WATER FLUORIDATION,
FLUORIDE VARNISH,
AND GROUNDWATER TESTING
FOR FLUORIDE
E. Angeles Martinez Mier, DDS, MSD, PhD
Director Fluoride Research Program
Preventive and Community Dentistry
Oral Health Research Institute
Indiana University School of Dentistry
TOOTH DECAY MANAGEMENT AND PREVENTION STRATEGIES

Despite marked reductions in dental caries
prevalence in most populations, there is still a
need for caries preventive strategies for high risk
groups.

Certain segments of the population experience the
largest caries burden
TOOTH DECAY PREVENTION STRATEGIES
 Increase
the resistance of the host
 Modify
or eliminate pathogenic
bacteria
 Modify
or eliminate cariogenic diet
FLUORIDE AS A PREVENTIVE AGENT
History
 First observations

Drs. Eager and McKay
- Colorado Springs
 Dr. Black

FLUORIDE:
MECHANISMS OF ACTION
 After
teeth erupt (post eruptive)
Topical effect on tooth decay (cavities’ formation)
 Antimicrobial effect

 Before

teeth erupt (pre eruptive)
Some minor reduction in enamel solubility
Burt and Ekstrand, 1999
FLUORIDE SOURCES AND THEIR
EFFECTS
Fluoridated community drinking water and
fluoride toothpaste are the most common sources
of fluoride in the US and are largely responsible
for the low risk for dental caries for most persons.
 Persons at high risk for dental caries might
require more frequent or more concentrated
exposure to fluoride and might benefit from use
of other fluoride modalities (e.g., mouthrinse,
dietary supplements, and topical gel, foam, or
varnish).


There are systemic and topical modalities
CDC, 2001
HOW DO WE KNOW IT WORKS?
 Exposure
to fluoride prevented the development
of fewer tooth decay, even in older children and
adults
Kingston/Newburgh study 1946
 Japanese camps 1945

 Animal
and laboratory experiments
Slide by Dr. Karen Yoder
SUPPORT FOR WATER FLUORIDATION
The Centers for Disease Control and Prevention (CDC)
consider community water fluoridation as one of 10
great public health achievements of the 20th century
SUPPORT FOR WATER FLUORIDATION
The past five Surgeons General supported
community water fluoridation and encouraged
communities to fluoridate their water. Here are the
most recent three statements
 2004, Richard H. Carmona, MD, MPH, FACS

2001, David Satcher, MD, PhD

1995, Audrey F. Manley, MD, MPH
HISTORY OF COMMUNITY WATER
FLUORIDATION IN THE US

Early studies in the 1930s - Dean and
collaborators


Initial water fluoridation 1945
Four classic studies have been conducted
comparing pairs of cities (fluoridated vs. nonfluoridated): 1940s, 1971, 1982, and 1992
HISTORY OF COMMUNITY WATER FLUORIDATION

ISDH began working with Indiana communities and
water utilities to implement water fluoridation on
December 22, 1950.


IN INDIANA
The first Indiana communities to begin community water
fluoridation were Fort Wayne, Huntingburg and Indianapolis which
began in 1951
Today we now have over 95% of the residents served by
community water systems receive optimally fluoridated
water.
NATURAL FLUORIDE IN INDIANA
If you consider all community water supplies that
contain fluoride in their water, the total systems
would be:
488 Indiana Water Systems with Optimal
Fluoride.
 Indiana has 91 community public water systems
serving approximately 328,000 Hoosiers that
contain naturally occurring fluoride at
recommended CDC recommended levels.
 26 schools fluoridate their school water supplies

NATURAL FLUORIDE IN INDIANA
State
Water Systems
County
EPA ID No.
Population
Natural Level of
Fluoride (ppm)
Indiana
Danville
Hendricks
5232004
4,220
2.0
Indiana
Decatur
Adams
5201002
8,650
1.6
Indiana
Geneva
Adams
5201003
1,420
1.6
Indiana
Lowell
Lake
5245029
5,790
1.2 (reduced from 4.4)
Indiana
Milltown
Crawford
5213006
1,064
1.6
Indiana
Marengo (Milltown)
Crawford
5213005
1,265
1.6
Indiana
Monroe
Adams
5242008
600
1.5
Indiana
Redkey
Jay
5238008
1,527
1.5
Indiana
Riley
Vigo
5243020
1,008
1.5
Indiana
Upland
Grant
5227022
3,330
1.8
Indiana
Whites Institute
Wabash
5285020
300
1.7
Indiana
Woodburn
Allen
5202024
1,321
2.0
INDIANA CERTIFIED DRINKING WATER
CHEMISTRY LABORATORIES

