Amended - Health and Social Services - Nov 13, 2008 Deferred - Regional Council - Nov 19, 2008 The Regional Municipality of Halton Report To: From: Chair and Members of the Health and Social Services Committee Bob Nosal, Commissioner and Medical Officer of Health Date: October 20, 2008 Report No. - Re: MO-37-08 - Water Fluoridation in Halton Region RECOMMENDATION THAT Regional Council supports the formation of an Ontario Water Fluoridation Office as endorsed by the Council of Ontario Medical Officers of Health, and that a copy of Report No. MO-37-08 re: Water Fluoridation in Halton Region be forwarded to the Chief Medical Officer of Health for Ontario and the Municipal Councils of Burlington, Halton Hills, Milton and Oakville. REPORT The purpose of this report is to give Regional Council information on water fluoridation before hearing several delegations expected on this issue at the November 13 th Health and Social Services Committee meeting. Background Fluoride occurs naturally and is often found in water sources, such as wells and lakes. Many communities in Ontario add fluoride to their drinking water for the prevention of tooth decay when natural levels of fluoride are below optimal levels for the prevention of tooth decay. Seventy percent of Ontario residents, or about 8.7 million people, receive fluoridated drinking water. In Halton Region, the majority of communities have access to fluoridated municipal water supplies. The lake-based water systems supplying Burlington, Oakville, and the newer developments in Milton are fluoridated. In Halton Hills, the well-based water system is also fluoridated. The older section of Milton is the only community in Halton that does not have full access to fluoridated water. The fluoride level in fluoridated drinking water is set between 0.5 to 0.8 parts per million (ppm), which is the optimal range for the prevention of tooth decay. The guideline for the maximum allowable fluoride concentration in drinking water in Canada is 1.5 ppm. Fluoride levels in 1
drinking water are monitored regularly by Halton Region Environmental Services, and reported to the Health Department to ensure recommended levels are maintained (i.e., 0.5-0.8 ppm). Fluoride is added to the water supply in the form of hydrofluorosilicic acid. The operational procedures and dosage requirements are conducted in compliance with the Safe Drinking Water Act requirements. The hydrofluorosilicic acid added meets the requirements of the National Sanitation Foundation (NSF). Council was previously updated on water fluoridation in Report No. MO-12-04. Health Benefits of Water Fluoridation Water fluoridation is a safe, effective, and cost-effective way to prevent tooth decay. In Halton, tooth decay is still a health concern; for example, about 50 percent of 9 year-old children have experienced tooth decay (Report No. MO-12-08). Several reviews on the effectiveness of water fluoridation have been conducted over the last decade, including: York Review (UK), A Systematic Review of Public Water Fluoridation (2000). U.S. Centers for Disease Control and Prevention, Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States (2001). Australian Government, National Health and Medical Research Council, A Systematic Review of the Efficacy and Safety of Fluoridation (2007). Public Health Branch, Ontario Ministry of Health and First Nations and Inuit Health Branch, Health Canada, Benefits and Risks of Water Fluoridation (1999). These reviews have all concluded that rates of dental decay are lower in fluoridated communities compared to non-fluoridated areas. The fluoridation of drinking water is endorsed by over 90 national and international professional health organizations including: Health Canada, the World Health Organization, and the U.S. Centers for Disease Control and Prevention (CDC). In August 2008, a joint statement supporting water fluoridation was issued by Health Canada, Toronto Public Health, Ontario Association of Public Health Dentistry, Canadian Dental Association, Ontario Dental Association, and the Royal College of Dental Surgeons of Ontario (Attachment #1). The CDC has cited water fluoridation as one of the top ten achievements of public health in the 20 th century. It is estimated that in most communities, every $1 invested in fluoridation saves $38 or more in treatment costs (Office of the US Surgeon General, 2004). A major advantage of water fluoridation is that it benefits all residents in a community, regardless of age, socio-economic status, education, or employment. 2
Health Risks of Fluorides Dental fluorosis is caused by the excessive ingestion of fluoride during tooth formation. In the mild form, dental fluorosis appears as white flecks on the tooth surface. In the severe form, brown staining and/or pitting occur on the tooth surface. The concentration of fluoride used in fluoridating community water systems is low and is associated with low risk of fluorosis. Other sources of fluoride, such as toothpastes and supplements, are more significant in the development of fluorosis. Some members of the public have become concerned after seeing claims repeated in the media regarding the risk of bone diseases, thyroid disease, child development problems, and other health risks associated with fluorides and water fluoridation. These claims have been studied and there is a lack of quality evidence to support them. Fluoride, like many other substances, is toxic in higher doses. However, a low concentration of fluoride is used in community water fluoridation and this level is carefully monitored. Recently, associations between fluoride exposure and thyroid disease and effects on the brain have been reported. (1) Studies have reported an association between fluoride exposure and effects on the functioning of the thyroid gland when fluoride is consumed at high doses. (2) Similarly, studies from China and India report an association between consumption of drinking water with high concentrations of fluoride, at least 3.0 ppm, and lower IQs in children. However, the fluoride