover, for seven of the eight states the percam=p is berme en 80 and I00 pest, compared with a naroonal average of 611 percent (4). Since coatanrnity water fiuonaamm was initiated m 1945, the U5 population riving optionor levels of fiuo- ride in their dri kmg water gerneraliy has grown apace with the overall population growth and with tine grown: of the population on public water syserans Mgtae 1). Nevertheless. the gat betweai the total population sup- plied by public water and the population served by eoan- mtarfty water Huondation has riot narrowed sig ifr- tarrdy since 1965 M. A goal. of tie US Public Health Service was that by 1990 at least 95 percent of the popu- LIUM to piped water supplies would be serviced with opdrrmlt r fiuondsted wilier (8). Tan goat was not real- ized and the aurssniy revised goal for the year 2400 stated 'err Hesidg/ Amo* 20W, estakihshes a mace atodest and MH.stic target of 75 gaunt ML Of the 52 jmssdnctioas (50 states, District of Cohai,bia. Puerto Rico) aritrde d in th&Cerum for Dt-mmCrsntrors 2989 fluoridation teem. rine ,of the lowest ranking is - 0 m of the pe amt of the public water supply popul- tion druiartg fluoridated water were art the western on third of the catmiry (Washatgtort. Idaho, Wyoming, Montana, Oregon. Arizona, California, Nevada, arm Utah). TheotherIowestrankmgsmies wereKansas,New ruou4N a1R Aq woM 2u?Pni 'uopTpucng sa7En+ 0 azodaa ,(se== Smarr u=q oM aasq awU '(11) 8961 Pm 6661 aBM32R Pa gggnd uOuePuOng xnem 30 slmsai Lp pamat&w qR O?=maid scrum }o ssau � � r� ;o 4AMANnE s �ua�dar and tWgM2N'Apm= =w 't0U sap== Z ut =.Q 8 S6 30 sMUM OtP Pm 0961 ggnortp amp.=tn atp =D-25ng Pas Xv=W -861 w pmMFInd..lu=R aur> m wP=mL-T_ 30 uOQTP Pum" aft ul'(£) . '=A P111V 1psaS aLL'vOPtF 143 J;qvM. x009 Sq. uz U61 a wnr>M Li pw--uw am S%l Pus SMI nnnaz maid Puv'inO;sm-x Pumn ap'epvjr) "satims aau .sme.aaa aa. mmw� .a.,sq ucawwx njgmm °onvx" MOL v®,ma Awcnt Am&=Wy �+ma , n Pm S"L S459 S"i Ssal S,al IIonnuon13laxeM Pm uoqvpLdcd sn I 38C..OI3 Paa?ufl aP uq pauapuco seas uo_ vp%=,B 3SM 2%T, 30 s =iw ate, -Sma a aeswgauh= I="= us -guns uaaq a�Ey saipn�s uoagpcianB saar� ��a, 30 =Tnsas au •Awm =a aq ca Fossa dq c% JL= ;o si" anso( Pas stens av 3o =X== -um apuotq; dnpuoqvW amu: aq, UnLi MsM moi, 3o sz3amfl I�Q -uo};a 0o4Yp.�B jsaodr 4 io3 aq pre4s Sm= awtp Axa aq aq M Ped, uaqepuxw 0002'== aton '(3) ?p-ftvH Pm'A--sz1 AwN -A R £L £1L (aa) =fiuq2N- LI SES (14961)=O=uwK - 51 C58 (FlSt) ��- EI 998 C�96i) C 01 Q68 i 0Z L r06 (8961) waup N 000'3fi9'9E Y:) -do lym fedi nA ' 1 0 O'ODI (L96D AP - 7 3 (Sa=S 05 zmM =. mc=. PuwI o s 8uou� aearpuo� �N �1U �+S ., ward /PPF/ 000'9£3'nI 'CN ;.M ix cn in AN Lid&S m=M a?I4nd 9'09 eq pa -m5 -dad 3O % OWLS 'Q M Pampvmw W! ii q=.- m SamS asom a! aorle oumu mprM P amzls S s Igvl 179 TES LS4SL9"SEI WO'I 3'SIZ 00�3�ISZ — S aagun 999 83? £0'C6BS£ 00('0Lr5 000'3E5'S 'AV 'M M-9430 i 0Z 6'141 aefia'9 000'UM 000'3fi9'9E Y:) -do lym fedi nA NO'S:I'SN '(3S 8 �5 m 919WS 000'ESS'II 000'9£3'nI 'CN ;.M ix cn in AN (=m^' =WND IA 9'09 S8I'£05 51 OWLS 'Q 00076M XL'INN -LV'O:) (Z -*+T=S) A 3Q lcm 'Z:S'JN IVA 'AM "j If D SZ; 3'19 x_'99 OW6£ OD0b6!9'3t 000'90'59 " N 'SW'N1. %1)3 V17V (LOS) Al . I30 106.690'03 000'b T" oWosor5S 'NI `II'O)'V'YI'D'K'IM'NY4 (s PfYV) III CLI' 38L'L66'LI 000-M51£ 000'9W—'c IN 'dd :LN (==I:Rjo*D II 3'19 °°15Lr1 007�Y"Ii 000.960'£1 I2I''�'VW �.N':u1 �'�I (Pm��3'"aN) I =ZM 1MOI AM uatwd xl d Lq 3O PWXPUOnld �It4nd '(Uz=eN dq P A.WS /P PV VO ZaMm Pw Uanu ATR=sT; uOge�naad /mnSn;py 9auaw d -dcd 'I t3) l69bi) aaraS p�gian a� � aot)rpao� �ar�y.i�� 3o sma�3 2 mZYM `' 061 =%nm'I-ON '5519A Health and Medical Research Council of AusaaI.ia (L413), the New York State Department of health (14), attic.' the US Dewrurwmt of Health and Human Services (M Because of the thomugh nese of the reviews and sumznar3► publimdorts, reevaluation of individual water fluoridation studies would not be productive.. The efiec- dverdw of mmamnity ware: fluoridation well bee dis- cussed pru=Pally using the resousoes cited above. m vAdch the rmde= is reierred for saecift= Qrr7azea.De uovsDartztmn Both Murravand Run- C;u= (10) and Newbr = (11) remarked on the paucity of revorts deariing the , EF 1 1 of com uunai water fiuorioa- tion on tine deci� dentition. o mpared with the manv. record on the vmmurrent dentition. Nevem, suffiorsu dine al evidenm es avail2bk to conclude that dune are decided benefits to deciduous teeth from Wates All three initial US f oxidation studies resorted ad- vantages to die- deciduous teeth from coa> mrAl wat_: fluoridation -After 10years (1945-34), thedetcprevaience for Grand Rapiers' sac -year-olds, the peak caries preva- lence age for the deciduous teeth, was reduced by 54 pescemt compared to the prefluoridatiort levet (3). After 10 years of fluoridation in Newburgh, sac- tp nine-year- old chr7dren had almost six times as many caries -free primary cuspids and raomrs as children of the same ag- in fltoohde-dem Mnptan (5). During tine period from 1946 to 1960. there was a 13.7 percent dose in the annual cries increment of six-, seven-, and eight- year-old ightyear-old Evanston citildrews deciduous teeth, coa urec to a 39 per== decrease in the nortfluoridated oanaol city of Oak Park (3). Murray. and Rugg -Guam plotted the frequency distri- bution of the perceruag; of caries reductiorus for the dem teeth from 55 8unoridabonu studies reoortec between 1456 and 1979 (10). The modal peramtage-caries reauctron was 40-50 peroertt aigtae 2). Newbr= reported only one US study during the pe- riod of his review (1979-S8) in which the dfi- m of csm- a urW water fluoridation on the deciduous teeth were reported (11). Based upon examnutions conducted in 1984, thele was a 30 percent lower- caries prevalence (defs) in - to five-year-old Chia Fuad Start children frvanflnnorfdated urban and nonurban sites ern tnared to those from flvoaride-<ieflceti rtes. New- bruat noted that these daldren were frown low so=mw- n m-iie ares and were rot tepr esentati:ve of alldu'ldret in tttis age group. Newbrun also aced data for five -year- olds from. NIDIrs 1986-87 National Survey of Dental Caries in Lis Sdtoo) c3uiidnst. Five years is the last age when ehrldmn shell have only a deciduous de =tion. Thee was a 39 pamtt lower caries prevalence (dfs) for five-yw-old ch5drex with a history of continuous resi- dence in op6rnaily fluoridated covwmzr ides, compared to retort residing in $uonde-de&ient aorruritnnities. Because of the paucity of information on the effects of y umaL or r=oc rumen LAtruncv FIGURE 2 Distribotioa of Paoeange Caries Redactions (dem t Dedinaus TOssb frons 55 Ca®mna)Et-v WaterFmoridst. Stndie Ramrtedbetwem 195e.-79 Q@Y 21 U. 0 10 20 30 40 50 60 70. 80 90 too Percentage Caries Reduction •Ada=od and res =wadwith 1 1 1 communal water fiQatidation on the deciduous teett. , US children during the period of his review, bk-wbrts mchaded eight report from the United Kingdoar, whit , were pubbsbed between 1979 and 1988. Caries reduc- tions in the deciduous de=tiort of 40-60 percent were "awsistentiv reaoraed in foga- to five -yeas -old dvTdrert fsolu St:oricated COMIXIMIlitieS compared with those from t ones Most of the UTC studies -inciuded only children with life-long residence in the COMMUrdtieS.. O'Mullane et al. (16) reported the results of an exten- sive caries stnvey of children in tate Republic of Ireland - Between 1964 and 1972 most of the larger public piped water supphes were fluoridated; by 1986, 65 permit of the population was serviced by fluoridated water. Caries exaasatatrans of Five-year-old children conducted is 19M provided atfor tratiaan on the deciduous teeth. A compar- ison was made between children whose hotrw water supply had bast Suoeidated Wntirtuousty since birth (and who also map have been exposed to other f uoride whines) and children who had sever had any type of fluoride espostae. t7 "name and coworkers reported the me= dmdt score of tete durldrea residing in flnon- dated cmmummities was 1.8 corctpared to 3.0 for those residing at corrmuauides, a dif erenc— of 40.0 percent. Fifty= pemwt of chUdma from ti flinridaeed cmmaturtities, had a caries. feat dedduous dattiu = compared to 39 percent of da:krest in the flux hd&<Ieficierd cosamu pities. VoL' 33, Ho. t, Wiemer 1993 FIGURE 3 ?istnbutioa of Perc=znv Caries Radn4=ir>hrs (DMLFi1 is pennx mt Teeth i, 73 C—scrtity Water Fluoridariaa Sh mHes Repotted berwem 19s&-79 (10r 30 0 10 20 30 40 50 60 70 80 90 100 Percentage Caries Reeducton A comoanson was also made berme --n the 1984 data and walla data mne`md in 196I-63, fi Laddaf:n„ 'these was a suabsuanual caries decline ern Irish children during tae 20 years, vitt► the dechre being greatest aahong the residents of fluoridated oahauahi . The draft of five-vear-oids in 196I--tZ was 55. In 19$4, it was 3.0 for ti►oee reading in fluoride-deaestt com:trmities (46.4 perc>utt reduction) and 1.8 for guars residing in fluorinated communities (67.8 perc`nt reduction): t7Mullane and coworkers attributed the caries de:�ine m mums cities to the widespread use of fluande deradric es, wihicb- of cm se, also cordrftmte d to tke on decline in fluoridated co=mzz hies„ and to the diffusion of watt fluoridation berefits, mused by m= factors as the c ormnnption in fluoride -deft t ctrmmut- tudes of soft drinks bottled in fivaadated corn mides. Pam sed Dvditbm After 10 years, the results of fhro- riddadon is Grand Rapids. Newburgh, and Evanston demonstrated caries reductions of betweern 40 to 65 par` eerd m paaharhant teeth M. The paMi age drsiahe: Was geetest for pro dmW s,zrfa Mme nighty favorab{e fid prompted Arnold and cowatio ss, who were evaluating $uoridatiaa in Grand Rapids, to comzrkent that with the ehceeption of the decease m teazles is Emo- pe on ch0dre n caused by World War II sagarresnimons, 'rho such dramatic and persist mU inFdbs of caries in. large populati ort groups has ever been demote by any. ottha n cis. titian f3uoridation of a donusdc water suppiy- (3). FIGURE 4 Dism'bution of Peramuge Caries Rsducdorts (DMF= or DNEFS1 in Pe>manent Teeth from = C:ammunit,- Water Fnw datian Studies Repotted besweess lgrS q (II) 14 0 10 20 30 40 50 60 70 go 90 100 Percentage Caries Reduction. Murray and Rugo-Gunn plotted the hmauencv dim- bution of the percentage caries reductions in the perma- nent desnddon resulting from waoc fluoridation (10). Of the 73 studies that they reviewed, purbiisrhed between 1956 and 1979, 46 were from fire United States and the other 27 were from 16 other oou rttxieea The modal Der- centage cries reduction was S(-60'pez=e (Figure 3). Murray and Rugg -Genua cmnmerned that ttds figure •re 'is in agze°aheru with d,e oft -canted stat:=ricer: that'ovate= fluoridation red— dental deme by hal`.'" Newbrun reviewed tate results of 2Q reports on tttE effectivertess of osamuahal water fluoridation in inhi pit big dental caries in the permanent dentition (Il). Thr reports. published betwem 1379- M, wme based ori staid les cmd=tad m the United Stam Britain, Caaada„ )re )ard.andNew7eaLand. Wherttiheresubsofthese report were averaged, a mean caries reduction of 30.4 perctrh was obtained. When the reruns of fluoridation studies i the US and in otha tauntries were each averaged sept ratety, the mean ca ahtnbitios were 265 percent fc the US and 36.1 pecertt for the otbeer mhuttram Figure premiafreqaauydisWbW=oftheperce tagecarn reductiurts florin the reports in Newbrtrrt's review. Fc these reports published betweerh 1979 and 1989, ti anodal percentage caries reduction was 30-40 perm compared to the 50•-0 per formed earlb—by Mt=. and Rugg -Gunn TV= 3). Newbran (11) and others (15,17,18) have conhmw" on the narrowing of the relative caries difference be_twe duldre nlivingmHuoridatedarhdthowlivingisfluotic R] jour. -41 of Public E-iealth Derajssv TABLE 4 Cormal and Root Caries Prevalence is Adults Ra3ed an Fluaride Caaotntration of Wats supply (ii) Was=Fluoride Age No= Rerssice CanCer=Wion (cpm) or Range) Caranal axies. Russel and Eivove (1951) 0.I 20--44 F e;tmd e: aL (1957) Harm c aL (1989) Staxsm c aL (1990) Ram C auest Fn==an (1986) bur_ c aL (1986) Eituu et aL (1989) Staassn = aL (2990) 2-5 OJ 35 c05 07-I.0 02 Ib m3 fD-L2 07 35 45 07 -IA 02 Ib 20-44 40.1 39.8 74.1 752 43.0 40.2 X60 -60 39.8 43.2 74.I 752 43D 402 MOT of subj = Dr -S, % 153 395 M 164 174 IM 465 SM Mt 103 164 f5i 174 IM 463 502 •DhtiR lar coronal oris. DFS tar root gazer tTleee arose are aced by Newcrtm CII) and do not ncamaaty apaor m the raeteora ler tae meat artida :The only wnav bread is whim sante snbiem did act have a c ==ucw r=dence bbtwy. $rower baa"== as,es� &@Aei t matmtatities. The.reasons for this reduction at the rrmmsura,le benefits of -water fluoridation are dis- ccssed m the sechon of this review that addresses the issues of the dilution and diffusion of fluoridation beerae fits. Adults. Adults also bment f oat water fluoridation. Farb-- studies on the chests of fluoridation on denial caries in adults have been reviewed extm%sivety by Mur- ray and Rugg4ur n (10). Newimut's review has brotight the topicup to date (fi).Newbrunst essed thatinsaidies of adults, dw comparison was often between those hvmg in fluoride deficient or optimally f mridated communi- ties, and titwe living in aWm-optiatally fiaoridated c=t- mrmit tes. More studies are needed on the caries Levels of adults m which the conventional couq=ssott is made between residents of optirnafly fluoridated corm munities artd residents of mam=rdties that are fluoride 4Pfieim* Table*pse mrfttheresultsofreportsfromCartadaand the United States comparing the prevalence of coronal or root caries in adults living in ooh with differe rtt water fluoride cortcentrw2ons. The coronal and root car- ies prevalence rates of adults residing in the alzmtmities with the higher water fluoride m- _ _ _trations wereoon- sstently lower than the rates for adults living m commu- niyes with lower levels of fluoride m their water. In a recently completed study of approximately 600 11-2 75 109 87 15.6 124 15.1 109 ILS 77 Ob9 ODES 23 L9 3.0 Z3 U 2D Zl Z8 Is 88 27 I7 adttlls 20 to 34 Yeats old, the investigators fot and a po cent lower mean aoromi caries score (DFS) m *m'- who resided in opthsully or nanuaily.fluoriciatec caa1- trtsmities compared to subjects who had no exposure to fluoridated water (19). Pre- and posteraptive fluoriae cqx mune patterns relative to caries activity were also assessed but tie saatple site of then em uptiveemosure group was too aatall for meartingful aomaarisaa. Dilation and Diffusion of Fluoridation Nene8ts As cited abm corer= m of the caries prevaienre rates between op=aDy & wndated and ftuonde-=- dent amities conducted dining the last decade show less of a difference than aotnparisons reported t -An z+e 1980. Zile decease in the magm itude of the differ- euce in caries prevalence between A - - two types of probably is not the r esalt of an abam7ent of the ability of water Bnoridatiou to hlh bft caries- Radmr, it appears to be the result of what may be called "dilufine and "diffusion—Affects. Dfludmistheapparesttfedvctioninmeaswable wain fluoridation bene£ts resulting from theub4nitt= av ability of flnonde from other sources. Beginning In 1950s, each succeeding decade has seen the mtroducnv of new 8nandae plum induding ProfessronSHy 4' plied topical agents, fluoride too"astes, dicey f1uQ- VOL M, No, I, WMtes 1993 eidesupplwimts.nuoride=ud its andself-applied fluoride gels. This abundance of readily available Ruo- riae has t =Mkyuted to a lowering of the "aacxground- cants levels, both in fluoridated ana flu=a_e-aefttient comtrma hies, from which the effectiveness of communal water fluoridation is measured (20.21). Kamins - and rowark=s listed 14 studies in fiuorice-desident cornmu- rungs uh the US and elsewhere, which nollective:iv cov- ered about 30 years iron lase 1950s to the 1984x, in which the prevalez>m of dental caries nal declined 17 to 60 percent (14). UndoubtecUy, dose deck+esresulted partly from the ava labiliry and use of boot professional and fluoride produ= Diffus on is the extension of the beneats of commvmity wares fluoridation to residents of fluoride -deficient com- aumities- Diffusion can res¢tt iroan thee conshmtvtion of contato cLd bevrraLms and foods that were processed in opaaulfy $uoridaaed comrnurdlies and transported to fluoride -de t ones (". It can also o==- wined auT- dren cr adults who liven fhuorid---deft=e m marmrutities travel to opft ally fluoridated communities wh em tiney attend chid care centers, school, or work; Cprmzmably, reverse diffusion can also occur when beverages bottled in ftuonde-deficient communities are consumed in. fiuo- ridated c=mumities, or winen children or adults wino reside in optimally fluoridated communities routineiv travel to school or work in a community boat is fluoride descent. Reverse diffusion would have the same level- ing effect when caries rates in the two types of cotrnaan- nifiees are compared, although in anis situation, fluoride benefits are being denied rather than exzexided). Brtmelie and Carios analysed tine data from the sewnd NIDR national sm-M of caries in US schoolchildren. con pieced in 1987, in order to desem-doe the - F - — of _re to qty water flunriaatson (18). They reported an 18 pescesht differenm in caries prevaienm between school who were tine -tor; residestts of 23 optiahallp ftwncaeed and chose who were residents of fhuonidedendent ootzmuuuties. However, to control for the dRubm efieCts of other 9=ces of fluoride, ttte-v er3uded from their analysis those children with tiistori� of =osure to dietary fluoride: supplements e: topical fitroncies received m dental offices or school programs. After eliminating d se children, the differexce in.earies pr,evaienm was 5 pe dem The effects of diffusion on the benefits of water ftuon- datior, can, be dedaced by wnwarmg the caries preva- lence of sfioolchiidrenn is optanally fluoridated and those in fluoride-defioem commizr ities acc=% ng to tine seven US geographical regions. Table 5 rdnks the US geogravhical regions according to tate percentage of the population served by conmuunal water fluoridation (18). Comparing mean DMFS scores of children who are life- long residents of opb rnaily fluoridated comaiuraties and tnow without coahmianal water $uoride e=osare, tine magnitude of the peace ntap difiercnoe is lowest in the rep= (Repon III, Midwest) with the greatest es t of the pcpuiation having caananmitp water ffuori,dat iom In fact, is Region III, tineas is actually less caries in, the children with no residence history of communal wale" fluoridation. Brtutelle and Carlos (I8) suit that the tnePwle percentage difference in DWS scores for Re- p= III may be due to sampling liumnorts. Because so mucin of this region is fluoridated. the number of children who never had c== with fluoridated water was small Conversely, the- percentage, difference between mean DI,OS scores is great est in the region (Region VII, Pacificl with the lowest per==il of its population on coamnth- nal watt fluoridation The differesnce of 60b percent in Region VU is consisteritwitin the reportsof tine magnbude of the caries ialxRiitioa from water fluoridation in the 10.50s prior to the introduction of otMs fluoride inte ven- dons. 'line regions that are intern�diare is their extent of &wridafon have differences in ttaries scores between TABLES Cromparimoea of the Canes Pre+aimm erf LIS Schooich Zmrm with = without Resides= Mat m ies of Fb=%idarsd Water Exoow=t; Reiatzve to the Geogrsp= Regina is whim They Live as) DMPS—Reddertee I$.storq of % of Pop- Readviag Warn FWaridatim Difference in Mean DMFS Soor=s NOW9G Rank � Fhwhdawd Wats (198W Luehng III Gledwmt) 7Z2 (guest) 2.86 2169 -5.6 1 0owew I Q4ew Engiaad) 66.2 3S1 3.45 9.8 3 IV (Soul east) 575 275 3bD 23.6 6 V (Somite 57.4 2,49 271 8.1 2 II Qsiorttt 48.1 348 3.42 99 4 VI 04eethwe o 359 216 3.47 23.1 S VII (Padfic) 17.6 Clowest) 1.42 341 MA 7 (gust) 53.2 279 339 177 11968 aigr— ✓attar thaw 1989 li ma Crable Z, are uwd hat since tasty mate dandy essEam to the dant; of the azie 24 eemdens of fluoridated and fluoride -d scent mmmuni- tits dwalso are fab==edxa= ahnough irregular. While the bons in ann nptuag to correlate tine water ituo- ndaticu status of a repm with the caries status of mdi- `ryduais wits= the rep= must be recogsize-, the com- pan== in Tabie 5, nevertEeiess, suggest that ti,e extent of water fluoridation in a moan deter the magni- tude of cite diffusion efi= and its influence on tine rela- tive difference in meets pre-aLXd:,-- between optmaliy fluoridated and t manmuniti,es. Failxae to conSkies fluoride residence history, inaccu- rate reporting of resider= his� and untemtitteru cmrpuance with ecce- standards of water fluoride coo- ctennstioa am fluoridated commuz=es also can lead to improper assumptions coacm ing the true value of water fluoridation, generalky uusatimtg its bene- fits (IS.2324). Brunelle and Carios found that of time ar- p y 36,E suov cts is the NID& natio W caries survey for witom residene histories were available, 23 percent had Iife4ong exposure to fluori- dated water, 23 pert,°srt had never lived in a f uo idatec amity, and 54 percent had lived in both fluoridated and mes(18)_—hus,mom than five of every 10 LIS sdwoldu-ldre n have intermittently consumed fluoridated water because of residence chaffs. Hart et al. CM and Clovis et aL (26) have shown that for Amen and Canadian childrm respe+cdvety, a limited residence exposure to fluoridated wars will im- part daueal buffer. A higWy mobile American society, c mmpared to a refadveiy stable society when water &uo- ridatiaan was ialsoduced in the 1940x, also serves to blur tate distinction between populations that have or. have not been exposed to water f u ozidatsoa. . It is evident that a variety of fac�pal among trues being tie dilution eifec s of other sources of fluo- ride, the diffusion of the bestefits of water fluoridation beyond the gwgsaz*dc limits of the wrnammy being served, and the mobility of contemporary US soden -- have confounded time traditional distinction between mamruanities that are fluoridated and communities that ate fluoride def c= nt- It's no exaggeration to say that. for all praetiml purposes, the pia -ase "not exposed to fluon- dated water" now is a misnomer in the United States and, powNy, M t7rfiet: OMdoped countries ti,at ea,ploy fiuo- ridatim wieldy. EifeG as Dual Bene$is of Discheduzz:mg Water man Several studies have evaluated theefiact of disczantirr wing water fluoridation- Two of the earliest studies were in Churg, Illinois, and Antigo, Wisconsin (27,28). C,alesburg's water, wtdch ow%tained a natural fluoride concentration of 210 ppm, was replaced by fluondedefi- cient water (eO.I ppm F) in IM. within two years there was a 10 percent decrease in the number of caries -free 14 -year-olds and dunr DMFT stores inapased from 2.02 jo,aaal of Public K—ktt► De,dsny to Z.79 (M. In Amigo, fluoridation of the water supply was aismctanued in 1960 after 11 yesam Six years late the D)wO7 scores of second, fourth, and sixth grade =7 dren. had risen ov 70, 41, and 48 percent, respectively ly CM). The watt: fluoride motions were also reduured to suboptimal levels in Austin, )iota, in 1956 Q9) and Wick, Scotland, in 1979 (30). In both coamumities the caries prevake nce of the cinnldren uxzeased- In the more recent episode in Sadie. in 1979 resulted m a aownward acius=ve nt of the water fluoride concentra- tion from LO ppm to tirenatural level of = ppzrL Five - and six1var-old children. received dMical and radio- g; aahic carr conninaiionns in 1979, after file -long expo. sure to optimalh ftuandatea water. and similar aged ciuidrQn rt:erived czries eatanu�tts at 1984, after langrxposmreaa wats.The damftundoc rose from 3.14 in I979 to 430 in 1984, a difference, of 27d) petem and tate amts ux= went from 8.42 to 13.93, a difference of 39.6 percent. In Ked-Marx-Stadt (now Cite===), C,eramarry, to cem- ml pavaleas reduced the adjusted fluoride concentration from LO ppm to a low of 02 ppm (31). From 1959 to 1970 the water fhror=t concermat ion had been maintained at a axnsraat I.