TestAmerica Valparaiso
2400 Cumberland Drive
Valparaiso, Indiana 46383-2502
Contact: Ken Busch
Phone: 219/464-2389
Laboratory No.: C-64-01

*ESG Laboratories
5927 West 71st Street
Indianapolis, Indiana 46278-1729
Contact: Bruce Peavler
Phone: 317/290-1471
Laboratory Number: C-49-07

*Columbus City Utilities
1111 McClure Road
P.O. Box 1987
Columbus, Indiana 47202-1987
Contact: Garry Pugh
Phone: 812/376-2400, ext. 474
Laboratory No.: C-03-01

*Environmental Certification Laboratories, Inc.
11422 North US Highway 41
P.O. Box 569
Farmersburg, Indiana 47850-0569
Contact: Jac L. Padgett
Phone: 812/696-5076
Laboratory No.: C-77-01
Heritage Environmental Services, LLC.
7901 West Morris Street
Indianapolis, Indiana 46231-3301
Contact: Gary A. Klingler
Phone: 317/243-8011
Laboratory No.: C-49-01


Water Pollution Control Utility
2801 Gene Gustin Way
Anderson, Indiana 46011-1900
Contact: Rose Adams Whitehead
Phone: 765/648-6563
Laboratory Number C-48-01

*Marion County Health Department
3838 North Rural Street
Indianapolis, Indiana 46205-2930
Contact: Natalie Dorsch
Phone: 317/221-4678
Laboratory No.: C-49-04
South Bend Environmental Laboratory
3113 Riverside Drive
South Bend, Indiana 46628-3515
Contact: Michelle Smith
Phone: 574/277-8515
Laboratory No.: C-71-03


Citizens Energy Group
950 West 16th Street
Indianapolis, Indiana 46202-2276
Contact: Mark Gray
Phone: 317/941-7147
Laboratory No.: C-49-02

*Environmental Consultants, Inc.
391 Newman Avenue
Clarksville, Indiana 47129-3299
Contact: Robert Fuchs
Phone: 812/282-8481
Laboratory No.: C-22-01

*Environmental Laboratories, Inc.
635 Green Road
P.O. Box 968
Madison, Indiana 47250-0968
Contact: Chris Myers
Phone: 812/273-6699
Laboratory No.: C-39-01
INSTRUCTIONS FOR FLUORIDE/SODIUM
SAMPLE COLLECTION
1. The following instructions describe the method of collection:
a. Flush the sample tap for five (5) minutes prior to collecting the
sample.
b. Reduce the flow of the water and fill the sample container to the
shoulder
of the bottle. Replace and tighten the cap and make sure it is not leaking.
2. Complete an analysis request form (Inorganic Chemical
Examination of Water) with the following:
a. Name and address in the “Fill In this Space” box on the left side of the
form.
b. Email address, and/or fax number.
c. Collected by.
d. Date collected.
e. Under Remarks, write if water has undergone any treatment; e.g.
water
softener, reverse osmosis
INSTRUCTIONS FOR FLUORIDE/SODIUM
SAMPLE COLLECTION
3. Mail the water sample and analysis request form in the mailing container
provided to your laboratory of choice.
4. Results will not be valid if sample is over 28 days at the time of analysis,
therefore, samples should be mailed as soon as possible after collection.
OPPOSITION TO FLUORIDE
Not Natural – Pesticide/Poison
 Not Ethical – Mass medication
 Not Safe – Cancer/Osteoporosis/Fluorosis


There is no need for systemic fluoride
FLUORIDE IS A NATURAL ELEMENT


Found naturally in water sources in small but traceable
amounts, and in certain foods such as meat, fish, eggs,
bones and tea.
There is no difference in the way our body metabolizes
fluoride regardless of source.



Sodium fluoride (NaF) was the first compound used and
is the reference standardIt is more expensive than the
other compounds, but is easily handled and is usually
used by smaller utility companies.
Fluorosilicic acid (H2SiF6) is an inexpensive liquid byproduct of phosphate fertilizer manufacture. It is also
known as hexafluorosilicic, hexafluosilicic,
hydrofluosilicic, and silicofluoric acid.
Sodium fluorosilicate (Na2SiF6) is a powder or very fine
crystal that is easier to ship than fluorosilicic acid. It is
also known as sodium silicofluoride.
COMPOUNDS USED FOR WATER
FLUORIDATION
THE ETHICS OF COMMUNITY
FLUORIDATION


In June 2002, the American Society of Law, Medicine & Ethics, in
partnership with the CDC and HHS, convened a major conference
entitled “The Public’s Health and the Law in the 21st Century.”
More than 500 individuals from all of the fifty states attended.
These were their conclusions regarding water fluoridation:

Fluoride is naturally present in all water… community water
fluoridation consists of the addition of fluoride to adjust the
natural fluoride concentration of a community’s water supply to
the level recommended for optimal dental health.


