SR-502-001-05 (3)GB:epwm/adm/stfrpt/fluoride2.pwd
Council Meeting: October 23, 2001
To: Mayor and City Council
From: City Staff
Santa Monica, California
Subject: Consideration of Potential Fluoridation of City Drinking Water and Topical
Fluoride Application Programs
Introduction
This report presents updated information regarding potential fluoridation of City drinking
water, provides information regarding topical fluoride application programs, including
estimated program costs and key implementation issues, and recommends that City
Council provide policy direction to staff on these issues.
Backqround
In November 2000, Council considered the issue of fluoridation of the city's water
supply. The motion to direct staff to proceed with fluoridation failed on November 28,
2000. On a motion to reconsider, Council requested staff to return this item for
consideration. Additionally, on May 8, 2001, Council directed staff to research and
provide information relative to topical application of dental fluoride.
Discussion
Fluoridation of City Drinking Water
In October 1995, Governor Wilson signed into law Assembly Bill No. 733 which
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required water suppliers to fluoridate water by January 1, 1997, but only if funds to pay
for the costs of fluoridation are available from sources other than ratepayers,
shareholders, local taxpayers, or bondholders of the public water system.
Community water fluoridation entails an adjustment of the natural fluoride concentration
in water up to the level recommended for optimal dental health (a range of 0.7 to 1.2
parts per million, or ppm, as recommended by the Centers for Disease Control, or CDC).
Natural fluoride levels in drinking water normally fall below this level. In Santa Monica,
the water supply presently contains a natural fluoride level of between 0.2 and 0.4 parts
ppm. fluoride. Fluoride is also available in many foods and beverages. The dental
health objective in water fluoridation is the prevention of tooth decay. Opponents of
fluoridation assert that it is a toxic compound, presents an increased risk of
osteoporosis (decrease in bone density), and causes dental fluorosis (deterioration of
tooth enamel).
Grand Rapids, Michigan became one of the first communities in the nation to implement
water fluoridation in 1945. Since then, the CDC reports that more than 10,000 public
water systems and some 70% of U.S. cities with populations larger than 100,000 have
fluoridated water systems. In total, more than 135 million Americans are presently
served by fluoridated drinking water. As a result of AB 733, a number of California
cities have considered fluoridation. The City of Los Angeles Department of Water and
Power began fluoridation in 1999. The cities of Sacramento and San Diego are
currently fluoridating their systems.
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Not all California communities approve fluoridation. In March 1999, the voters of the
City of Santa Cruz rejected fluoridation in a local ballot measure. The Escondido City
Council voted not to approve fluoridation last year and the Santa Barbara City Council
rejected fluoridation.
An information item was presented to City Council on June 18, 1996, which
summarized public input received through a mail-in survey regarding this important
policy decision. A summary of the customer survey information from a citywide
resident phone survey conducted in November 2000 and the 1996 survey, are
presented below. In addition, City staff organized an Informational Forum on
Fluoridation, which was convened in September 2000. A summary of information
presented at this forum is also presented below.
Public Survev Results
In a random Citywide Phone Survey of 400 households conducted in November 2000,
51 % of respondents said they favor adding fluoride to the residential drinking water
supply in Santa Monica, while 31 % oppose (18% did not offer an opinion).
In April 1996, a survey "Fluoride: What are your thoughts?" was included with the City's
Annual Water Quality Report which was sent to every address (residential and business)
in Santa Monica. The question asked was "Should the City Fluoridate its Water
Supply?". The results of the survey were 69% in favor, and 30% opposed, and 1%
undecided of 2,085 respondents.
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The majority of the YES group had no comments. Of the 32 comments received,
"dental benefits" was the most common comment. The majority of the NO group (619)
had comments. The vast majority expressed concern about health risks, and a few of
the respondents sent in published articles opposing fluoridation. Other concerns were
"adding more chemicals to the water" and "increase in costs."
Informational Forum on Fluoridation
The Water Division presented an Informational Forum on Fluoridation in September
2000. The forum presented an opportunity for opponents of fluoridation (represented
by Citizens for Safe Drinking Water) and proponents of fluoridation (represented by
the California Fluoridation Task Force) to debate the merits of fluoride supplements in
the water supply. The event was moderated by the League of Women Voters of Santa
Monica. The audience also had the opportunity to submit written questions to the
speakers' panel. Time restrictions prevented the presentation of all questions to the
speakers. Copies of all of the questions are provided in an attachment to this report.