(':.l ppm. These was an interruption in watt fivoridat km f x=1910 to 197'1 that is -steel I5 ye ars, followed for the next five years by suboptimal Teves of water fruorioatioa vmtiL in 19T1, the optimal ftaoHd, level was tutored. During this 18 -year period aL schoolchildren in Kari-M=-Stadt receivead regular vi- --... suaI-tame cries emminaftons from the same dental examiner. For S- to I5 -year-old children , draft and DhdFI' score showed a reduction during tare original period of optimal finondadon, inneased dun ng the period when the water fluorine canceri ration fell., and there w+em re- duced again when fluoridation was fully restored_ Arecentstu vdwdtmermiredthe ff tofdefluoriaa- tion was conducted m Stranraer. Scotland, wrach was fluoridated m 1970 and them defluoridated in 1983 be- cause of a Judgment by the Scottish court (32-34). The conseaue nc s of de$nrondation in Stranmer, as well as those o�� fox Vrkr, are of vartiratar iaursest since thev happened d= -Ing the overall seczrfaz caries decline o=ming thtu3agitout the United Kingdom, which has been ataiinned largcfy to the use of fhtandated tooth- PaSM& In 2980, after 10 years of 8uoridado n, the' DMFf of 10-yeas-okmwas 1.66, compared with 335 for 10 -year. olds 0year- olds in Amrana comparable fivadde-defid c =mcu:- nity_ This was a difference of SOA percent. After dt fluons atw ,.tinemean DMFf of St m=er lGlear-olds inaeesed. despite the secralar decline brat continued in Annan. In 19M, three years after deilner&Utiacr,. the DMFI' of 10-ycsr-olds in Stranraer was 39 percent lows than in time same aged dWdre n in Annan. By 1988, the mean DMFr of Stranraes 10 -year-olds was IM cam- pued with 256 in Annan. a different of only 11 percent VoL 33, No. 1, Warier 1993 (34). At the same time. dental treatment needs and costs rose in Sttanraer. Between 19804;6, the costs assodated with restorative care had risen by a dramatic 115 perCety, compared to a 9 per= t rise in Aruuuu Salivary fluoride levels are low m individuals who reside in communities where the water fluoride concen- tration is low (3538:. When the fluoride =vert=tion in d3� water is reduced to suoopti=al levels, the con- centration of fluoruie in dental plaque can de=ease to ak nost norm easurabie Duels (39). Inasmuch as the per- manent teeth of the 10 -year-old Stranrae: titldren who were examined in 1988 were Lwr:iy fatm%ed during the period of optimal ftuoriaation, the decreased caries pro- teetion might be attaputed to the lack of pmteruptive fluonae contact that, pzestmnably, reduced salivary and plaque fluoride concentrations (40). in its review of the benefits and ris)a of communal water fluoridation, the Ad Floc Subc==tte° on iitia- riae of the L'S Public- kIWth Service proposed that one criterion for conferring effiattiveness of an agent is the disappearance of effects when the agent is removed (15). The report aces the studies desaioea aeove in which increases in caries scores are associated with discordi or- ation of cornu nal water fluoridation as additional evi- dence of a -1-1 re iationship between avczral concert- tratiorts of fluoride in drinbng water and caries ress- tance. h� —i"" ai Action of Fluoride is Dt3nk3ar water The nux ieanistns by which fluoride prov=es a anw tesistaner have been reviewed by Newbtun (41), Murray and RuO.Gurn (,M, and )vEcMxxg and Ripa (43). The Utter state that fluoride ate :tan ns can be grouped irm five categories= increased enamel resistance to acid der mir eraliratioa, increased rate of posteruptive mah=&- tiore, tineralization of it cip lesions, intsfae:n� with mic ompnistns. and improved tooth morphology. Furdtermo e, it is crosto Bary to classify fluoride therapy and mechanis= under two broad categories systemic and topical. Systesnic atethods are those is which fluo- ride is ingested and the unerupted teeth are the targets of fluoride activity. Topical finorides are not trmM to be ingested and = poster up on the tees P� D� S r +w r w� �.tIIrf_� n .tM tY ;xII��7P What wawa fluoridation began, most scientists be- beeved dw the anbcarus activity of fluoride was prmia- pally a mint of ib i ncorporad m into the apatite aystais of developing ennneL finis luaus$ the stability and redvdng the soinhslity of the apatite stracau e- However, the oureWian. between enamd fluoride concentadou and caries experience was inmmzsoestt (21.43). Perhaps this e . voml f r=ing should have been expected, tton- side: ing that the etff=ts of some preeruptive rnechanisrns of fluoride, such as improved. aystaliinity (42,43) and ocmcaL^ium phosphate converson (44), cannot be aeea- sured by an enamel biopsy. Since a conclusive relation- ship between. fluoride Levels m sound enamel and caries protection could not be estab'dd u!d, the emphasis is re... search, about f uande mechanisms shifted from thte tSL ation of high Levels of flueriae in spin eriarel (sysranic effect) to the presence of low coruceturatiatts of fluorine in the intraoral environment (topical effect) and to the role of fluoride in remineralization (45A6). In 1991, the Ad Hoc Subeonunittee on Fluoride smted,'The theory of preemptive fluoride aioorporation as lite sole or princi- pal med=sm of caries prevention has been lamely discounted' (15). Dam from both, early and recent clinical studies of water fivoridatiaa and owner systemic fh=de awd=s support the view of bots: a pre°rsmtive and a posteruptive kdiue ce on lacier (21). Pzeezaative Effects. The Grand Rapids, Ivewba and Evanston water fhtiondation studies all demon- strated pvaater percentage reductions in the younger age groups of auldrem who had the greatest amount of preeruptive fluoride contra (3). Of more recent vintage. Driscoll et aL reported greater canes protection to teeth that were unerupted at the start of a fluoride suppieme nt program compared to teeth already in the mouth (47). in that study cb9dren. received I or 2 mg F/day as tablets for sac scttoot yea= The control group was given piac= tablets. Fouryearsafter discontinuing the study due mean DMFS increr�nts for earhy erupting teeth in dadre n. using 1 ing F/day and 2 mg F/day were 15.0 perces* and "S.3 peroer less than in the control children, res ile=- dvely. For Late a mpting teeth tete trawn. DMFS increments were 384 percent and 336 peeeset less. However, Thy. Lstrup believes brat the most ritual period for caries protection from fluoride is wizen the teen► are emerg mE into the oral cavity (48), and Driscoll and coworkers findings could reflect the effect of topical fluoride comae at the titre of tooth ernergenee_ Burt and coworkers fundings are leas subject to antithetical iarerpretatim (25?. These investigatorscompared the DMFS increment of chadren, initially six and sever yea=s old, who lived h a fluoride-deficient.cmr= trtity (0.2 ppm F),but who hat resided in fluoridated coazauatities prior to the a mptirn of their permarmi teeth with diildret of similar age wh+ were life-long nide nus of the le—deficientcomma nity. The mu t: rodents had a three-year DMFS terse mem of 235 ootnpare i with I -M for the Suoride-ocposa grvtxp, a difference of 268 penceaL Burt and cQwoem mnedu,i-d! "Despite evidatce that the bmefib of liatite ingestion, of fluoridated water are topical in nature, the fact that many of the affected teeth in this study wet mneruptedatthetitheof the fluorideexposureme=the pct cup . benefits cannot be ruled out.' 26 Posteraptive Effects. In addition to indicating a pre- erurdveeff— fsndislgsfromd*originalUSfiuoridation sestinas also de>=nsaated poseerupdve benefits Chi). In his review of frr_se studies, McCure stated "Ilse evi- denoe stmngiy sug;ested that there were beneficial ef- fects on teeth which were formed or emtpted prior to the in tiation of water fluoridation" (3). Beltran and Burt CD cite recent studies from Britain (49) and Denmark (37,50) that provide additional evidence of post eruptive cents from systffitic fluoride. In the British study, the four-year mean caries went of d iidren who were L years old when fluoridation (1.0 ppm F) began was compared with that a a control group residi in a fluoride -deficient ozantsmmity (cal ppm .r) (49). Children were transported to a central facility so that the exanunations were cott- duazd without the ematiner knowing to which group the cisucren betlonge- The forts year mean DMFS m me- ments of the fluoride and control groups were 6n and 9.19, remectiveiy, representing a difference of 27 percent. Since a ll orntost of the pe; ananertt teeth had erupted pnor to the inftiation of Quoridation, the difference was at =b- uted to "s•bsta*nkas toviral Me=ss on tmed already ermined at the start of fluoridation." 6a er, less direr., argazrumts may be cornside3ed to support the claim of posteruptive besee£ts from water fruosidatiott For i sante, it is known that when cmc= ceases, caries prote:cdon durunishes (see section 'Effect on Dental BeraErts of Discontinumng Watts Fluonda- tion'). It may be irue rred, therefore, that the continued caries protection in fluoridated areas into adulthood is the result of repeated topical contacts Beltran anti -Burt -M) proposed that if the maim OF of fluoride is a post>'ruvove one, then caries mcverience in communities with long-standing comprehensive top- ical fluoride progtaats should approach that of eomumu- tud s vinere the drinking water is ffuoricated. however, th>°y admitted that the clan al results they presented Tacked consistency and failed to resolve the issue. Rina 61) reviewed the results of three US fluoride mouthrixnse programs thatused historical controls to assess the effec- tivanrss of this topical intervenfaan (52-54>_ In all three studies, the results showed that wines the children began tinting as . thesewasa caries rami of app w=%attdy 50 petertL, which is sanilar to that re- ported in water fluoridation stsdies. Ripa believed that siry a the children were five to sac yeas old when they entered the nuxidamw prograans, the fluoride xgutiort cmdact e+d nx)st of the pennarie nt teeth as they emerged into the mnouzsh and this was a major factor dete:anuning thecu im reductions achieved. This interprentioa agrees withThyivr%:(s contention thatthe mostiutportamt tune forf donde totontact de teethis when they areempting into lir inxith (48). Pre- res Posteuptive Effects. Groeaneveld et al. ana- lyzed theresuitsofcaries cam nationsbetweetn 1953 and I971 in the Tiel (1A ppm F)-Culembotg (0.I ppm r), journal of Public Health Drndstry Netheriands, water fluoridation studv Mon. Chadrr were followed longitudinally and emramfned every tv►, years from seven to 18 ye ars of age, urtdl water duarida- tiotn PridedThose living in fluoridated Tiel received flu- oride continuously from birth. The analysis is too corn- ple= to describe he--- but their condusions c=A= *+g lite reiative benefin of pre- and posaeruptive fluoride Contact are stiaumar*� (1) The izutsation of enamel lesions is hardly affected by water fluoridation- however, lesion progression is slowed by posteruptive fluoride contact. (3) For I5year-olds exposed to water fluoridation since bath. the DMFS reduction was half due to cite preeruptive effect and half to the postenttpove effect - C3) The best protection is achieved if ftuoridation is available from birth, but 85 cmceent of the arsaXduumt protection will occur if fluoride cortsun vtion starts be- tween ages three and four. (4) About tow -thirds of the caries protection imparted to pits and fissures from water fluoridation comes from preerruptve conte= For smooth sures, the effete of preeruptive contact accounts for 25 to 50 percent of the caries ix up . Groenevdd ex al -'s auaivsis needs ver- ification by others (55). NeverdmW ss, itindi caws that the cariostatic activity of water fluoridation includes both systendc andtopical aecinanisats. Safetv of Commrraal Watr-- Fbmwidation Fluoride metabolism studies have consistently estab- lished that the prbxipal fate of &Wasted fluoride is either truuary etaQeti of or retention by the skceieton and teeth, Because of the affinity of the fluoride ion for raldfied tissue and its mt>ctntratim in tete kidneys, tine safety of fluoride in relation to the skteieton, the teeth, and renal ftm.-=n specifically will be discussed. Because of the importance of the rdationship between can mortality and frumi,datwt, this will be an additional safety topic. For a discussion of finmide safety concerning other is- sues, such as the effects on other organs and tissues, hypersetstivity and allergy, rernoductive toxicity and birth deieets.re3adersarertierrededsevvhere(L?,14, S-%). Several reviews of finoride safety ove= the last decade mute the pdrepal source astnaial for this section (12,14,15,50.Additional pstasarysousrcesarecimd where appropria�• Skeletal Ptaora di and tDsbeoeteiQoai:. Fnd+monic sk d- esal ffuotms is aortfitned largely to trvpiral cbmans with very high levels of at least 10 ppm f oxide in the water Skeletal ftnotosisalso has been observed in wvdwrs eon to high levels of fluoride in industry, such as ah=num production. Skeletal -fluorosis has several stages and is usually charattQiffi by Steralized bone pain, sd frnrss and pain of the joints, and arthritic sya p- toats. Radio� findtrtgs have shown ostaosdr3oss of the pelvis and vertebral coluanrt (12,14,15). Theta have been five reported cases of tripptirtg skei- "'OL. -�J.i\O. "'%Lzkwa .Z,2- etal fluorosis m the United States. These individuals were exposed to natural levels of fluoride in the drinking water ranging from 3.S -&.Q porn. and. in the two eses with an estabbsihed history, the daily urates consumption was Msivey high (15). Radiographically 6etecmbie os- teosdmas has been reported fn other mmv=uals ex- posed to 4.0-8A ppm F, but ti ee were no clinical symp- toms of skeletal fluorosis (14). Skeletal fluorosis has not been rq*rced in the US at water fluoride concn=tiens below 3.9 p=n, nor is skeletal fluorosis a =Arc health probiest in the L'S (15). Sone Fracmie and Oswoperosis. Sodium fluoride is used sometiates in the United States and other countries to tree 0SMoporvsis. The tstinilr= daily dose is about 40 mg )aiaF, and although tate US Food and Drug Admin - L -mm lion has never approved NaF treatment for osteopo- rosis, it is approved in other countries. Peopie on the regipnau have displayed an increase in the density of the ,ver tebrae(trabecuiarbon_)byasmuchas?5pe =t over four, years. Some studies have shown that there is a smut] taneous duke in conical bone, such as the shaft of the radius, causing concern that the ooservea increase m bone density may be at the expense of o*,L portions of the skeleton losing calcium. The inddetce of vertebral fracture IS the most ix:tpor- U t outmnne in osteoporosis treataiett using fluorine (151. While stwdiim have consistently shown that a daily NaF reg= -dm will i mrrw vertebral bone mass the find- ings on reduced vertebral fracture are mooed, with two web -controlled — m , studies fait' ng to snow areduction in bone fume rates (57,56). In 1989, an FDA Advisory Cornmitt:'e concluded d -at NaF hasnotbeen shown to be e ve in reducing tote incidence of vertebral fractumvs resulting from osmvporosis (15). Bennseof theefitstof fluorideinbXream+gtrabecular bore mass and apparently reducing cortical bone mass, interest also has focused on the relationship between the., concenuat. of fluoride in watt supplies and both the prevalence of osteoporosis and the prevalence of frac- tures,especially the hip. Simonen and Iaitahen coatoare+d the incides cr of femoral -neck fracture over a decade in twoFrrtnish towns, one with an adjusted ware fluoride coneomitation of 1.0 ppm and the other with OD to 0.1 ppm F C59L They found dw the risk of fracture in both ateu and woumn was sg:rifimatly higher in the fluorine` deficerht cCroom may. A study in Natrth Dakota reported *at rte, especially w=nen. exposed to water mn- tainir g abort 4.0 ppm F had less osteoporosis and verte- bral collapse titan a caatparable group in a low4hnoride area (60). 'These studies have failed to find a relationship be- tween water fivaride levels and hip and long bone frac- bm (61-53), whereas odw r studies have found a reWiori- ship (64AM. Cooper et aL evaluated hospital discharge records for 197842 in 39 counties in England and Wales (631 Approx mately 20= alien and women above aged 45 years were admitted with hip fractures (fracture of the proximal femur). The water fluoride concentrations in the counties untie: study ranged from almost none (0.(X}5 ppm) to approximately 1D pptn. No significant correia- twn was found between water fluoride concentration and the ptevaietu= of hip ftacture. In tate United States. Jacobsen et aL analyzed nationwide hospital discharge records iron the health Care Financing Adm& station and rite Depart:xtsnt of Veterans Affairs of white women aged fa years and older for the period 1984--57 (04). Tire), found a distinct norm to south pattern for hip fracture, with the louver rates in the North and lite higher rates m the South. Although dwy stated that no pcesentky recog- nized factor or factors adequately explained the get` - graphic variation, they nevertheless found an Mor eased wevalence of hip fracnae associated with the availability of fluoridated water. The report of Jacobsen et aL caused Coeoe-and Jacobsen to reevaluate the data from the UK to a lett; to the editor of the imrncd of the Arscrz= lv aE=; Aswci= tt, they said that after weighting their data for each conn y by the size of the population aged 45 and older, they found a positive correlation between ware" fluoride levels and the prevalence of hip fractures, i.e_, the higher lite fluoride level, the greater was the risk of hip fta==e (66). In a prospective five-year study of women in theIowa communities conducted between 1963, S and 198&-8°, Sowers et aI. also reported an asso- ciation between water fluoride concentration and bone fractures (651. They reported a twofold increased risk of fracture of the wrist, spine, and hip in -16- to 60-year-oic women m the higher fluoride cornmut ty (4.0 paced cont pared with the cvnavl community (1.0 ppm). Phipps and Burt reported no diffezesuco in cortico!baro mass when the density of the distal radius was measured inpost-menopausal women who were life -song residmt: of communities with either 3-5-42 ppm F or 07 ppm F v the water (671. However, they concluded that one predic tar of cortical borne mass was fluoride exposure, with th higher fluoride ievel assvdated with lower bone atlas Considering the conflicting repotts. it must be coneitede that the auestion condoning the role of ware fluorid exposure is boot osteoporosis and bone fraQum is urm solved (15). Resin Fes. The kidneys are potential targets c acute and d%ronic fluoride toxicity because they retno'% fluoride from the biood,and the kidney cells that o trate tante are exposed to high finoade Concentratior The National IGdney► Foundation has attested. that wat fluoridation does not harm the kidneys (56). Despite t impataneeof thek idneysaswaystationsforthedispm of fluoride from the body, there is no evulence that t incidence of mortality from any reseal disorder is i aea.9ed by water mnmkdrig 1.0 ppm F=. Furtheaaha in several epicieniologicsturdies.lo:ng-term of water containing fluoride as high as 6.0 ppm NO found not to be assodat d with the induction or e�oc 28 banner of lddnev dydwtcdm (14,15). Whsle higher fluo- ride mnoau±ad= are ddmftefy found in Calcium ooa- late kidrney stones from re idents of fluorinated com- pared with kidrney stones from residents of fluoride -de- ficient communities, the effect of fluoride on stone formation is poorly ur4erstood. At least one group of investigators believes that there might be a dose-de_mn- dent fluoride it f tion of kidney = ne fotatadon. In- eeasng fluoride concentration, for **+� from 0 to 10 ppm, inhibits the growth of takium oxalate crntais (65). However, concentrations as high as 10 ppm are not rele- vant to controlled water fh n—fion Studies have shown that pesorns with renal iitsuff- dmy have deceased fluxide dearance and wM have ddevated plasm levels of fluoride corrtpmed with unaf- fec individuals (14). For these pe oph- the need is recognized to use water for henuxHaiyms that has a low fluoride coarceslaation, as well as a low conimritzaziorn of other uxu- Recently. Bello and Cate man showed that hea"lialysis patients who reeved malyss fklids imm, a @noridated tap -waw r solace purified by reverse os t - w had a higher plasma fluoride level titan those woo used a aoam>erffilly prepared peritoneal dialysis fwd (69)_ They attributed this diff ince to the fact teat al- though reverse osanosis sysrim>ss remove most of the fluoride from watt;, this process caraunproduce dialysis fluid from a fluoridated water source that is as low as the fluoridec orv=trationinacoms►eittialpreparation.They speculated that since anmicipal water fluoridation and the reliance on reverse owroQ■ systesas for wateparifi- catioa are both axnz nontpiace, many h=ndialysis pa- tierds are being overexposed to fluoride, which ray ac - annulate in their skdetan In Sw rat, patients with irin- paired kidney function have an increased risk of stodml f3uorons and in young children whose teeth are f nm=g these is a risk of dental fluorosis. Cases of both, usually associated with high fluid inspire, have been reported (14). Hyperfluoridation of a water supply can occur due to -overfeeds' involving egtupateatalalfunctiaxt (70,71) or to "atxidmtS - in which equipment