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Dental Public Health SeminarUCSF

May 20, 2008

Fluoridation in Southern California:Are we there yet?

Howard Pollick, BDS, MPH

Clinical Professor

School of Dentistry

University of California

San Francisco

Tim Collins, DDS, MPH

Dental Director

County of Los Angeles

Chair, California Fluoridation

Advisory Council

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Brief History of Fluoridation in Californiahttp://www.sdcds.org/general/article.aspx?aid=35

• Prior to the implementation of AB 733, California was ranked 48th in the nation in the percent of residents receiving community water fluoridation (15.7% of population on public water supplies in 1992).

• Subsequent to the Fluoridation Act, the California Endowment allocated $15 million to the Fluoridation Work Group to develop community support for fluoridation and allocate capital funds to selected communities.

• The Work Group members included: The California Dental Association, The California Department of Health Services, The Dental Health Foundation and the California Fluoridation Task Force.

• As a result of this project, the cities of Sacramento, Los Angeles, Santa Maria, Escondido and other communities now fluoridate their water supply.

• San Diego remains the largest city in California and the nation without the benefit of optimal community water fluoridation.

In 1995, State Senator Jackie Speier authored AB 733, the Fluoridation Act, which mandated the fluoridation of water systems with 10,000 service connections or more when funding was available.

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CDC Data on Fluoridation

• California in 2002 • 27.6% of people served by public water supplies• Rank - 45th of 50 states• data current as of 12/31/04, according to the CDC website. • data are based on what the State of California provides to CDC • California not yet participating in WFRS:

– Water Fluoridation Reporting System

http://www.cdc.gov/fluoridation/statistics/states_stats2002.htm

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How many people are served by community water fluoridation?

• In terms of population served, according to the 2002/4 CDC fluoridation data and the 2006 US Census population estimate data

• California is the most populated state (about 36.5 million and ranks 6th in population on CWF – 10.1 million);

• Texas is 2nd most populated (23.5 million, and ranks 1st in population on CWF – 15.4 million);

• New York is the 3rd most populated (19.3 million, and ranks 2nd in population on CWF – 14 million);

• Florida is the 4th most populated (18 million, and ranks 4th in population on CWF – 12.2 million);

• Illinois is the 5th most populated state (12.8 million, and ranks 3rd in population on CWF – 12.7 million);

• Ohio is the 7th most populated state (11.5 million, and ranks 5th in population on CWF – 10.4 million)

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How many Californians are served by community water fluoridation?

According to what is posted by the California DPH at:

http://www.cdph.ca.gov/certlic/drinkingwater/Pages/Fluoridation.aspx

• There are 21,846,061 people with access to fluoridated water in California (whether naturally occurring, adjusted, consecutive or variable; origin and date of population data State Department of finance estimates 2006-7; fluoridation data updated December 7, 2007 according to California Dept. of Public Health.)

• According to the US Census Bureau, the population of California in 2006 was 36,457,549 http://quickfacts.census.gov/qfd/states/06000.html

• Assuming all data to be accurate then 60% of Californians have access to fluoridated or partially fluoridated water.

• These data need to be verified during 2008 for the communities supplied by MWD of Southern California, because we do not know the exact distribution of that fluoridated water and the blending or variation with local water sources.

• For example, the City of San Diego only receives 9% of its water from MWD, yet the entire population of San Diego (1,255,000) is listed on the website as receiving partially fluoridated water.

• The percentage is probably nearer 50%, which would rank California at about 40th. However, it would still rank California #1 in population served by fluoridated water.

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Growth of California FluoridationJanuary 2006 - December 2007

California Population and Public Water Systems Receiving Fluoridated Water

January, 2006 September, 2007 December, 2007

Type PWS Count

Population (Million)

PWS Count

Population (Million)

PWS Count

Population (Million)

Adjusted 46 8.46 50 8.63 53 9.27

Consecutive 29 1.44 35 1.69 67 2.92

Variable 11 1.12 10 1.05 163 10.47

Natural 3 0.02 6 0.07 6 0.07

Total 89 11.04 101 11.44 289 22.73

Note: 1/1/07 State population was 37.7 million. PWSs served approximately 36.6 million.

Source: Dave Lancaster, Sacramento District Engineer, CDPH. April, 2008

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Some of the Players - not including local coalitions

California Department of Public Health

• Donald O. Lyman, MD, ChiefDivision of Chronic Disease and Injury Control

• Kathleen H. Acree, MD, MPH, JD, Chief Chronic Disease Control Branch

• Rosanna Jackson, Chief, Office of Oral Health

• Lynda DyaneDivision of Drinking Water and Environmental Management, Drinking Water Program

• David Lancaster Division of Drinking Water and Environmental Management, Drinking Water Program, Sacramento District

• Steven J. Silverstein, DMD, MPH, UCSF Project Administrator

California Dental Association FoundationCalifornia Fluoridation Advisory Council

• Jon Roth, Executive Director CDAF

• Tim Collins, Los Angeles County Dental Director

• Jeff Album, Delta Dental

• Al Arizmendez, Miller Geer Arizmendez, Inc.

