Public Health Leadership:
THE KEY TO A HEALTHIER
NATION
CDR María-Paz U. Smith, DMD
Career path:
1) Indian Health Service – Pine Ridge, SD - 1996-2000
2) US Coast Guard – Cape May, NJ - 2000-2004
3) US Coast Guard – Comprehensive Dentistry
Residency – US Navy, Bethesda, MD – 2004 2006
4) US Coast Guard – Senior Dental Officer in
Yorktown,VA – 2006 - 2011
5) US Coast Guard – Senior Dental Officer in Elizabeth
City, NC – 2011 - 2016
THE ROLE OF
FLUORIDE IN
CARIES
PREVENTION IN
CHILDREN
PREVENTION
• Stop, arrest, halt, hinder, impede,
curb, restrain, hamper, obstruct,
inhibit, delay, retard, slow, thwart,
foil, frustrate, check, block, balk,
control, preclude, forestall, avert,
avoid, ward, prohibit, ban, bar,
forbid, interdict, taboo, debar…
It’s better to PREVENT
than to LAMENT!
The mandibular incisors are usually
unaffected…
Why?
The child falls asleep, and the milk or
sweetened liquid becomes pooled around
the maxillary anterior teeth
Controversy about fluoridation of the
drinking water supplies
 Many who oppose water fluoridation is because it is a
form of compulsory mass medication
 Cancer – many articles have been written for bone
cancers and bone fractures due to fluoridation (nonsupported according to CDC)
 Osteosarcoma – rates are significantly higher in male
children with raised fluoride levels
 Renal disease – no evidence that the fluoridation of
drinking water will be detrimental to the patient with
renal disease
Fluorosis
Water is naturally fluoridated to
levels well above the
recommended levels – prevalent
in some parts of India,
inTanzania
Severe
fluorosis
Mild
fluorosis
Skeletal Fluorosis
Most experts in skeletal fluorosis agree that ingestion of 20 mg
of fluoride/day for 20 years or more can cause crippling
skeletal fluorosis. Doses as low as 2 to 5 mg/day can cause
preclinical and earlier clinical stages. The situation is complicated
because the risk of skeletal fluorosis depends on more than the
level of fluoride in the water. It also depends on nutritional status,
intake of Vitamin D and protein, absolute amount of calcium and
ratio of calcium to magnesium in drinking water, and other factors
THE FLUORIDE ION
 The inorganic form is what we use in water
fluoridation and is the one that can produce
the reduction in dental caries. The organic
form is what is commonly used in the
production of pesticides, nerve gas, and
many other organic compounds. The
organic form has no effect on dental caries.
(Incidentally, tests that are taken to measure the concentration of
fluoride in the water only measure the inorganic form of fluoride)
Fluoride Carcinogenicity
 3.2.3 Carcinogenicity
In 1987, the International Agency for Research on Cancer (IARC) reviewed the
available data concerning the carcinogenicity of fluoride and concluded that there
was inadequate evidence of carcinogenicity in experimental animals (IARC, 1987).
Two separate sets of long-term fluoride carcinogenicity studies in rats and
mice have been published in the 1990s (NTP, 1990; Bucher et al., 1991; Maurer
et al., 1990, 1993).
These studies have been extensively reviewed with the general
conclusion that they do not provide adequate evidence to
conclude that fluoride is carcinogenic (USNRC, 1993; WHO, 1996; IPCS,
2002).
Drinking Water Fluoridation
 To date, no federal appellate court or state court of last
resort (i.e. state supreme court) has found water
fluoridation to be unlawful {in the United States of
America}
Total US population, persons
US population on public water systems
304,059,724
269,911,707
Total US population on fluoridated drinking
water systems, persons
195,545,109
EPA (United States Environmental
Protection Agency
 EPA regulates public water systems; it does not have
the authority to regulate private drinking water wells.
Approximately 15 percent of Americans rely on their
own private drinking water supplies, and these
supplies are not subject to EPA standards, although
some state and local governments do set rules to
protect users of these wells. Unlike public drinking
water systems serving many people, they do not have
experts regularly checking the water’s source and its
quality before it is sent to the tap. These households
must take special precautions to ensure the protection
and maintenance of their drinking water supplies.
