Fluoridation

Background

For more than half a century, community water fluoridation has been the cornerstone of dental caries prevention in the United States (13). Defined as the adjustment of the natural fluoride concentration in a community's water supply to the level recommended for optimal dental health (a range of 0.7 to 1.2 parts per million) (1), community water fluoridation is the single most cost-effective public health measure to prevent tooth decay and improve oral health over a lifetime (4). In 1999, the Centers for Disease Control and Prevention (CDC) identified the widespread practice of fluoridating community drinking water as one of the ten great public health achievements of the 20th century (12). The U.S. Community Preventive Services Task Force strongly recommends community water fluoridation as an effective method to reduce the prevalence of dental caries in the public (2).
 
The proportion of the U.S. population living in communities with fluoridated water supplies is approximately 66 percent (1). Although 26 states and the District of Columbia have now met the Healthy People 2010 national health goal of providing 75 percent of their population with fluoridated water, approximately 100 million persons still lack the benefits of community water fluoridation (12).
 

Policies

 

1. Pass state legislation requiring fluoridation of community water supplies. Legislation can often result from concerted action by local coalitions.

Implementing community water fluoridation is an effective, low-cost policy intervention. Costs range from a high of $3.00 per person for water systems serving less than 10,000 people to $0.68 per person for systems serving populations greater than 50,000 (13) with benefits extending throughout the population served (1). Whether enacted at the state, county or local level, legislation requiring community water fluoridation directly benefits the public's health.
 
Such legislation is often preceded by community coalition action. Local organizations working to expand fluoridation can benefit from joining a coalition, because they allow organizations to more effectively pool resources, which gives the coalition the ability to generate more political sway. In this way, coalitions can be advocates for change at the local, state and federal levels.
 

2. The federal government, state governments and foundations consider providing financial incentives (grants) for states to implement community water fluoridation programs at the local level.

While the average cost is less than one dollar per person per year (13), budgetary constraints can prove a barrier to implementation of community water fluoridation programs. Governmental and nonprofit funding agencies should consider funding water fluoridation efforts as outreach to local communities.
 

Effectiveness Data

There are a variety of policy strategies that have increased the number of persons with access to community-fluoridated water:
 

• Local referenda have resulted in the implementation of community water fluoridation in Yakima County, Washington in 1997 (7); continuation of optimal fluoridation in Clark County, Nevada in 2000 (9); and the inclusion of community water fluoridation on the November 2002 ballot in Washoe County, Nevada (9).

• State-mandated water fluoridation has significantly increased populations served. In 1995, California passed Assembly Bill 733 mandating community water fluoridation in public water systems with 10,000 or more service connections (4), as long as funding is provided by an outside source, such as a private foundation or government grant (8). Implementation of this law by the cities of Los Angeles, Sacramento and Mountain View has increased the percentage of Californians with access to community-fluoridated water from 17 percent in 1999 to 30 percent in 2002 (5, 8). In 1999, the Nevada Legislature passed Assembly Bill 284 directing the Southern Nevada Water Authority and the City of Henderson to begin fluoridating community water supplies (3). 

Governmental and nonprofit funding agencies are recognizing the need to provide funds for the implementation of community water fluoridation programs:
 

• The Colorado Legislature created a grant program through Revised Statute 25-21.5-101 (The Colorado Dental Care Act of 1977) that, in addition to funding other oral health programs, assists communities in obtaining equipment and training to fluoridate their drinking water systems (6).

 

• The Children's Health Act of 2000 allows the Secretary of Health and Human Services to award grants to states and tribes to increase the resources available for community water fluoridation, for example, to purchase fluoridation equipment, train fluoridation engineers, develop educational materials on the benefits of fluoridation and support an infrastructure to monitor and maintain the quality of water fluoridation (11).

 

• In 2001, CDC allocated $1.2 million to six state and territorial health departments to improve oral health services. This included funding for development and coordination of community water fluoridation systems (10).

 

Resources

American Dental Association
http://www.ada.org/public/topics/fluoride/fluoride.html
The ADA's web site offers links, resources, and documentation on the effectiveness of fluoridation. The "public" portion of the site highlights useful information for lay persons and community activists; access to the "professional" portion of the site is restricted to members. Key resources available to the public through this site include ADA's Community Organization for Water Fluoridation, Community Water Fluoridation Resources Kit, and Fluoridation Facts.
 
