Policy

Public Policy

57. What is public health?

58. Valuable measure?

59. Reduce disparities?

60. Support for fluoridation?

61. Courts of law?

62. Opposition?

63. Opposition tactics?

64. Internet?

65. Public votes?

66. International fluoridation?

67. Banned in Europe?

57. What is public health?

Answer.

Public health promotes and protects the health of people and the communities where they live, learn, work and play. Public health measures improve the quality of life for members of the community.

Fact.

Public health has numerous definitions and dimensions. It can encompass issues of research, education, regulation, policy and more. It focuses on the health of entire populations that can vary in size from as small as a local neighborhood to a small-sized community and a large-sized city. It also can focus on populations with a state, national or even global perspective. But how does public health affect our everyday lives? Individuals are touched by public health measures every day without giving them a second thought. For example, garbage pickup and disposal prevent the spread of disease. The stoplight at a busy intersection protects motorists and pedestrians from injury. Building sidewalks in communities provides the option for people to walk to help control their weight and improve their heart health. Smoke-free laws help prevent lung cancer. All of these are public health in action.

Community water fluoridation is another example of a public health measure.

Optimally fluoridated water is accessible to the entire community regardless of socioeconomic status, educational attainment or other social variables.1

Individuals do not need to take special action or otherwise change their behavior to obtain the benefits of fluoridation.

Frequent exposure to small amounts of fluoride over time makes fluoridation effective through the life span in helping to prevent tooth decay.2

Community water fluoridation is more cost-effective and cost-saving than other forms of fluoride treatments or applications.3,4

During the 20th century, the health and life expectancy of persons residing in the United States improved dramatically. Since 1900, the average life span of persons in the United States lengthened by greater than 30 years; 25 years of this gain are attributable to advances in public health. Many notable public health achievements occurred during the 1900s. In a series of reports during 1999, the Morbidity and Mortality Weekly Report (MMWR) profiled 10 public health achievements chosen to highlight the contributions of public health and to describe the impact of these contributions on the health and well being of persons in the United States.5

Ten Great Public Health Achievements — United States, 1900-19995

Vaccination

Motor-vehicle safety

Safer workplaces

Control of infectious diseases

Decline in deaths from coronary heart disease and stroke

Safer and healthier foods

Healthier mothers and babies

Family planning

Fluoridation of drinking water

Recognition of tobacco use as a health hazard

In discussing the contribution of fluoridation, the October 22,1999 MMWR6 noted fluoridation of community drinking water was a major factor responsible for the decline in tooth decay during the second half of the 20th century. Although other fluoride-containing products are available, water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of communities, regardless of age, educational attainment, or income level.6

58. Is water fluoridation a valuable public health measure?

Answer.

Yes. Community water fluoridation is a public health measure that benefits people of all ages and is a public health program that saves money for families and the health care system. Because fluoridation reaches large numbers of people where they live, learn, work and play, it is more effective than other forms of fluoride delivery. Water fluoridation reaches everyone in the community regardless of age, race, education, income level or access to routine dental care. Because of the important role it has played in the reduction of tooth decay, the Centers for Disease Control and Prevention (CDC) has proclaimed community water fluoridation one of 10 great public health achievements of the 20th century.5,6

Community water fluoridation is a public health measure that benefits people of all ages and is a public health program that saves money for families and the health care system.

Fact.

Throughout decades of research and more than 70 years of practical experience, fluoridation of public water supplies has been responsible for dramatically improving the public’s oral health status.

It has been said that those who cannot remember the past are condemned to repeat it. As generations pass, details from life in the 1930s and 1940s fade. The oral health of Americans suffered greatly during the time of the Great Depression and into the era of World War II. There were no public health programs in place that addressed tooth decay and the loss of teeth was viewed as an eventuality. In fact, as World War II approached, those joining the U.S. Army were required to have six back teeth (three on the top and three on the bottom) that opposed each other to serve the function of chewing food and six front teeth (three on the top and three on the bottom) that opposed each other for the purpose of biting into food. The number of men disqualified for dental reasons far exceeded all expectations as “dental disease” became the most common reason for military deferment. One out of eleven registrants examined was disqualified for military service due to dental issues.7 After Pearl Harbor it was apparent that the manpower needed to fight a global war could be obtained only if dental standards for induction were drastically relaxed. By March 1942, the standards had been revised so that a man who was “well nourished, of good musculature, and free from gross dental infections” but who was completely edentulous (without any teeth) could be inducted if his condition was corrected or could be corrected with dentures.7

Because fluoridation reaches large numbers of people where they live, learn, work and play, it is more effective than other forms of fluoride delivery.

