USPHS 2011 Scientific and Training Symposium June 20-23

1. USPHS 2011 Scientific and Training SymposiumJune 20-23 Public Health Leadership: THE KEY TO A HEALTHIER NATION

2. CDR María-Paz U. Smith, DMD Career path: 1) Indian Health Service – Pine Ridge, SD - 1996-2000 2) US Coast Guard – Cape May, NJ - 2000-2004 3) US Coast Guard – Comprehensive Dentistry Residency – US Navy, Bethesda, MD – 2004 - 2006 4) US Coast Guard – Senior Dental Officer in Yorktown,VA – 2006 - 2011 5) US Coast Guard – Senior Dental Officer in Elizabeth City, NC – 2011 - 2016

3. THE ROLE OF FLUORIDE IN CARIES PREVENTION IN CHILDREN

4. 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…

5. It’s better to PREVENT than to LAMENT!

6. The mandibular incisors are usually unaffected… Why? The child falls asleep, and the milk or sweetened liquid becomes pooled around the maxillary anterior teeth

7. 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

8. Fluorosis Water is naturally fluoridated to levels well above the recommended levels – prevalent in some parts of India, inTanzania Severe fluorosis Mild fluorosis

9. Skeletal Fluorosis Most experts in skeletal fluorosis agree that ingestion of 20 mg of fluoride/day for 20 years or more can cause crippling skeletal fluorosis. Doses as low as 2 to 5 mg/day can cause preclinical and earlier clinical stages. The situation is complicated because the risk of skeletal fluorosis depends on more than the level 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

10. THE FLUORIDE ION • The 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)

11. Fluoride Carcinogenicity • 3.2.3 Carcinogenicity In 1987, the International Agency for Research on Cancer (IARC) reviewed the available data concerning the carcinogenicity of fluoride and concluded that there was inadequate evidence of carcinogenicity in experimental animals (IARC, 1987). Two separate sets of long-term fluoride carcinogenicity studies in rats and mice have been published in the 1990s (NTP, 1990; Bucher et al., 1991; Maurer et 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).

12. Drinking Water Fluoridation • To 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 304,059,724 US population on public water systems 269,911,707 Total US population on fluoridated drinking water systems, persons 195,545,109

13. 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.

14. Water and Food Well – Water System

15. Pine Ridge Indian Reservation, SD

16. Black Hills, SD

17. Map of South Dakota Rain water from the Black Hills, SD usually takes 10,000 years to trickle down to the Pine Ridge Indian Reservation – not knowing what minerals or the amount of minerals that is carrying

18. United States Map of Fluoridated Water

19. Communal Water Fluoridation McDonald 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)

20. Fluoride Statement – Philadelphia, PA 1951-2001 The Philadelphia Water Department feeds fluoride into the water supply system, as a 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 the Commonwealth of Pennsylvania, Department of Public Health, issued July 22, 1952, at a concentration of 1.0 milligrams per liter. This level is within the current maximum contaminant limit established by the United States Environmental Protection Agency and in accordance with the United States Public Health Service, Division of Dental Public Health Guidelines.

21. 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 Philadelphia with NO fluoridated water

22. Costs incurred to the city of Philadelphia in Fiscal Year 1999 (Per year )

23. Dr. Raymond F. Gist, 2011 President of the ADA “Dentistry has succeeded in preventing disease better than any other area of health care. Water fluoridation is one of our most potent weapons in disease prevention, and we want as many people as possible to have the benefits of this simple, safe, inexpensive and proven health care measure”

24. FLUORIDE USE When should fluoride use begin? Infants and children between the ages of 6 months and 16 years should receive fluoride

25. 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

26. Remineralization with Fluoridecontains increased concentrations of fluorhydroxyapatite, making the remineralized tissue more resistant to future attack by acids

27. Fluoride Supplements Concentrations 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 ppm Fluoride mouth rinse solution of 0.20 % sodium fluoride = 920 ppm – this has to be given to children under supervision

28. Fluoride Supplements • Fluoride gel of acidulated phosphate fluoride = 1.23 % = 12,300 ppm • Stannous fluoride 0.15 % or 1,500 ppm • Fluoride 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

29. Optimal Fluoridated Drinking Water - ADA 0.7 ppm because people in warmer climates tend to drink 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

30. 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

31. Parts per Million Conversions ppm 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/liter 0.7 ppm = 0.7 mg/liter

32. World Health Organization DataDMFT (Decayed, Missing and Filled Teeth) 29 April 2011

33. Powerful tool = FAMILIES

34. 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

35. Healthy Mothers = Healthy Babies Women are the ones who can make more and better decisions on healthier choices for their babies

36. 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

37. A Fluoride Diet • 3.73 ppm Brewed black tea • 2.34 ppm Raisins • 2.02 ppm White wine • 1.09 ppm Apple-flavored juice • 0.91 ppm Brewed coffee • 0.71 ppm Tap water (US – wide average) • 0.61 ppm Chicken soup broth • 0.60 ppm Diet coke (US – wide average) • 0.48 ppm Hot dog • 0.46 ppm Grapefruit juice • 0.45 ppm Beer • 0.33 ppm Flour tortillas • 0.03 ppm Milk (2 %)

38. Mothers are usually the key to good hygiene, good health “Thus, clinicians may consider dental caries in the mother as a risk indicator for caries activity in her child. Our findings suggest that reducing caries in young children may require improving the oral health of their mothers”. Dye, Bruce et al. JADA – February 2011

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

40. Support Programs All these programs, like: Headstart, WIC, National Women’s Health Week, Best Bones Forever! And many more should be advertised; parents should be encouraged to take advantage of the multiple benefits these offer to families Minority Groups

41. NHSA = National Head Start Association We Believe • all 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

42. “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)

43. WHO Fluoride 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.

44. References • 1) American Dental Association – ADA at www.ada.org • 2) 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.org 5)www.Knhttp://water.epa.gov/action/advisories/drinking/fluoride_index.cfm.owYourTeeth.com

45. References • 6) www.facebook.com/USPHSConference and http://twitter.com/@USPHSconference • 7) www.cdc.gov/fluoridation/benefits.htm#3 • 8) “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

46. References • 10) 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

47. QUESTIONS?

48. THANK YOU!