• Edgar Dymally,Senior Environmental Specialist, Metropolitan Water District of Southern California

• Wynne Grossman, Executive Director, Dental Health Foundation

• Dave Heumann, Water Quality Compliance, Los Angeles, Dept. of Water and Power

• Gayle Mathe, CDA

• David Nelson, CDAF

• Howard Pollick, UCSF

• Marjorie Stocks, Fluoridation consultant, CDAF

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California Fluoridation Map

http://www.cda.org/page/Fluoride_Map

By zip code

2004

Not complete

Not updated

e.g. None in Santa Barbara or San Diego Counties

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In 2003, MWD Board votes to fluoridateIn 2007, MWD fluoridates

• The Metropolitan Water District of Southern California is a cooperative of 26 cities and water agencies serving 18 million people in six counties.

• The district imports water from the Colorado River and Northern California to supplement local supplies…

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2003 - Glen Peterson Honored by California Health Services

Department for Advocating Drinking-Water Quality

For the past five years, Mr. Peterson championed the issue of fluoridation before the Metropolitan board and has become an outstanding advocate. The Metropolitan board recently voted to fluoridate (water treated at) their five treatment plants. Because of Mr. Peterson's commitment and dedication, fluoridated water will be a reality for almost 18 million residents of Southern California."

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MWD’s Service Area

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Fluoridation Status of Southern California

Public Water Systems• http://www.cdph.ca.gov/certlic/drinkingwater/Pages/Fluoridation.aspx • California Department of Public Health (CDPH) maintains a table

(last updated December 6, 2007) that identifiespublic water systems in California that fluoridate (Excel)

their drinking water supplies, are:• naturally fluoridated, or • receive purchased fluoridated water.

The table lists the average monthly fluoride levels in those systems, if the data are available.

Ranges of fluoride levels are provided where monthly data are not available.

Fluoridation level information is also available in Consumer Confidence Reports, provided to you each year by your public water system, or you may contact the public water system directly for the information.

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LOS ANGELES COUNTYAdjusted Systems - Water Systems that add fluoride to the optimal level.

• City of Long Beach - 490,166• City of Los Angeles - 4,000,000• Metropolitan Water District of So. California - ?• City of Beverly Hills - 44,290

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LOS ANGELES COUNTY• Consecutive Systems - • Water systems that distribute 100% fluoridated water that is received

from another water system.

Golden State Water Co. (Culver City) [o] 31,789

Foothill Municipal Water District [o] 84,000

City of El Segundo [o] 17,024

City of Lomita [o] 20,181

Los Angeles CWWD 21 (Kagel Canyon) [h] 990

Cal-Water Service Co. (Palos Verdes) [o] 68,766

Los Angeles CWWD 29 & 80 - (Malibu & Marina Del Rey) [u] 24,621

Mesa Crest Water Company [o] 2,500

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LOS ANGELES COUNTY• Natural Systems - • Water systems with sources that have naturally occurring fluoride

ranging from 0.3 to 2.0 mg/L. • Annual average fluoride concentration is > 0.6 mg/L.

• Kinneloa Irrigation District - 1,500• Rubio Canon Land And Water Assoc. [t] - 9,600• City of Sierra Madre - 10,570

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LOS ANGELES COUNTY• Variable (Partially Fluoridated) Systems - • Water systems with fluoride levels ranging from

< 0.3 to 2.0 mg/L. (below optimum to above optimum)

– Contact the water system for more information.

• 67 Water Systems• Population - 3,394,841

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ORANGE COUNTY

• Adjusted Systems - • Water Systems that add fluoride to the optimal level.

• City of Huntington Beach - 199,326• City of Fountain Valley - 55,000

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ORANGE COUNTY

• Consecutive Systems - • Water systems that distribute 100% fluoridated water that is

received from another water system.

Laguna Beach County Water District [o] 25,000 South Coast Water Dist. (South Coast) [o] 20,000 South Coast WD (Capistrano Beach) [o] 20,300 Joint Regional Water Supply System [o] --- Moulton Niguel Water District [o] 161,900 El Toro Water District [o] 50,700 East Orange County Water District (Wholesale Zone) [o] --- Santa Margarita Water District [o] 140,000

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RIVERSIDE COUNTY• Adjusted Systems - • Water Systems that add fluoride to the optimal level.

• Eastern Municipal Water District - 380,025• Eastern Municipal Water District (EMWD) purchases about 75

percent of its water from the Metropolitan Water District of Southern California (MWD).

• As a precautionary measure, health care providers have been advised to suspend administration of fluoride supplements to their patients for one year. For additional information about drinking water fluoridation, contact your dentist or doctor.

http://www.emwd.org/news/news-archives/news_07/07-23_flouridation.html

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RIVERSIDE COUNTY

• Consecutive Systems - • Water systems that distribute 100% fluoridated water that is

received from another water system.