In January 1945, a community water fluoridation trial began in Grand Rapids, Michigan followed within months by trials in Newburgh, NY (May 1945), Brantford, Ontario (June 1945) and Evanston, IL (February 1947). Reductions in tooth decay were dramatic leading to the rapid adoption of fluoridation in cities across the U.S. As a result, tooth decay declined sharply during the second half of the 20th century. Tooth loss was no longer considered inevitable.

Former U.S. Surgeon General, Dr. Luther Terry, called fluoridation as vital a public health measure as immunization against disease, pasteurization of milk and purification of water.8

Another former U.S. Surgeon General, Dr. C. Everett Koop, wrote:

…this preventive measure (fluoridation) is the single most important commitment that a community can make to the oral health of its children and to future generations. I urge all health officials and concerned citizens to join me in supporting this commitment and in the task of achieving water fluoridation for all community drinking water supplies which lack the fluoride content needed for the prevention of dental caries.9

In 1999, because of the dramatic role it played in the reduction of tooth decay, the Centers for Disease Control and Prevention (CDC) proclaimed community water fluoridation one of 10 great public health achievements of the 20th century.5,6

In May 2000, U.S. Surgeon General Dr. David Satcher issued the first ever Surgeon General’s report on oral health titled, Oral Health in America: A Report of the Surgeon General.10 In 2001, Dr. Satcher issued a statement on fluoridation in which he noted:

…community water fluoridation continues to be the most cost-effective, practical and safe means for reducing and controlling the occurrence of dental decay in a community…water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations.11

In the 2003 National Call to Action to Promote Oral Health,12 U.S. Surgeon General Dr. Richard Carmona called on individuals and groups who are most concerned and in a position to act to apply strategies to enhance the adoption and maintenance of proven community-based interventions such as community water fluoridation.12 In his 2004 Statement on Community Water Fluoridation,13 Dr. Carmona wrote:

While we can be pleased with what has already been accomplished, it is clear that there is much yet to be done. Policymakers, community leaders, private industry, health professionals, the media, and the public should affirm that oral health is essential to general health and well-being and take action to make ourselves, our families, and our communities healthier. I join previous Surgeons General in acknowledging the continuing public health role for community water fluoridation in enhancing the oral health of all Americans.13

In 2013, U.S. Surgeon General Dr. Regina M. Benjamin wrote:14

…As Surgeon General I have been working hard to encourage individuals and communities to make healthy choices because I believe it is better to prevent illness and disease rather than treat it after it occurs. Community water fluoridation is one of the most effective choices communities can make to prevent health problems while actually improving the oral health of their citizens… Fluoridation’s effectiveness in preventing tooth decay is not limited to children, but extends throughout life, resulting in fewer and less severe cavities. In fact, each generation born since the implementation of water fluoridation has enjoyed better dental health than the generation that preceded it…14

U.S. Surgeon General Dr. Vivek H. Murthy issued a video statement supporting community water fluoridation in December 2015.15 In his video and written statement on fluoridation issued in 2016,15, 16 Surgeon General Murthy emphasized:

Our progress on this issue over the past 70 years has been undeniable. But we still have work to do. Because we know that so much of our health is determined by zip code rather than genetic code. That’s why creating a culture of disease prevention through community efforts — and ensuring health equity for all — is one of my highest priorities. Community water fluoridation helps us meet these goals; as it is one of the most cost-effective, equitable, and safe measures communities can take to prevent tooth decay and improve oral health.15,16

Today, the focus in achieving and maintaining health is on prevention. Established by the U.S. Department of Health and Human Services, Healthy People 202017 provides a science-based, comprehensive set of ambitious, yet achievable, ten-year national objectives for improving the health of the public. Included under oral health is an objective to expand the fluoridation of public water supplies. Objective 13 states that at least 79.6% of the U.S. population served by community water systems should be receiving the benefits of optimally fluoridated water by the year 2020.18 Data from the CDC indicate that in 2014, 74.4% of the U.S. population on public water systems, or a total of 211.4 million people, had access to fluoridated water.19