Water and Food
Well – Water System
Pine Ridge Indian Reservation,
SD
Black Hills, SD
Map of South Dakota
Rain water from the Black Hills, SD
usually takes 10,000 years to
trickle down to the Pine Ridge
Indian Reservation – not knowing
what minerals or the amount of
minerals that is carrying
United States Map of Fluoridated Water
Communal Water Fluoridation
McDonald and Avery in their book Dentistry for the
Child and Adolescent (Sixth Ed - 1994) state that:
“Communal water
fluoridation remains by far
the most cost-effective caries
prevention measure”. (Page 235)
Fluoride Statement – Philadelphia, PA
1951-2001
The Philadelphia Water Department feeds
fluoride into the water supply system, as
a service to the Philadelphia Health Department,
in compliance with the Philadelphia Health Code (Ordinance 6-214),
established in December 5, 1951, and under permit provisions of the
Commonwealth of Pennsylvania, Department of Public Health, issued
July 22, 1952, at a concentration of 1.0 milligrams per liter. This level
is within the current maximum contaminant limit established by the
United States Environmental Protection Agency and in accordance with
the United States Public Health Service, Division of Dental Public
Health Guidelines.
Philadelphia, PA – University of
Pennsylvania
Children with healthy teeth who lived
within the perimeter of Philadelphia =
water fluoridated (year 1996)
Children with rampant caries who lived
OUTSIDE the perimeter of Philadelphia
with NO fluoridated water
Costs incurred to the city of
Philadelphia in Fiscal Year 1999
# Tons
Cost/Ton
Total Cost
Fluoride
444.5
$447.28
$198,815.96
Zinc Phosphate
(anticorrosive)
1075.6
$393.47
$423,216.33
$622,032.29
(Per year )
Dr. Raymond F. Gist, 2011 President of
the ADA
“Dentistry has succeeded in preventing disease better than
any other area of health care. Water fluoridation is one of
our most potent weapons in disease prevention, and we
want as many people as possible to have the benefits of
this simple, safe, inexpensive and proven health care
measure”
FLUORIDE USE
When should fluoride use begin?
Infants and children between the ages of
6 months and 16 years should receive
fluoride
Remineralization
“Saliva, which is supersaturated with calcium
and phosphate and contains acid-buffering
agents (such as bicarbonate, phosphate),
diffuses into plaque where it neutralizes the
microbial acids and repairs the damaged
enamel by a process knows as
remineralization” p. 218-219
Remineralization with Fluoride
contains increased concentrations of fluorhydroxyapatite, making
the remineralized tissue more resistant to future attack by acids
Fluoride Supplements
Concentrations of fluoride in toothpaste in the United
States range from 1,000 – 1,500 ppm
Fluoride mouth rinse OTC solutions = 0.05 % sodium
fluoride = 230 ppm
Fluoride mouth rinse solution of 0.20 % sodium
fluoride = 920 ppm – this has to be given to children
under supervision
Fluoride Supplements
 Fluoride gel of acidulated phosphate fluoride = 1.23 %
= 12,300 ppm
 Stannous fluoride 0.15 % or 1,500 ppm
 Fluoride Varnish is availabe as sodium fluoride 2.26 %
or 22,600 ppm or difluorsilane at 0.1 % or 1,000 ppm
 Tablets, lozenges or liquids are available also. Most
supplements contain sodium fluoride as the active
ingredient. They are usually 1.0, 0.5, or 0.25 mg
fluoride
Optimal Fluoridated Drinking Water ADA
0.7 ppm because people in warmer climates tend to
drink more water
1.2 ppm because of the reduction in water ingestion
“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”
DePAC Minutes Jan 2011
OPTIMAL COMMUNITY WATER
FLUORIDATION - ADA
The ADA supports the Department
of Health and Human Services’
recommendation to set the level for
optimally fluoridated water at:
0.7 parts per
million
Parts per Million Conversions
ppm is a term used in chemistry to denote a very, very
low concentration of a solution. One gram in 1000 ml
is 1000 ppm and one thousandth of a gram (0.001 g) in
1000 mil is one ppm
1 ppm = 1 mg/liter
0.7 ppm = 0.7 mg/liter
World Health Organization Data
DMFT (Decayed, Missing and Filled Teeth)
29 April 2011
Switzerland
0.84
1998
No water is
fluoridated, but
salt is
UK (England and
Wales)
0.9
1996-1997
11 % of water
supplies are
fluoridated
USA
1.4
1988-1991
More than 50 % of
water is
fluoridated
France
1.9
1998
No water is
fluoridated, but
salt is
Powerful tool = FAMILIES
Families
“The fact that children acquire their dietary
habits, oral hygiene habits, and oral
microflora from their parents makes dental
caries more an environmental than a
hereditary disease” p. 221
Healthy Mothers = Healthy Babies
Women are the ones who
can make more and better
decisions on healthier choices
for their
babies
Healthy Parents = Healthy Children
“Research by Kohler, Andreen, and
Jonsson (1984) demonstrated that
reducing the numbers of oral
Streptococcus mutans in mothers
delayed the colonization of the
organisms in the mouths of their
children” p. 218
A Fluoride Diet













3.73 ppm
2.34 ppm
2.02 ppm
1.09 ppm
0.91 ppm
0.71 ppm
0.61 ppm
0.60 ppm
0.48 ppm
0.46 ppm
0.45 ppm
0.33 ppm
0.03 ppm
Brewed black tea
Raisins
White wine
Apple-flavored juice
Brewed coffee
Tap water (US – wide average)
Chicken soup broth
Diet coke (US – wide average)
Hot dog
Grapefruit juice
Beer
Flour tortillas
Milk (2 %)
Mothers are usually the key to
good hygiene, good health
“Thus, clinicians may consider dental
caries in the mother as a risk indicator
for caries activity in her child.
