HHS Recommendation for Fluoride Concentration in Drinking Water for Prevention of Dental Caries

Subject of Planned Report: Recommended fluoride content (mg/L) in community water systems to prevent dental caries (tooth decay)

Purpose of Planned Report: To update and replace previous U.S. Public Health Service recommendations for adjusted fluoride concentration in drinking water to prevent dental caries, because of new data that address the prevalence of dental fluorosis, fluid intake among children, and the contribution of fluoride in drinking water to total fluoride exposure in the United States.

Type of Dissemination: Influential Scientific Information

Timing of Review: July – November, 2012

Type of Review: Individual

Opportunities for the Public to Comment: The HHS recommendation (proposed) was made available for public comment on January 13, 2011. The 30 day public comment period was extended through April 15, 2011.

Peer Reviewers Provided with Public Comments before the Review: Yes

Anticipated Number of Reviewers: 3

• Michael Kosnett

Academic and Professional Credentials: MD, MPH Organizational Affiliation: Adjunct Associate Professor, Department of Environmental and Occupational Health, Colorado School of Public Health, Denver Areas of Expertise, Discipline, or Relevant Experience: Occupational and Environmental Toxicology; Clinical Toxicology of Heavy Metals Recommended by: HHS Federal Panel on Community Water Fluoridation

• Nancy K. Kim

Academic and Professional Credentials: PhD Organizational Affiliation: Adjunct Associate Professor, School of Public Health, University at Albany, State University of New York Areas of Expertise, Discipline, or Relevant Experience: Environmental Health Recommended by: HHS Federal Panel on Community Water Fluoridation

• Steven M. Levy

Academic and Professional Credentials: DDS, MPH Organizational Affiliation: Professor, College of Dentistry, University of Iowa, Iowa City Areas of Expertise, Discipline, or Relevant Experience: Oral Epidemiology; Epidemiology of Fluoride Intake, Caries, and Dental Fluorosis Recommended by: HHS Federal Panel on Community Water Fluoridation

Primary Disciplines or Expertise: Epidemiology, oral epidemiology, environmental health, metabolism and effects of fluoride on teeth

Reviewers Selected by: HHS Federal Panel on Community Water Fluoridation

Public Nominations Requested for Reviewers: No

Charge to Peer Reviewers: A notice by the Department of Health and Human Services, Proposed HHS Recommendation for Fluoride Concentration in Drinking Water for Prevention of Dental Caries, was published in the Federal Register (FR) on January 11, 2011.  This notice provides new guidance supported by available scientific information.

The original document published in January 2011 has been revised with addition of the HHS Inter-Agency Panel’s review of public comments and supporting references. We are requesting your critical review to determine if the revised document (HHS Recommendation for Fluoride Concentration in Drinking Water for Prevention of Dental Caries) is consistent with available scientific information.  For purposes of this guidance, the optimal concentration of fluoride in drinking water provides the best balance of protection from dental caries while limiting the risk of dental fluorosis.

As you review both documents (original FR notice and summary of public comments), please assess whether any key studies have been left out or, in your opinion, misinterpreted–and whether the conclusions are appropriate, given the evidence.  Please consider the information on cumulative sources of fluoride exposure and risk of severe dental fluorosis among children, provided by the U.S. Environmental Protection Agency and referenced in the document.  These EPA assessments were externally peer-reviewed prior to publication in December 2010.   In addition, please remember that final decisions on policy related to the fluoride concentration in drinking water to prevent dental caries remain within the purview of government.  This review focuses on the scientific information that serves as a foundation for such policy.
Specific questions for your consideration include:

1. Are there omissions of critical information or key studies related to the main reasons for the proposed change?  Main reasons are the following:
   • Community water fluoridation remains an important, cost-effective source of fluoride;
   • Given the current availability of fluoride from multiple sources, the proposed concentration of 0.7 mg/L is expected to reduce the risk of dental  fluorosis among children.  That value is the lowest concentration in the currently recommended range of 0.7-1.2 mg/L and is expected to reduce total fluoride intake of young children;
   • Given the current availability of fluoride from multiple sources, the proposed concentration of 0.7 mg/L is expected to achieve caries preventive benefits  comparable to the currently  recommended  range of 0.7-1.2 mg/L;
   • Because no association was found between fluid intake among children and adolescents and outdoor ambient temperature, a rationale for the current recommended range of 0.7-1.2 mg/L no longer exists.
2. Are conclusions about the main reasons correct?
3. Have public comments been appropriately considered in the final document?
4. Has inappropriate information been included? If so, what should be removed?  Please explain.
5. Do you have concerns about technical or factual accuracy of statements? If so, please explain.
6. Is this document clear and easily understood by a general audience? If not, which sections need revision?

Last Revised:  06/11/13

See original, http://aspe.hhs.gov/oash/floridation.shtml

ASPE = Office of the Assistant Secretary for Planning and Evaluation
U.S Department of Health and Human Services

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