The proceedings are available for review on video tape.
Both sides of the debate presented information discussing the health and safety
impacts of community water supply fluoridation. From information presented at the
forum, as well as from a literature review by staff, a summary of highlights and
arguments presented by each side of the issue has been prepared and is presented in
Attachment A.
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Topical Fluoride Application Programs
To obtain information on topical fluoride programs targeting school-aged children, City
staff researched numerous web sites, locating resources ranging from model
school-based fluoride programs operating nationwide to studies and dental health
initiatives targeting school-aged children in California. Staff interviewed
representatives of over fifteen government organizations (including ten cities),
universities, and school districts involved in improving children's dental health care.
Systemic fluoride is ingested when added to public and private water supplies, soft
drinks, teas and other foods or supplements. Fluoride is distributed throughout the
body by the blood stream and is deposited in bones and hard tissues such as the teeth.
Topical fluoride is found in products, including toothpastes, dental varnishes and
rinses that contain fluoride and are applied directly to the teeth and rinsed from the
mouth without swallowing.
Most fluoride programs for children (other than water supply treatment) are
school-based and target elementary school-aged children. The three most common
forms of topical applications or fluoride supplements found in school-based programs
are mouth rinses, tablets, and varnishes. A new type of application is a sealant, a
plastic coating which is bonded to the chewing surface of a tooth, and is frequently
used in conjunction with fluoride for the prevention of tooth decay among school-aged
children.
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If a topical fluoride program remains under consideration, the following are likely next
steps and issues to explore:
Involvement of Santa Monica-Malibu Unified School District: It is essential to
include school district staff in any further exploration regarding a possible
school-based fluoride program. Programs require a high level of coordination,
documentation and participation by elementary school staff.
Funding sources and partnerships: Partnerships should be established with
entities that are already providing successful fluoride programs in Los Angeles
and Orange counties to extend services to Santa Monica. The participation of
the Los Angeles County Department of Health Services should be enlisted.
Outreach and education strategies: Parental consent is required for participation
in fluoride programs. Santa Monica-Malibu Unified School District reports that
only an average of 25% of eligible children return consent forms for free vision
examination services, pointing to the need to develop effective outreach
methods if a voluntary fluoride program is undertaken.
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Fluoride for adults: Access to dental health care education and fluoride for
low-income adults and seniors my be a desirable extension of any topical fluoride
debate. More information on need and benefits would be required.
Budqet/Fiscal Impact
Fluoridation of City Drinking Water
A cost estimate was prepared for the design and construction of chemical feed and
storage facilities to apply fluoride to the water supply at the city's Arcadia Water
Treatment Plant. The estimate for the one-time capital cost is $365,000, based on a
fluorosilisic acid feed system. Annual operational and maintenance costs are estimated
at $35,000. If the City Council decides to fluoridate the water, the State of California
Fluoridation 2000 Task Force has stated $365,000 would be made available as a grant
to the City for the purpose of funding capital facilities. Annual operating and
maintenance costs of $35,000 would be included in the Water Division annual operating
budget. Design and construction of the chemical feed and storage facilities would take
approximately 12 months to complete.
Topical Flouridation
The estimated annual materials costs for school-based topical fluoridation programs
range from $1.25 per child (fluoride mouth rinse program) to $55 per child (for one-time
fluoride varnish that includes teeth cleaning). In addition, the estimated annual cost for
the administration and staffing of school-based fluoride programs ranges from $50,000
to $200,000 per year
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depending on the methods used, number of participants, number of required volunteer
and paid staff, and whether or not the fluoride program is part of a more comprehensive
approach that includes outreach, base-line dental screening, and education. Programs
in all ten cities researched were provided by their respective County Health Departments
and/or partnerships between the County/State and private foundations. School-based
programs do not address possible fluoride needs of adults and the broader community.
Cost estimates for a program in Santa Monica would have to be developed upon further
Council direction and assessment.
Recommendation
Staff recommends that City Council review the information presented in this report and
direct staff to either: 1) proceed with fluoridation of the City's water supply, making the
appropriate inclusion of the project and its funding requirements in the FY 2002-2003
capital and operating budgets; or 2) not proceed with fluoridation of the City's water
supply and continue to monitor this issue; or 3) proceed with further research and
analysis of a topical fluoride application program, exploring the likely next steps and
issues identified by staff in this report, and return to Council at a future date.