Our findings suggest that reducing
caries in young children may require
improving the oral health of their
mothers”.
Dye, Bruce et al.
JADA – February 2011
ORAL HEALTH
Lead by example!
How can I help my children to brush?
www.knowyourteeth.com
Academy of General Dentistry (Fact Sheets)
Support Programs
All these programs, like:
Headstart, WIC, National
Women’s Health Week, Best
Bones Forever! And many
more
should be advertised; parents
should be encouraged
to take advantage of the
multiple
benefits these offer to families
Minority Groups
NHSA = National Head Start Association
We Believe
 all children should reach their full potential,
 every child can succeed,
 we can impact the success of “at risk” children,
 quality early education fundamentally
transforms children and families
“The News About Fluoride, and It’s Good” by Dr.
Ross S. Fuller
“This lowered rate of dental caries is obtained in the
United States at an average
yearly cost of
$0.51 per person… how can there be any
doubt as to the success public water fluoridation has
had on reducing the impact and cost of dental disease
within the general public?” P. 19
Dated: Sunday March 13, 2011 – Newspaper: Daily News
(local in Virginia)
WHO
Fluoride is one of the very few chemicals that
has been shown to cause significant effects in
people through drinking-water. Fluoride has
beneficial effects on teeth at low concentrations
in drinking-water, but excessive exposure to
fluoride in drinking-water, or in combination with
exposure to fluoride from other sources, can give
rise to a number of adverse effects. These range
from mild dental fluorosis to crippling skeletal
fluorosis as the level and period of exposure
increases. Crippling skeletal fluorosis is a
significant cause of morbidity in a number of
regions of the world.
References
 1) American Dental Association – ADA at www.ada.org
 2) McDonald E. Ralph et al Dentistry for the Child and
the Adolescent. Sixth Edition. Mosby-Year Book, Inc.
1988. 928 p.
3) American Academy of Pediatric Dentistry
www.aapd.org
4) Academy of General Dentistry www.agd.org
5)www.Knhttp://water.epa.gov/action/advisories/drinki
ng/fluoride_index.cfm.owYourTeeth.com
References
 6) www.facebook.com/USPHSConference and
http://twitter.com/@USPHSconference
 7) www.cdc.gov/fluoridation/benefits.htm#3
 8) “The News About Fluoride, and It’s Good” article by
Fuller, Ross S., Daily Press, Sunday, March 13, 2011.
Page 19
 9) “Assessing the Relationship Between Children’s Oral
Health Status and That of Their Mothers”. JADA.
February 01, 2011. 142:173-183
References
 10) Li, Y. et al. The fidelity of Initial Acquisition of
Mutans Streptococci by Infants from Their Mothers,
JDR, February 1995. Vol 74, No. 2, 681-685
 11) Fact Sheets. Academy of General Dentistry.
www.knowyourteeth.com
 12) Data from WHO Oral Health Country/Area Profile
Programme Department of Noncommunicable
Diseases Surveillance/Oral Health WHO
Collaborating Centre, Malmo University, Sweden
 http://www.whocollab.od.mah.se/euro.html
QUESTIONS?
THANK YOU!