Partnership for Prevention
http://www.prevent.org/Winword/oralhealth.pdf
http://www.prevent.org
The Partnership for Prevention's web site provides information on a variety of health issues. Oral Health: Common and Preventable Ailments provides a useful overview of general oral health and fluoridation's contributions toward improving oral health.
 
The Dental Health Foundation
http://www.dentalhealthfoundation.org/topics/fluoridation/index.shtml
http://www.dentalhealthfoundation.org
The Dental Health Foundation provides effective resources for developing a community water fluoridation program. Especially useful is their publication The Oral Health of California's Children: Halting a Neglected Epidemic available online. 
 

References

1. Centers for Disease Control and Prevention. (2002). Populations receiving optimally fluoridated public drinking water -United States, 2000. Morbidity and Mortality Weekly Report, 51(07), 144-147. Retrieved July 29, 2002, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5107a2.htm
2.  Centers for Disease Control and Prevention. (n.d.). Promoting oral health. Guide to Community Preventive Services. Retrieved July 29, 2002, from http://www.thecommunityguide.org/home_f.html 
3. Clark County Election Department. (n.d.) Clark County question No. 1: Water fluoridation question. Retrieved May 3, 2002, from http://www.co.clark.nv.us/election/general_2000/QUESTIONS/2000_Gen_CC_Question1.htm
4. The Dental Health Foundation. (2000). The oral health of California's children: Halting a neglected epidemic (p. 13). Oakland, CA: Author.
5. Martinez, M. (n.d.). The Dental Health Foundation California Fluoridation Project. Retrieved May 3, 2002, from the National Institute of Dental and Craniofacial Research website: http://www.nidr.nih.gov/sgr/children/Fluoride.pdf 
6. National Conference of State Legislatures. (2000). Access and primary care: Oral health. Retrieved May 3, 2002, from http://www.ncsl.org/programs/health/oral.htm 
7. National Institute of Dental and Craniofacial Research. (n.d.). Successful fluoridation by ballot. Retrieved May 3, 2002, from http://www.nidr.nih.gov/sgr/children/Fluoride.pdf
8. Nelson, D. (2002, October 23). Personal communication with Center for Health Improvement.
9. Nevada State Health Division Oral Health Initiative. (2002). Retrieved May 3, 2002, from http://www.health2k.state.nv.us/oral/Fluoride.htm
10. Palmer, C. (2001). CDC allocates $1.2 million to state oral health services. Retrieved May 3, 2002, from the American Dental Association website: http://www.ada.org/prof/pubs/daily/0107/0716cdc.html
11. Partnership for Prevention. (2001). Scorecard-March 2001: Tracking high-impact actions that Congress can take to protect and promote the nation's health. Retrieved May 3, 2002, from http://www.prevent.org/Winword/final_scorecard.pdf
12. U.S. Department of Health and Human Services. (2000). Objectives for improving health. In Healthy People 2010: Vol. 2. (2nd ed., pp. 21-5, 21-21). Washington DC: U.S. Government Printing Office.  Retrieved July 20, 2002, from http://www.health.gov/healthypeople/Document/HTML/Volume2/21Oral.htm 
13. U.S. Department of Health and Human Services. (2000). Oral health in America: A report of the Surgeon General (p. 160). Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health.

 

Acknowledgements

Andrea Azevedo, BDS, MPH, Dental Health Consultant, California Department of Health Services, Maternal and Child Health Branch, Sacramento, California
 
Anthony D. Moulton, PhD, CDC Public Health Law Program, Centers for Disease Control and Prevention, Atlanta, Georgia
 
David Nelson, DDS, MPH, Fluoridation Consultant, California Department of Health Services, Office of Oral Health, Sacramento, California
 
David Pisani, Manager, Policy Development and Analysis, California Dental Association, Sacramento, California
 
Marjorie Stocks, MPH, Project Director, Fluoridation Implementation Project, Dental Health Foundation, Oakland, California
 
A special thanks to the Public Health Law Program, Centers for Disease Control and Prevention; portions of this document have been adapted, with permission, from the materials presented at their June 2002 The Public's Health and the Law in the 21^st Century conference.