In response to concerns expressed by community members, on February 8, 2010, the Fairbanks City Council passed a resolution (Appendix A) establishing a committee charged with the responsibility to examine evidence related to fluoridation of public water supplies and to provide the City Council with a report containing analysis and recommendations. The committee was to obtain documentation provided by both proponents and opponents of fluoridation and to supplement this documentation with information from other appropriate sources. The committee was to make its final report to the City Council by early July, 2010, but the committee was unable to meet this deadline due to the complexity of the assignment and the schedules of the committee members.
The committee, referred to in this report as the Fairbanks Fluoride Task Force (FFTF), is composed of the following members:
Paul Reichardt, PhD, (Chair), Professor of Chemistry Emeritus, University of Alaska Fairbanks
Richard Stolzberg, PhD, Professor of Chemistry Emeritus, University of Alaska Fairbanks
Rainer Newberry, PhD, Professor of Geochemistry, University of Alaska Fairbanks
Bryce Taylor, DDS, Dentist, Fairbanks
Joan Braddock, PhD, Professor of Microbiology Emeritus, University of Alaska Fairbanks
Beth Medford, MD, Tanana Valley Clinic, Fairbanks
The Fairbanks Fluoride Task Force makes the following recommendations: (pages 6-7)
1. Primarily because (1) the ground water used for Fairbanks public water contains an average of 0.3 ppm fluoride, and (2) higher concentrations of fluoride put non-nursing infants at risk, the task force recommends that supplemental fluoridation of the Fairbanks public water supply be terminated. The task force further recommends that the Fairbanks community be informed of possible dental health implications from not fluoridating the water. Rationale: Not fluoridating Fairbanks water will reduce the fluoride content from 0.7 ppm to 0.3 ppm, which is the fluoride concentration of the raw water used by Golden Heart Utilities (GHU). This will reduce, but not eliminate, the risk of significant incidence and severity of fluorosis, especially fluorosis associated with the use of GHU water to prepare infant formula. Doing so will also address ethical concerns raised during the task force’s public testimony. However, the effect of this reduction in fluoride concentration on the caries rate in the Fairbanks community, while most likely small, is unknown and unpredictable. Those who depend on 0.07 [sic; should be 0.7] ppm fluoride in tap water for their dental health need to be informed of the possible adverse consequences to their dental health caused by reducing the fluoride content of Fairbanks tap water from 0.07 [sic; should be 0.7] ppm to 0.3 ppm and of the measures that can be taken to address these possible adverse consequences.
The task force has made this recommendation to terminate fluoridation of GHU water with full knowledge of and respect for the positions of the American Dental Association (ADA), the Centers for Disease Control and Prevention (CDC; part of the U.S. Department of Health and Human Services), and the World Health Organizaion in support of fluoridation of public water supplies. While the task force members agree that water fluoridation may be an important element of an effective dental health program in many communities, the majority of members are not convinced that it is necessary in Fairbanks because of the fluoride content of the city’s ground water and the alternate sources of fluoride available in the community. Five task force members, with various degrees of conviction, support this recommendation, while one member supports continuing fluoridation at 0.7 ppm.
2. The Fairbanks City Council’s decision-making process on fluoridation should involve representatives of the Fairbanks North Star Borough government. Rationale: An estimated 25% of area residents who receive GHU water reside outside the city limits.
3. Local dentists and physicians should be encouraged to provide their patients with up-to-date information on the benefits and risks associated with fluoride. Rationale: If nothing else, the recent notice that the secretary of the U.S. Department of Health and Human Services has proposed a new recommendation on fluoridation of public water supplies indicates that the citizenry should be informed about the state of contemporary research findings and analysis related to the role of fluoride in dental health. All of the members of the task force went into this project with incomplete and in some cases incorrect information about the issue. We suspect that we are not unique in that respect.
4. The Fairbanks City Council should encourage the local school system to review and modify, as appropriate, its approach to providing education about good dental health practices. Rationale: The local schools have an excellent opportunity to help all families in the community to learn about and to implement good dental health practices, which can include optional opportunities for topical fluoride treatment (in the form of rinses and toothpaste, for example) as well as techniques for minimizing unnecessary and/or unwanted exposure to fluoride.
Chapter 6: Exposure: Findings (pages 27-28)
1. The problematic relationship between fluoride concentration in drinking water and “fluoride dose,” due to varying amounts of water consumed by individuals and to other sources of ingested fluoride, severely complicates attempts to determine both health risks and benefits associated with 0.7 ppm fluoride in drinking water. In particular, commonly available foods and beverages contain from high (greater than 2 ppm) to negligible levels of fluoride, and fluoridated toothpaste is variably used and swallowed. We believe that these factors grossly complicate interpretation of drinking water studies and explain why the numerous studies conducted have come to a variety of conclusions that, in some cases, are quite different.