Fluoridation is not mass medication, since it is naturally occurring.
The key to the implementation of water fluoridation in public
systems is the education of the public as well as legislators.
THE ETHICS OF COMMUNITY
FLUORIDATION

Conclusions continued:

There exists a long history of proven efficacy and safety of
fluoridation, which is an especially important tool for those at
greater risk for tooth decay, as its benefits extend to all in the
population.

The consequences of oral health policies that do not take full
advantage of scientific knowledge and tools, are a frightened and
tentative population, millions of children without the benefits of
fluoride, and costly remediation of dental disease.
REVIEW OF FLUORIDE BENEFITS AND
RISKS
Review of Fluoride Benefits and Risks
Conducted by the Department of Health and
Human Services

There is no evidence linking fluoride to cancer and
other systemic diseases
Scientific Reviews
EXPERT COMMITTEES AND SYSTEMATIC REVIEWS


All are in agreement
Evidence does not support an association
between water fluoridation and any adverse
health effect or systemic disorder
WHY DO WE CONTINUE USING PUBLIC FLUORIDATION
PROGRAMS?
Cost benefit
 Tooth decay reduction


Combination of fluoride modalities is partially additive (higher than
the percent reduction from each modality but less than the sum of the
percent reduction of the modalities combined)
CDC, 2001
WHY DO WE CONTINUE USING PUBLIC FLUORIDATION
PROGRAMS?

Tooth decay reduction
Initial studies of community water fluoridation demonstrated
that reductions in childhood dental caries attributable to
fluoridation were approximately 50%-60%. More recent
estimates are lower 18%-40%
 Decrease is likely caused by the increasing use of fluoride
from other sources and the diffusion or "halo" effect of
beverages and food processed in fluoridated areas but
consumed in non-fluoridated communities


Indirectly spreads some benefit of fluoridated water to non-fluoridated
communities
CDC, 2001
TOOTH DECAY REDUCTION
 18% - 60 % more children
with mouths like this

18% - 60 % less children
with mouths like this
OPTIMAL COMMUNITY WATER
FLUORIDE LEVELS
Current optimal fluoride
concentration in water: 0.7
ppm
EPA maximum allowable
level: 4 ppm
http://www.cdc.gov/fluorid
ation/
NEW HHS RECOMMENDATION FOR FLUORIDE
CONCENTRATION IN DRINKING WATER FOR
PREVENTION OF DENTAL CARIES

HHS recommends an optimal fluoride concentration of
0.7 mg/L for community water systems based on the
following information:
◦
◦
Community water fluoridation is the most cost-effective method
of delivering fluoride for the prevention of tooth decay;
In addition to drinking water, other sources of fluoride exposure
have contributed to the prevention of dental caries and an
increase in dental fluorosis prevalence;
NEW HHS RECOMMENDATION FOR FLUORIDE
CONCENTRATION IN DRINKING WATER FOR
PREVENTION OF DENTAL CARIES

HHS recommends an optimal fluoride concentration of
0.7 mg/L for community water systems based on the
following information:
◦
◦
Significant caries preventive benefits can be achieved and risk of
fluorosis reduced at 0.7 mg/L, the lowest concentration in the
range of the USPHS recommendation.
Recent data do not show a convincing relationship between fluid
intake and ambient air temperature. Thus, there is no need for
different recommendations for water fluoride concentrations in
different temperature zones.
FLUORIDE IN WATER
•
•
Well water
Bottled water
•
•
•
Water concentration varies from 0 to 7 ppm
A few bottle waters state concentration (Gerber’s 1 ppm
water)
Not constant by brand name
•
•
•
Soto Rojas et al., 2001
Steinmetz et al., 2010
Recent regulations
• Code of Federal Regulations] [Title 21, Volume
2][Revised as of April 1, 2004]
• Fluoride in bottled water should not exceed 1.4 ppm
ANNUAL COST SAVINGS FROM FLUORIDATION BASED
ON COMMUNITY SIZE
Griffin, S.O. et al. J Pub Health Dent 2001;61:78-86.
PROFESSIONALLY APPLIED TOPICAL
FLUORIDE