Established by the U.S. Department of Health and Human Services in 1996, the Community Preventive Services Task Force develops and disseminates guidance on which community-based health promotion and disease prevention intervention approaches work, and which do not work, based on available scientific evidence. The Task Force issues findings based on systematic reviews of effectiveness and economic evidence. The Guide to Community Preventive Services (“The Community Guide”) is a collection of evidence-based findings of the Community Preventive Services Task Force and is designed to assist decision makers in selecting interventions to improve health and prevent disease.20

The Community Guide reviews are designed to answer three questions:

1. What has worked for others and how well?

2. What might this intervention approach cost, and what am I likely to achieve through my investment?

3. What are the evidence gaps?20

The Community Preventive Services Task Force recommends community water fluoridation to reduce tooth decay.21

Reports have been released by the U.S. Department of Health and Human Services that encourage the use of preventive interventions to improve the overall and oral health of the nation.22,23 Specific to oral health, two reports issued in 2011 by the Institute of Medicine acknowledge water fluoridation is an effective intervention for the prevention of tooth decay. Advancing Oral Health in America24 referred to water fluoridation as an effective prevention intervention, while Improving Access to Oral Health Care for Vulnerable and Underserved Populations25 acknowledged that evidence regarding community water fluoridation programs continues to validate its effectiveness, safety and cost-saving benefits.

59. Does water fluoridation reduce disparities in dental health?

Answer.

Yes, evidence indicates water fluoridation helps to reduce the disparities in dental health at the community level. Populations with lower socioeconomic status (SES) who live in fluoridated communities have less tooth decay than their peers in nonfluoridated communities.

Fact.

In the first ever Surgeon’s General Report on Oral Health issued in May 2000, U.S. Surgeon General David Satcher noted that community water fluoridation is safe and effective in preventing dental caries in both children and adults. Fluoridation benefits all residents served by community water supplies regardless of their social or economic status.10 In 2001, Dr. Satcher issued a statement on fluoridation in which he noted:

…community water fluoridation continues to be the most cost-effective, practical and safe means for reducing and controlling the occurrence of dental decay in a community…water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations.11

“…water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations.”

Established by the U.S. Department of Health and Human Services, Healthy People 2020 provides a science-based, comprehensive set of ambitious, yet achievable, ten-year national objectives for improving the health of the public and reducing health disparities.17 Starting with Healthy People 2000, one of the overarching goals of Healthy People has focused on disparities. With Healthy People 2020, that goal was expanded to achieve health equity, eliminate disparities, and improve the health of all groups.25 Healthy People 2020 provides the following definitions.

Health disparity — a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.25

Health equity — the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.25

The association between social class and disparities in dental health has been established through extensive studies and reviews.26-28 Studies in communities both with and without fluoridated water consistently have shown higher levels of tooth decay in lower socioeconomic groups. Additional studies have evaluated the differences in children’s tooth decay experience among socioeconomic groups and the effect that community water fluoridation has had on that experience.29-35 In areas with water fluoridation, children with low socioeconomic status (SES) had greater cavity experience than those with high SES. However, the tooth decay rates were higher for children with low SES who had no exposure to fluoridation compared to children with low SES who had exposure to fluoridated water.29-35 These studies demonstrate the positive effects that fluoridation has in reducing oral health disparities.

In 2011, a report by the Institute of Medicine, Improving Access to Oral Health Care for Vulnerable and Underserved Populations,36 acknowledged that evidence regarding community water fluoridation programs continues to validate its effectiveness, safety and cost-saving benefits.

Under the topic “Oral Health,” Healthy People 2020 includes an objective to expand the fluoridation of public water supplies. Objective 13 states that at least 79.6% of the U.S. population served by community water systems should be receiving the benefits of optimally fluoridated water by the year 2020.18 Data from the CDC indicate that in 2014, 74.4% of the U.S. population on public water systems, or a total of 211.4 million people, had access to fluoridated water.19 Conversely, approximately 25% or more than 72.7 million people on public water systems do not receive the decay preventing benefits of fluoridation — a powerful strategy communities can implement in efforts to eliminate health disparities.