2. The concentration of fluoride in raw Fairbanks city water averages 0.3 ppm and is adjusted to 0.7 ppm in the treatment process. Because removing the fluoride from the raw water is impractical, the City of Fairbanks does not seem to have a realistic option for “fluoride free” city water (for a discussion of fluoride-removal processes see Fawell et al., 2006). Whatever benefits and detriments are caused by fluoride in drinking water will continue to a smaller degree if Fairbanks city water is no longer fluoridated.
3. Fluoride concentrations in Fairbanks area well water vary from 0.1 to greater than 1.0 ppm. Thus, some well water in the Fairbanks area contains more fluoride than fluoridated city water.
4. Fluoridation of Fairbanks city water has ramifications throughout the surrounding area because of the distribution of GHU water by College Utilities and several suppliers of trucked water.
5. The practice of fluoridation as carried out in Fairbanks has sufficient safeguards to protect public health beyond whatever health effects are associated with 0.7 ppm fluoride. The chemical employed is of sufficient purity and the manner in which it is added and monitored meets or exceeds standard practices.
6. An analysis of the estimates in Tables 5.3 through 5.8 and Figures 5.2 and 5.3 indicates that two segments of the Fairbanks area population must be considered separately with respect to professional recommendations on upper limits of fluoride exposure: (1) the average consumer of GHU water (fluoride concentration of 0.7 ppm) who is greater than five years of age is projected to consume less than any of the daily upper limits set by the ATSDR, EPA, and IOM, and (2) children less than six years of age (with the exception of nursing infants) are projected to have total fluoride exposures that remain below the upper limit set by IOM but range from near to above those set by EPA and ATSDR. It appears that drinking water with a fluoride concentration of 0.3 ppm would bring total fluoride exposure for “average” drinking water consumers of all age classes to below the lowest of the recommendations of upper limits (ATSDR). However, due to the tremendous variability in amount of drinking water consumed by individuals, the fluoride exposures of significant portions of the population are not adequately represented by the average values.
7. Nevertheless, the estimates of Table 5.9 highlight additional concerns about fluoride exposure of non-nursing infants in their first year. The use of fluoridated water to make up infant formula leads to levels of fluoride consumption that exceed recommended upper limits. While the magnitude of the problem obviously declines with a decline in fluoride concentration in the water used to make up formula, the most conservative of the upper limits of fluoride exposure would be approached or exceeded even when using GHU well water (fluoride concentration averaging 0.3 ppm) to which no fluoride has been added. The American Dental Association has addressed these concerns by recommending that infant formula be made up with “water that is fluoride free or contains low levels of fluoride” (www .ada .org/1767 .aspx). While bottled water would seem to be the water of choice, the data of Table 5.2 indicate that not all bottled waters available in the United States meet the ADA criteria. The use of bottled water for this purpose is further complicated by the absence of information about fluoride content on the labels of most bottled water. The only certainty for consumers seems to be that the distilled water sold in supermarkets has an undetectable concentration of fluoride.
Chapter 6: Efficacy of Community Water Fluoridation: Findings (page 36)
1. There has never been a double blind, randomized, long-term study of the effectiveness of community water fluoridation on decreasing the incidence of caries. Nor has there been a comparable study on the effect of discontinuing water fluoridation on the incidence of caries.
2. The degree of caries reduction due to community water fluoridation was large and significant in the first decades that it was done. In recent decades, the degree of caries reduction attributed to community water fluoridation has decreased as other sources of fluoride have come into common use and as effective dental health measures have become more prevalent. The relative importance of water fluoridation is currently much smaller, more variable among populations, and perhaps unknowable.
3. The problematic relationship between fluoride concentration in drinking water and “fluoride dose” (due to varying amounts of water consumed by individuals and to other sources of ingested fluoride) severely complicates attempts to determine both health risks and benefits associated with 1 ppm fluoride in drinking water. In particular, at this time commonly available foods and beverages range from high (greater than 2 ppm) to negligible fluoride content, and fluoridated toothpaste is variably swallowed. We believe that these factors grossly complicate interpretation of drinking water studies and explain why the numerous studies conducted have come to a variety of different conclusions.
4. Studies of the relative effectiveness of community water fluoridation among socioeconomic groups give contradictory results. Dietary habits, dental hygiene, and intervention by health/dental providers are independent factors that confound the investigation of the efficacy of fluoridation of water on caries prevalence.