COMMUNITY WATER FLUORIDATION
IN
NEW YORK STATE
MAY 7, 2013
Jay Kumar, DDS, MPH
Why Do Cavities Matter?
Dental Caries
Facial Cellulitis
Dental Extraction
Dental Caries
Dental Caries
Teeth problems caused by cavities
Source: Pew Children’s Dental Campaign
June 22, 2012
Goal #5: Reduce the prevalence of dental caries
among NYS children. Prevention Agenda Target 2017.
Third-grade children
50
45
40
35
30
25
20
15
10
5
0
Medicaid (2-20)
46
45.4
42
40
24
Prevalence
45
40.8
21.6
Untreated
Sealant
Dental Visit
Fluoridation:
Increase from 71.4% to 78.5%
Why water fluoridation?

Reduces cavities by up to 40% — for
both children and adults

Helps Americans keep their teeth

Saves millions in treatment costs and
eliminates pain and suffering

Nearly every large city and more than
204 million Americans benefit

CDC: One of the 10 great public health
achievements of the 20th century
Source: Pew Children’s Dental Campaign
A Public Health Achievement
“Fluoridation is the single most important commitment a
community can make to the oral health of its children and to
future generations.”
Dr. C. Everett Koop
Surgeon General (1982-1989)
“Fluoridation is the single most effective public health measure to
prevent tooth decay and improve oral health over a lifetime, for
both children and adults.”
David Satcher, MD, PhD
Surgeon General (1998-2002)
One of water fluoridation’s biggest advantages is that it benefits
all residents of a community—at home, work, school, or play—
through the simple act of drinking fluoridated water.
Regina M. Benjamin, MD, MBA
Surgeon General
Source: Pew Children’s Dental Campaign
Fluoridation in New York State




Fluoridation efforts started in 1942
Newburgh initiated fluoridation in 1945
Focus on research and evaluation
Approximately 12.5 million residents or
approximately 72% on public water supplies
receives fluoridated water
The Weight of Science
Opposition to
Fluoridation
June 22, 2012
Mean claim per recipient for caries related procedures was
correlated with county fluoridation status
1.66
1.33
1.23
Spearman Correlation Coefficient -0.53 (p < 0.01).
Each bubble denotes the size of the Medicaid population.
Savings from Water Fluoridation:
What the Evidence Shows




Louisiana: A statewide analysis of Louisiana Medicaid
reimbursements for caries-related procedures delivered
to children, aged 1 to 5 years - Savings $66.8 per child
A Texas study confirmed that the state saved $24 per
child, per year in Medicaid expenditures.
A 2010 study in New York State - $23.65.
Researchers estimated that in 2003 Colorado saved
nearly $149 million in unnecessary treatment costs by
fluoridating public water supplies—average savings of
roughly $61 per person.
Scientific Review




National Research Council Report – Fluoride
in Drinking Water (2006)
Griffin SO et al. Effectiveness of fluoride in
preventing caries in adults. Journal of Dental
Research 2007;86(5):410–414.
Scientific Committee on Health and
Environmental Risks of the European
Commission (SCHER 2011)
EPA Reports
Fluoride in Drinking Water:
Proposal to Change Standards

EPA Drinking Water Standards





Maximum Contaminant Level Goal
(MCLG) – 4 mg/L
Maximum Contaminant Level (MCL)
Secondary Maximum Contaminant
Level (SMCL) – 2 mg/L
4.0
3.6
3.2
2.8
2.4
2.0
CDC Recommendations for Fluoridation
(0.7 -1.2 mg/L)
1.6
New York State Standards
0.8