60. Along with the American Dental Association, who supports community water fluoridation?

Answer.

Many organizations, such as the National Dental Association, Hispanic Dental Association, American Academy of Pediatrics, American Medical Association, American Public Health Association and the World Health Organization also have policies that support community water fluoridation.

Many organizations, such as the National Dental Association, Hispanic Dental Association, American Academy of Pediatrics, American Medical Association, American Public Health Association and the World Health Organization also have policies that support community water fluoridation.

Fact.

The American Dental Association (ADA) adopted its original resolution in support of fluoridation in 195037 and has repeatedly reaffirmed its position publicly and in its House of Delegates based on its continuing evaluation of the safety and effectiveness of fluoridation.27

The National Dental Association (NDA) is the largest and oldest organization of minority oral health professionals in the world.39 Representing more than 7,000 minority dentists, nationally and abroad,39 the NDA seeks to provide continued advancement of the highest quality of oral health care and safety for the public.40 In 2012, the NDA adopted the following position:40

It is therefore, the position of the National Dental Association that Community Water Fluoridation is safe, beneficial and cost-effective and should be encouraged and supported under the following conditions:

Community water supplies should contain the optimal fluoride levels as recommended by the U.S. Public Health Service (a range from 0.7 – 1.2 parts per million)

Local communities and dental societies should be in agreement with and support the fluoridation project in their communities.

Appropriate resources monitoring capabilities should be available to ensure that the appropriate water fluoride monitoring infrastructures are in place at all times in the impacted communities.40

In a policy position released in 2012,41 the Hispanic Dental Association (HDA) noted that the HDA mission works toward the elimination of oral health disparities in the Hispanic community and that the benefits of fluoridation are critical to HDA’s endorsement. The HDA position statement41 includes the following item:

Therefore, it is the position of the Hispanic Dental Association to:

1. Endorse community water fluoridation in all communities — especially the Hispanic and underserved communities — as a safe, beneficial and cost-effective public health measure based on science for preventing dental caries and to aid in the reduction of oral health disparities.41

As part of its core values42 the American Academy of Pediatrics (AAP) is dedicated to promoting optimal health and wellbeing for every child. With a strong emphasis on policy, advocacy and education,42 the AAP is a strong advocate for community water fluoridation. In support of water fluoridation43 the AAP states:

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth. Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration.43

The American Medical Association’s (AMA) mission is to promote the art and science of medicine and the betterment of public health.44 Its House of Delegates first endorsed fluoridation in 195145 and the AMA reaffirmed its support for water fluoridation in 2011.46

The American Public Health Association (APHA) champions the health of all people and all communities and speaks out for public health issues and policies backed by science.47 It has supported community water fluoridation as a safe and effective public health measure for the prevention of tooth decay since 1950.48 The APHA reaffirmed its support in 2008 by stating that it strongly endorses and recommends “the fluoridation of all community water systems as a safe and effective public health measure for the prevention of tooth decay.”49

The goal50 at the World Health Organization (WHO) is to build a better, healthier future for people all over the world. The WHO, which initially adopted policy recommending the practice of water fluoridation in 1969,51 reaffirmed its support for fluoridation in 199452 stating:

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.52

In 2004, the WHO once again affirmed its support stating that “Water fluoridation, where technically feasible and culturally acceptable, has substantial public health benefits.”53 In 2007, the Sixtieth World Health Assembly adopted WHA60.17-Oral health action plan for promotion and integrated disease prevention54 which urges member states to:

(4) for those countries without access to optimal levels of fluoride, and which have not yet established systematic fluoridation programmes, to consider the development and implementation of fluoridation programmes, giving priority to equitable strategies such as the automatic administration of fluoride, for example, in drinking-water, salt or milk, and to the provision of affordable fluoride toothpaste;54

In 2016, WHO officials wrote:

The use of fluoride is a major breakthrough in public health. Controlled addition of fluoride to drinking water supplies in communities where fluoride concentration is below optimal levels to have a cariostatic effect began in the 1940s and since then extensive research has confirmed the successful reduction in dental caries in many countries.55

Additionally a list of more than 35 organizations with positions/policies supporting community water fluoridation can be viewed on ADA’s website at www.ADA.org/fluoride in the section marked “Fluoridation Links.” Each organization is listed with a link to their specific fluoridation position/policy. Below are just a few of the organizations listed on the website.