Evidence Based Recommendations
http://www.ada.org/sections/professionalResource
s/pdfs/report_fluoride_exec.pdf
JADA, 2006:37;1151-9

All patients moderate to high risk should receive
topical fluoride
FLUORIDE VARNISH
Fluoride varnish is available from multiple manufacturers. New
presentation – tooth color
FLUORIDE VARNISHES
• There is positive evidence for use of fluoride varnishes in
caries prevention in permanent teeth.
• Studies have suggested that after 2, 3 years the caries
reduction was higher than that of topical gels or foams.
• Effectiveness associated with number of applications.
`
Tewari (1990)
In the US fluoride varnish is approved by the
FDA as a "device" and must be used "off
label“ for the prevention of caries.
Results of Cost per Treatment Averted (Hospital and Nonhospital)*
Quinonez, R. B. et al. Arch Pediatr Adolesc Med 2006;160:164-170.
Copyright restrictions may
apply.
FLUORIDE VARNISH


According to the Medical Practice Act, MD’s may
delegate any procedures they decide to delegate.
Furthermore, in Indiana, there is no Medicaid
reimbursement for fluoride varnishes applied by
physicians.
All states but HI, AR, IN, DE and DC have
legislated reimbursement and that allow
physicians to perform fluoride varnish
applications and to bill Medicaid. All of those but
AZ are currently paying.
FLUORIDE RESEARCH AT INDIANA UNIVERSITY
SCHOOL OF DENTISTRY




Long regarded by academic peers and industry as a leading center
for preventive dentistry research, the Oral Health Research
Institute has served as Indiana University School of Dentistry's
core research facility for over four decades.
This self supporting institute was has been a leader in dental
research since early 1920's
Beginning with stannous fluoride toothpaste, the first clinically
proven decay preventive formula, OHRI has an impressive
portfolio of clinical trials and testing capabilities that has
contributed significantly to dental health in the U.S. and abroad.
Site of clinical trials of the first fluoride-containing dentifrice and
effective tartar control dentifrice systems
FLUORIDE RESEARCH AT INDIANA UNIVERSITY
SCHOOL OF DENTISTRY


Fluoride Research Program aims at optimizing the beneficial
effects of fluoride while reducing its detrimental effects
The primary objectives of the fluoride research program are to:





develop diagnostic methodologies to accurately determine fluoride
presence
determine the role of fluoride in the onset and progression of tooth
decay
develop and refine methodologies to diagnose dental fluorosis and
determine the mechanisms by which fluoride affects the development
of dental and skeletal fluorosis
identify sources of fluoride exposure and intake
design fluoride-based community interventions to address and
identify disparities in dental caries and dental fluorosis prevalence
QUESTIONS YOUR COMMUNITY MAY HAVE ABOUT
FLUORIDE
Is it true there was a lawsuit for a child who
developed fluorosis and the parents won?
 Is it true fluoride causes cancer or dementia?
 Is it true fluoride causes arthritis?
 Is it true that fluorosis weakens the teeth?
 Is it true that there is new evidence on the
harmful effects of Fluoride on the developing
brain?

WHEN LOOKING FOR FLUORIDE INFORMATION THE
SOURCE MATTERS
Fluoride Action Network website http://www.fluoridealert.org/health/
What the anti fluoridationists site says
Many participants reported that they were at least occasionally distressed
or worried over the appearance of the children's teeth, that it hindered
children from smiling freely, and that it was an unsatisfactory
appearance."
SOURCE: Martinez-Mier EA, et al. (2004). Development of a
questionnaire to measure perceptions of, and concerns derived from,
dental fluorosis. Community Dental Health 21:299-305.

What the article actually says:
As the TSIF (fluorosis) scores became more severe, the proportions of
participants that reported that they were at least occasionally distressed
or worried over the appearance of the children's teeth, that it hindered
children from smiling freely, and that it was an unsatisfactory appearance
increased.”
FLUORIDE –PRODUCTS

Good resource of information:
Canadian Drug Product Database
 Base de doneé sur les produits pharmaceutiques
http://webprod3.hc-sc.gc.ca/dpd-bdpp/languagelangage.do?url=t.search.recherche&lang=eng

FLUORIDE –PRODUCTS

When faced with a new product, how do I find
evidence to decide if I want to use it?
http://www.cochrane.org/reviews/
http://www.ada.org/prof/resources/topics/evidencebased.asp
Acknowledgements
Thanks to Drs. Domenick Zero and Karen Yoder for
their contributions to the development of this
lecture.
THANK YOU FOR YOUR TIME!
If you have any question do not hesitate to contact
me
esmartin@iupui.edu