is toot duaecdy in- voived C72). Thee has bean one report of a hypesfluorida- tion arr!iel in a mmvdpai water supply. in that hi- smrar flwnde was aoadentagy added to tale water sup- ply of Annapolis, Maryiar4 at a kvei of over 3(? ppm for sever -Al days (72). As a result; a resk art undergoing kidney dialysis with softered tap water instead of p=k- fied water tried and wve n odu r dialysis patiaRts benrne exa=neIy i7L These individuals west m ed -stage rwAl e ism and wit not receiving the ra dudes tded diaf}- sis procedure No lmtoward effects were documented in the population at large_ C.sacmMortality.Afterteteintroduction ofcoasruaal water imoridation, frveretpoa is appeared in the 1950s that evaluated general mortality rates in US a==ru n tin with different concentrations of water -borne fluoride Journal of Public Health penny ('-5). Aro relationship ber. a fluoride concentration and cancer was deter. Two studies froza the UK, whit appeared in the eariv 1970s, also reporter: no s association benween ez_+ce- rates and water fluoridation USL En. a series of publications and public- armoT*-•cmra= begiaudAg in 19T, Yramouyiannis and Burk claimed that dltir anai%s o: canoe- morta&T statisaias showed that fluoridation sigrdicantt_v irt�d therisizof =Icer and that 10 LIS cities that had institzrted controlled fluorida- tion programs had a rapid R*^rtase in cancer- mortality rates compared with 10 USctins over the same time period. The metaodoiogy of Y-larnouviartrus and burn was arit =ec, rnainiy for &dura to add for confounding variables such as age and se- differerices thataffectcanc� The National Cancerinstitateand otiums who neanalvied the same -- nux aiity data, using F*F' art rn�dlods, iasied to fro.: si�in- creases IIL cuxr-- Gffith in the: r-rH 5 with f uoridated water. The consettszns of the scientific corner dty is that the snubs of Y-anunryUnnis and Burk do not support the corn—��+n that huoridatiots nurses cancer (15). Addidonai epidemiologic studies that tnvestigated a possible fink between waterffuohdationand carxz rmor- bidity and mormlity have best cor===ed is several aourtuimi nciudizngthe liaised Staters C73-77), the lirdted Kmpdom t7S-SI). Canada (62.83), and Australia (84). aIL over 50 epicb etiologic studies have evah ated the possibility of an ass=== between cancer atonality or morbidity and wain f3noria2tiaa. The overall conchision Bora those smuts is that tl-&m is no amdibfe evid tm that water' ftuandation kicreases the risk of === Sev- eral indev=tdesz manzrds9ians have reviewed the scien- tif= lits wature on a canoes-{uondation lank and all came to a smmisr mnciusiort (85487). The report of one of these comrussiart�, reeds, is parr (85): We have found wdiktg in any of the anajor classes of evndemiolog cW evfcrmce which could lead us to aoct- clnan d= either f wr=e nattratty m wap=, or fivande adriad to Wats saDpliC% is int a of indvcin$ca=e:, or of ine -asing the anormary lion rim. Tkus ststezt>r applies both to -as a whole; and to once at a large nuatber of specie tiers. In t bas we =acar with the: SrM majority of aderttifie investipwo and c=mznen=mm iter this tie kL The only corauary em e m am are m ora view aszrilm:able to errors is data. errors in anaipticil bx:h- aigue, and errot in sceazifx IogiL The i nue of capon and water fluoridation in We 1969 with the ptemlabme :ukase of data from a study of dumc is oxicitp and—cmiong—m-dicity . of NaF i' laboraury armals, canducted by dee Natiarrtal Tonieo. ogy Prograisi OqM of the National institute of Environ- mental Health Sciencesin the NTP sandy, fiaorfde, as NaF, was adrruinistmd to male and female male rats and anode Vol. 53, No. 1, Wuttcr 1953 29 TABLE 6 Lose sad Number of Animals in the KTP Studv of the Toxicity and Ca d-ogcnidty of Sodb= Fluoride (151 * of 1 nrm is Dose (cum) Daily Dose of NaF in mg/kg/Body WeiFim Rats Micr NaF F Rats Mice Male Fe waie Male 0 0 OD OA 8o 80 80 80 25 11 13 24-28 50 50 So 50 100 45 52 5.6-112 s0 50 So S0 IT 79 9.6-85 16J-I8B so 80 80 80 TABLE 7 Fsnacce Conemtsstions in Bone Ash and 1---;A ct of Oshwsarr=as in the NTP Shady of the Toxi&yand of Soditmt Fronde (M ird:jdPnof Osaosatoa¢las Dose (pym) F Corcerttrarion m Bone Ash in µg F/mg Ash Raa W= NaF F Rats Mice Male Female Male 0 0 0.4s -0M 0.4-2-092 0 0 0 0 25 II 038-I35 IM -1.61 0 0 0 0 100 45 3AS-3.73 3-3-437 I 0 0 0 17a 79 52. -SM 5b9-624 4' 0 0 0 in concentrations of 0. II, 45, and 79 ppm (Table 6). Osmoo=znas were found in one high -dose (45 ppm F) and faun hgr&n dose (79 ppm F) male rats (Table 7). In dela group. orte of then q toma, xu was extraskele- tal ---khat is, it did riot ongmate m bores 'There were no osmosarcomas is tine ie=ie rats or in ti* mice of either s-- Oral squamous ceU neoplasms also were diagnosed it tine dosed and control rats, but the inQd— rates between dosed and control animals were not statiszicalky signifi-aatiy differ$tt (M. Timresults of the NTP sndy were reviewed fa April 1990bytheIMPeerReviewPaaei.Thepanel conchuied that, tuider the cotditiorts of the two-yw study, Brest was'equivocar eviderceof caraxKV=dcacdvityofNaF m ante rats, based upon the small m:atber of - am is dosed aniavts 'Eqc voml' is a das ificatfon for trace do destor netted by studies that are in- to pieted as showing a atargnal utatase of neopiastas thatmaybechemicanyrelate&7bepandalso =ncbmied that dinar was no evidence of cararwgnk activity fiom NaF in the feanaie rats or in tate orale or female avre Me doses of fluoride inn the NIP ssndywese cmremeiy highwhen contr= ed to optiatally add or above-op- hmal naturally ooetariag levels of fluoride is US dzwk- ing water. In, the two-year NTP study, the fluoride cor,- onuration in the bones of the dosed animals increased by a faint of apprmtdmateiy 2 to 10 (Table 7). Both tats and take had dose-related fiuorosisof the teeth and female rats iad osteosaaosis of the long bones. _ Ina semrats° mraatoSb1z Y study, amu nisaoned by the Pr=-- & Gamble Comparty and cornual¢ rmm 199i t61983: rats and mice received dafiv doses of 0. 1, 4, M and 25 mg NaF/kg body weigh~- Two osteosatma as were idettified in low-dose (4 trig NaF) fanaIe rats that dived before the end of the study; one fibroblastic sar- coma, possibly with osteoid forestation, was found in a mid -dose (10 tag NaF) male ra~ and one osteosarcmna was found m a hig}rdose0 mg NaF) mate rat Benign os anus izramged in high -dosed male and featale arise (15).TheC2t,4:tcgettidtyAsse9une ntCnw%nittee,Canner for Drug EvaWation and Research, of the US Food and Drug observed that, tarda the asrdi- b= of the study, malignant tsanors were not retested to fluoride ingestion, is rats or mice, but brat a significant increase in the a 4,4en of benign osowntas was ob- served in high -dose mire. , . The Ad Hoe Submmadtwe on, Fluoride of the US Pub- lic Health Service dwacmrized the =flied results of d ese two animal studies as follows (15): Whm the NTP and dlne Pm=w & Gamble studies are rambfnad, that is a total of eight Individual aec/spe its 30 grotras eomuted. Seven of these grouts slowed no si- rd&= evidence of analifsuns tumor formation. One of these groups, male ran from the NTP sntdy, snowed "eauivocal" rMe=ofoXdnoSCUCity, rvhirnis deitned by MP as a marpnal increase is neoniasms -- i.e. osteo- sartsnrtas — tn-- may be thermally relarzd. Taken to- gether, the two anianal studies avatlable at this base mina to establish an association+. between fluoride and cancer. in view of the N -M findings. the National Cancer Insti- tute in 1990 conduc-ted a study of pricer utddetce in fluoridated and fluoride -deficient US communities (se= Ref. 15 for a lull desaipdoril. Cancer incidence rates between I973 and 1987 were evaluated in witites in Iowa and the Seattle metropolitan arm. A county was consid- ered exposed to fluoride if the proportion of the poouia- tion served by ftuoridated water movased from less than 10 percent to pat—than 60 percertt within a tiuee—year period. Consul counties had less than 10 percent of the population served by "Wsted or naturally fluoridated wa= through 1987. Emoted numImns of lanes cases were e=7ve d from the rates m nonexposed aunties and the nmasur a of tisk was the ratio of observed to vpxied cases For none of the cancers surveyed, including osteo- sarooma, could a coriasres link berwee n cancer Inci- dence and water fluoridation be established (M. In a separate case Matta of study mvolvang 22 watched pair cases of osteosarcoma and controls from Iowa and NIebmska, McGuire et al. did not find the development of o,teasamoma. o be associated with fluoridated water exposure (88). Although the investigators emphasized that the sample size of their study was sataIl, they de- tected a negative relationsiup between fluoridation. and osteosarcoma, $ rig that warm fluoridation at tt mananehded levels might have a proactive, or antimuta- ger:i,- edi -- The investigators undnaoed that they are tzrrreznthymvestigatingdushypothess inaiargm,nation- wide study. Demta) Fhmrosis. Dental fluorosis is a develrnmw nal defect of enamel that occurs when an excessive amount of fluoride is .ingested during the period of camel for- mation. The severity of the defect depends uporn the anumm of fluoride ingested. the duratiaan of exposm-, and the age(s) witern t>q:osme occum in humans, the defect consists of submuface is, an irtc in the ptrrasty of subsurface err mel (89). The strum ral arrAr%V= enc of the mumd aystals ap- pears normal, but the width of the imese. ystaZme spaces is ism=msed. Clinically, the w=2d appens opaque or matte white, in contrast to the gio%T translucence of notarial enacted. In arumals exposed to very higgh data of fluoride„ hypoplastic enamel lesions, seem clinically as surface malformations or pitting, can also occur (90). In h zirnans, the pitting pre=sent in severe rasa of dental fluorosis is the result of postesuptive breakdown of po- rous surface ertaanei (89.91-94). However, Richards be- lieves that, with eca=%e.ly hi¢h dnsrc r+F a,,...:.te a.. -- - Journal of Public Health Dentistry TAME a Dean's Deaeal FAWrosis Qassifintion CUS1 Fluorosis CI&SeAntion Score Desedocon of Enamel Normal 0 Smooth" Flossy, pale cramy- wh= transi=ent sursace Questionaoie 03 A few white fleck or whim Very mid 1 rectus Susan onaaue, pant -white arms covering ng c2556 of tooth suriam Mild 2 Whne otsa.aue arras coveting ,Mule% of tooth satiate Moderate 3 All tooth surfmm aEyCaed: brown stain: mariced wear on severe 4 All tooth staraees afrecaed: brown stain; disat ere or cor.- fltttest pitting enamel develor wrd, preenmtve pitting might also ocr= (90). Postumptive stabtatg of the whits' areas air oceans in severely affected enamel (94). Historically, the reran "anotdW enamel' has been used- as sed_as a designatiom for externa fluorosis. Its use is natfo=- nate, since -mottled- meazLs colored spots or blotches, and it inac�y iznditat+es that all affected teeth, have unesthretic blemishes Actually, the degree of fluorosis runsa mntanuum from bareiynoticeable white striations that tray affect a small portion of the esnamel to confluent pitting and urwstheac dark brown or biack staining that affects almost the entire enamel surface (95). Ear)v re- searchers who mawined du7dre t eodubiting the milder foeaes of flnoross felt drat the teeth were cosmetically more attractive them teeth that developed m arms with water In fact, in 19M, McClure corn - =anted, "these is a consensus that an optimum quantity Of fluoride may actually erJuvm the appearance of due- teeth ueteeth (3). Because "mottled esramer inaocuraudy de - scram the less severe forms of the condition. and gives the ertm eons tmpreesim that all affected teeth are cos- metically eoatpcombed, its use should be discontinued iA favor of dertaal 8ruorveds or elQ 1 fluorosis Dean developed a dental fluorosis dassifiCation that categorized the c mHfionacwrdingtoitsseverity(Table 8) (96.97). Wath Dean's method, an individual fluorosis score: or a eoneriauanity fluorosis index (eIf) could be obtab ed. The fluorosis A-6firation of an iitdivid wasba sed on the two most affected teeth. If the two ttee;tt+ were tot equally affected, the classification was decd mb-cd by the Ie involved tooth. The CFl was calcu- lated from, tine mem'6f the individual scores within a VoL S3,14o.1. Winne 1993 TABLE 9 public Halth Sigauiftnaee of Cognmunity Fluorosis Endes According to Dean (95) --- - -- Comunuairy Fluorosis Public KwIth indoc Flange sr 0.044 Neptsve 0.4-0.6 Borderline 0-6-1.0 Siigiht 1.(1-20 Medium 2X014.0 Marked 3.0 -AZ Very norked FQ = z ( few mnc , x individual fluorosis score ) number of individuals When the CSI readied 0.6, Dean believed it warranted consideration as a public health econcern (Table 9). Since Dean's classification systeat was gttialisthed, other fluorosis indices have been developed, including ones by Moller (398), TYhylsaup and Feie skov (93), and the KDR (tooth sarmce index of fluorosis) MM (99). These have been reviewed by Fiomwi= (°S), who. along with others (100-102), has empha=ed the problemof distinguishing dental fluorosis from nonfiuoride enamel defects. Enamel opacities can be classified into three cat- egories: fluoride -induced opacities, ire.. dental into:osis; nonfimride-wduced opacities of kwwn etiology; and idiopathic opacides (101). Sonde believe tint the clerical appearazticeand the distrcbutionof taheehamel deiectscan M%ableOgffWrdMdM2=drdWStocwrectiyide2tify dental fluorosis from other rendition {I5,°5,102}. Fiaweve:, others believe that a positive clinical diagnosis can be supported only by an adequate history of exposure to fluoride- Cuttzess and Suckln1g, who develoved a flow, chart for the differerttial diagzwsxs of dental fluorosis, andieated that only when the condition is er=nxnteved in an endemic fluorosis area where above -optional water fluoride amtiditions prevail, can a diagnosis of dental fluotoss be shade confidently, without recourse to an individuals medical/dental history or )abpratory anaiy- sisofwaahel,hair.nails,ormiz (10U.ConSdenceinthe diagnosis of fluorosis increases as the pre:valenm and semity of tine defects increase. Diagnostic mttaertamty increases with lower prevalence and severity, which is ganerany the in the United States (101). Aunt of whedvw the presralenm or severity of er+awd fluoross in the United States has changed over hone is based on three types of titre -related cvmparisor>s (1) a campmisosn of different cities with sin lar fluoride oar>�hnatiorns uzng the same f umusis it dex but differ- ent emmit ess, (2) a co=parison of the sante ones using the sante fluorosis index but different ammo m Q) a ooa>�Sarisorn of tate saane aties using the same fluorosis irndoc and the sante encaminers. Studies concerned with TABLE 10 P --Mt Pievalenze of Dental Fluorosis in 2935-40 and is -- 1976-87- Using Dear's lodes (15) Water Fluoride Total tt of % Fluorosis Concent alien Gtiets Prevalence (Mean) (ppm F) 1939-4b I976 -M 1939-40 ITr&42 4.4 10 3 09 6.4 0.40.6 3 1 5.6 2.4 4 4 13.6 rI.7 1 3 30? 237 2 1 44.0 2.3-ZJ 1 5 73$ 78.3 Sv2 0 3 — 74,0 sz-Z.7 b 0 >33 0 2 — 834 tieese tile+-` types of its have been reviewed by tine Ad Floc Subcommittee on Fluoride of the LIS Public Finalth Service and the condusions of the suboorremitte- will be presenter: here (i51. In addition, Brunelle has reported the only national US survey of dental fluorosis, which was conducted in 1986-97 an schnolclildren, (103). I}iffsrent e: iiieSlSarere FFrcexosss Fsrac/Dif fer,eatFsmee_ users C mpmwons. Comparisons were made between the prevalence and severity of fluorosis in 1939-40 is 21 Lia alis axnd the pmvale nce and severity in 1976-82 in 24 difrerent dries (Cable 10). Dean's index was used as the measure of fluorosis, In cities with less than 0.4 ppm. F, the mean prevalence of fluorosis increased from les than t pet veru to appnsx- imat ly 6 p==L Nearly all of the increase occurred in the very mild and mold catepries In dties with optimal water -fluoridation (07-12 ppm F), lite xnean dental flu- orosis prevalence inaeased from 14 to 22e percent, and the increase was limited alnxm entirely to the rnilaer forau Except for the 13-17 ppm F category, cries with above - optimal fluoride conaehaadm-s showed a slight increase M fluorosis prevalence. from 44 to 53 percent where the water fluoride concentration was 1.8-2.2 ppm. and from 74 to 79 percent in sties with 23-7-7 ppm, F. If moderate dental fluorosis has increased since the 1940s, the in- crease most 15ply has occurred in comnumities with fluoride comm% ations of 18-21 ppm F (15). Surae Citiedsww Fluorosis Ld=VWVTNt Eieaet, - ers Cowpabons. During the 1980s, Driscoll et al. (104) wmveyed children for ih=osis in Kewarv�e.II_ (I-6 ppm F), and Krmiar et al. (105) eot,dt—I a similar survey in Newburgh (1.0 ppm F) and rmpton, NY (03 ppm F). Both groups =spared their results to hir mcal data from the same mmmsuhities. reported in 1942 and 1955, respectively (106,107'). Dean's CFI was used as the index. In 1980 Driscoll and coworkers found tate CFI of Kewanee was 039 compared to 031 reported in 194: (104). Approximately 85 pe m—ent of children were diag- nosed as normal (no or questionable fluorosis) in 1942 and I98Q_ The investigators found eight out of 336 ch` dren M4%) with moderate or severe f=rosm cotnpared with none with those ci:k siA-tions in the earlier survey; however, they could not ascertain the cause. Comparing Dean's findings of nearly half a century eauriier- to dear own, Driscoll a ral. conciudec. 'No important changes in the prevalenLM and severity of fluorosis had takert piaco berween the two periods.' Kmn& and mworicers reported that for seven- to 12 - year -olds in optimally fluoridated Newburgh, the CFi scutes were 0.14-O.2I in 1986, mataared to 0.11-0.18 in 1955 (105). For fluorine-aeadent IIV=)n, the Com[ was OM in 1955 and 0.13-0'�.3' in 1986. The investigators concluded that for tie Huondate3 coacmunity, over the three -decade scan, -tip difier+ences ove• time were n a- ligiaie- and -no change of cxis atanCe- had occurred - There was an 'mavase in the p vvaalenre of fluorosis in fluoride -deficient Kingst= prinaaally in the very mild and amid categories, to aaproxdmateiy the same level as fluoridated Newcurgh. Mule the Cri was well betow U. the level Dean felt might prompt public health con- cent, tate findings izdimtal "the availability of fluorides in nonfluoridated areas- Somm Ciiies/Sa w Ffstorosis LulexlSamw E=m mino C m paaiwas. Heifetz and aowona rrs examined eight- to I0 -year-old and 13- to ISyear-old children m bout B)inois mmau zuties with optimal and two, three, or four times tie optimal levels of fluoride (108). The towrinations were conducted in 1980 and repeated in 1965. The TSIF index was used. The studywas evsssect:ional, e~ , for the eigfu- to 10-ymr-olds in 198() who were avanlable as 13- to I5 -golds for the second man. There was little difference in the distribution of TSI"r scores between 1980 and 1985 for all tooth surfaces of eight- to 1O -year-olds, at all fluoride levels. In comas;, is 1985, there was a greater prevalence and severity of fluorosis for the I3- to 15 -year-olds„ at every fluoride level. compared with 1960. However, the mos` severe categories of fluott>sis were Trot detected at eid-w : survey, and the fluorosis that occurred at the opdnun n fluoride love[ was d uvacterized as "only whitish discolmitions" (108). From their data, Heifetz et al. hypodwsmd about the changes in fluoride mgestibn that tray have occurred dura g the lifespa r, of the du7dre n m their study (1(1$?. A similar analysis was conducted by the Ad Floc Subeorsn- mittee on Fluoride (I5). The following represents the combined cornd=;ions from these independent analyses (1) Fluoride fngesdOn was lowest from 1965-7[k (2) fluoride argesdon began to increase in the early 197Os. (3) There was little or no additional change m fluoride intake between 197D-77. (4) Fluoride ingestion continued to remain about cort- Journal of Public Hea.Ldh Dent=v TABLE 11 Cmmaarism br C—Vxpi & It %ioa of Per—=age of Popaiatim Rsadv>aF Fbacridated Water- with Mean DMFS Scam of Schoolmildrm and Meas CM Scam (18,,2031 . % of pop. Receiving Adpated or 1AMn . NaomaY DMI7 Mean Fwoddated ScsaolchUdm CR Fee= Wa= C19M (1986-$7) (198&4M III Qviidwest) 712 Cl) [1] -? 91 (3) [11 0M Cb 111 I Cly'_ r-F;iand) 66—Y m [21 3.b0 M [51 038 (3) [31 rV (Saud easy 37.5 M [31 3.06 (4) [21 0.44(3)(21 V (5oudrwe t) 57.4(4) 2.V CI) 0.72(l) 11 (Northeast) 481 S) [41 3-43(6)[41 036 (6) [41 V1(N-west) 35.9(6) ZT C2) 0.40(0 vII 0?