public health leadership: the key to a healthier nation

Public Health Leadership:THE KEY TO A HEALTHIER

NATION

CDR María-Paz U. Smith, DMDCareer path:

1) Indian Health Service – Pine Ridge, SD - 1996-20002) US Coast Guard – Cape May, NJ - 2000-20043) US Coast Guard – Comprehensive Dentistry Residency – US Navy, Bethesda, MD – 2004 - 20064) US Coast Guard – Senior Dental Officer in Yorktown,VA – 2006 - 20115) US Coast Guard – Senior Dental Officer in Elizabeth City, NC – 2011 - 2016

THE ROLE OF THE ROLE OF FLUORIDE IN FLUORIDE IN

CARIES CARIES PREVENTION IN PREVENTION IN

CHILDRENCHILDREN

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 PREVENTthan 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 (non-supported 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

FluorosisWater is naturally fluoridated to

levels well above the recommended levels – prevalent

in some parts of India,inTanzania

Mild fluorosis

Severe fluorosis

Skeletal Fluorosis

Most experts in skeletal fluorosis agree that ingestion of 20 mgof fluoride/day for 20 years or more can cause cripplingskeletal fluorosis. Doses as low as 2 to 5 mg/day can causepreclinical and earlier clinical stages. The situation is complicatedbecause the risk of skeletal fluorosis depends on more than thelevel 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 IONThe 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 CarcinogenicityIn 1987, the International Agency for Research on Cancer (IARC) reviewed theavailable data concerning the carcinogenicity of fluoride and concluded that therewas inadequate evidence of carcinogenicity in experimental animals (IARC,

1987).Two separate sets of long-term fluoride carcinogenicity studies in rats andmice have been published in the 1990s (NTP, 1990; Bucher et al., 1991; Maureret 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 FluoridationTo 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 304,059,724US population on public water systems 269,911,707Total US population on fluoridated drinkingwater 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, SDusually takes 10,000 years totrickle down to the Pine Ridge Indian Reservation – not knowingwhat minerals or the amount of minerals that is carrying

United States Map of Fluoridated Water

Communal Water FluoridationMcDonald 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 feedsfluoride into the water supply system, asa 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 theCommonwealth of Pennsylvania, Department of Public Health, issuedJuly 22, 1952, at a concentration of 1.0 milligrams per liter. This levelis within the current maximum contaminant limit established by the United States Environmental Protection Agency and in accordance withthe United States Public Health Service, Division of Dental PublicHealth 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 Philadelphiawith 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 thanany other area of health care. Water fluoridation is one of our most potent weapons in disease prevention, and wewant as many people as possible to have the benefits of this simple, safe, inexpensive and proven health care measure”

FLUORIDE USEWhen 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 Fluoridecontains increased concentrations of fluorhydroxyapatite, making the remineralized tissue more resistant to future attack by acids

Fluoride SupplementsConcentrations 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 ppmFluoride mouth rinse solution of 0.20 % sodium fluoride = 920 ppm – this has to be given to children under supervision

Fluoride SupplementsFluoride gel of acidulated phosphate fluoride

= 1.23 % = 12,300 ppmStannous fluoride 0.15 % or 1,500 ppmFluoride 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 todrink 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 Conversionsppm 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/liter0.7 ppm = 0.7 mg/liter

World Health Organization DataDMFT (Decayed, Missing and Filled Teeth)

29 April 2011Switzerland 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 whocan make more and better

decisions on healthier choices for theirbabies

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 Diet3.73 ppm Brewed black tea2.34 ppm Raisins2.02 ppm White wine1.09 ppm Apple-flavored juice0.91 ppm Brewed coffee0.71 ppm Tap water (US – wide average)0.61 ppm Chicken soup broth0.60 ppm Diet coke (US – wide average)0.48 ppm Hot dog0.46 ppm Grapefruit juice0.45 ppm Beer0.33 ppm Flour tortillas0.03 ppm Milk (2 %)

Mothers are usually the key to good hygiene, good health

“Thus, clinicians may consider dentalcaries in the mother as a risk indicatorfor caries activity in her child.Our findings suggest that reducingcaries in young children may requireimproving the oral health of theirmothers”.

Dye, Bruce et al. JADA – February 2011

ORAL HEALTH

How can I help my children to brush? Lead by example! www.knowyourteeth.com Academy of General Dentistry (Fact Sheets)

Support Programs

All these programs, like: Headstart, WIC, National

Women’s Health Week, BestBones Forever! And many

more should be advertised; parents

should be encouragedto take advantage of the

multiplebenefits these offer to families

Minority Groups

NHSA = National Head Start AssociationWe Believeall 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)

WHOFluoride 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.

References1) American Dental Association – ADA at

www.ada.org2) 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.org5)www.Knhttp://water.epa.gov/action/advisories/

drinking/fluoride_index.cfm.owYourTeeth.com

References6) www.facebook.com/USPHSConference and

http://twitter.com/@USPHSconference7) www.cdc.gov/fluoridation/benefits.htm#38) “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

References10) 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

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