American Association of Dental Research

American Association of Public Health Dentistry

American Water Works Association

Association of State and Territorial Dental Directors

Centers for Disease Control and Prevention

International Association of Dental Research

National Institute of Dental and Craniofacial Research

Many organizations in the United States and around the world recognize the benefits of community water fluoridation. The ADA has developed a list of “National and International Organizations that Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay.” Please see the ADA website at www.ADA.org/fluoride for the most current listing as well as information on reproduction and distribution of the list.

However, support for fluoridation doesn’t end with a list of organizations. In many cases, local newspaper editorial boards support fluoridation. Perhaps the most notable of these efforts occurred when the 2013 Pulitzer Prize for Journalism — Editorial Writing56 was awarded to Tim Nickens and Daniel Ruth of the Tampa Bay Times, St. Petersburg, Florida, for their diligent campaign that helped reverse a decision to end fluoridation of the water supply for the 700,000 residents of the newspaper’s home (Pinellas) county. Copies of their 10 editorials from 2012 can be viewed at www.pulitzer.org/winners/tim-nickens-and-daniel-ruth.

61. Has the legality of water fluoridation been upheld by the courts?

Answer.

Yes. Fluoridation has been thoroughly tested in the United States’ court system, and found to be a proper means of furthering public health and welfare. No court of last resort has ever determined fluoridation to be unlawful. Moreover, fluoridation clearly has been held not to be an unconstitutional invasion of religious freedom or other individual rights guaranteed by the First, Fifth or Fourteenth Amendments to the U.S. Constitution. And while cases decided primarily on procedural grounds have been won and lost by both pro- and antifluoridation interests, to ADA’s knowledge, no final ruling in any of those cases has found fluoridation to be anything but safe and effective.

Fact.

The legality of fluoridation in the United States has been thoroughly tested in our court systems. Fluoridation is viewed by the courts as a proper means of furthering public health and welfare.57 No court of last resort has ever determined fluoridation to be unlawful. The highest courts of more than a dozen states have confirmed the constitutionality of fluoridation.58 In 1984, the Illinois Supreme Court upheld the constitutionality of the state’s mandatory fluoridation law, resolving 16 years of court action at a variety of judicial levels.59 Moreover, the U.S. Supreme Court has denied review of fluoridation cases thirteen times, citing that no substantial federal or constitutional questions were involved.58

Fluoridation is viewed by the courts as a proper means of furthering public health and welfare. No court of last resort has ever determined fluoridation to be unlawful.

It has been the position of the American courts that a significant government interest in the health and welfare of the public generally overrides individual objections to public health regulation.58 Consequently, the courts have rejected the contention that fluoridation ordinances are a deprivation of religious or individual freedoms guaranteed under the Constitution.58,60 In reviewing the legal aspects of fluoridation, the courts have dealt with this concern by ruling that: (1) fluoride is a nutrient, not a medication, and is present naturally in the environment; (2) no one is forced to drink fluoridated water as alternative sources are available; and (3) in cases where a person believes that fluoridation interferes with religious beliefs, there is a difference between the freedom to believe, which is absolute, and the freedom to practice beliefs, which may be restricted in the public’s interest.61,62

Fluoridation is the adjustment of the level of a naturally occurring mineral found in water in order to prevent tooth decay. Courts have consistently ruled that water fluoridation is not a form of compulsory mass medication or socialized medicine.58,61,63 In fact, water that has been fortified with fluoride is similar to fortifying salt with iodine, milk with vitamin D and orange juice with calcium — none of which are medications.

In recent years, challenges to fluoridation have been dismissed for a variety of reasons, including that plaintiffs admitted they could not establish injury by virtue of fluoridation and that state law supporting fluoridation prevailed over local attempts to oppose fluoridation.

Interestingly, pro- and anti- fluoridation interests have each won and lost legal challenges regarding which state or local agency has regulatory authority over fluoridation, which of course varies by state and locality.

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Feb 19, 2020 | Posted by in General Dentistry | Comments Off on Policy
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