- t — 17.8 (7) [5) 3.37 M [31 OJ V) (31 ( 1 �fe the belt and right oitumms am mnxwd nom gnm=n to Iasi is ke=MS with the eoaaive telatio sit io omeeted bawem the wtaaa of o:==aaosp Brace i600n and the amity fiLlorosk, Under Tne taid- dbeaohsmaisancedEromlesttogeeatatiala gwiththera2xave reladonAdp emeaad betw the stator of warily fl, =Aatsoa and retia p wataum I Im me. but omu>iag Beeaw V and VL stant through 1962 The Last mon, heywevt3, is surprising, since the late 1970s saw a reduction in the American Academv of PeGlatZies supplemental fluoride a"+,ed ie for children to age two, as well asa voluntaryr eduction in the fluoride content of baby formulas and foods to approxdmateiy 0.1 p= F. Perhaps the evrnseauences of these changes will I - - - 1 e snore apparent with time. National Ft'norosis Swvey. In the first: national survey of dental fittorosis arno ng L35 schoolchildren, cora luc ed in 1986-57, 78 parent were found to be normal (no or questionabLe fluorosis), 21 percent had very mild or mild fluorosis. I pause had moderate fiuoross, and (I3 per- cent had revere finorosis C103). Mefrcr to Table 8 for a description of Dean's fluorosis categories.) The. highest prevalence of fiuomsis, as well as thehighest peraTaage of duldren with nnoderate or severe fluorosis, was found in. Region V (Southwest), where natural fluoride cor=m- tratioas are known to be above optiaumrt in many com- amruties Table ll pr+eser figtaes by gaognaphic region for the, percentage of the population with adjusted or naturally ffnoridsted water, the toucan DIADS of schoolchildren is 198647, and the mean CFI from the :time survey. Cor ventibnal wisdomdicta that there should be a dux positive relationship between the percentage of tine re- gimW populatierts receiving fluoridated water and the CHs of the regions and a ngatwe relationship between the percentage of the regional populations receiving tIL- VoL 33, No. i, Winter 1993 oxidated water and the mean caries prevalence of the regions. Notice that there is not an exact rank -order rela- tionship between the percerttage of the population con- summing fluoridated water and ddv-- the mean caries scores or the mean al sones, One probable reason for the lack of a straightforward re iationshm is the constanp- tion of water containing above-optirral natural concen- trations of fluoride that tends to lower caries prevalence and to raise the CFL Large pence: tages of the populatioris m Regions V and VI reside m comaumities with above- o=rAl fluoride levels. When Regions V and VI are omitted from consideration, thus reducing the confound- ing variable of naturally ocaL=mg high fluoride levels, the rank -order of the columns falls into bioses agree==L The analysis presented in Table Il is only observer- tional, and it is subiect to the saute limitations already discussed for Table 5, namely that regional fluoridation data are being linked with caries and fluorosis observa- ttiorts of individuals. Nevertnewss, cors deraS the ambi- ent fluoride in the ervirm nem the reasons hips pre- sented rysented m Table 11 are surprimnngty strong. This suggests titan, despite the many other sources of fmoride available, mmaumity water fluoridation still e:ts a major mflu- enc a on both caries and fluorosis and it is probably not szaa>idr*g that, wncoadzznty, these has been a decease in the orevaienee of the fosse and an masse in the prevWince, of the latter. Any e»iaruxion of these phe- nonena m the U5 must mcivde the complex role of watt -borne fhtodde. Nohwata solaces of fluoride that can inaease fiuoav- sis risk include dietary fluoride suppu==vs, the mges• tion of fluoride toothpaste by preschool children. and the inadvertent ingestion of otitc topical futorides. Fluoride dentifrices are the most ubiosrutatrs of tie topical fluoride =I hods and their use las been closely exarrawd as a possibie contrEbuang factor to the fluorosis increase. :may, preschool chilatest writ swallow some dnvi- frim wires* brn4ir%(ID9), and although children's ages when dentifrice use bean (110) and the amount of den:- tifr' used (111) have best ids as fluorosis risk factors, clinical studies so far have Failed to cmf= den- tifsice mggesd nr as a prirruary cause for the increased prevalence of fluorosis (51). Carsversdy, the w2propel press. . L and use of fluoride suppi w� has been identified as a major risk factor, i ndicat:ing the nerd for dose scrutiny of the prescriptive practices of pity and daw-ft Ever p=opes @uorfde pmt use may crns'state a fiuprosiE risk faux is s chadrm wlrst otic uncordroUed sources of ingested fluoride are elm. skated QW IIT..1131. Further ais=smm or the reiation- ship between dental fluorosis and tune ottva fitnoride modalities falls outsddP the scope of a review on water fluoridation and readers are referred elsewhere (1551.114,IL5). 33 TABLE 12 Re=Mn coded Opcmal Fiutzide Levels Aocordiag W Air TeReentaaes (4) ceded Recou=ended Mutual Average: Fluoride Cort crol of )A= Daily Air Coneeacadon Range Teases ('F) (pon) <cPC%) 40.0-M.7 '.? 1.1-L7 53.5-583 :.I 1.0•41.6 56.443S ID 0¢I-5 63S -M.6 09 OS -1A 70.7492 0S 0.7-1.3 79.5-9U C 7 o.o- u Technical add Cas. Asoeets Liquid consumption, is affected by the local ambient taryaature and, theetore, the amount of fluoride i><t- gested daily from fluids is influenced by climate (116,11.7). In 1962, the US Public Health Service ester - fished Limits for optimal levels of fluoride m muuarg water for the North American dnzuve zones (3). The motion standards, which were revised in 19s2. range from 07 to L ppm F and are presented in Tabie 12(4). Three factors complicate the relationship between an assented presence of a specific corce tration of fluarid:: m the drinking water and caries ptvteetion: na=tty, van- ation in the attaticipal waterfluoride concen tation (I IS), the mnsumgtion of beverages or of water. o dter than from the zrr nicipal water supply (118), and variable compu- ance with the %=fixed water fluoridation standards (119). The use of home wale: pur ficwdon ws tern, Pith reverse osmosas or diseation types, can recur= the eon- centzarion of fluoride in piped water sources to below optimal Teves. Bottled water also has become a popular substitutefortapwater.Theamcmr toffluoridembottled watts varies and may result in bdividuals consunung too li ttie or too much fluoride for their dimate zone. Het tz and cvwotkers reviewed the health histories of I,VS children in a pnvaee pediatric dentistry practice m order to deme the prevalence of bottled watts usage as a prianarysotreceof drb*ingwatter(I18).TheinvesdPtms asked the brands of bottied water used and detem=%ed the aatauat of flunoriA Lary cone& eo at that time. Oi the 1.126 ch&b n. I= (95%) Lived in homes served by murodpal water soLucm the other 5 percent used well water. One hundred twenty-four children (IL0%) did not use thew available &1nicirg wam w wuma. Of tate, 105 used bottled water and the other 19 had home water purification systems. Depending on tete brand, the bot- tled `~rater contained Ecom 0.04 to 1.4 ppm F. The investi- gators concluded that of the 105 children using bottled 34 Jousaal of Public Health Dem istry water as their prurm y water source, 17 percent were TABLE U wins less than the recommended daily amount of Maur CorQtpowuJo Lased for Comity Water fluoride. %2 percent were seceivir g more and 1I percent Fiaaridaaon (19e9) (4) Were re M%ra%g the correct amount In this study, the bottied water came from nine different bottled water commanies, six of width were located in Colorado. How- ever, in anode r study of the fluoride concert of 24 brands of bottied water from the U5 and abroad, l8 (75.0%) had fluoride cattcenurations of 034 ppm or less, two (83%) had a fluoride concentration of 0.55 ppm, and fbur (I6.6%) had fluoride concentrations from 0.70 to 1M ppm (IIZ_ Several studies have reported discrepancies brrween the irUmumd and actual concentrations of fluoride in fluoridated water supplies C24,=D-I25). The stale of Mi- nois enacted marniatary fluoridation legislation in 1967. Kathy and cowortcers reviewed monthly laboratrny slips from 249 fluoridated pablic water systems in minois for a five-year period from 1977-81 (24). Compliance was not consistent Municipalities with large populations and water plants with low chief operator turnover more cote- sis� mainralned the re=mw%e tded fluoride level. Other characteristics that influenced compliance rates were the source of the water supply and the classi cu= of the water plant operators. Thus, even though a com- munity practices watt fluoridation, the addition of op- timal aatoants of fluoride cannot be assumed The Centers for Disease Control reported that in 1988 evere were neariy9=mnnidpa1 water systeaes with the fluoride cortce:t. ttion adj" zted to an optimal amount (4), serving aj�ately 123,900.000 Americans. The three prindbal types of fltmrictation distztbutfon systems used in tine LIS are the saturator, the dry -feeder, and the acid - feeder systams. The Indian Health Service uses another type, the Venturi fluoridator system, in some small iteral communities. Descriptions of these systerns have been published (126). The true° prirtdpai compounds used for fluoridation in the LS are hydroftuoslicic add, sodium siicofitmride. and soditun fluoride (4). The fluoride compound used as the fluoride st7urt a and tree distrtbu�txort system .trust be compatible. A saturawr systm is used with Varnrlar sodium fluoride, a dry -feeder system with sodium sMcDfluonde or sodi= fluoride, and a solubor feeder with hydrofluoszbdc add (ML Sodismt fluoride was the fast cwtpomnid used in COD - trolled fluoridation. programs. Becanse of its low moat, sodium siicmfluoride replaced sodium fluoride as tate most frequently used compound for fluoridation Withm tate last 20 years, hydrvfluosilicic add has be=re the preferred cotupound m the U5. In 1975, hyd:ofiuosilicic acid was used by 37.4 per M of tate fluoridating tzttutic- ipalities (5). In 1969, it accounted for 573 percent (Table 13) (4). Several factors are respormble for the inert+eased preefery toe for hydroilues7icie and, indndingits low cost and relative ease in handling (5). Pop. Served SyS== Compound a % % r T', 99X4 62 :,187 .57 acid Sodium silicofluoride 33 0.494 29 1.432 16 Sodium fluorine 11.474,400 9 2,431 2 Toral 1" 324 100 9= 99 The --k--' teed was tot mdiaaed fpr all svxiems mnxw erg so daa aariaaoasaim� Recant publications have addressed the econornis of cnataumal water fluoridation Murrav estimated titre art- nual cost per person of fhioridation in 1961 for F=g I-ong, Watford, Engianc:, and a series of US cities (126). He believed that assessments of fluorination costs twat by the US Public. Health Service were inflated because of failure to amortize the costs of fluoridation ezu =mer : over a 1x -15 -;veer period. The costs of caries-prevertuve pnagrams, hu ludiag water fttraridrati=6 were discussee at symposia held at the University of Michigan in 197L and 1989 (127,128). Also in 1989, White and coworkers -- -.. addressed issues associated with cost -benefit and cost- anah►ses of counnunAl watt; fluoridation The cost of communal watt fluoridation is usually e gxvssed as the annual cost per capita of the total potr ulaMm being served. Costs include amortization of initial capital oaxmdmaes and the annual operating costs for supplies„ ataattenanca, and salaries Costs vary accord- ing to a plants capacity, the type of installation and fl we=e comported. tete number of mMcn= pou= and tate er u&M natural fluoride concentration. Internadon- ally, costs obviously wiR vary depending on tete nature of the local economy -m which Am dat= is intiodtti md. However, a universal eoanaatic fence for watt_ fluorida- tion is treat cost varies arversety with the si= of the pope being served. Itt 1978,Newbtun estiatubed that the approximate an- nual cost of water fluoridation programs was $0.20 per capita in the U5 (127). He esi>atated that, after fluonda- tion had bem operating for 12 years, a ataxianml annual savings in dental treawwwA expmeilttue would be $10.00 per capita,. so that the appcoX i_. —t cosi-bette6t ratio for water fluoridation would be USM In 1989, Garcia reported that direct annual costs t fltmridadort in tete-US ranged from Sa.12-5131 per pet son with a mean of SO54 (128). Site presented costs based upon capitalization of ndsting equipment and on equip- ment repLx neem costs. Based upon the capital cost of voL 53, No. 1, Wilmer 1993 existing eauiptnent, she reported that the annual cost per person to fluoridate communities with populations of 2.000 or less was $0.77-51.16: for comrnuniiies between 2200-20,Wo it was S02I--50.95: and for communities with populations over 100,000 the cost was 50.12- 0—n. The omst data on fluoridation collected by Qu=a were reanalyzed separately by each of the five work groups at the Michigan Workshop (1301. The results of the reanal- ysis are colle=vely sununarized as follows Communitc Size Range of Costs (pe: person/yr) >2)0AW 50.12-0.21 10,0�=,000 sols -n �s <10,000 SO bid -4i The costs are in 1968 collars using a 4 percent discount rate, and flue range considers hieh and low estimates of a�mnptio aon labor, capital, number of injection points. fluorine - coahvound, aurid use of weighted and un- weigsilted averages. The greatest variability was shown in the smallest cities bemuse of their sensitivity to changes m the variables that comprise the analysis Whit_ et al. reviewed eight published reports treat corn, pared the cost of fluoridation with its beaeut or effective- nss (129). The cost -benefit analyses all used treatanent savings, aqxes5ed in dollars, as the measure of fluorida- tion success. The cost-effedivmwns analyses used caries prevented or sinuses saved as the measure of effective- ness. In these studies, which were published between 1973 and 1987, the cost -benefit ratio varied from 1:25 to 1:115, and the cost was given as between 50.2(3-51.22.per• surface saved_ They stated that the effectiveness of water fluoridation is influenced by at bast three variables (1) thebaselimcarisrateand changeindiseasepatternover =—v-- (2) the mobility of the population of the commurdry, and (3) the rmahber of people at risk for caries. White et aL believed that, of the three, the mast impouurtt is the disease fluctuation over rials, which was not duly con- sidered in otiherpublished analyses They concluded that 'water Suondation is one of the most cost—effective pre- ventive dental programs and, indeed, may be one of the most costive preventive programs in health care.' Alteraari es to Commmmity Water Pinoddabon The principal regtmvcnent for cc== 6-d waterer fluori- dation is a cen piped water systtsn (I25). As of 1988,1= pacer of the US population, approximately 30 zrdM= people._trsed private webs or other souraes, rathe than a mur pal water supply (4). Far d w se mdi- viduals, alterr6vive sources of fluoride are recom- in the LIS, in lieu of aoatauamal water fluoridation, other community-based methods of supPlyirtg syst�eatiz fluoride to duldren are the fluoridation of an individual sehoors water supply and the esudAislmww t of a school- based fluoride supplenhentprograat Also used in the US, as we[I as other countries, are school-based fluorine mouthrinsing programs that provide topical fluorine contact to the teeth. Fluoridated salt has bean sold is Switzerland sinme 19!5 (131) and recently has been inaoduced into other Ct)MMes, in=udirb Fran `L Mexico, Jamaica, Colotnt ia. and Costa Rica (17). This method is believed to be as efieaive as communal water fluoridation, proviaed the daily intake of fluoride, messuma by urinary codon L-ve�, is similar (131). Fluoridated salt is usefhui in coun- tries with a lark of centralized water supplies tnat make water fluorination tecmically difficult and expermve. The addition of fluoride to salt is not —di— cad in the CI5 because of its well-developed network of munianal water systems and because of the presence of nattually o¢=ixg ovtiaeal or highs levels of fluoride in taanv cammtmities. Other considerations are the propriety of promoungsaltingest on with i s known link to hypertese- stor, and tine substantial variation in the ingestion of flimriae !roam salt. Mick has also been used as a vehicle for fluoride and beta proposed for use by children in areas where the water supoiv is fluoride defiaemL However, studies of this partinuiar method are limited (132,133). School Watt Fbmari� Sdw& water fluoridation is well suited for rural areas where the schools are suo- plied by their own wells and especially where child e in many grade levels from kindergarten through 12th grade aqv attend class in the --or adjacent buildings. Considering that the age group served may Lange from approximatdy five to 18 years, the teeth could remove both slmen c and topical fluoride exposures In 1,054 the first evaluation of sd u)d water fluoridation began in SL Thomas, US Virgin islands (134). Since chil- dren have z limited exposure to th= school's water, it was fluoridated at :3 ppm, slightly over three times the optianuat indicated for the c m v=dty. Otlhe+ studies followed in Kentucky.Pm=yivania,andNorth Carolina (135-138). In Seagrove, NC, after 12 years of school water fhoririatzon adjusted to seven !frees the oetznhuamf or that locale (63 ppm F), students had 48 percent fewer DMF surfaces compared with children, examined before the fiuorie;-Hon program began (134). in 1976, atter eight years of school water fluoridation at 63 ppm F, cont mu- ous participants in the seventh and eighth grades = Seagrove were e=unir ed for demal fluorosis of tete ca- nine'!, pteatoia=s and se=od moiats (138). These teeth were mmeralizing at the time of the dddren's entrance into the progre aL Of 134 examumed du dzen. 11 had 'gnestionable" fluorosis and the rest were classified as r=naL Because tiee caries adubum from adjusting to seven times the optimal fluoride level was only slightly greater than the caries mkdbiti:m from adjusting to 45 times optimal (137), the c nTmt recommerdation is that the lower level, Le -an adjastueentto45 tanestfheoptimal 36 fluoride wncmtraaon for the area, be used for school watt fluoridation programs, (140). Despite the domm=tad effectiveness, of this method., it has not been widely iacspiemneated. At its hmgtht, only 500 schools with sli,l more titan 200,000 schcic� children. participated (17). As of 1999, the Cettes for Disease Contrai reported that =456 schookbildre . in 351 schools were involved in school water fluoridation crograws, predommandy in K uucicy North Carolina, and Indiana (4). Consolidation of scieool districts and extension of aumidpal water supplies may have mn:rfo- sited largely to the reduction in the number of programs. iivaride Stzaniemers.tPzoLrrams. What itis not feasi- ble to adjust water fluoride to optimal levels is a mmmuniry or to initiate school wars' fluori- dation the use of dherary ftttoride =ppIe=te= in schools has been considered. Sdwot-based fluoride suppienimtt programs use daily a ? 1 mg NaF tach, which provides 14 mg F This dosage for schm"ged Chfiaren is based on current American Dewai Associatiocn and American Academty of Pediatrics recommendations why the water is fluoride deficient (03 ppm F or less) (141). As with school water fluoridation programs, children may have t3tezr fast contact with school-based fluoride sazplentEatt programs at kindergarten- However, sap- piezne nt programs can begin earlier at age three or four m Head Start or at bath in individual home programs. The younger the childrest are when introduced to fluo- ride suppiesztents, tate greats will be the systemic contact to the teeth. Nevertbeless, honw-based programs are no- torious for tfieir lack of tong-trxan c=q)hattce, which is a marked disadvaruage to this veapproact- Resnits of chnical trials of fluoride mmol haul been reviewed by Driscoll (1421 and Me3Ibeg and Riva (1431_ An average DMM reduction ofaapzmimateiy 32 - perce=tt can be expected. Because the tabiets are chewed, swished, and swallowed, both systexrtic and topical bee efas accrue to the teeth when the ciul=m entry de program at age five or s= in school-based fluoride tablet studiesteeth that erupted during the study (144) or late-e•aptarg teen (145) received the a%= bestefit For instance, DePaolaand Lax reported that use of acidulated Nat; tablets for two school years produced an ovamft cat les redttcdun of 23 pe rcerd 044). However, the caries reduction for t eestn that erapted durmg the study was 53 percent. Fluoride WAets were put of a m fluoride regimen provided to schoolchildren in Neism Catm:ty, Vwgixtia (146). inadditim to thediewy.&wride suppkmatt, the ctuldrert were provided with a fluoride dentifrice for home use and rinsed once a week =school with a 02 pera nt NaF rmse (900 ppm, F). UtiIizutg a hismwiral control, the investigators a 65 per�stt lower DMFS prevalence lit sac- to 19-yw"ids who, de- pending upon eicir school grade, had pattiapated con- timtously in the program from one to 11 years. Since tine Nelson County study retied upon a historical control, the jovzaal of Public HealthDftvisuy results also reflect the general deduce in caries that has occurred in US schoolchildren. This circumstance, sou pled with the multiple fluoride regi tma that was used, makes it =Vossibie to separaw the effects speafscaliy attxtbutable to the fluoride tablets. On the other hand, trials of fluoride tabiets in the US that used Ment placebo contra s were all mrxhicted were than a decade ago. beiore the mai= dine in caries pmvalenm had been d Presumably, studies conducted today would produce a iowt-- absolute diffwe ,= in teeth or staraCs saved as a result of tine fluoride tables auerver, tion. Car= has reviewed tae costs of school -used fluoride suppknv= ptogs-aatss in terwLs of IM dollars. She re- posed a mean cost of 52.5" ve= child with a range of SaB5- 5.40 (228). Differences in cost result vrir� from wheats- tie ve:sorwtd mvotved with the program are salaried or vownte_ss. Flnaade Mattaz irse Prosxams. Fluorine moudunins- ing is a widely used public health method. In the US, it is second only to mwtauatal water fivaridation. The exact ntwnber of American children particimiing in school- based fluoride mouthzinsing is not clear, and the figure has been reported as tow as 2-4 mMion (147) and as high as 12 million (148). School programs in the United States usually use a Q' pea c tt NaF solution (900 ppta -rl. Chuldrern most after rinse once a week uxndes stupervisic with 10 rel of solution fur one wtinut- U 1®dergarren &ildren participate. trey raise with 5 mL The results of fluoride moudsxirtsing studies have been reviewed re=dy by Izverett (149) and Ripa (51). Both agree that studies of fluoride mouthrinsing have given omm=teatty positive results, with few reportmg caries inhtbitians a less than 20 ; Py nmhtidpa found titan for No-th Ate*+ stuff in which a mouthrinse concen- tration of 900-1400 ppm F was used, Dh(FS reductions of 16 to 44 petit, with an average of 31 percent, were obtained is damn nines (51). Four swdie5 have been. condnmmi in fluoridated aoatwttmi- ties, of which three were positive (51 L Howeve , since the disease levels m fluoridated communities are usually lower than an ones, tete number r of Par- faots saved per year fmm 8wmiL- m=tg is less (ISD). IPvee t Aiscu2sed that while atost fluoride mouthrinse, studies Yielded statistically significantcaries inhibitions. those using a hWarical control design could be chal- lengedbye of the background dexFizee in caries prev- akrsoee that was also oc==rmg (14%. He observed that event the more , eawt trials using appropriate control groups were reporting sum Der differences m. tete caries incide m between tete experimental and control groups. Irve ett cotncuded that f mum fluoride moutitrinse p, graars were uniikel}► to reettlt is annual savings in DN.. fiia=ortt greater thm 0.4 smfaces, thus reducing th cfinical importance of tate re mIt. Ripa and coworim found that participation in a VoL 53, No. 1, Wirmrs 1993 schooi-based fluoride mouthmrusing PsOgrzIn PTOQuced a g terpercentagrcaaies reduction in smooth Proms serrates than in eithe occlusal or buccolingual V=faces (151). Aha seven years of rhes OF procural surfaces accounted for 5.9 percent of the total caries prevalence. co,pared with 10.1 percent in children examined before ft program began. Although this result was based upon a historical caamari-v0n. it is cottsstwt with the known axion of $uonae, in =nooth tooth surface caries. The cost of supplies to conduct a fluoride moutfms- mg program nave been estunatea to rang; nom SOb9 to S.