Documenti di Didattica
Documenti di Professioni
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Issues
Should public water be fluoridated? Benefits reduced dental carries Risks dental fluorosis bone disease Dose - Response
Mild fluorosis
Severe fluorosis
SOT Fluoride - History 02/11/10
Fundamental Issue
History of Fluoride
1899 - Sodium Fluoride -- Herbert H Baldwin reported symptoms of acute toxicity (e.g. gastrointestinal upset) doses as low as 0.1-0.3 mg/kg. 1909 Colorado stain (fluorosis) Frederick McKay, observed children in the Pikes Peak region had of stain or mottling on their teeth but fewer cavities
1931 G.V. Black (father of modern dentistry) and others concluded fluoride ion in the water was the cause
SOT Fluoride - History 02/11/10
History of Fluoride
1939 Gerald J. Cox first publication recommending the addition of fluoride to drinking water to improve oral health at 1 ppm level 1940s - several paired city studies conclude fluoride in drinking water is beneficial 1945, January 25 - Grand Rapids, Michigan first community in the world to add fluoride to its drinking water to benefit dental health 1940s Fluorine used in bomb making (University of Rochester Harold Hodge)
SOT Fluoride - History 02/11/10
Stannous Fluoride
1951, Joseph C. Muhler and Harry G. Day of Indiana University reported that stannous fluoride as a tooth decay preventive and the university first sold the technology to Procter & Gamble to use in Crest toothpaste.
CDCs Recommendation
Nature's Way to Prevent Tooth Decay
...fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children
CDC (1999). Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. MMWR, 48(41); 933-940, October 22.
SOT Fluoride - History 02/11/10
2006 - ADA & CDC offers interim guidance on infant formula and fluoride
SOT Fluoride - History 02/11/10
Ethical Issues
Individual vs Public Health? Fluoridation of public water is "compulsory mass medication" Individual Consent? Legal human rights choice? Improves dental care for low-income people. Not mass medication because fluoride is natural. Similar to fortifying foods with vitamins
SOT Fluoride - History 02/11/10
MCLG-MCL
MCLG maximum contaminant level goal - level of a contaminant in drinking water below which there is no know or expected risk to health - non-enforceable public health goal MCL maximum contaminant level - highest level of a contaminant allowed in drinking water - enforceable standard - set as close as feasible to the MCLG; technology and costs are considered
SOT Fluoride - History 02/11/10
SMCL
SMCL secondary maximum contaminant level - non-enforceable guideline for managing drinking water for aesthetic, cosmetic (e.g., tooth discoloration), or technical effects
History
1986
MCLG and MCL set at 4 mg/L to protect against crippling skeletal fluorosis SMCL set at 2 mg/L to reduce occurrence and severity of objectionable enamel fluorosis.
1993
MCL reviewed by NRC in 1993 4 mg/L is appropriate as an interim MCL More research needed on fluoride intake, enamel fluorosis, bone strength and fractures, and carcinogenicity.
Exposure
Drinking Water Contribution to Total Exposure Drinking Water Natural Sources - 2.0-3.9 mg/L (1.4 million people exposed) 57% - 90% for average individual 86% - 96% for high-water intake individual - 4mg/L (200,000 people exposed) 72% - 94% for average individual 92% - 98% for high-water intake individual Drinking Water Artificial Sources - PHS recommends 0.7-1.2 mg/L (162 million people exposed) 41% - 83% for average individual 75% - 91% for high-water intake individual
SOT Fluoride - History 02/11/10
Enamel fluorosis
Enamel fluorosis is a dose-related mottling of enamel ranging from mild discoloration to severe dark stains and pitting in children (0 to 8 years). Permanent condition. Historically, condition considered cosmetic because it is not associated with tooth loss, loss of tooth function, or psychological, behavioral, or social problems. Cause: receiving too much fluoride during tooth development. Committee separated severe from moderate fluorosis.
Severe: mottling with enamel pitting and/or loss Moderate: mottling but no enamel pitting or loss
SOT Fluoride - History 02/11/10
NAS Recommendations
New risk assessment should be performed on fluoride. The assessment should include new data on health risks, better estimate of total exposure to fluoride, and updated approaches to risk assessment. Key end points for the risk assessment are severe enamel fluorosis, bone fracture, and stage II skeletal fluorosis. Committees conclusions about the adverse effects at the MCLG and SMCL do not address the lower concentrations of exposure that occur with water fluoridation.
SOT Fluoride - History 02/11/10
APPROPRIATE RESPONSE??
Precautionary principle (Wingspread, 1998)
1. Take anticipatory action to prevent harm 2. Burden of proof on proponents, not public 3. Must examine all alternatives (do nothing) 4. Process transparent & stakeholders involved
WHATS NEXT??
A comprehensive analysis of all the effects of fluoride (adverse, beneficial, incidence, severity, reversibility etc.) Move from reasonable assurance of no harm to a risk/benefit analysis (MOA and dose response).
Safety factor=2.5X
4
ppm in drinking water
?
2
2.5ppm=threshold for severe dental fluorosis SCL=2ppm: 4-15% mod. dental fluorosis
?
1ppm=target level of water fluoridation
1
0
0.15
4ppm (2L/d, 70kg adult) Average dietary intake Age 0-2 yrs Fluoride 0.71.1 ppm
Dose (mg/kg/day)
0.10
Crippling Skel. Flsis at 40 yr (NRC 77) EPA RfD Optimal theraputic dose range
0.05
0
STANDARDS THERAPUTIC/DIETARY RANGE TOTAL INTAKES
SOT Fluoride - History 02/11/10
Figure 2: Tooth Decay Trends for 12 Year Olds: Fluoridated Vs. Unfluoridated Countries. Data from World Health Organization. (Graph by Chris Neurath).
US vs Europe
The U.S. Centers for Disease Control listed water fluoridation as one of the ten great public health achievements of the 20th century. Most European countries have experienced substantial declines in tooth decay without its use, primarily due to the introduction of fluoride toothpaste in the 1970s. Fluoridation may be more justified in the U.S. because of socioeconomic inequalities in dental health and dental care??
SOT Fluoride - History 02/11/10
More Information
Web Sites
Toxipedia Fluoride
http://www.toxipedia.org/display/toxipedia/Fluoride Wikipedia - http://en.wikipedia.org/wiki/Fluoride
Anti fluoridation groups -- Fluoride Action Network - http://www.fluoridealert.org/ - www.fluorideACTION.net Pro fluoridation -- CDC on Water Fluoridation
http://www.cdc.gov/fluoridation/
American Dental Association Fluoridation Facts 2005 - http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf American Dental Association Fluoridation http://www.ada.org/public/topics/fluoride/
SOT Fluoride - History 02/11/10