levels in the drinking water consumed by test subjects in these studies are much higher than would be allowed in Ontario and elsewhere in Canada the maximum concentration is 1.5 ppm. Thus, these results are not valid for assessing the safety of fluoride in drinking water in Ontario. Any new or unexpected findings must not be automatically discounted, but at the same time it is reasonable to wait for expert group interpretation and additional study to see if the results can be verified. To date, none of the various claims have been accepted after careful scrutiny. In March 2008, the Government of Canada issued a joint response to an environmental petition to discontinue water fluoridation (Petition No. 221). Some of the report s conclusions were: The fluoridation of drinking water supplies is a well-accepted measure to protect public health and is strongly supported by scientific evidence. Health Canada has reviewed the available information regarding the potential effects of fluoride on thyroid function and found that current science does not show a causal relationship between exposure to fluoride and thyroid function. Federal and Provincial Reviews on Water Fluoridation Health Canada will be revising the technical support document for the Canadian Drinking Water Quality Guideline for fluoride. The review will take into account the latest evidence and the updated document is expected in 2009. 3
The Ontario Ministry of the Environment will be undertaking a review of the existing policies and regulations under the Safe Drinking Water Act that pertain to the addition of inorganic fluorides to drinking water. The results of this review are expected by early 2010. Support for the Formation of an Ontario Fluoridation Office The Health Department supports the formation of an Ontario Water Fluoridation Office as endorsed by the Council of Ontario Medical Officers of Health. This office would collect and evaluate research, address concerns regarding fluoridation, and evaluate the effectiveness of fluoridation in Ontario. The Health Department asks Regional Council to also support the formation of the Ontario Water Fluoridation Office. This support would not be financial support of the Office. Oral Health Status of Children in Halton Region Information on oral health status is collected using the Dental Indices Survey (DIS). The DIS is conducted over a two-year cycle in elementary schools in Halton Region. Schools are randomly selected from each municipality. Both treated and untreated dental decay are recorded for all affected teeth (primary and permanent teeth). Dental decay experience includes decayed teeth, filled teeth and teeth missing due to dental decay. The DIS survey is not intended to assess the effectiveness of water fluoridation in communities. Information is not collected on children s history of fluoride exposure and the level of fluoride in their drinking water. Results for each municipality for the past three DIS cycles are given in Table 1. Prior to 2001-03, DIS results were not reported by municipality. The 2001-03 survey included 5, 7, 9, 11 and 13- year-old children. The 2003-05 and 2005-07 surveys included children aged 5, 7, 9 and 13 years. Several trends are indicated by the DIS results: 1. Overall, the rate of dental decay has decreased from previous surveys. Although results suggest improvements may have occurred, a high percentage of children still experienced decay (e.g., 38% of children in the most survey had experienced dental decay). 2. Decreases in rates of dental decay have occurred in three of the four municipalities (Oakville, Burlington, and Milton). However, rates have increased in Halton Hills. Demographic changes resulting from migration may be a possible reason for the changes, but current data are limited and do not allow us to explain the findings. 3. Dental fluorosis rates have shown large variations by municipality over the three DIS surveys. Virtually all children with dental fluorosis have mild or moderate fluorosis. No cases of severe dental fluorosis were found in the 2005-07 survey. The Health Department will continue to monitor the oral health status of children in Halton in order to determine whether these trends continue. 4
Table 1. Oral Health Status of children by municipality for 2001-03, 2003-05, and 2005-07 DIS surveys 2001-03 Burlington Halton Hills Milton Oakville Dental decay experience (%) 46.7 43.3 53.9 36.9 Mean number of teeth affected by dental decay 1.44 1.29 1.82 1.02 Dental Fluorosis*(%) 35.2 39.9 24.6 40.9 OVERALL (n = 2,725) 2003-05 Burlington Halton Hills Milton Oakville 45.2 46.9 46.2 57.8 52.7 1.40 1.55 1.53 2.23 1.83 35.1 25.4 21.2 15.5 20.3 OVERALL (n = 2,463) 2005-07 Burlington Halton Hills Milton Oakville 50.9 35.4 52.4 25.3 38.8 1.78 1.28 1.93 0.85 1.25 20.7 37.1 17.3 35.1 48.4 OVERALL (n = 2,547) 38.0 1.28 * Dental fluorosis results do not include 5 and 7 year-olds. 34.5 Conclusion Water fluoridation is a safe, effective, and cost-effective way to prevent tooth decay in a community. Fluoridation is well-supported by scientific evidence and endorsed by many public health, dental and medical organizations. Health Department staff will continue to post information to the website and provide information on water fluoridation, and monitor research. Regional Council will be updated as appropriate on this issue. FINANCIAL/PROGRAM IMPLICATIONS The cost of fluoridating community water is included in the base budget for Public Works and Engineering Services. 5
RELATIONSHIP TO THE STRATEGIC PLAN This report supports Strategic Plan Theme #3, Create and Improve Safe, Healthy, Liveable, Inclusive Communities, and goal #1, provide accessible, affordable public health and social services to the community. Respectfully submitted, Joyce See Director, Community Health Services Robert M. Nosal MD FRCPC Commissioner and Medical Officer of Health Approved by Pat Moyle Chief Administrative Officer If you have any questions on the content of this report, please contact: Dr. Robert Hawkins Tel. # 7798 Gisèle Franck Tel. # 7834 6