=/child/veer (in 1968 dollars) (128). The material costs vary depestding upon how tine rinse is disused. The least costly mtediod uses vu= bottles to dispense the appropriate voiume of solution: the most eve use prey berm; indhvid a paaers If volume -ss super- vise the program, its cost tends to m low. -Paid personnel will obviously ince ase the total cost In an evaivation of 11 different sawol-based fiuoride mouthrinse programs. Gama calculated the average cost to be SIM /child/ year (128). In a recent pave study, kindegartea and first grade study m Springrieid. OF., were assigned to one of d uve erouvs: one group rinsed once a week in school with a 0.2 percent NaF solution, the second grout chewed and swallowed daily in school a 2? mg NaF tablet (lA ung F), and the third group did both procedures (152). For ethical reasons, there was no viacontrol group. vEigtu-year DMFS in- were 3.6,2 E, and2.4 for the tins-, tablet, and combined programs, respec- tively. Even though the combined regimen showed ire Cres caries protection cnmaared with the moutltrinse, the investigators mIt that the additional cost, time, and effort reatuixed to carry out the vrdsae would appear to outweigh the small savings in DMF suria� Thesr fore, they rer,ao - riesnded that ongoing fFnoh& month - rinse programs should not be replaced with programs employmg both prooeaurts. Sociovoliticsl and T eta] Issues McClure subtitled his 1970 book on watt fluoridation 'Rine Search and the Viraory' (3). Yet, in 1985, an article appeared in a prestigious rsardestal joarTal , 'America's Longest War-. The Fight over Fluoridation, 1950-. (153).Thisarddeaexnbeathems'Faantreg3tutm to fluoridation that began in 1949-50 is Stevens Putt. Wincormm, and that cm=me5 to this day. In a sur -M of state distal dh ==5 conducted in 19K the Aa -A— DentalA sorlabmf=ndthatdc=tgtinefiveyearsprmr to the survey, there had bees 255 chaGasgrs to dental programs (154). Of time. 82 percent cm= ned flesorida- tian and 13 percent involved school fluoride msoutltrane ptograars. As a result of the csa nanges.14 per of the program* were delayed or aans7ed and 36 pesnest were tis nat,ed. McClure & claim of vicmrry was prem m=-- Theexpansion of fluoridation in the L` %i States has 37 slowed (7). Issued in 1980- one of the US Public Health Service's objectives was that within 10 years, at least 95 percent of the US population with asrrnm=Uri, water systems should be savices with optanally fluoridated water (8). That objective was not met According to the Centers for Disease Control, by December 31,1989, oniv 621 percent of Americarm living in asffis with public water syste:tns were drh%i=tg fluoridated ware (4). Far. of the )ick of success was a result of a change in how federal ftmds were allocate` to the states. Allocation citiu%ged from cat pascal gran= ustdc which money could be dedgnated specifically for fluorhdanon, to block grants, under which fluoridation competes with other uses for the money M. The year 20M oral heilth obec- aves propose a 75 =cestt target that is less than the 015 - pacer 5percent originally proposed (9). Considering the hi,� level,: as)evstated, "Withoutamajorutc essemes npha- sis among natunial, state, and local health policy make it is auesdonabie whew the proposed year = fluon- dation ... will be able to be trier" (1!5). That aauwnition also applies to the current level - It would be ideal if health issues were deeded b-.- health yhealth emits. For water fluoridation, this is rarely tine case, as the issue has found its way into the political arena (17). Authorization to finoridate a public ware suppiv can be made by adam=strawm dps u=, surds as by civ or county owcuaves or come ls„ public utility boards, or public health boards, by a votes initiative; or by legisla- tive action. State legisladaa providing for waterfluohda- tion is of two types. It may be mandatory, in which mmaumidw of a cam= size are rued to fiuchdate their public water supplies, or it may be permussive, or enabling, in which a local authority is empowered to araiuittt fluoridation (126X%). Eght states, the District of Cohmtbia, and Puerta Rico have mandatory laws rd qui ng the fluoridation of public water supplies. Unsuc- cessful armawts for mandatoz-v fluoridation legislation were made within the last decade by Fiawahi: and Penn- sylvania (I55). States with enabling fluoridation legisla- tion inchuie Alaska. Nevada. and Massachusetts (126)_ Massachusetts statute easpowers the State Commis- sioner of Public Health to recommend fluoride adjust- ment of the public water supply of arty city, town, or district The cont mortes is regtured to notify the local boards of health, and the boards essay, if they consider doing oro ins the best interest of the residents under ttseir pmsdiction,orderfltmridatimofthe publirwatersupgly (1.26). With either a mssrdatrory or enabling statute. the legis- latim may also anew orreguire t hats vote or ref erenclum be takes on fisc: issue (136). Nevada. for irsstaaa, requires thatany proposal for aporia -mm acusis be snbmnft3nd to tine votes wittms the affected masmrasity. Unfortunately, referenda bave proved to be the --i-of of fluoridation. Easley found d= bmweeen 198049, 63 pestxsst of 163 commsusity fluoridation referenda failed to pass. Con- 38 ve<sdy, of 281 fluoridation initiatives in which only a gove Hing body was involved, 78 petcecst were success- ful (15-2). Easiey concluded that, in the absence of a state mancam tine most effective means to implement coaunu- nity water fluoridation is to 'pursue promotion with the local leVsiadve body and hope that a re%sendtmn does not ensue' The pro beeltia � b=e& have presernud a ou nrndary foraoass rs+suus de ;ss}s_&-r. emergedja Wisconsa1137--159). To expiai n this phenomenon. a World health Organi=ion publica- tion Iists thrcehetors (126): Fir=.igmta—and.rqnf*- soa on thepart of the public about the da -21 -haulm bene m of fiuoddaho^ in the late 1960s it was bdieved that during a fluoridation campaq= people weer- Con- fused by ezaosiue to conflicting arguments. However. m a 1977 national survey conducted by the Gallup Organi- zatior. 49 percent of adults mrrectfy answered that the purpose of fiuuoridation was to reduce tvotin decay, and in a 1980 Massachusetts survey, 76 percent of respon- dou s. mrrecsiv believed that the purpose of fluoridation was to improve dental health (160). In Massachusetts this knowledesable public opauon did not translate into voter ace_�cance, since, of 14 referenda held between 198D and 1993, local Massachusetts voters rejected iluo- ridation inn l l of tine= and the pooled results sinowed that :. only 39 percent of those voting favored fluoridation (160). While these findings do tot refate the conwntion that people may be confessed during a fluoridation cam- paim diev indicate that simply understanding the ben- eftts.of watt fiuon iancin may not be sufficient to nuke peooi= favor it Seim , aasoisaienoa(K t>bcpidic a ane aumatt codv*et, in a 1960 survey conducted in thirek California con==iSes that had or -were scheduled for fluoridation reiwen= the majority of respondents did not hold opirm s against drinking fluoridated water (161). Moreover in a survey of mothers of preschool duidrm frost low socioeconormc area of Seodand, the rrxAh rs held more positive attitudes toward vaecna- tions against caries than toward watt fluoridation (162). which seemed to indicate that ambivalence toward sd- esae was not a major cot rL T itnfar�ma, Sapolsky (163) pro- posed what Hast;itet later tested the 'confusion hy- podumds' (164). During a fluoridation campaign. esters are ecposiedtocomfttct ngarg=mwftbyvmirvidualswho claim to be expem and the votes have duty idea i- fying correct information, misinformation, or die information. As catalogued by Horowitz, not only do artifluoridationists asses that fluoridation is not effec- tive against caries. but they also allege that fluoride pro- nates -hewer, sickle cell anemia. kidney and heart dis- Journal of Public His Ith Dmtistry eases, birth defects. Alzheiae es Disease. and Acm r lmauae De&ieney Syndroane (AIDS) (17). Theo ala. nave port ayed'fluoridation as a cotnanrnist plot a cor, spiracy of the sugar and ahmtinun. i unLstries, and an invasion of freedom of choir since it for mediration on peopie who may not want it (17). Armed with these manyacrasadom the antiRuoridadonistsoan easilygm, erate a moain na of doubt in votere minas, which oiten is int to sway thein against fluorination. Con- versely, finoridatioa's supporters meed to try to prove, widwaany question of a doubt. tinat fluoride is safe and effearve in order to gain the vote-. Simply put. raising doubt is ewd than suppressag it A four factor, not listed by the World Health Orea- ni —tion, but which may acinuses inwormnc-- is rte issue of aoutmili :ix Onec de�tk . it is o' , r - -St that at d.6.- Scottish heScottish study cited above: Kay and Blfnkhorn found that the mothers whom they interviewed prue:rred meduxu- of prevetnting disease time were dietamd by tined desire to renin some control of the situation (16L This smd- ment echoes the statement of the lead-• of a successful 1983 rtanpaign to de$voridate Levittown, NY, who ex- plained that a strong eiement of the anaftuoriaationists' argument was that. "We're skeptical of government—we want control over what our children consume" (137'1. The antiSuoridanornists have also taken their bar* against cxrmm dty water fluoridation to local, state, au, federal counts. Utigaticm against fluoridation beQpn.ir--- the early 1950s in NorthinaatQtnn. MA., and San Diego, CA. In both cans„ the legality of fluoridation was upheld (165). Gesneralfy, the opponents of fluoridation contend that fluoride is biological harmful and water fluorida- tion is an unreasonable exercise of police power, tinct fluoridation is a violation of religious freedoan, that fi uo- ridation violates constitutioral guaranteer of personal liberues and protections hcoan harm to the public. and that fluoridation. is a foam of class legislation (see review by Sock (16:5)).However, to *0610" r+eoortilm * ap--wEgKLSi. Btocklists 13 fluoridation cases that readned the US Snprezre Court betweert 1.054 and 1984 (165). Afore was actually heard by the court Either the case was dzm=med for lack of a substantial federal gaestm or the court de:ued the writ of crrda,.i for which no rasa need be given Essentially, fluoridation has bean upheld asa lunate ere des of govenmrsm nal The continued constitutional kg b=kcy of fluorida- tion upheld by US conats bodes favorably for the future %of water &tmridation, There are other favorable signs, as well. Although the absolute rnumber cd fluoridation ini- tiatives decreased during the 1980s. Easley's statist j show a higher permntage of facvorabk outcomes during the second half of tote decade MS). For tine first half, 2 : percent of fluoridation referenda were favorable com- pared with 52 pert mt is the seaxnd half; li wwise, favor- Vol 03, No. 1. Wnt w I993 able outcomes for fluoridation initiatives instituted by legislative action ina'eb5ed from 74 percent in the fust half of the decade to 86 percent in the second hall A suecessrul outcome for a fluoridation initiative se- qWm cretin planning (166.167). Tire success of a I& - Crosse, WI, fluoridation reierendt= W, 1988 was atWED- uted to a well -conserved pian tfiw included broad-based mtrtmunfty setppor. led by afor a bette hearth c=unitte~ cartsvltation and support from congaed proiessional organizations; knowmageabie smerl= *- re- pordngby the press; the timing or the ballot m coincide with the W isconsinmesiaential priataty eiecdan in order to ensure a targe vote tar nocz and tine support a sow local cHropracmrs, who, as a group, traditionally have been fivatidation ovooneitts (166). Even the 1995 vote against ftumridation inSanAntonio cannot be consdeaed a cornpiete fariktue. The organization ana play— of the fluoridation advocates were va41e3u and fluoridation was narrowly deiced by a margin of 42.32 to 394!0', comaareci with a 2 to I anargin when San Arnania is were offered the same choice 19 years eariic (168). Rec=dy, Martin has amh—z d the fluoridation deflate at a social, rather than a dertai s::Iu fir level (169). He that his analysis is not concerned with the scientific merits of fitwtiQation, but rather with the eie- tomtit that have conixfoated to maidng fluondauon an issue of unresolved public debates He considers the pub- ic argumtent on fluoridation an "ocattise of powew✓' in- volvingproponents and opponents, organized dentistry, individual researchers and the research establishinertt, and certain eienvffm of i viustsy including the ahmrtututst and festUizer industries, tie sugar -food industry, and over-the-counter dental products manufacturers. MardWs book is +r*+am- wu-- it attentpts to avoid tine "rightness!' or "wTmgiess' issue in favor of how scim- dfic knowledge is used and shaped in the course of what he calls a bitter public debate Conclno= t'C :rrnv rdty water fluoridation is one of the most sura cessful public health dices preves tum pr,og rar s ever F i iitiateeL It inns the potential to bereffi all age groups and i all sodoe=== strata, including the lowest, which has the highest caries prevalence and is least able to afford E ptevea ve and rest MdW service. Con=wnity water t fluoridation is also the most cost-effective of aR coat mu- oity-based caries preventive mediods (128). Early water BucruLwon studies produced caries re- dncciow of 40 to 60 pat rstt-for the per- manent derdtion, and slightly lower reductions for de- dduous teeth (10). Remit studies have found a smaller differaha'in the caries prevalenceen between optimally fluoridated and communities(ID.This change is be iered to be due to the avaL*Mty, begiaaang in the early 1950s, of a variety of fimride products, mdudiag pr ofesmmlly applied gids and solutions, der - 39 tifsices. mnouthrmses. and systt rnic supplements. Use of horse products reduces the caries prevalence- in both opcmnally fluoridated and fluo dent cmmrnuni- ties and, thaviore, decreases the magnitude of the caries difference between the two. The presence of fluoride in beverages and foods that are processed in fluoridated matauu ities but transported in, and consumed in, fi uo- ricie-deficient ones further acts to biurr the distinction, S7) caries activity between fluoridated and fiuoridedeacient coa""mities. Corbin has written that it is "virtually die to find 'nonduorid.e' a=menities due to the many oppor- tunides for alternative exposures to fluoride" (170). Com- munities in the United States stM may be classified as being optirnally Snoriciated or fiuoride-deficent based upon the corcentrad n of fluoride in tete dymk ng watt however, because flu=es is ubiquitous in food ar= cental health products, practically no A.a=rican todav is unexposed posed to iiwriria Tl>ereiare, to designate a US coati- ummity as stricdy fluoridated or fluoridedeficient: may now be a spurious distinction and. in the future. should no ionge: be em. ha.sived. Rather, the emphasis should be directed to the geographic and socinemnomtic diffez- ences in caries prevalence in the United States While it is desirable that initiatives contirme to huxease the number of Amerkcans arinidng optimally fluoridated water, the underlying goal should be to attain a rtratorrrtiv iom caries level for all chic regions of the country and for all socioecommic strata. Along with analyses of the benefits of any health pro- cedure should be studies of cuinddew risks that might be reasonable to expect Bemuse fluoride is primarily aepositz'd in the bones and teeth or excreted in the route, the efi eco on the body's hard tissues and iddneys have been ame'aally well studied. In addition, Ruoride risk amessmott has also considered the relationship between fluoride in the drinking water and cancer. At the=—ie optimal fluoridation was introduced, it was known to result is about 10 percent of the population developing very mild fluorosis (5). In the 1940s and 14Ms, this risk was considered acceptable, considering titre substantial caries preventive benef is both i n absohim and percentage terms. However, reports published in tate 1980s found an morose m the prevalence of fluorosis m @norsde-cef detest oom=mitie s and, to a lesser - - i t, in Btrmidated ones This inaease is principally iii the milder forests of fluorosis, which was considered by some earty atve5tipto s to enhance the appearance of the teeth radrs than to be wstnedmDy detracting. Nrnrdteless, the ine mese, in the prevalence of fluorosis is prima #= evidence that inannased fluoride ingestion has ow=ed among young children. it Inas not been deter truned whether the observed int=ease it fluorosis is a necessary tradeoff for the reductions in caries prevalence that have been achieved or whether the same reductions could have o==red without the increase in fluorosis. 40 Leverett presented a graph coamaring recent caries and fluorosis levels with water fluoride mncmtrations (171). When siaular emnpar'isons were first done sourer 40 to 50 years ago. Tieing the data available tier., the caries and iluorosis cover intcsected at a water fluoride con- cmtratwu of 13 ppm. The curves prepared by Leverets ir,tssected at Q.8 porn. a difference of 33 pe cem Levetest attributed this difference tn the inQeased locution of fluoride that has occurred as a result of fluoride becom- ing more ubiquitous in tine environmumt bean it was a hal` century ago. Frudence dictates tnat buavertent and un- necessary nuoride ingestion should be avoided. This re- quires that dentists be aware of the inCiicatiotts and propertechnin=s forprote Sultrin topical fiuorim treat - zt=oe that: consume:r products, such as fitrorice centi- fticcs and m.outhrinses, be laoeied theirpropm ase. especially formol -aged ciuldrer.:and thatphy- siaans, dentists, and piarasaasa know when dietary fluoride supplements are a>dien-d and wisat the recom- m mded dosage m In add=x%, rurti>m research. is indi- cated to undm-stand bene the cmxqAexities of fluoride ingestim► from multiple smzrces, especially from watt= and other beverages, dietary suppiernents and denti- frices,, and their roles in fluorosis etiology and risk. af- otAcshdia. The vrobiem is twofold. Fitz, few gpes vi bmt ft appears to i di eracraoiiar baae.a+rci�artl�mmusaeaw and de=au"he Sem+nd, it should be detmmtined if the overall effects on the bones provide a health benefit or pose a health thereat. Although fluoride may innse the bone mass of the vertebrae, there is not strtmg evidence of a concuaataut reduction m the incidence of vertebral frau or an aneviatien of the clinical svmvw zs of osteoponoai✓. Like- wise, time evidence of a relationshio between tiuoridated wate- and the ince' ;e„. of bone frua= is not clear, with different studies reporting mote, less, or thesatne iradence of bone fractures in mm»sitieswith nat=atty higher adiusu%Lievets of fiu==eisthe drank- . ingwaver compared with caaaQ.tutities (15.61-67). No untoward effects on the keys result firm drink- ing waves mut utitr g optimal levels of fiooride. Ever whmbdghconcesiftatiortsoffiuoride,astsro I as30ppat, were k adverterAiy added to the drmidng waves, healthy individuals did not suffer harmdul kidney ere— (92). May comproamL%ed patiem undergvfng hemo- dialyss regent the use of waterwith a low conte rmation of fluoride as well as a low mrnocntration of other ions. 1 -be r6a6mtship between water flumidatinn and can- ner is especially imyortant baauae of peopWs fear of carsoer and because ar.ti&ro, "l tionistt' tactics a piMlize on that fear in an effort to defeat fluoridation. The can- eer/fluoride issue was exacerbated in 198%-A0 by the Journal of Public Heath Dendsa release of the res lts of the National Toxicology program's study of sodium fluoride m laboratory am mals. An indexer lent pec review panel am ultrded Haat there was "eouinoml" evidence of carorogesddty from sodium fmande in male rats. based coon the fundings of a small nuamie; of osteasan=nas in the NT? study. The panel iound no evidence of caranogetiaty in ftmcale rases or in male cr female mice (is). Artotiw-- study, coaaatis- sioned by the Procter be Gamble C.omparty, famed to find an associat between malignant taumtoes and sodium ffuonae mgesdan by mice and rats of eithc sex (L4)- The Ad Hoc Subcomlmittee on Fluoride of the US Public Health Service mat wienm the results of these two animal studies were considered together. they faced to estabbm an association between fluoride and caertter '('S.'.cl iveo:donedevid=iiologicstudiesaisohave failed to find a correiat= between fluoride in time watt= szr*y and carg--.:very review of this evidence by expert committees has iound nates ally or adj.isted levels of fiuoriae in watt not to be associated with canoe in humauts. Because watt= fnwridation provides proves. dental bene fits with mira ai risks, the freauerd success of anti- Suotidatim.ists in prrvtsuir.g fiuorication or removing it from sties in which it had been established is perplennc,,. Reawns that nave been proposed to explain the antifruoriaationistsrity were listed am the sectio. "Sociopoiitial and heal issues.' The argmu w nts of the an ' which are designed to date doubts, are easier to advance than ones that must instin conft. Bence in fluoridation. Nevertheiess, the antifiuoridac bora sW campaigns are usually well orp=zed arxi often enlist the support of coama.msity leadets, politicians, and the mesiia, and they have been cul m creating an aura of =u where no scientific oarmovemsy ex- ists- The x- istsThe cental public health mnurrunitys success rate in aecoatalisi.irrg time fluoridation of mm.icipal water sup - pines =oust inter• WeB-viarmed profiuoridasion cam- paigcrs have been stacnesiul (166,167), and the eiemus of Breese campaigns srouid be studied carefully. Cortsi& ering the graying of the Aa>micart popufaflea, tine bee - fits of f3uoridatim far adults num be more folly doca- mteeseted and pubiicbmd. More research on the effects of fluoridation on bone is needed and, if the Bangs are postuve. will support claims of general hearth benefits in addition to dermal benefits. Fatally, it must be made dear dMt Ackno vledtmtea�L% Mw tauha thateb Alia! fiorowiM paeadmt of tbeA-- Amex dan= of Pubbe Haatth Dwtittoy,ter w*wA=gthev vitatim to vote this mview, xod alma the fallowing iadtvuba6 wbo mbogy red the ongmat dm& Steven NL Levy, chaisaeaa� AAPHD oral tiaaith C� rxmer; Bean A. licit laame Dari+. Steve Cerbm.lamps= X Dobemy, Ft....-►..+ 5. Fleeowntz Rab�s Lmman. R -Gay itaaar. mad Ma3c S:e.., t VoL 33, No, t, W m=1943 Refesemces Al -A history Was fluassmiatamms 1a 1. Me,star 1T, R+` ��haadbmokaa2a Fbaomde m otaea PsW� 1961:I.3Q. tad d Bmvuws. tw+: awl avaroos_ M=ZS=Pbs m arai 2 Mvm F). Ftuaad- aOd ammo: New Yatic. NY: Ksrpsr IVL 3 in� � USCavu��g QESm.1970. a and the v y 5hiaso- 4. Cereus tar Db,,w Canted Fluared=Cft aama 1995' - ' Washmpa. = US Dcper=-,r m imllh and Ii=L= Servws. juty 1991. Www gaaddaece. lm Mems;R Rax LW- Fh&mde 5. Laakr Ci and dim -1 avoacadaai C -mF, in prereatie omtis>3r• Theory 1961105-Mv. 6. t exra to the .dinar. Lo. Ange i m wars is tart gy�idattei I !softie Heath Dew 1991:51:31-t 7. Lb, FL The oodaam sates of US public -a= msppiiea. Puhli $n Heath pjp I966:101:1S7-W- U5 Pnbinc Fielth Se+*iar: Pra®toaag DC US Govammeser Pssm- oo}emvm far the m^^^ W -E-- i g Office 1980 21m Naamal bsltb 9. Ub PahbC Health Sav=z-- eer.Cva esiititaa pranceae and dhtave wevenwa Washmpoa. D` US Dem of H aIth and Fnm+an Savors. 