• City of Perris [q] - 6,715• Western Municipal Water District [o] - 61,000• Western Municipal Water District (ID A - Rainbow) [o] - 102

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RIVERSIDE COUNTY

• Natural Systems - • Water systems with sources that have naturally occurring

fluoride ranging from 0.3 to 2.0 mg/L. • Annual average fluoride concentration is > 0.6 mg/L.

• Indio Water Authority - 15,392

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SAN BERNARDINO COUNTY

• Natural Systems - • Water systems with sources that have naturally occurring

fluoride ranging from 0.3 to 2.0 mg/L. • Annual average fluoride concentration is > 0.6 mg/L.

• Redlands MUD - 20,627

• Twentynine Palms Water District is not included in the database, even though the CCR shows 1.54 mg/L F naturally occurring.

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SAN DIEGO COUNTY

• Adjusted Systems - • Water Systems that add fluoride to the optimal level.

• City of Escondido - 122,000• Helix Water District - 261,000

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SAN DIEGO COUNTY

• Consecutive Systems - • Water systems that distribute 100% fluoridated

water that is received from another water system.

Vallecitos Water District [o] 81,000 Carlsbad Municipal Water District [o] 81,000 Fallbrook Public Utility District [o] 32,000 Rainbow Municipal Water District [o] 19,000 Rincon Del Diablo MWD (ID-1) [o] 25,000 Ramona Municipal Water District [o] 40,000 Valley Center Municipal Water District [o] 26,000 Vista Irrigation District [o] 121,000 Padre Dam Municipal Water District [s] 126,000

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SAN DIEGO COUNTY• Variable (Partially Fluoridated) Systems - • Water systems with fluoride levels ranging from

< 0.3 to 2.0 mg/L. • Contact the water system for more information.

Yuima Municipal Water District (IDA) [p] 996 Yuima Municipal Water District [p] 500 Lakeside Water District [g] 35,000 City of Oceanside [p] 177,000 City of San Diego [p] 1,255,000 Olivenhain Municipal Water District [p] 58,000 Otay Water District [g] 150,000

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San Diego County Water Authority Fluoridation Map http://www.sdcwa.org/manage/pdf/FluoridationMap.pdf

Ventura County• Adjusted Systems - • Water Systems that add

fluoride to the optimal level.

• Port Hueneme Water Agency

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• Consecutive Systems –

• Water systems that distribute 100% fluoridated water that is received from another water system.

• 16 systems• Population - 288,932

• Variable (Partially Fluoridated) Systems –

• Water systems with fluoride levels ranging from < 0.3 to 2.0 mg/L. • Contact the water system for more information.

• 9 systems• Population - 350,018

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Healthy People 2010http://www.healthypeople.gov/document/html/volume2/21oral.htm • National Objectives• 21-9 • Community water

fluoridation• Increase the

proportion of the U.S. population served by community water systems with optimally fluoridated water.

• Target: 75 percent.• Baseline: 62

percent of the U.S. population was served by community water systems with optimally fluoridated water in 1992.

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Healthy People 2010http://www.healthypeople.gov/document/html/volume2/21oral.htm

• Community water fluoridation is the procedure of adjusting the natural fluoride concentration of a community’s water supply to a level that is best for the prevention of dental decay.

• In the United States, community water fluoridation has been the basis for the primary prevention of dental decay for nearly 55 years and has been recognized as 1 of 10 great achievements in public health of the 20th century.

• It is an ideal public health method because it is effective, eminently safe, inexpensive, requires no cooperative effort or direct action, and does not depend on access or availability of professional services.

• It is equitable because the entire population benefits regardless of financial resources.

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Healthy People 2010http://www.healthypeople.gov/document/html/volume2/21oral.htm

• Water fluoridation reduces or eliminates disparities in preventing dental caries among different socioeconomic, racial, and ethnic groups.

• Fluoridation helps to lower the cost of dental care and dental insurance and helps residents retain their teeth throughout life.

• Of the Nation’s 50 largest cities, only 7 do not benefit from community water fluoridation.

• The consumption of fluoridated water provides both systemic fluoride exposure to developing teeth and frequent topical exposure to erupted teeth, promoting remineralization of early caries among persons of all ages.

• Operators of municipal water plants need to maintain targeted concentrations of fluoride in water in fluoridated communities.

• Ongoing education for water plant personnel must continue with appropriate surveillance by State and local health officials.

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Projections for Fluoridation in California

California Dental Association Foundationhttp://www.cdafoundation.org/access_to_care/direct_programs_for_the_underserved/fluoridation/

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Many people to thank

• In addition:• American Public Health Association• Oral Health Section• Annual Meeting, San Diego• October 28th 12:30 - 2:00 pm• “Fluoridation in California: Is San Diego fluoridated?”• Panel:

– Howard Pollick, Tim Collins, Jon Roth, Eleanor Nadler, Marjorie Stocks

– Ron Roberts (Supervisor San Diego County) – Scott Peters (President San Diego City Council)

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Questions, Comments

howard.pollick@ucsf.edu