Prepared by: Environmental and Public Works Manaqement Department
Craig Perkins, Director
Gil Borboa, Utilities Manager
Communitv and Cultural Services Department
Barbara Stinchfield, Director
Julie Rusk, Human Services Manager
Betty Macias, Senior Administrative Analyst
Attachment A: Summary of Fluoridation Arguments
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Attachment A
Highlights and Arguments Presented
at the Informational Forum
1. Is fluoride, as provided by community water fluoridation, a toxic substance?
PROPONENT:
Acute fluoride toxicity is not possible from drinking fluoridated water
Fluoride is not toxic at the concentrations found in optimally fluoridated
water.
Chronic fluoride toxicity is not possible at the low levels of concentration
provided in community water fluoridation.
Effects of fluoridation have been studied for more than 50 years and the
vast majority of the evidence indicates that community water fluoridation is
safe and effective.
While large doses of fluoride may be toxic, the recommended amount of
fluoride found in optimally fluoridated water is not.
OPPONENT:
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Fluoride used in water fluoridation is a toxic waste product.
Hip fractures and osteosclerosis are scientifically associated with water
fluoridation.
Severe skeletal fluorosis has been documented from water containing only
0.7 ppm of fluoride.
Several studies have shown that fluoride inhibits broken bone healing and
contributes to damage from osteoporosis and abnormal collagen
formation.
2. How much fluoride should an individual consume each dav to reduce the
occurrence of dental decav?
PROPONENT:
Appropriate dosage varies with age and body weight.
Fluoride, like other nutrients, is safe and effective when used and
consumed properly.
Fluoride intake has a large range of safety, as established by the Food and
Nutrition board of the Institute of Medicine.
The upper limit of fluoride from all sources (fluoridated water, food,
beverages, fluoride dental products, and dietary fluoride supplements) is
set at 0.10 mg/kg/day ( milligram per kilogram of body weight per day)for
infants, toddlers, and children through eight years of age.
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OPPONENT:
It is impossible to consistently supply any medication through drinking
water.
Adding fluoride to drinking water invariably leads to uncontrolled random
dosages.
Infants and adults who drink more beverages will be overdosed.
There is more fluoride present in our diets now (from food, beverages and
brushing from fluoridated toothpastes) than in the 1950's when the
recommended water fluoride concentrations were established.
3. Does fluoride in the water supplv, at levels recommended for the prevention of
tooth decav, adverselv affect human health?
PROPONENT:
Scientific evidence overwhelmingly indicates that fluoridation of community
water supplies is both safe and effective.
Currently allowed fluoride levels in drinking water do not pose a risk for
health problems such as cancer, kidney failure, or bone disease.
After 50 years of research and practical experience, the preponderance of
scientific evidence indicates that fluoridation of community water supplies
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is both safe and effective.
Following a comprehensive 1991 review and evaluation of the public health
benefits and risks of fluoridation, the U.S. Public Health Service reaffirmed
its support for fluoridation and continues to recommend the use of fluoride
to prevent dental decay.
The World Health Organization reaffirmed its support for fluoridation in
1994 stating that: "Providing that a community has a piped water supply,
water fluoridation is the most effective method of reaching the whole
population, so that all social classes benefit without the need for active
participation on the part of individuals."
OPPONENT:
Fluoride is a toxin that is as toxic as arsenic and more toxic than lead.
Even the tiny amount one ingests from fluoridated water can eventually
cause harm because it accumulates in the body and increasingly builds up
in soft tissues and bones.
Fluoride seriously weakens the human immune system, making it harder to
fight off infections and chronic diseases.
People with diabetes, arthritis, impaired kidney function, or low thyroid
function may find their health problems aggravated by drinking fluoridated
water.
Despite U. S. Public Health Service and American Dental Association
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claims of fluoride's complete safety and their aggressive goal of forcing all
of America into fluoridation (now approximately 70% of cities with
populations exceeding 100,000) the rest of the world remains unconvinced.
4. Can dental fluorosis be prevented in children's teeth?
(Dental fluorosis is a change in the appearance of teeth caused by higher than
optimal amounts of fluoride ingestion in early childhood while tooth enamel is
forming)
PROPONENT:
The occurrence of dental fluorosis in the United States can be reduced
without denying young children the decay prevention benefits of
community water fluoridation.