1990 Wa=Rommdatm and ddld dental ,a.Msas+ty B. += AI - health. Were FsuradatiM and accit d+rn 1 mmith m==a=ny nmmn adresas the wade. Es` ode se one peen nsm. Dental vn-ilier handbook m 2]. 2nd o-' Eovwt. MA: WogatPSC. 1!0=,i 1L Newbtum E. Effo=- e s of w u: gvacdatiaa I Public Heads Det 19897491Boec iae}279` M- r,_,,,^, Rennet of wexidm6 L' Naumul Health rad Moiiol Rester oa-n' a maaadets in the tunnel of dmtii erns Amt Dost i l:a Nw3aaal health and taadic 1 tasansh ----t Tbu eihmvessms of wars tinmm d -ft, Ana mb= Amaaliaa Govaaasam Paw-im-B sgw%vr,.1991. 1C bo lS.Mahanev�MCaCL d asks ej CIRev �L laModd 19` 8L IS. US PWAiC FAd& 50viae. Re parr a the ad bore sub-MMUtsse nes flna ddr of the to mm bnam asvaaesmmal beth and strand aeoerams Reeiww ci fbuataoe bme£sa and rnia. Wir Amo - tan. DC t]5 De es mmw m Heath and fr zeros Savw- 2991- 16 CrMullaae DM. Oadoom L Esolland T• D' S. Wbdtam H. �veaasofwas fhe®damm.ss emearzvazrianaf eitmaloaa as hishc daldxm Camaatoarisy Dort Hen lth 19 17. HCmw= Pte. The fuaae serf wmsae &= datum t4taaddes I Deet Ras 2990si94esoe »i 16. Br mdle j&Cuito lP. Reowtumdsmdemtai ernes m tl5 dul&m and the effact of water !b"I'm I Deas Ren I9900GPNC 19. Grmborwki M Haat L Spadafam A_ HOw 8aaridso m afivra adttlt dental oaa.I Am Dort ANW- 199 m4h-54 20. Graz A`- ploandsne. M=e im< a neer best btu Can Dorn Assoc I 19873:7" 2L Rein= ED. Hmt 131L mw peas- and pasosn - e$sm of Batetide in the aria d odboa. j Petbiie Htaith Dos I9 4m 2L Otws j, liat'g.sva. J&PSOOddiki--b-frate �b UmCotmosnt tyDeesOodEpiei®io: 73. GmmbwwmidD-Me IkWt mfama.asro r+aad GatomtmSy Dort atalL-alrSmiot t9e6c1�' { 2L Kasby RA. Nakow" C bmig- L Fa® usicambod with mm=m- nasee ad V.Opo wstsa I3aaeids levels. I Asn Dmt Aeaae I%S:ti45t1-t3. 25. &IIt HA. EtdamdSA. Lomdss Wj. Detmtal besam 8ss of 1>mmd seats m 8nmddemtad wtmes ten deo �D�jm �ILm�� X Oum J, i�� JA. moatpmsm wvg* of mmidsm.7 is ihrmridamsd and mocam mm d ' ria Cai: Fm 19ftinmi-IS. 27. Wiry RbL The edeas om Amari cx:dm of a ehamge from a M medated to a llmmd&-tm Kraal wauy I Dort 231rmazhe CW, Doherty P& Am Mc C'mt:abad fhaarjdatian. aeon! efbsm of Asian m AM*M, Wne v= - I Am 41 Amo=1970gt =--( 29. jard= W_ The Asesda am3sool health study. Am I Pub& Pisalth mz-M-?+01-7. 30. Senzrom rw, McGII D$. Tanis IL Cwies vrev 6-m im Nardmam Saxiand bedare rad 5 yms afer sena: ae�saondatsod Hot Deet I 1967:ISM4.6. 31. Ktmasi W. Effaa of m in waum &= idatimm m the rales mrwxiwae of the p� sod w= -w ar7 der�+on Cana Res 1ggQ14:3pri0. 32. Arwood D, Biiakham AE Trasds m 4ional bualtls of 10 -yarned smooia0mm m TottthwesG Smebtt►d afus aemean of ware: ftsto- radaarm Carnet 190 Iul3Q2M6Ml2fi&-7- 3a. Attwood D. Miokhara A+ A Lsssermmt of the dmeat health of zuam S� des foaawmg the Co ma+ort ai Was fssaotsc ma Camaatadty Drat Hsleh 1989ab•26 L14. 34: Attwood D. BSakbaa AS. Dmni bmlth of adwmldsiMam Dors JJ Liter, Water thsmasdadaa esa�' m soe:th+ceee 1991%L•CsS- 35. Grobbier Sat, Raddy I, Van W. CW. Cai= ... paoeooetrus.11- tine, and vii levels of humor renal niaaeae from areas of varnrzs lb,nAds lere3s. J Drsat Re 19d?�619865 36. Ohveby A. Twmzm S. Ektuaard L Diurnal fhaootle mezmmsatsosz m wetoicsalin m ism kvmgm a kmg and a lor+-9var a atm. Cilie Res 199024a4L7. 37. Rentor C. Ihyhaum A. Fiurside uta wheat aiiva, anal dean1 trues amaataw tm nates With biilth ear kav doom of Harrod- m the d mirmg water. Cabs Res i994:18X4sd 3a Leveeu DH. Adair Sb1. 9dolds C8, Fn I. R+ b-w� saeiva+ ran plague thraeeae lr:+as and dental rtmau� sea t9um- eiated and naaofaa Xw d a [Atssaai- Cartes Res I967;2I:-V94. 39. Noble rias Semler M, Cury f& Dad viaaue fhsmedefe k ww alae natation of water 9zaaodanCe- Ceras Res I9sS -31647. 4t1 LamttraaD.LissmMl.F�asiaae,O,Tsmes� Ibeediacsoflbaotoue ID sa&vs an rexraaaatioa»aa t# rime a mame3 m h� Caws Rea 2961x5.341 -S. 4L 14owosam E- The tam of f to preve nave i�. is Cad,: ,V. 3rd edC3iotm.IL--Qtaaesse:aoe- 4 - Marine JI, Ru88�a Al- Moots of "Mak of fkww g't m sties tea: Fkravode is ons peerestiao- Detbl --can- hero- bookno 20L tad e L Bosom. MA: Wogbt PSG 196 32 43.. Mebibesg IL Rtoa LW. watiaaiet maammsa� of fhtortde 1= Pu - wide to vnrvmuve dermas:. Theary nand darer! apPliamo� Chia�.1L• Ciz�>rsazet.1963:41� 4t lhvrvn WE t;.mgm-f Tad. CbOw LC l e a of fhaottde oa a -.A > y and Ganeavte. Caaea Res 19T13115uml 1Y.11&41 - 4i Sz7vessstame LM, Weld Is: 7immwman BF, Clari4 o OH* Fstl+a� W. R�atiaam mf aassaai rad a:tstiaai hates m nam>an•demt maa+d m vino. Cane Ra 1961:19:138-�. 46L No I w R eese IDB. C IUMV N" Sba� M, S. Fshaace' meso mf r�adiatiaa in Yate and in veva- J= I -eh SA. Famas r6anegas6sodemmnsaUmmomofteethDamon M Presa.1966e9141. 47. DrixaQ WS, Heafss Sia. Hrrmeae IA- Catees �"e a of Itsseode tabiem m eebaalei A&M fom wars afar CISBCOVISOMOCIft of �t:I Am Dat Amw 196Ta�i- 4L 'ihrlstrup A. C9aiol eridemar at the rale of peearpdw @rnadde in nae prevmom I Dort Ras 1990;fi96pac {ra1•?42.5i1 49.13ated. IL► Teasdalt L Bloodwatth G Gas tnes+eatmm over 4 7� is mdaiLdeea etpld ZZ at tbsiroa af.t►ases �atim- flet Dort 51 TA a enam C Kana L ria dnmae. and amanj aam m 7-gw►aid �11dm gvm f� t aAm team irbm* after truth Ca>Se Res 2979.Li2Sts'7r► SL Ripa Lw. A et12klOs of � eumdds nmdk*& ldaofd=!r. mmaasho�.mpeasoNsadadf+PQiid �ialinasseeeaof dsesasd Mi.. and taatsed fltams+ae,s peevalw_ J Public 13mith Dams 1991�1?s 4L rad S2. &iebasa B, SsZvessoam s. Fmt j,.Baeitrtim j. _ ammpiiaaor wilt • oonmmnasty 4iaaae�tlan�P�� i�l�sleh peeventim Gs Fade ko�rtm tistvm:gZe Des I962.-42142-51 S3. Levema M 5vams OB, Im+m Wirddytlnamg a!� mooebrimre in an �'idaad maICUe antlr. test=is atter xrm yeas I Ptahb: Heath Dent 1 SAS95-IOL D� 54 tttpa uh Lake Per ti °mt°aema 1 NIF wh a s- tar with a n2 parent 42 dm===waum=vjpm altasireschool cars j Public Hmlth Dau 1993AM k3r(2 SS. Cac mmrveld A, Van Eck RAMI, Bache -Dieu R Fivaode in - ptrw mon is the effect pre- or Poet -eruptive. I Dent Ra 1990396 Lm):m-S. 56 Ra IwL mcbq :ti Denwrestte u of Public Hath pone~ sum=m u on &aoadaoom of ozr=n=mry watersuppbm and synoms of ftm dammr;isoirtL t of&mridesand8uaridancnmbmaambelth Lamsm6 !&-Mulutam Damu mem of Pubbc Health, IM. S.. FCewtio2tie M. Paaaon E PhUliea E N-ison D, TM*y B. Patftt AM. Gaontiateota sodium fl�esis ehtripy dues eta tecerae vette walnaataeeau eaaosm>nwtimnsalwmopoetaeis(At==4.lBone Miser Res 1969.K6upo11I:sv : 58 Puggs BL, Fiodgum Sr', O'Fapm W74 at aL Effect of fhwode astmms m the Ieveaas rate im pos menopousai waemm with oeooaoroe.s N Engl I Mad 199032 -9- 59. Simooea 0.1-- d. Doe f uohdatem of dsmkiag-waver pre- vent borne iragility and mteoporoeut Lancet 1985 Atr6 24: 6a Be= - m M Sadowalcy N. Hegeed DM. Gw i CO, Stare f3. Pr e- akmm of owe000eom is hip, attd low-8umot arm is Noah Dai ca.IAMA 19&d9&499 -50t. 61. A--', L Aibava El✓., Ktvrvuori t Ksz=anm P. Flip sam=e inc- cmmw noc afissed by 9aQimum asuo&garoas sarmec m laad AgnOnWOSand1986073445. C Avosn L b Teem LG Rdstiataebm between loetghero- sad Wnes&gac . Caadmacs1966::I7s-9 63. Caooer C Wadaam C Lamy RF, Bake DIY. Watts 9 2ari moaesstzaoat and ftmme of the pro3mmal neem=. J i:ptdemroi Coccu= atp tialth 1990A 17-29. 6C 1--oam -9, Gotbag I. wxks TP, Brody IA. Stites W. lru= AA Reposul vamaomam ti C--,4atoeofhmfrmcm= US wha rwom m aged 65 vemnand Olde. JAMA 1990:21 C 2. 6& Sowers NFL Calc MK. la=m-- b A+LL Walbam BS A aroaoac:ive study of bogie z ] mat:at and hmc=e in atmmimeabe with diSamm I Amid, ccx w=L Am I Eodemiol 1941;I33649,6 66. Caoes C Iaaomm Sj. Watsr Huacicknm and bip Ramon Gmwl. IA9A19%26a,-Ii bpi. Phwps = Bart BA. wase•-bomebXnde and etatinl bme numm a mmtietmon of two aotzmms>mtaes. j Deet Res 19903+9:125eb0. Eli Hmmg F, Besdimum T Seller EL Rwkihagager C Fhraoasaon of dtsakag wanes elle xs on kkbWy stone hx=a csL Thal Rea 1983;I3:ITrg. 69. BeDn VAO, Citeltaaa Hj lftgtL fbtoade ansoems m btmodialy= aenmaL Am 1 fey Dis 1990:15: D -C 70..Ltlared D= Powell M Anderam R5. A &W de oversed modast atliaias5faa-p Mil+limmjAmWaterWoomAsoc19B%-7- S-. 43 7L Peetmm L$ Denis D ikown D, Hama JL Heigersas 5D. Coc=m&- rdty health ea-- Ora W oni l vests amppiy hyp e�eaoridataoa aaomemut Am I PubbC Funis, 196 OR7I1-L?. 72 ADA=mm L Find IH. 5adey D. Fisroode iatosiosim is a c alym uns*-,MxrykamcLMMWR 19Sa 2K=L346 73 Hoon- RN, McKay fw Ftaumam JF Ir. FLuoodamd ch -h -g wmw sad the as x of gaols I gist Caacs lost 1976i7757- 6& 74. Erado n XL MamLb y in -&-ad etfe with lbaa 6 -m -i and aero- &aoridawd waset:t{s hens New Ettgi j Mad 197& nu 16 7S. Rowx E Shames AL F, nldb M, Fibro= Rig. Ttmda ion eabm asomb y is rel -bet to Bmoodaocen sri Ata j Elmd-W I97S:107;104_IZ 76, shoves C Can=s mortality aad&aritistlan of t am safpiies in 35 US visas lest j Epidemid 1983:2239740L 77. CW1rmCGaotsmmWttyby�andboaridxmdwemcsapplis I Fpi t Cammsmity Haalth L9824%07 -Q, 7L Cdlvaa C Caawry Ll. Camp mo:mUq in Eagiand •ere esMasim to is.sisofenttt=anroaetasatg&erotidetar water.ttpptialEptd�ol Gaatmta:i3y Filth 19859.ZiA. 79. Ma6m L Cmm bscW a is tsistim to amide laves, in waste tatppbm Bat Dust J 197S:Lm={ B0. CoCk-mamSssi P, Fitsteao L Deed IL Atso idaritan of was rm*phm and naosmoraW E a tomb bor and sffars in gibe UK on tisk of drambotaca a r IEpidwoW Ceet=uzdtyHa-hh I991;35=4Z. 6L Cnffeth GW. Fbxndaum and tamers moraltty ion Amgieey. j EVWkW 9 CC===ty (smith 19859-2446 82 Glattm E Wiese H- inverse Maaoeesbip beewam @sable and oaecr 02 mouth aged etttaat? Acs= Cedoned Shad 1979•$7514. jonaul of Public Health Dermstry a Raman S. Beckm G. Grmeard bL Fran IR. McCullogb RW, Tate RA. Eleseei&wm and naoe as amalyUs Of Canadim dZMIIQXS water &wndasim and emasmortabtY dna. Ovxwet; bdoxmmu m Direr Deaor®mt of National AwLth and Welbos.1977. 81 Ridvzcb C& itad JM• Qmw MxWitr am adacmd N~ 5omth Wales l -k- with dumrtated and Don$ttMdated water std OWL. Med f Aust 1979;.'321.3. a ym= Er- Ruoridaban of wase: aDd macer. a review of the epicr nwiotonl rvideooe. Ras:cn of a woddag Pam. Laodoc Fie: bi{iotv's StarJODerti Oe3si� 19�. 86. lateDatioaai Agmen iso. Rma= an Canomr Ioorpmie ffi=i m Im MoeoFulb on the evahuum of ataaop i mak of dm meds to ismaaas same uumabe a=bm numriatm►ones and mama aetaaoemda, and iaarp= f6-wi� toed is drinkimg water and maul ctemmuoas. Cemex: Wood Health Orgamiatioa. lan•+s;�� 87. Navmal Aeaaenev of Smamms, Natia=al Raasarta Catmal. Serie Demsm*g Waxer Com -mm Lhaekmgwauer and itealtlr W state. =- National Anwinvyof Soemoe Pzss.19T1381-9. 8 88. MsG=SAC Vanah{e=McGu3reMELBucwwahw W DuaLoam CW. is t=ae a link emvaen &---:- ad wags sad oteaosaa aa®a? J Am Dart Aaaac 1991;I�-ti 89. Fresmy Q Adana F, Baatm V. The ttatme and maaaai�ts of omal boo rows is nsam. I Amt Rs L490a*Gac ink692-nt 9a 1 ANawreandmoma oidmalftuoevsmin.-I I Dtmt Res 1990*9ffoe-- E+s1:701-SS 9L Thyisaup A. P -m aimave dr.oeomust of isdaead aqui tun m &ammmd mamd in a 6-ysrold gat. Saari I Du Res I9l63i9224ad ' 9Z Fiaeiezm V. Matey F. Faealoov Q Paseevativve tooth age sad xver- ny aid -ml Buotcon m Kmri Sated I Dent Rtes 198694:445 -ID. 4i Thvisow A. Fri rsimv Q niauai avpcua=¢ of de=al ancroms is t+rm+anew tram m eeiaaan in lme*vc manges_ CQ,=mau -y Dart 001 Enid -i IYJ *ms -2$. 9C Ngamga PbI. ctdia ML Piasmaafi T r%a ial reo= of lamgssu- distai am -e move mange m @tgoroet magttee observes m tt met overa 2112 yarperio& Ent Afr Mod 11990':1:17-23. 95- I iurvvt= EEL faa:m for me= dmtat Etta ops. J F4sbT;c Fi-lth Deet 1986o46:1754KL 96 Deem Fir Clammificabom of mined- mamd cbagmom I Ant Dent Aso=133421:1421.4 97. Dem Hr. the m e sugation of vbvm*wp cg effem by the eoidt:- totaiopaitass:61 .br-MombomFB,acAuorm mid ductalhim lth Wieabaeptaen, - Amman Asa mbm Aw the Advaaazmemt of Soma 19Q 9& Moae ff. Detml fiuteons or nae. CapeebaF= Rboo:e PubLa- baas,.1968. 99. Horowitz 1'g5, DOmmali WS, Mepm RI, Fitzfe¢ SL Kind A_ A M- mesbad 6or ane nMg the ptsyaiatoe of ducat 2 @uo mw2--the room saucem imm at ftmmr .I Am Dont Amore IML10487-4t 100 Oaem Ot�l`hldiara4cC. La.im jLAeeview of di$atsual v-grto�s of Omsk Mamvm and atm Ebsaride arstad cidem Can Dsa Assoc j 196831.74'3-7_ 101. Coats tW, Suddiag CW. DiffamtiaL eaagnow of doral @uortt as, I Dent Rs 4,?m ICM Ruseii AL The diSamtlal em- pow of nuoride and my giaoode emmumd oeaeonds. I Pokbc Hmkh Dont 19612L;143.& I03. Brunelle jA- Tbeprersiaxwof dowl&aotaa s m US cbikkm 1987 (Abwmct I Dust Pm L%90 5pc b k99& IOL DamB W5. HcwowFi5,1/eyeesa RL Hmihtts SE, Kl prom A. Tw-ELiiesvalmmafdtatalccdmasddentall in bast. jAm Drat lM 105. Kumar IV, Graem EL WaLam W, r e,, is T'rmrda is dental ftsmersanddumlc simpmya6nnmint4awbacglrandKmgyem, NY. Am I Public Hal* 19899.565-9. 105 Dam Hr,AmoldFAlt.EtvamE.Dae mdcwstemdd-la c m V: addidaoal Sardis of tbtselaNan at ibttidde dosastic waters to dmsl Dots eexwimmin4A25 tmaTdne aged 12 to 14 yams. of 13 outer in 4 sate PmbSe Health Rap L%237:ILS3.79. 107. Ast DB. Scrim DJ, Wades L C utwoU iCr. Newbur5b Kmgse czrww&moodsamdy)aV:mm6w-4rfb c landrwat8mo�apha fincimp after tm ymn of 9aae dm sa}ammQ j Am Dent Asa 10& Had= S. O sColl M Horawets sib Kiegtnm A. Ptee atenoe of dmW nam and d-1 fluanaa m atlas with opamal and above- opcm al water4l;aci le mnomaatraet a 5 -year inflow -up wavey Vol. M, Na L Wuua 1943 I Am Dent ASSOC 29MI1 6:490-S. 109. g�14 Pt. by hiubm i'P�c Sam ith Dew 1997.3214 '� �� and tisk of Aunrow among duI- t to dronLabin aw Fm J m Ashevibe.lvath Czro�mz [A a L PuhiicFislsh Dou L992.rZ:I83�9. 111. %wo w old MC Rist hm=rs assooatad wth dead Saortans Iowa Cir±r Uni•.st7 of loweL 1991. LM pp. Thoom tis 5tatmard I. Bovero I, Tsnan on A Gavm V. Fhwdde an- of some bOW4 %sante amd remmmascatmts fez fihe=x:,- ngpow- a,mt:oa,. I Pedodw=199a.ICIC3-7. t 1; 5esrtaard L S2i=15. K -u W Laksopomkou P. Tw==Mas A. Fhaoridt levels amd fmmz=e amammaam of frets pane J CFia Pedis, Dent I991:16:384a T 2t 5=un= SM, Brat BA. Treads in the =Walmm of cmnl in the U=tad 5otes a review. j Public FmIth Dant 1967.4771-4. ILL Peoc:-p M Seaham JW. Reiationshin of tot &uodde lank, to beneficial effacm and wxrnek firs j Dent foes t990;69Geioc its? 3& I1fi Gafag- DL v -;n- j3L bvevitt CA St "h W. Dart M CIimaa and Brad a.,.. c- Pubhc Health Rap 1957:72-484-9Q. 1I7. GalagaaDL V --W- ALDm===gopdash=avarid;e=wmn- awmwL Pubki: Hal- Rin I957TLA%1 IM SaUZ CM. Hicks ML HM EbL Prtevaiooe of bottled wrsta wage ov pec iawedenolpsams iasaiiamnshadaatal kteallh.J Cak�o D� Asaoe 119890W:5-9- 119. Kuthy RA Wulf CA Conus S8- Use ert a ==r anoe mics far mommzmmty ftuaedatim Public Hsllh Rep 1967;:laL-4I5-2d Ila Scho S=z = Tavlar FB. Hess WL Fzmm +R is eases �saode meaeaaatioos. tam J Pttkitic Fisksh I95fi48:Itar 9. UL Sweeney FA M=phy TL St -hereat J. Fxco2iahm is maianiaia 9 Rett*- cM=Uatrma at otacaml level in Mrtsammaa tatbbc wags smolia.I Mas Dent Soc i97L=):14p-58. - IZ' afL M3.e A -,-,A e amomtatim m dcankdag wase of ndatmg m Tarns, Tex Dent J I97896(Q:10-I2 123.. Doug= BL Creena K. Rsseas fm dsatepaaoa m rMor m of the amoest of ihaacde presort m a aota+m of waaz. j Public Fidah Daae 196828:49.51. 12t Dw- JA. Bahw=n K Craves R. Andersen P. Fawncie level vazsaium in five fluoridated cuss [AbstraaL J Dins Rm 1982ja1tr sc1sk281_ M L -g IC. Sesawe K Mmi=Mg awnde is v®tars tttmhras watts. J Public Health De: 197333X;,,= IIS Wcdd Hskah Orgnrzaoom. Cam==dr► water StaaQdatiad Ia= Mm=Y JL ed. Appropone we of A -z -de kw htaatiA b -I M Ge- raevr Wodd Health Orpmiatioa.19863&T,a. I27. I3ewbrtm F- Case cdw= vin and pacaakfty bmvz s is the svaseaiaoe tree of fhxm,6- is Burt BA. at The szsdve effieecr a' raemo3a of.eatrue pcevmtsoa m eirmol patbkie beatlt� Ptoeae . F cz&wodmb=attheU=vc=yofNficknst=.AMAtoar.U=veaty of Muga School of Public Hs11}a, 29782.4L UL Gana AL Cates inod,tssQ and cases of preventive programa j Public Honith Deat 1999:i96oae kaaX -7L IV. White BA, A,tcak4kxW seri AA. Weion MC. taom is the ofotgat�ta@t>a<idatioa. jDmtF.auc M Bart Rwalb 1L of dw wai'aboQ. J Pubbe HnIth Dtmt 1999A.9F. P= hnM-7. I31.. Woad H -ft QW iz a Salt fbo-Wataao. Err Mhms7 IL .d. wpptapdats rase of fain da For brrtam lmllh Gmavar World Health orgaalanon.19&&74.si. M Watdd A had d wA is W=My jI. o& Appt:opoaae tan erf f3oadde firer bermes laraWZ Csevc Wand HosIth I WO !'W. Iii. Mu=ylL AJ.Otbwnwthodsofrfsatsetiead=bWaa- dw of f9ua dA& la: Fhweide m tams peevmtim Dotal pracb- 6mst ha dbook no M 2md ad. Basta,. MA: WAgbt PSG, I9MA- &C I34. Hato-= M Lzw FE Prst:ires T. Eflsea of school water f3uadda- bmco dmolauaaa.Se:Thaaas. VLPmbMcHskshRep i9�$D3Bt- L 135. F3ay.et>Y FS. Hd6erz m Law FE Stool Ssraefdantia aesrdls m Eek Lsks Pt®rytvattia. Md Flinn Cbtmq. Kmwcky- ratttraa M. port. I Am Dat Assoc 1%&713124.4. 43 Iib Harowitz i -S. HxLfe= SB. Law 4'L Dnm,=U WS. School flaondaam studies la aY Late. Pa=sytv%:= aunt Nor C-2nN, Kmtucky.. r"uls afta eip}st vMs. Am I Public Hokeh 1%83L -=to -5o. =- bioeowitz M. Hdiea S8. taw FE Effect of adwd water auoeuda- tim on oenk nam final remha m Ma Lhm Pvvnsyr ama, Liter M vers I Am Det Assac 197284332.5. I3S K== S8. H=pw= M DW=C WS. M- of school warn faro- ri iaoam cm dent ass tombs m Saagarq Norah CarohDA. &b= cigar vmas. I Am Dost Assoc I97P9y:t4ab. 139. Fsofes Sa. Ho vw =t M B=aG& lA• Ef err of =hod watw auo. eaaatsaa m amt saes tesufa m 5agwe, tioetfs Ciradizta, airs 12 vea;rL I Am Dent Also: 19i`:106334-7. 14C H=M%sht= M C of arhool water fh=n-am aad di- etszy msmmi-alted��,;�, jPubliciisbti� Dat: I984#45oc issY Ea 14:. Rita L Dehaiu P. Fxrowitz K a aL A guide to the use of flutaide is tae prevmesm of aend ants tad ec j Am Dau Atanc 196aiL-504-6& IC-Daratb WS- The use of fbxn tables for the viceve== cf cmnb Dries is Form a D„ Schulz EM. eat: isaatanonai wvriomw on fh,m ata Menta;. ata mo* Ejalhmore MI? tlrav®c7 Of Marviatn` 1974233-9& 143. MCMMT Ji~ Rita► L%k% Dienrvtit a Etna. Iw lluo- sae m am%m save dmnsert. Thozy sad dtasai appuaaoaz Chi- Mgr- 1a-.Qtaaatasat¢ I983:= 49. 144. DePacu PF, LazbL Tae aces rahibdtmg e$eta: o: addnkated oacrF paaa-ftuamee chewable nbkm a ew►o-vsr *cubic-bbmc saadv. j Am Dint A30oc 296876:534-7. t4 . r ---nn WS. Faife¢ SSL Karts DC F1%a of dewabie tabim on Mental ata is smooi m , realm afar stx vera or use. J A= Det Assoc 197E$7°SZ -k 146. Hon7w zFEAhew RLL"-Sd.D=m=RWS.LiSKCambiom fietoodr. 9t9o066ised pevlamm m a seat ata: rend= c as 11 -vest study. j A= Dass Assoc 1986 M-fi" -5. 1C. S=Kmar SWL Bur. BA FW== eamsaee m M=zgm =wol- ehilasm. j Public f ieskth Dint 199051iF.&23.- 14b iv M& AL Btmidle IA A ===Nry of tae NM ..=tg ase vrrvmaandemamxatnntaevgramJA=DmtA=oe F9B3:207?b> 9_ 149. LevQest DE-LESr=vaum of gwith fivaeide aoksmms in peeveatsmg c oroaal and tint a== J Public Health Dent F 984•: k96oac Fad-316b� ISI 5onarma:i M& Seam= JW. Crave RC Dmke y IA. Bads JD- Fluo- :ice momtittmse urograms m Fauoridaod omz=t=ma I Am Des Asoc 1.9�III7k;•i9. IS Rim LW. Leis CS,. Spoors A. Tee $c mss wtnea of-paradaots is a schoo basad &troeide maw tarogsam visit impliaaaos for tae use of sa&k=m I Public flops Det FS` DMIMa WS. IvowpdA aywor R. Sekw RFL Li SK Fmmt :¢ S. A camp®sm of the vnffl t-Cmmve.4i- of Fat+aodr modem its. Finatrior tables_ and both vroadtmes a final results after *girt yes>1 I Pubbe kidth Dot 1992:9-111-1& ISL Mdda7 Dir An emu's kmgst wrs the fight over Fatoridx=n. 19so., won= Q198596mmec} t40`53 151. Caeuaal = Deal Hodsh and Ei+sllh Plarn=g Oppa ntiaca to littoode !Xop J Act DMAM= I9<[UIL'l0at a. 15b Rli01i$ LsswSOati aWand dint heaslth Eat Digest HsbsssLeltiaiatlnn 19ti334331. I57. Faaml�a j.wTkmbMmM.Siasmtettee<+da m @tamdseimiaMaao- ebxmm= an a=dyni: J Pubkic Ha ih Dent 14Ti3iS&IM. M hazier MFh--idatl-arwvww ofs=altPubaeJJMLL& Dem I9aQJia314.3i M Fr>mes Pj. Ptiaeltlsa to prsesvefltraeide men radenaias and :asss- I64 Wattmaub 0. Cawx)Uy CK LambQt CA. Deaugtas CW. What roadma ktaotr abosa Fh--tzm j Psrblic Fielth Drat IMA5:2" 161. Pdkidt HF. A prete6etmdsm stmveyat do dsttm atttlhsdo sad wamded vow- Com=umry Dot Health F 9s8S-�49.6t 19- Kay EL ffitaimm AS. A study at motwre at --A- toward the prevotim of saes wtth partiatlar releaser to tlataidatian and vnrlmab= Cem==xkty De3u Hutth 19a97&3V-6L ISL Sapalaky Hist The &wndasm monovmr an slteraadve apta- UsbcM. Pubtkc Op pion Q tW-332" 44 16L ids 14- aaniiic a b&=y and ooaczonzal sytr, dw A 6 j Am Dent Asec I983;I0k486-M 16i Mo& If Anft&=w atiottia romw the -- -I baa» bt au odsam j Pubb--Feshb DeMt 198 PWIM4& i(,& jmm Its. Mot = Dtti[. D=ncbe T8. Ph=da*M M VC=nr- Igr c oz=bu=g Lacca to nears. Am j Pubic Fysltb IWOR11405.8. 1E. Smith KA. Q— KA. A dab— ==P@-ga the Plu>eslis j Pnbiic Fi—lth Dau I99(tsD 15�. journal of Public Hahft Dewy 168. Btv+va j,°. Aieafaa l.'� ilse Ssa Aataaeo &�oodatiaa i::ac Deaf Selz Q 1986;2QkI;-t9. ttt of . sum ae�eea �chQe�ltibs�: ti:' �ee'e Vai'alay of Pew 170. Corp S8. Fl=uiabm thea and now. Am j Public Hmitb I989'�_.56i 3. 17I.IsvQerDY AaDnxaianelsa.aofsyxeoae$aoadl��daatiolts fix the M& Ipahlici wd& Deaf 199151:42-7. NATIONAL. CONF LEN- CE ON SPECIAL CARE LSSA IN DEN'S iS'L ZY held on rT!day afbenux= On Satm-day, April 3,1993, thm are dree half-day marrn%g sesmons inchzding • Jnr. a. Lt • y • . • and da { •- • .. modificasons of amiral clerAistry the rxn For more Wore ation and/or a cls► of the pmgram, plmse write to the Feder don of Special Care Orprd=ti0ns in. Dentistry. 