LEARNING OBJECTIVES

• Understand the biologic mechanism of

fluoridation
• Understand the benefits, possible adverse
effects and fluoride dosing
• Understand the community and well water
fluoride content issues in SC
COMMUNITY WATER
FLUORIDATION
• Single most effective public health measure
to prevent tooth decay
• CDC has proclaimed fluoridation as one of
the ten great public health achievements of
the 20th century
• Fluoridation is a powerful strategy in efforts
to eliminate health disparities among
populations
COMMUNITY WATER
FLUORIDATION
• Fluoridated water is accessible to the
entire community
• Individuals do not need to change their
behavior to obtain the benefits
• Frequent exposure to small amounts of Fl
over time makes Fluoridation effective
throughout the life span
Community Water Fluoridation

• Community public health measure that is

cost effective and saves $
• The cost of drinking fluoridated water for a
lifetime is about the same as the cost of
one dental filling
• For every $1 invested in water fluoridation,
$38 is saved in dental treatment costs
Water Fluoridation

• Reduces decay by 20-40% EVEN in

conjunction with Fl from other sources (e.g.
toothpaste)
• 26% fewer cavities in 12 y/o children living
in a state with >50% community water
fluoridation
• Healthy People 2010 objective is for 75%
public fluoridation; currently @70%
 Public Water Fluoridation Stats
• United States as a whole
– 72.4%
• South Carolina
– 94.4%
• Rank
– 9th best!!!
• www.cdc.gov/fluoridation/statistics/2008stats
Caries Prevention and Fluoride-
mechanism of action
• Benefit results from (a) uptake of systemic Fl by
enamel crystallites during pre-eruptive tooth
development & (b) uptake of topical Fl through
repetitive demineralization and remineralization
cycles in the oral cavity after tooth eruption
• Fl uptake allows formation of
fluorohydroxyapatite (FHA)
• FHA less susceptible to acid attack than
Hydroxyapatite in normal tooth enamel
Dental Fluorosis
• Caused by excess Fl intake; @ risk 0-8y/o; highest risk
boys 15-34 mos; girls 21-30 mos
• No significant dental risk > 8y/o
• MILD: chalk-like lacy marking across enamel surface;
not readily apparent to casual observer
• MODERATE: >50% of enamel surface is opaque white
• SEVERE: enamel is pitted and brittle and may develop
areas of brown staining (think of Dr. McKay and
Colorado Brown Stain)
Frequency of U. S. A. Pediatric
Fluorosis
• Age 6-11: 40%
• Age 12-15: 49%
• Age 16-19: 42%
RDA for Fl

• 0-6 mos: 0.01mg

• 7-12 mos: 0.5mg
• 1-3 yrs: 0.7mg
• 4-8 yrs: 1.0mg
• 9-13 yrs: 2.0mg
• 14-18 yrs: 3.0mg
Fluoride dosing that should not
result in more than mild Fluorosis
• Birth to 6 months: 0.01 mg/day
• 7-12 months: 0.05 mg/kg/day
• 12 months to 8 years: 0.1 mg/kg/day

• 1mg=1ppm
• 0.7 ppm is 2011 current target water fluoridation dose
• Community water systems are allowed to provide water
up to 4.0 ppm (MCLG; Maximum Contaminant Level
Goal) without taking corrective action
Fluorosis

• True risk not clear re the variables of

duration, timing, dose, biologic variability,
cumulative dosing of fluoride from non-
water sources (toothpaste, food,
therapeutic Fl treatments, etc)
Fluorosis

• The most critical ages of susceptibility are

from 0-6 y/o with the highest risk in boys
from 15-24 mos and girls from 21-30
months. After age 7-8, fluorosis does not
occur because the permanent teeth are
fully developed although not erupted
Mild Fluorosis
Moderate Fluorosis
Severe Fluorosis
Fl in formula
Product/mean ppm +/- 1SD
Powdered mild base/0.12 +/- 0.08
Powdered soy/0.16 +/-0.09
Liquid concentrate milk base: 0.27 +/- 0.18
Liquid concentrate soy base: 0.50 +/-0.08
Ready to feed milk base: 0.15 +/- 0.06
Ready to feed soy base: 0.21 +/- 0.01
Fl in Formula
• Most infants exceed the upper tolerable limit of Fl if
formula prepared with 1ppm water @ 0-12 months of
age
• 6-12 month infants unlikely to reach adequate Fl intake
if fed ready to feed, powdered, or liquid concentrate
reconstituted with <0.4 ppm water
• No ready to feed formula will exceed the 0.1 mg/kg/day
RDA upper tolerable limit
• True risk of fluorosis not clear re “brief” exposure to
formula before switching to regular milk @ 1y
• What impact does Fl in solid food have on this Fl dose?
Fluoride Content

• Toothpaste: 0.15% Fl ion (1.5 gm/L);

0.243% NaFl (2.43 mg/L)
• 5% Dental Fluoride Varnish: 50 gm/L NaFl
or 2.26% Fl ion (22.6 gm/L); available in
0.4ml and 0.25 ml volumes in disposable
kit form; 9.0 mg of Fl ion in 0.4 ml dish or
5.6 mg Fl ion in 0.25 ml dish
Other selected fluoride sources
• Bottled water not required to label Fl content;
assume sub-optimal content unless fluoride
content labeled; the distributor can tell the
customer on request
• Seafood: likely high content
• Foods/Beverages frequently prepared by
manufacturer with community water; may not
be included in label
• Breast milk: very little fluoride
Fluoride content of selected
foods ppm
• 2% milk = 0.04
• Wheaties = 0.4
• Cherrios = 0.9
• Minute Maid OJ = 0.39
• Tea = 0.1-0.6
• Chicken = 0.06-0.1
• Hunt’s Tomato Paste = 0.27
• Sardines = 0.2-0.4
COMMON WATER FILTERS

• Include carafe filters, faucet filters, under the

sink filters, and whole house filters
• In general, the amount of Fl filtered depends on
the type of filter, age of filter, working condition,
and presence of activated alumina (up to 80%
removal) or carbon in filter (generally little
removal)
• Each type of filter needs to be assessed
individually
WATER FILTRATION

• Reverse osmosis filters remove 65-95% of Fl

• Steam distillation units remove 100% of Fl
• Water softeners do not remove significant
amounts of Fl
• Consumers using home water treatment
systems should have their water tested at
least annually
WELL WATER SAMPLES

• 1/18/10-6/22/11
• 339 bottles released
• 170 bottles returned
WELL WATER SAMPLES ppm

• 1/18/10-6/22/11
• 0 to 0.69 = 129--76%
• 0.7 to 1.20 = 13--8%
• 1.21 to 2.01 = 17--10%
• 2.01 to 3.0 = 9--5%
• 3.1 to 4.0 = 1--<1%
• >4.0 = 1--<1%