Studies of fluoride intake from the diet including foods, beverages, and
water indicate that fluoride ingestion from these sources has remained
relatively constant for over 50 years and, therefore, is not likely to be
associated with and observed increase in dental fluorosis.
Inappropriate ingestion of topical fluoride can be prevented, thus reducing
the risk for dental fluorosis without reducing decay prevention benefits.
numerous studies have established a direct relationship between young
children brushing with more than the recommended pea-sized amount of
fluoride toothpaste and the risk of very mild or mild dental fluorosis.
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Parents, caregivers, and health care professionals should judiciously
monitor use of all fluoride-containing dental products by children under age
six.
OPPONENT:
According to the National Research Council fluorosis affects 8% to 51 %
and sometimes as many as 80% of the children growing up in areas where
drinking water contains one part per million (1 ppm) fluoride.
The visible damage to tooth surfaces results in mottled, brittle teeth that
are prone to fracture and may cost many thousands of dollars to
cosmetically repair.
Fluorosis is permanent damage to the enamel which consists of white or
brown spots that appear on children's teeth.
Fluorosis affects more than teeth, since at the same time the enamel is
being mottled other hard and ligament tissues are being affected as well.
Scientists have been pressured by political forces into validating there are
no adverse health effects associated with fluoridation at levels up to 4
ppm.
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5. Is water fluoridation an effective method for preventinq tooth decav?
PROPONENT:
Water fluoridation continues to be a very effective method for preventing
tooth decay for children, adolescents, and adults.
Although other forms of fluoride are available, persons in non-fluoridated
communities continue to demonstrate higher dental decay rates than their
counterparts in communities with water fluoridation.
Studies conducted between 1976 and 1987 show decreased levels of
dental decay ranging from 15% to 60% from water fluoridation.
Community water fluoridation remains the safest, most cost-effective, and
most equitable method of reducing tooth decay in a community in the
United States and in other countries.
For very young children, water fluoridation is the only means of prevention
that does not require a dental visit or motivation of parents and caregivers.
OPPONENT:
Adding fluoride to drinking water has not been shown to be effective in
reducing tooth decay.
In animal studies there was no correlation to the amount of fluoride and
tooth decay.
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In the largest U.S. study on fluoridation and tooth decay, U.S. Public
Health Service dental records of over 39,000 schoolchildren showed that
the decay rate (decayed, missing and filled teeth, or DMFT) of permanent
teeth was virtually the same in fluoridated and non-fluoridated areas.
With tooth decay rates declining overall, the mere fact that tooth decay
dropped after the addition of fluoride to the drinking water supply cannot be
attributed to that single factor.
6. Is community water fluoridation the most efficient means of deliverinq fluoride
in terms of cost?
PROPONENT:
Fluoridation has substantial lifelong decay preventative effects and is a
highly cost effective means of preventing tooth decay in the United States,
regardless of socio-economic status.
Water fluoridation costs the average customer $8.00 per year, versus
$24.00 per year for fluoride supplements.
The lifetime cost per person to fluoridate a water system is less than the
cost of one dental filling.
Indirect benefits from prevention of tooth decay include: 1) freedom from
dental pain, 2) a more positive self image, 3) fewer missing teeth , 4) fewer
cases of malocclusion aggravated by tooth loss, 5) fewer teeth requiring
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root canal treatment, 6) reduced need for dentures and bridges, 7) less
time lost from school or work due to dental pain or visits to the dentist.
With the escalating cost of health care, fluoridation remains a preventive
measure that benefits members of the community at minimal cost.
OPPONENT:
The only study that directly compared dental practice and cost in
fluoridated and unfluoridated communities showed no significant
differences in the cost and nature of dental care relative to fluoridation.
In fact, the same study found that dentists' income in fluoridated
communities was slightly higher.
Fluoride is more toxic than lead and to put it in drinking water will not serve
the health of the public nor will it reduce medical or dental costs.
For the phosphate fertilizer industry, which produces fluoride waste as a
by-product, water fluoridation is an efficient, cost effective solution for
disposing of its pollution because for every pound of the fluoride ion, the
industry also gets rid of another 5.8 pounds of pollution in the drinking
water.
In order to ensure the optimal dose of fluoride is delivered to the target
population, we must dump several thousand times the necessary dose into
our water supply and, therefore, our environment.
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