211 E. Chicago Ave., 17th Flow, Chicago, IL 6061L 246 Journal of Public Health Dentistry The Fluoridation War: a Scientific Dispute or a Religious Argument? NO= WS MATMX MAY BE Ernest Newbrun, DMD, PhD (TLE 77 U.S. CODE) Abstract Communal water fluoridation is not considered controversial by the vast major- ity of the scientific community, however, politically it has persisted as an issue that many legislators and community leaders have avoided because of an aura of dispute. it has been a battleground for vigorous opposition by a very small but outspoken minority who have foughtitwith the dedication of religioustealom This paper reviews the nature of the opposition, who they arm, the broad thrust of their arguments, some of the specific issues they have raised, and their techniques: (J Public Health Dent 1996,56(5)246-521 Key Words: AIDS, antifluondadonists, cancer, courts, dentalcaries, effectiveness, community water fluoridation, safety. When I was invited to participate in this symposium celebrating the 50th anniversary of controlled communal water fluoridation at Grand Rapids, Michigan, I was asked to discuss the opposition to this measure. Fortu- nately, I was given carte blanche on how to address this topic and I confess the title is of my own choosing. Profes- sor Donald McNeil has referred to "the fight for fluoridation" and described it as "America's Iongest war" (1). He went on to state that "a few things remain constant in America—death, taxes, baseball, and since 1950, wide- spread, often successful efforts by a passionate minority to keep fluoride out of public drinking watez" (I). Health professionals and biomedi- cal researchers see water fluoridation as a scientific issue, and almost all agree that questions about its efficacy and safety were more than adequately settled long ago. Opponents, however, object to fluoridation on philosophical principles concerning the rights of in- dividuals to freedom of choice on health matters. With the exception of some Christian Scientists, few oppose it on strictly religious grounds, but many of those opposed to fluoridation are willing to fight with the dedication of religious zealots—hence the title of my lecture. In this review I will exam- ine the nature of the opposition, who they are, the broad thrust of their ar- guments, some of the specific issues they have raised, and their techniques. The Andfluoridationists When Trendley Dean, Philip Jay, and john Knutson met with the mayor of Grand Rapids 50 years ago to gain his approval for a water fluoridation experiment, no opposition existed to becloud the issue C2). However, com- plaints oinplaints of ill effects due to water fluori- dation were reported shortly after January 1, 1945, the official starting date. These complaints included: "Since they've been adding fluoride in our drinking water I have been gain- ing weight rapidly," and "Bathing in fluoridated water is causing a rash all over my body." awing to delays in delivery of the equipment, fluorida- tion did not actually start in Grand Rapids until January 25, yet the coat plaints preceded the implementation of water fluoridation! Initially the complaints came from isolated indi- viduals, but eventually there grew to be an organized network of hardcore opposition to this public health meas- ure, easure, not only at a local level, but at national and international levels. This opposition is not altogether surprising from a historical perspective, as there was opposition in the 1920s to pas- teurization of milk and immunization of children against diphtheria and smallpox. Similarly, at the turn of the last century there existed fierce oppo- sition to chlorination of the drinking water. More recently, gene splicing and organ transplantation have en- countered some hostility. In all of these cases, the opposition perceives these procedures not as advances in public health and preventive medi- cine, but rather as "tampering with nature" and as forged medication. At a national level, the aniifluotida- tionists include the National Health Federation, the Center for Health Ac- tion, Citizens for Health, and the Safe Water Association- Theiractivities are detailed elsewhere (3,4). The Nafimx Fluoridation Nerds was published quar- terly "in the interest of all organiza- tions and individuals concerned with keeping our drinking water free of chemicals not needed for purification" and was illustrated with clever car- toons ridiculing academia, the health establishment, government, and in- dustry for their endorsement of fluori- dation. In addition, local "pure water' associations have been organized to prevent fluoridation, their name itself being something of a misnomer as there are over 40 different chemicals, apart from fluoride, that are com- monly used in water treatment plants to make water potable (S). It is important to distinguish people who have voted against this measure in referenda but have not been active opponents from those in the much smaller but extremely vociferous group who are the real "antifluorida- tionists." According to most opinion surveys conducted between 1952 and 1977, the antitluoridatiordsts consti- tuted about 10 to 20 percent of the US population (6). In a more recentsurvey of parents' attitude toward fluoridated Dr. Newbrun is professor emeritus of oral biology and periodontology, Department of Stomatology, University of California, san Frandsro. `end correspondence to Dr. Newbrun at Division of Oral Biology, University of California San Francisco, 513 Parnassus Avenue, San Francisco, CA 94143-0512 Vol. 56,1`0.5, Special Issue I996 drinking water, 10 percent disap- proved, 78 percent approved and 12 percent did not know or refused to answer M (Figure I). Disapproval ranged from 4 percent in communities that were -already fluoridated to 16 percent in communities that were not The opponents of fluoridation are a heterogeneous lot and cannot be de- scribed easily. They come in many guises, including some, but certainly not all, of the following. right-wing extremists, misguided environmental- ists ("Greens"), chiropractors, elderly persons concerned about the costs of fluoridation, food faddists, and anti - science "naturalists.' Other species have emerged, including the self-pro- cUdmed "neutral" who tries to portray an image of dispassionate open-mind- edness, but clearly has accepted the opposition's arguments irrespective of whether they have been adequately tested and answered (5-10). Another is the "born-again andfluoridationist" who previously accepted the main- stream belief in the benefits of fluori- dation, but has experienced an epiph- any so that the scales have fallen from his eyes and he has seen the light (11- 13). Chronology of Opposition Arguments As would beexpected, the nature of the opposition has undergone some changes over the past 50 years Gable 1). In the 1950s, in the heyday of the McCarthy era when N=n had suc- ceeded in winning elections by Red - baiting his opponents and the Rosen- bergs had been convicted of espio- nage, fluoridation was portrayed as a "Red conspiracy" that would produce "moronic, atheistic slaves' who would end up praying to the commu- nists. Groups such as the John Birch Society and the Ku Klux Klan rallied to oppose fluoridation. In the film "Dr. Strangelove," who can forget Sterling Hayden's hilariously paranoid por- trayal of Col. Jack D. Ripper, tate de- mented commander of Burpelson Air Force Base? He was obsessed with "purity and essence of our natural body fluids" and therefore only drank bourbon with distilled water because he did not want his "bodily fluids" violated by fluoridated water, a Com- munist plot He was convinced that fluoridated water caused postcoital exhaustion and would have none of it In the 1960s Rachel Carson, in her 247 FIGURE 1 Attitude Toward Fluoridation of Drinking Water [Survey of 1,200 parents by Gallup Organization, December 1991 (7)] DO YOU APPROVE OR DISAPPROVE OF FLUORIDATED DRINKING WATER-, FUSED PROVE PPROVE 0 20 40 fi0 SO 100 % OF PARENTS GALLUP POLL, 1991 TABLE I Chronology of Antifluoridation Propaganda Period Antifluoridation Propaganda 195)s Communist plot 1960s Environmental concerns, use of buzzwords: toxic waste, pollutant, poison _ 1970s Anti -military-industrial complex mood: conspiracy of US government, health establishment and industry, human cancer 1980s Aging, Alzheimer's disease, AIDS 19905 Bone fracture, decreased birth rate, human cancer book -Me Silent Spring," expressed her concerns about the effects of insec- ticides on wildlife and the foods we eat Americans became more aware of the problems of unbridled industrial pollution and abuse of insecticides Accordingly, antifluoridation propa- ganda switched to environmental con- cerns, using buzzwords like toxic waste, pollutant and poison in refer- ence to fluoride. In the I970s, in the aftermath of the Vietnam War, the antMuoridationists cashed in on the anti-establishment and anti -military-industrial complex mood of the country. Fluoridation was portrayed as a conspiracy among the US government (Public Health Serv- ice), the medical -dental establishment, and industry. The year 1975 was also the time when John Yamouyiannis, during the Los Angeles referendum, attempted to link water fluoridation with the risk of human cancer (14-16). By the 19Ws_ w}run d --r;ro— 1.,, came more health conscious and were exercising in large numbers, anti- fluoridationists claimed fluoride caused aging, Alzheimer's disease, and AIDS (17,18). Now, in the. 1990s, fluoride is charged with being the cause of bone fracture in postmeno- pausal women and is blamed for the declining birth rate, as well as again being accused of causing cancer. Al- though I have given some chronologi- cal order to the antifluoridation propa- ganda, clearly some of these tactics have been recycled periodically and some have never gone away. For ex- ample, as recently as 1992 an opponent referred to water fluoridation as so- cialistic mass medication, repeating the term -sod ized- in reference water or medicine five times in tn, same article (19). Who said McCarthy- ism is dead? Ax nrments of the Opponents 248 California, a state that ranks near the bottom (48th) in the nation with re- spect to percent of the population (189x) enjoying the benefits of water fluoridation, I have been called upon to participate as a scientific expert on fluoridation in several city council or water au thority hearings in Los Ange- les, Marin County, and the East Bay Municipal Water District, as well as to testify to the California legislature. In addition, I have testified to a commit- tee of the US Congress, in the Queen's Court in Canada, and the Ministry of Health in Chile, and I have submitted written testimony to a Royal Commis- sion in Victoria, Australia. I have de- bated antifluoridationists on televi- sion and radio and appeared on call-in radio programs to answer questions about fluoridation. I have heard or read most of the arguments that the opponents have presented, although I confess I have never heard them spe- cifically claim that fluoridation causes nymphomania and satyriasis, as oth- ers have reported (2). I feel I have been in the trenches in this fluoridation war for most of my professional life. Al- though the specific arguments of the antifluoridationists may change with the Zatg6st, the basic tenets have changed very little over the years. They are as follows: fluoride is a poi- son and causes deleterious health ef- fects, fluoride is ineffective in prevent- ing reventing decay, fluoridation is costly, and fluoridation interferes with freedom of choice and infringes on individual rights (Table 2). Claims that Fluoride is Ham►fuL Opponents identify fluoride as a poi- son both specifically as being toxic and generally as being responsible for a wide spectrum of common ills includ- ing allergy, birth defects, cancer, and heart disease, as well as rarer condi- tions such as crib death, immune defi- ciency, and Gilbert's syndrome (20). Antifluoridation propaganda fre- quently shows fluoride with a skull and crossbones, labeled poison, ignor- ing the matter of dosage. When anti- fluoridationists speak about fluoride, they compare it with lead and arsenic (17,21), rather than with essential ele- ments such as iodine, zinc, or iron, or with Vitamins A and D, which are also toxic in excess. Waldbott, one of the earlier physicians to oppose fluorida- tion, listed the illnesses attributable to "artificial" fluoridation as: stomach and intestinal, stomatitis, polydipsia, Journal of Public Health Dentistry TABLE 2 Principal Antifluoridation Arguments and Profluoridation Answers Antifluoridation Arguments Profluoridation Answers Poison Safe at 0.7-12 ppm Ineffective 15-40% less caries Delays caries Less caries at all ages Costly Cheap 25¢ (median/person/year) 26 50¢ (mean/person/year) Freedom of choice Individual restraints in the interest of Individual rights community public health TABLE 3 Expert Reports on the Safety, Risks,. and Benefits of Water Fluoridation Year Organization Ref 1957 Commission of Inquiry, New Zealand 25 1968 Royal Cor*+micaon of Tasmania, Australia 26 1970 World Health Organization, Geneva, Switzerland 27 1976 Royal College of Physicians, London, UK 28 1977 National Academy of Sciences, Washington, DC 29 1977 Commission of Inquiry, Victoria, Australia 30 1982 International Agency for Research on Cancer, Geneva, 31 Switzerland 1985 Department of Health, San Francisco, California 32 1985 Working Party (Knox), London, UK 33 1990 State Department of Health, New York 34 1991 National Health and Medical Research Council, Canberra, 35 Australia 1991 US Public Health Service (Young), Washington, DC 36 joint pains, migraine -Hike headaches, visual disturbances, tinnitus, and mental depression (22). Regrettably, all too often these illnesses are re- ported as anecdotal cases that are not based on randomized clinical trials. Such uncontrolled or poorly control- led observations can be dismissed - It is beyond the scope of this review to respond to all the health -elated claims of antifluoridationists; these have been amply detailed elsewhere (23,24). Reports of independent ex- perts in relevant fields of medicine and epidemiology, as well as scientists and water engineers, have been unani- mous that the benefits of water fluori- dation far outweigh any potential risks. Data .concerning the safety of water fluoridation have been re- viewed repeatedly by international, national, state, and local authorities (25-36). Scientists have recently re- viewed the results of more than 50 epidemiologic studies on the relation- ship between fluoride concentrations in the drinking water and the risk of human cancer, as well as animal toxic- ity data (37). The conclusion of all of these reports has been uniform: there are no significant health risks associ- ated with water fluoridation at an op- timal level (fable 3). At optimal fluo- ride concentration the growth, health, and development of children is nor- mal Claims of carcinogenicity, terato- genicity, genotoxicity, and the like have not been substantiated under rig- orous scientific examination. Mortal- ity rages and other health statistics (other than dental caries) in fluori- dated and nonfluoridated communi- ties are similar. No injury from opti- mally fluoridated water has been proven to date. Dental fluorosis, mostly of the very mild to mild degree, may occur in some of the population. but this is primarily a cosmetic issue and not an adverse health effect Claims that Fluoridation is Ineffeo- VoL 56, No. 5, Special Issue 1996 Live in Caries Reduction. Several op- ponents have criticized the design, analysis, or conclusions of the studies on communal water fluoridation, im- plying that water fluoridation is inef- fective in caries reduction (I3,38,39). Sutton's (39) claim of examiner bias and the need for blind studies has been amply answered by the consistent finding of lower caries prevalence in comparisons of fluoridated with non - fluoridated communities, when ex- aminations of patients or of radio- graphs were conducted under blind conditions (40-44). Diesendorf (38) considers that the temporal red uctions in tooth decay observed in nonfluori- dated communities as well as in fluori- dated communities cannot be attrib- uted to fluoride, implying that changes in dietary patterns, especially sugar consumption, are responsible- Unquestionably, esponsibleUnquestionably, decay rates have fallen in nonfluoridated communities, but not to the same extent as in fluori- dated ones (45,46). This temporal de- crease in caries rates in nonfluoridated communities is primarily due to the widespread use of fluoridated denti- frices, particularly since the I970s. A recent review of the efficacy of water fluoridation based on surveys con- ducted in the decade of 1979 to 1989 in Australia, Britain, Canada, Ireland, New 7.ealand, and the United States concluded that the current data show a consistently and substantially lower caries prevalence in fluoridated com- munities (47). The effectiveness of water fluoridation has decreased as the benefits of other forms of fluoride have spread to communities lacking optimal water fluoridation; still, even a 20 percent additional reduction of decay due to water fluoridation is sub- stantial. Economics of Fluoridation. Oppo- nents have argued that since only a very small fraction (less than 0.1 %) of public water supplies is actually drunk, most being used for other pur- poses such as washing, watering gar- dens, and flushing toilets, water fluori- dation is inherently wasteful. Of course, the same logic also would stop water chlorination as wasteful. The in- itial outlay for equipment costs of large cities may be quite considerable,- however, onsiderable;however, this is amortized over 20 to 25 years and the cost of an extra build- ing facility, if any, is amortized over 50 years. Operating costs for supplies and water engineers are quite small when calculated on a per capita basis. In the United States the annual cost of community water fluoridation aver- ages 50e per person (25t per person median), depending mostly on the .size of the community, labor costs, and types of chemicals and equipment util- ized. Accordingly, lifetime costs of fluoridation are about 538, which is less than the $42 cost of an average two -surface amalgam restoration. Fluoridation remains the most cost-ef- fective caries preventive measure wherever there is an established mu- nicipal water system. Freedom of Choice and lnhinge- ment of Individual Rights To oppo- nents of fluoridation, the issue of free- dom of choice and individual rights is sacred and probably the most impor- tant single issue on which they all agree. In 197I an opinion survey on the attitudes of opponents to fluorida- tion was carried out by the National Fluoridation Naos, which has a circula- tion of I0,000 (48). Although only 571) responses were received, 97 percentof those responding considered fluorida- tion "unconstitutional" Objections based upon "philosophical, ethical, or moral beliefs" ranked first in validity and priority and second in importance out of 10 categories. In contrast, "health hazards" ranked eighth in va- lidity and fifth in importance and pri- ority (Table 4). In other words, oppo- nents do not really believe all their own propaganda, about tete dangers of fluoridation; they use the health risk argument for political purposes to scare the public What really turns on the opponents, 24! motivates them to donate mor tc their organizations, to particip. in massive letter -writing and facsimir- sending campaigns, and to persona lobby legislators is their opposition to government involvement in health care -what they refer to as "mass medication" or government bureau- crats "trampling on your health free- doms." The legal validity of fluorida- tion has been thoroughly tested in the United States over the past decades and invariably confirmed. The courts have agreed that while the Constitu- tion guarantees the right to protect one's own health, this right is subject to regulation by police power in the interest of the public's health (4). No appellate courtin the United States has ruled against fluoridation. In the Netherlands and Scotland, fluorida- tion has been overturned on legal grounds. It is worth noting that in Scotland Lord jauncey, the judge, while sustaining the petitioner's plea that fluoridation for the purposes of reducing caries was ultra vires the Strathclyde Regional Council, vindi- cated the safety and effecti:vene f water fluoridation (49). Techniques Used by Opponents The methods used by the opponents in attempting to block fluoridation have been detailed elsewhere (50,51) and will only be summarized here (Ta- ble 5). Let me offer examples of neu- aaliziing politicians, of the big lie, and of reasons for not debating with oppo- nents of fluoridation. The US Postal Service was urged to issue a postage stamp in 1935 to com- TABLE4 Relative Rankings of Grounds for Objections to Fluoridation by Opponents Responding to Survey Validity Importance Priority 1. Philosophical 1. Ecological 1. Philosophical 2. Ecological 7- Philosophical 2 Ecological 3. Cather 3. Common sense 3. Common sense 4. Common sense 4. Lack of benefits C lack of benefits 5. Economic 5. Health hazard 5. Health hazard 6. Lack of benefits 6. Other 6. Other 7. Other damage 7. Economic 7. Political 8. Health hazard 8. Political 8. Economic 9. Religious 9. Other damage 9. Other damage 10. Other 10. Religious 10. Religious `National Rwrilatwn Nems (48). FKII memorate the 50th anniversary of water fluoridation—hardly a contro- versial issue considering that the post- al service has issued commemorative stamps for Elvis Presley and Marilyn Monroe, both of whom died of a drug overdose. Other countries have issued postage stamps recognizing water fluoridation. Apparently the members of the US Postal Commission were `neutralized" and have as yet refused to issue a fluoridation commemora- tive stamp. In September 1984, Wendy Nelder, a member and at that time president of the San Francisco Board of Supervf- sors, requested an investigation into fluoridation as a cause of increased risk of AIDS, cancer, and other dis- eases (18). In a debate on the "Today" television show, she stated that the death rate in fluoridated communities was 300 percent higher than in non - fluoridated ones and subsequently claimed an "overwhelming increase of the death rate from heart disease in fluoridated areas" (52). In a few min- utes she was able to present much mis- information that would require a much longer time to refute. Nelder was referring to the Bartlett (8 Ppm F) -Cameron (0.4 ppm F) study in Texas of residents who had lifelong exposure to natural fluoride (53). In the ten-year period from 1943 to 1953, 14 persons died in Bartlett whereas only 4 persons died in Cameron, hence the "300 percent' inose (Table 6). What she failed to inform the viewers was that in Bartlett, 15 percent of the population in 1943 and 12 percent of the population in I953 were older than 70 years of age, while in Cameron dur- ing the same time span only 4 percent were older than 70 years of age (Figure 2). No wonder there was a higher death rate in the fluoridated coatmu- nity! Such tricks of lying with statistics are not new (54); nevertheless, the use of uncorrected data, particularly in re- Lation to cancer deaths, is typical of the opposition, and was used most effec- tively in the Los Angeles referendum in 1975 (55). Another convincing example of why not to debate with opponents of fluoridation comes from San Antonio, where in October 1985, on the eve of a referendum, proponents and oppo- nents of fluoridation participated in a televised debate. The station manager required that all debaters be San Anto- nio residents, which disqualified Dr. Journal of Public Health Dentistry TABLES Techniques Used by Opponents to Prevent Fluoridation • Neutralizing politicians: creating the semblance of "controversy" by using massive letter -writing campaigns, telephone calls, and even threats • The big lie: alleging serious health hazards, including many different diseases attributed to fluoridation • Half-truths: fluoride is a poison and causes dental fluorosis ■ Innuendo: urging fluoridation be delayed until all doubts are resolved • Statement out of context: citing only a portion of a study and misrepresenting the conclusions ■ "Experts" quoted: all doctors are considered equal by viewers of TV or newspaper readers; some dentist, physician, or scientist can always be found who will oppose fluoridation ■ Conspiracy gambit health establishment, government, and industry are in cahoots ■ Scare words: pollutant, toxic waste, cancer, artificial, chemical • Debating the issue: debates give the illusion of scientific controversy, even though the vast majority of health professionals and scientists support fluoridation FIGURE 2 Comparison of Age Distribution of Population 70 Years and Older in Bartlett M".2 ppm F) and Cameron (QA -05 ppm F) [Data from Leone et al. (53)] 20 Bartlett Cameron TABLE 6 Number of Participants in 10 -year Medical/Dental Study of Residents in Bartlett and Cameron, Texas, with Mgh and Low Levels of Natural Fluoride Bartlett (8 ppm F) Cameron (0.4 ppm F) 1943 116 121 1953 96 113 Deceased 14 4 'Data front Leone et a1(53). C. Everett Koop, the prestigious Sur- geon General who supported fluori- dation. However, john Yiamouyannis, who lives in Ohio, showed up at the station with a San Antonio voter reg- istration card and was allowed to de- bate. The antifluoridationists took the night with a barrage of assertions phrased in scare rhetoric that were dif- ficult to refute in 30 seconds or less and Vol. 56, NO. 5, Special Issue 1996 2`. went on to win the referendum (56). opinion about fluoridation of the California Senate, Jun 21, 1995. water by the mayor of a large Ameri- 12 Lee J. Opponents' testimony. Hearing o What Motivates the Opponents? can city (57). AB733before the Senate Health and - morn ����" California! As the opposition is a heteragene- I accordingly put before him the ate, Jun 21,1995.' ous group of individuals, no single epidemiological evidence; and to 13. Calquhaim J. Fluoridation in New Zea motivating factor accounts for their help him appreciate the direction tared. Am Lab 1985;18.66-72,98-109. 