Fluoridation Target is 1 mg/L ( Range
0.8 -1.2)
State MCL is 2.2 mg/L
1.2
0.4
0.0
News Release
FOR IMMEDIATE RELEASE
January 7, 2011 Contact: OASH ashmedia@hhs.gov 202-205-0143
EPA isa.jalil@epa.gov or 202-564-3226
HHS and EPA announce new scientific assessments and actions on
fluoride
Agencies working together to maintain benefits of preventing tooth decay
while preventing excessive exposure
WASHINGTON – The U.S. Department of Health and Human Services (HHS)
and the U.S. Environmental Protection Agency (EPA) today are announcing
important steps to ensure that standards and guidelines on fluoride in
drinking water continue to provide the maximum protection to the American
people to support good dental health, especially in children. HHS is
proposing that the recommended level of fluoride in drinking water can be
set at the lowest end of the current optimal range to prevent tooth decay,
and EPA is initiating review of the maximum amount of fluoride allowed in
drinking water.
************************************************************************
HHS’ proposed recommendation of 0.7 milligrams of fluoride per liter of
water replaces the current recommended range of 0.7 to 1.2 milligrams.
Reasons




Americans have access to more sources of fluoride than
they did when water fluoridation was first introduced in
the United States in the 1940s.
The prevalence of dental fluorosis has increased.
Severe enamel fluorosis is the clinical end point for
setting EPA standards.
EPA and HHS scientific assessments to balance the
benefits of preventing tooth decay while limiting any
unwanted health effects show that this can be achieved
at 0.7 mg/L.
Lack of association between daily temperature and
children’s water intake in the United States.
Tooth Decay
Dental Fluorosis
National Research Council Report – Fluoride in
Drinking Water (2006)

The Committee considered three toxicity end
points for which there were sufficient relevant
data for assessing the adequacy of the MCLG
for fluoride to protect public health:
 severe
enamel fluorosis,
 skeletal
 bone
fluorosis, and
fractures.
Prevalence Severe Fluorosis
Prevalence of Severe Enamel Fluorosis below 2 mg/L F,
NRC Report 2006
30
EPA’s Point of Departure
25
20
15
10
5
0
0
1
2
3
Fluoride Level (ppm)
4
EPA ASSESSMENT
The data in Table 8-2 indicate
that some children drinking water
at the 90th percentile intake
level up to about age 7 are being
exposed to fluoride on a daily
basis at levels at or higher than
estimated acceptable intake
levels when the concentration of
fluoride in their drinking water is
at or above 0.87 mg/L.
Strong evidence exists that the prevalence of severe enamel fluorosis is
nearly zero at water fluoride concentrations below 2 mg/L.
2006 National Research Council Report – page 294
Reduce the MCLG of 4 mg/L
Water fluoride
Prevalence
4 mg/L
~10%
<2 mg/L
~0%

Conclusion that the MCLG should protect against
severe enamel fluorosis is consistent with
recommendations of Institute of Medicine (IOM).

IOM (1997)

Age-specific tolerable upper intake levels (UL)

Set to reduce moderate enamel fluorosis
Strategies to promote fluoridation


Build support - Internal & External
Engage partners and stakeholders
State Oral Health Coalition
 Rural Water Association
 Local Health Departments
 State Dental Association
 Foundations




Develop resources
Provide training
Explore financing options
Resources

New York State Department of Health
(NYSDOH) website
 CDC

and ADA
Technical Assistance Center in Rochester
 ILikeMyTeeth.org
- NewYork.ILikeMyTeeth.org
 Fluoride Science.org


Rural Water Association
Local Health Department
 Water
Fluoridation Manual
Fluoridation Manual

Addresses





Benefits
Safety concerns
Cost
Operations and
Engineering
Contains:



Articles
Fact sheets and official
statements
New York specific
information
NewYork.ILikeMyTeeth.org


Component website on
ILMT
Features information
specific to NYS including:





NYS laws and regulations
Electronic copy of
fluoridation manual
New York fluoridation
maps
Links to other fluoridation
websites
Fact sheets and
resources
FluorideScience.org



Topic summaries
Critical appraisals
Videos featuring
fluoride researchers
Training

New York Rural Water Association (NYRWA)




Operations and Engineering
Benefits
Safety concerns
Technical Assistance
Thank you
jvk01@health.state.ny.us