14. DdaneyJJ, Yamouyannis J. Burk D. Can prodigious hours of work and untiring "fluoro- m which the evidence tended, I cer from our drinking water? Congress efforts. A few might be true g told him that every time an Amen- Rec H1273I-4, Dec 16, 1975. phobics" who believe their health is can municipality determined 15. Ylamouyannis L Burk D. Fluoridat;o, threatened. Some believe that caries can be prevented by good diet and that against fluoridation there was a 8 and cancer. Age -dependence of once morality related to artificial fluoride those who eat sweets and drink sugary little clamor of rejoicing in the cor- ner of Mount Olympus presided tion Fluoride 1977;10:102-23. 16. Hunt J, Boulton S, Lennon MA, Lowry RI beverages deserve what they g et But over by Captooth, the God of Den- Jones S. Putting Yiamouyannis into per most oppose fluoridation on philo- sophical grounds because they per- nal Decay. Of course, the more dif- spective Br Dent J 1995;179:121-4. 17. Y,amouyannis J. Fluoride, the aging fac ceive it as government intervention in ficult part of the fluoridation en- terprise is not scientific in na- tor. Delaware Health Action Press, I983 18. Hsu E, Liebert L Netdees -fluoride" m personal health Of worse, most pub- turn-! mean that of convincing marks troy have been mo muds Sar lic health measures do affect individu- disaffected minorities that the Francisw Chronicle 1984Sept S. als, as well as entire communities. Purpose of the proposal is not to 19. Rothbard MAI. Fluoridation revisited. New Am 1992;Dec 14:36.9. Why has fluoridation been singled out as the target for such Iong-lasting poison the populace in the inter- 20. Lee J. Gr7berCs disease and fluoride in - and firm apposition? The ardor of the ests of a foreign power or to pro- mote the interests of a local chetni- take. Ruaride 1983;16:139-45. 21. Caldwell G, Zanfagana PE Fh hda tion opponents bordersoncrusadingSimi- ml manufacturing company, a big andPretruth decay. Reseda, CA. Top -Ecol lar to that engendered by the oppo- nents of abortion and gun control employer of labor. 2L Waldbott GL Fluoridation: the great di- Some opponents probably PP are P Y Pam' Acknowledgments teanma Lawrence K5: Coronado Press, 1978. noid and truly believe that a cabal of The author is indebted to Ms Evangeline 23_ Hodge HC Evaluation of some of the government, health professionals, and I Bash for her careful editing. objectims to water fluoridation. in - b`un F_ ed- Fluorides and dental L industry is involved in promoting fluoridation. The fact that the alumi- References Springfield, IL- CC Thomas,. 19862-21-55. 24. Cauncilon Access, Prevention, and W num and phosphate fertilizer indus- 1. McNeil DR America's longest war the professional Relations, American Da. tries have not provided financial sup- fight over fluoridation. Wilson Q A oc atiom fluoridation facts. Chicago, for fluoridation referenda seems 1985y.140.5.3. IU American Dental Association, 1995 - ,port to have escaped their attention. Yet in 2. Knutson JW. Water fluoridation after 25 years. J Am Dent Assoc 1970;60:765-9. 25. Commission of Inquiry, New Zeal, d. Report of the Commission of Inquiry on the American litical stem there Po s)' 3. Bernhardt M, Sprague B. The poison- the Fluoridation of Public Water Sup - are numerous examples of companies mongers In: Barrett S, Rovi n S, eds. The plies. Wellington: New Zealand Govern - supporting what they perceive to be in tooth robbers Philadelphia, PA GF ment Printer R E Owen„ 1957. their industry's interests (e.g., beer Sd&leY 1980:1-8. 26. Royal Commission of Tasmania. The and Soft drink manufacturers donor- 4. Block L Andihsoddationists persist the constitutional bass for fluoridation. J fluoridation of public water supplies Hobart, Australia Covernment Printer ing vast sums of money to campaigns public Health Dent I986;46:188-97 D. E. Willanson,1969. against laws that require bottle depos- 5. Reeves TG. Water fluondatiot>_ A man- 27. World Health Organization Fluorides its, or tobacco companies supporting ual for engineers and technicians At and human health. Geneva: World opposition to anti-smoking ordi- tont:, CA' US Gove:nmemt Printing Of- Health Organization, 1970; monograph nances). The leading opponents of fice,1986. series no 59. 6. Horowitz AM, Frazier PJ. Promoting the 'Wk - Royal College of Physicians of London. fluoridation, for the most part, have no use of fluorides in a community. In; New- Fluoride, teeth and health. Tunbridge record of scientific productivity or re- brun Z ed- Fluorides and dental came. Welk, UK Pitman Medical Publishing search creativity (at least not in peer- 3rd ed. Springfield, IL- CC 'Phomas, 1986'269-nr , Co., Ltd„ 1976. . 29. National Academy of Sciences, National reviewedourna, nor ls)have the 1 Y 7. Gallup Organization, Inc. A Gallup �' Research Count L Safe Drinking Water played a leadership role in their pro- study of parentd behavior, knowledge Committee Dnrtk mg water and health. fessions. However, their vocal oppom- and attitudes toward fluoride. Princeton, Washington, DC: National Academy of tion gives them an instant plat- M: Gallup Organization, lnc,199I_ Sciences Press, 1977. form -invitations to speak all over the 8. Hileman B. Fluoridation of water. Chem Eng News 1988;6626.42. 30. Commission of Inquiry. Report of the Committee of Inquiry into the Fluorida- United States, Canada, and elsewhere, 4. Groth E The fluoridation torrtrovetsy tion of Victosfal Water Supplies. Mel - and to testify at government hearings which side is silence on? BL Martin 8, ed. bourns Australia: FD Atkinson Govern - and in court cases. In other words, they Scientific knowledge in controversy. The meet Printer, 1977. achieve a recognition and an illusion social dynamics of the fluoridation de- ri �1• International Inorganic fluoridfor �& -n bate. Albany, NY: SUNY Press, 1931:169- ger of wet that the would not other- Po Y 92, graphs on the evaluation of the catc.. r wise enjoy. 10. Martin B. Soendficknowledgein mntro- gestic risks of chemicals to humans; v-' Let me conclude by quoting from versy. The social dynamics of the fluori- 27). Geneva, Switzerland Internatin Nobel Laureate Professor Sir Peter dation debate. Albany, NY: SU1.'Y Press, Agency for Research on Cancer, 1982. Medawar, who, when he was director 1991• 11. Kennedy D. Opponents' testimony. 37- Werdegar D. Reply to Board of Supervi- son on questions about fluoridation. Sin of the National Institute for Medical Hearin on AR Tit t -f, 0.e -• °--=- ^ n C. 252 33. Knox EG. Fluoridation of water and can- cer: a review of the epidemiological evi- dence. Report of the working party, Lon- don, UK Her Majesty's Stationery Office, .19x5. 34. Kaminsky LA, Mahoney MC, Leach J, Melius J, Miller K. Fluoride benefits and risks of exposure Crit Rev Oral Biol Med 1990;1261-81. 35. National Health and Medical Research Council. The effectiveness of water fluoridation. Canberra, Australia: Aus- tralian ustralian Government Publishing Service, 1991. 36. US Department of Health and Human Services. Review of fluoride -benefits and risks. Report of ad hoc subcommit- tee, Committee to Coordinate Environ- mental Health and Related Programs, US Public Health Service Washington, M US Government Printing Office, I991. 37. National Research Council. Health ef- fects of ingested fluoride. Washington, DC National Academy Press, 199S 38. Diesendorf M. The mystery of declining tooth decay. Nance 1986;322 I25-9. 39. Sutton PIN. Fluoridation: errors and omissions in experimental trials 2nd ed. Melbourne, Australia: Melbourne UnF- vetsity Press, I960L 40. Ast DV, Smith DJ, Wada B, Cantwell KT. Newburgh -Kingston caries fluorine study. XIV. Combined clinical and roentgenographic dental findings after 10 years of fluoride experience J Am Dent Assoc 1956;52314-25. 41. Jackson D, James PMC, Wolfe WB. Fluoridation in Angelsey. Br Dent J 1975; 138:165-71. 42. Hardwick J, Teasdale 1, Bloodworth G. Caries increment over 4 years in dtildren aged 12 at the start of water fluoridation Br Dent J 1982;1 -'a:217 -22- 43. 982;153217-2Z43. Jackson D, James PMC, Thomas FD. Fluoridation in Angelsey 1983:2 clinical study of dental caries. Br Dent J 1985;158:45-9. 44. Thomas FD, Kassab JY. Fluoridation in Angdwy 1983: a clinical study of dental caries in mothers at term. Br Dent J 1992;173:13640. 45.0'MuAane D, Clarkson J, Holland T, 0 -Hickey S, Whelton H. Children's den- tal health it Ireland. 1984. Dublin, Ire- land Governer n t Publication% 1986. 46. Evans DJ, Rugg -Gunn AJ Tabari ED. The effect of 25 years of water fluoridation in Newcastle assessed m four surveys of 5 -year-old children over an 18 -year pe- riod. Br Dent J 1995;178:60.4. 47. Newbrun E Effectiveness of water fluoridation. J Public Health Dent 1989; 49:279-89. 48. Anonymous. Results of opinion survey on attitudes of opponents of fluoridation. Journal of Public Health Dentistry Nat Fluoridation News 1972;18(1)-2-C 49. Opinion of Lord Jauncey in cause Mrs. Catherine McColl against Strathclyde Regional Cou rtcEL June 29, I983. Strath- clyde Regional Council, 1983. 50. Easley MW. The new andfhroridation- ists: who are they and how do they oper- ate? J Public Health Dent 1985;45:133-41. 51. Sprague B, Bernhardt M. The tooth rob- bers. In: Basun S, Jarvis WT, eds. The health robbers. Amherst, NY: Prome- theus Books, 1993295-305. 52. Nelder W. Industrial world has outlawed drinking fluoridated water. San Fran- cesco Business J 1985;Jul 29-5. 53. Leone NC; Shimkin MB, Arnold FA, et aL Medical aspects of excessive fluoride in a watersupply. A ten-year study. In: Shaw JH, ed. Fluoridation as a public health measure. Washington, DC: American Association for the Advancement of Sci- ence,1954:110.30. 54- Huff. How to lie with statistim New York NY: WW Narton,1993. 55. Newbtun E Acbievemeents of the sever ties: community and school fluoridation. J Public Health Dent IM40:234-47. 56. Scudder JH, Spitzw N_ San Antonio's battle over fluoridation. Wilson Q 1987;11:162-71. 57. Medawar PS. The Limits of sereno= New York NY: Huger and Row, I984. ALL-INCLUSIVE INEXPENSIVE LESS ABSENTEEISM DUCED COST TO TAXPAYERS WIDELY ENDORSED �ir�a'i v '1 Vii,. '+ ate -•7: is ' 6'C. , ttls�v 'n[ -lEds ri s' ' L i ale. rf �iLuoridateG \ s do '.1 -jc _'mac--• - _' _,_. r•_._ ...... 1aa[OJd uoi1epiaonl j i@IeM etuaoj!lej � y COMMUNITY WATER FLUORIDATION FACT SHEET • Fluoridation is a community health measure that benefits people of all ages. • Fluoridation is safe. • Fluoridation saves money. • Fluoridation protects over 300 million people in more than 40 countries worldwide, with over 10,000 communities and 145 million people in the United States alone. • Fluoride exists naturally in rocks, soil, fresh water and ocean water; and is essential for protection of teeth from dental decay. • If a community's water supply is fluoride -deficient (less than 0.7 parts per million), fluoridation simply adjusts the fluoride's natural level, bringing it to the level recommended for decay prevention (0.7 - 1.2 parts per million). • Studies show that water fluoridation results in up to 60% less decay in baby teeth, and up to 35 % less decay in adult teeth. • Over 50 years of research and practical experience have demonstrated that there are no harmful effects as a result of fluoridation. • Leading scientists and health professionals, numerous professional organizations, and governments around the world endorse community water fluoridation. The United States Public Health Service recommends community water fluoridation to prevent dental decay. • Numerous city councils and health boards decide to initiate fluoridation each year. Enlightened community leaders have come to realize that fluoridation is in the best interest of their entire community - adults and children - even senior citizens. • Once water fluoridation begins in a community, it should not be discontinued. If fluoridation stops, tooth decay rates will rise once again. • Depending on the size of the community, its labor costs and the kind of equipment that is used, water fluoridation costs about 20-50 cents per person per year. • Information regarding costs associated with community water fluoridation equipment and supplies, or the existing level of fluoride in your community's water, can be obtained by calling your local or state health department, local water supplier, or the Oral Health Program at the Centers for Disease Control and Prevention. ��'-���= _ z __ �,__� �.. x.� _ x .�� h� c"$ � . I�isy ' n ., .r ' i -b s+ -P' �=-tx.?if �'.� lr-s .Y _ T I „'� ry„x�Fa... ri!•; ".' �sSr4se�0ma-+ct.rb _ ', __� r . - - ?iR, "�,�. J.�yrM:nrNdr:pc�,k,X,y�,y -� �� r � s 4 � =r � s Y � 7rSi' �, �:. ' � X4411 ^� � i � t: �,�..�. ! , vi � � w r� r lam. + ' � •�`-�r��.: _. lj. .�`�2L �. � L . L.� /f � �,- -. � , s .. { t d+riwe"N/r:rK'h.R..a� � 11. alt' . t � . , .._ -s=� ��" f{F1F{_ �. -. E -p � 3 tl f+i L� Yr ,� _ _ _ f� i i f �[ . 1 r J {.� z iC r WHAT IS WATER F'L��l QRIDATION? • To fluoridate water means to raise the natural level of fluoride in the drinking water of a community for dental health. Fluoride is a substance found in all water. Fluoride protects people of all ages against tooth decay. It makes teeth stronger and harder, so that they last longer. Water fluoridation is an inexpensive and safe practice. Many communities have been adding fluoride to their water for over 50 years! WHY IS DENTAL HEALTH IMPORTANT? The health of your teeth affects the health of your whole body. Here are some of the benefits of healthy teeth: a 0riq f r 00a t i O p WHAT ARE OTHER WAYS TO IMPROVE YOUR DENTAL HEALTH Fluoride is very important for dental health. Here are some other things you and your children can do to take care of your teeth. Eat well. Milk and other , calcium -rich foods make teeth stronger. It is also important not to eat too much sugar (sweets and desserts). Brush your teeth every day using a fluoride toothpaste and use dental floss. ® See a dentist twice a year to get your teeth cleaned and checked. Ask your dentist about dental sealants. 7-7 • 6 aen* a�th e t t e '01 h e UCSF School of Dentistry Department of Dental Public Health & Hygiene ani The Dental Health Foundation ..,.6S The California Department of Health Services 0 Maternal and Child Health Bureau 1' California Wellness Foundation For additional copies, contact: The Dental Health Foundation 510/663.3727 or DHS at 9161323-0852 The Dental Health Foundation 520 Third Street, Suite 205 Oakland, CA 94607 mater Fluoridati00 C A L I F O R N I A W A T E R F L I1 0 R I D A T I 0 N P R O J E C T Providing the health benefits of fluoridated water to all Californians L-! FOR MORE INFORMATION, PLEASE CALL CALIFORNIA DEPARTMENT OF HEALTH SERVICES: 916.327.8903 Special thanks to the University of California -Son Francisco, Deportment of Dental Public Health and Hygiene, for funding this brochure. Yo Authored by State Assemblywoman Jackie Speier and passed by the California Legislature, AB 733 authorizes fluoridated drinking water in public water systems with more than 10,000 service connections. Speier, like many Californians, assumed every water system was fluoridated until her children started accompanying her to Sacramento, a nonfluoridated community. You can help California fulfill the bill by contributing to the estimated $200 million needed to build the fluoridation systems. Your all-important support will benefit the health of all Californians, in addition to saving state taxpayers millions of dollars each year. That's a significant amount of money when you consider Oenti-Cal, California's dental welfare program, costs taxpayers more than $700 million each year. By comparison, water fluoridation costs about 54 cents per person annually—about $70 in one's lifetime. That's less than the price of a single dental filling. Fact is, water fluoridation is the most economical and effective way to prevent tooth decay, particularly among children. Projections indicate that tooth decay for children will decrease as much as 30 percent within five years of water fluoridation. Prevent- ing just one cavity in each school -aged child in California will save taxpayers an estimated $385 million over that same five-year period. The 1993-1994 California Oral Health Needs Assessment of Children revealed that children in California have much higher rates of oral disease than their counterparts in national studies conducted 10 years earlier. In fact, untreated tooth decay for six -to -eight year olds in California was more than twice as high as the U.S. average for this age group. upport SOURCE: CALIFORNIA ORAL HEALTH NEEDS ASSESSMENT OF CHILDREN, 1993-1994 Children who experience dental problems early in childhood are likely to experience recurring tooth decay as adults. Fortunately, water fluoridation results in up to 60 percent less decay in baby teeth. Adults benefit, too, with up to 40 percent less decay. That's very reassuring to the elderly who are susceptible to root surface decay, in addition to families with limited income and other Californians who do not receive routine, preventive dental care. ALL -NATURAL WITH NO HARMFULEFFECTS' Fluoride exists naturally in rocks, soil, fresh water and ocean water. Like zinc, iron and other minerals, fluoride is classified by the National Research Council as an important trace element in human nutrition. The first U.S. city to fluoridate was Grand Rapids, Michigan in 1945. After 11 years of study, scientists reported that the cavity rate among schoolchildren in Grand Rapids had dropped 60 percent. Since then, more than 3,700 independent, peer- reviewed studies have documented the health benefits of fluoridated water. Millions of people have consumed water containing natural or adjusted fluoride at 0.7-1.2 parts per million with no adverse effects. NWIDE In 1952, San Francisco became the first major city in California to fluoridate. Soon after, communities such as Berkeley, Palo Alto, Long Beach and Beverly Hills followed suit. Today, more than 100 state, national and international health and civic organizations endorse water fluoridation. This includes the U.S. Public Health Service, the World Health Organization, the Centers for Disease Control and Prevention, in addition to every U.S. Surgeon General in the last 50 years. Naturally occurring fluoride is already present in most drinking water across the U.S. in variable levels. The two most commons fluoridation treatment systems use sodium fluoride and hydrofluosilicic acid. These chemicals are compatible with other chemicals now used in water treatment and do not cause any additional operating problems with existing plant processes. Fluoridating community water systems is an easily implemented procedure. The treatment systems take up minimal space and, in many situations, can be installed in existing structures at water wells and treatment plants. Basic fluoridation systems include a storage tank for the chemicals, a metering pump to inject the fluoride chemical solution into the water supply, plus associated piping. Actual fluoridation only involves a minimal adjustment of water to reach an optimum level: one part fluoride treatment per million gallons of water. Once implemented, fluoridation levels are monitored and calibrated on a weekly basis and reported to the state as part of ongoing compliance evaluations by the California Department of Health Services' Office of Drinking Water. Every dollar of the $200 million required to fluoridate California's public water systems goes toward capital costs. This covers acquisition of land, provision of equipment, site visits, permits and construction inspection. In addition, the funds raised will provide up to two years of operations and maintenance cost for each new system. If you wish, you can direct your donation to a specific water system. Otherwise, the money will be placed in a trust. The Fluoridation 2000 Workgroup will allocate those funds to water systems based on the Office of Drinking Water's priority list of cities, with the highest priority given to systems with the lowest cost -per -service connections. Imagine the good your generous contribution can do to improve the dental health of all Californians while saving millions in taxpayer dollars. It's a grin -grin for everyone. Now and in the future. For more information on the California Water fluoridation Project, please call 916.327.8903. TT U w co rr, C) q= Ix m (;,` > 3 m �i -�; q CD Ln o m 2f CD TT U co rr, r1l Ln m 2f CD So zz CD c 0 M ;:a CD L/I z TT U