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HomeMy WebLinkAbout02272012 City Council Work Session Notes - Fluoride WORK SESSION NOTES ON 4(31 ( (,fo ri d,,aa Purpose: &VTh Poa :94-1 sent. C t n , , k'l h11 6i/'a���oune.lMen¢bcrs P Q✓G t:• PQ )Gf/� fin Y Co'AO ;oirl I C-n) Called by: 001A I ICO Time (9CO fry) Date a- a, - ****************************************************** C t 1 I� UV L 1(Pl t- 1,0 ntia 00im k cot, P /C 7 .en5 e �) c(f1' 11,1 J\(1WIn Lc ) ( alee (01 tic: `'4' ricy N:11,4q-jdo Oil a tetrift4K Gt!�'U� �. r-i te.j t�Q rnrxr� — • � z mI'1(-1�1 W b il (AA- 6k.'° C H 01 CA_ °rt Mal rOlti4M nOj1R pyna5r' c tic t.cf. , fin Memorandum Date: February 27, 2012 8C4) To: Mayor and City CouncilP t,4sw • From: Johanna Kinney, City Clerk Subj: Election and Referendum/Initiative information, timeframes, and deadlines After receiving direction from the council to research the possibility of a referendum petition on Resolution 2010-015, the following information has been determined: According to City Charter 4.8, "The filing with the city clerk sufficient referendary petition within thirty days after the passage of the act of the council to which such petition refers shall automatically suspend the operation thereof, pending repeal by the council or final determination by the electors."(emphasis added) Because this resolution was passed on February 22, 2010 and thirty days has passed since approval, Resolution 2010-015 is not subject to a referendum of the voters as previously suggested and discussed. Generally speaking, depending on when a referendum petition is certified, it can go to a regular or special election. However, the City Code states certified initiative petitions go to the next regular election. A CI iii-c-461 Vert Possible council options regarding this issue of fluoridation of city water: p ovine int i/ • Do nothing, which has the same effect of upholding Resolution 2010-015. • Amend or repeal the existing resolution, by directing staff to bring forward a resolution to council (which would require general consensus)or a council member could prepare a resolution. Possible citizen options regarding this issue of fluoridation of city water: • Lobby council members to do either one of the above options,based on stance on this issue. • Submit an application for initiative petition to call for a binding vote of the people at the next regular election. Council has requested information on the timeline for ballot items. According to City Code 4.15,for a citizen initiative: 1. Application for initiative filed by citizen sponsor(which is referred to in the code as"contact person"). 2. Clerk has two weeks to review application for certification and determine if the application is in proper form and meets the criteria as set forth in City Code Section 4.15.015. 3. If approved, City Clerk has two weeks after certification of application to prepare a petition for the initiative. 4. Citizen sponsors now have 90 days to secure the proper amount of signatures (25% of the votes cast at the last regular election). 5. Once received, the City Clerk has ten days to certify whether the petition is sufficient. If insufficient, the City Clerk contacts the contact person and identifies the insufficiency. If insufficient due to lack of signatures,additional signatures may be obtained and filed before the eleventh day after the date on which the petition was rejected (if still insufficient, the contact person may file a protest with the City Manager,which will be presented to the City Council to hear and decide the protest). 6. The Clerk shall present a certified sufficient petition for initiative to the City Council at the first regular meeting after certification. Unless City Council enacts substantially the same measure within 30 days of submission of the certified petition,the City Clerk shall,with the aid of the attorney, prepare an ordinance or resolution to implement the petition and shall submit it to the voters at the next regular election. *One very important deadline that is not determined in the City Code is the deadline for the City Clerk to submit the regular ballot for printing. Absentee ballot begins typically two weeks prior to the election date,so ballots are printed and received by mid-September. The City Clerk's deadline to submit the ballot proof to the printers is mid-August;right after the declaration of candidacy period has ended. Per the inquiry of the council,if a citizen wishes to bring forward an initiative petition with intent of a citizen vote on the October 2, 2012 ballot, it could take up to five months for the contact person, the City Clerk, and the council for adequate preparation. This conclusion was determined by anticipating each timeframe was used fully and not including the time preparation for the clerk to prepare an ordinance or resolution to implement the petition to submit to the voters at the next regular election. Depending on the nature of the petition and ballot language,pre-clearance may be needed from the Department of Justice. Items of this nature typically include proposed changes that may affect the rights of the voter. Sponsored by: Oates „` CITY OF SEWARD, ALASKA RESOLUTION 2009-043 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SEWARD, ALASKA,SUBMI'T'TING AN ADVISORY BALLOT PROPOSITION TO THE QUALIFIED VOTERS AT THE OCTOBER 6,2009 REGULAR MUNICIPAL ELECTION REGARDING WHETHER FLUORIDE SHOULD BE ADDED TO THE CITY OF SEWARD WATER WHEREAS, SGS (City's certified lab) conducted a standard water test, that measures 0.1 parts per million and higher, on March 9, 2009 and fluoride was not detected in the Seward City water; and WHEREAS, the United States Public Health Service (USPHS) established the optimum concentration for fluoride in the United States in the range of 0.7 to 1.2 parts per million; and WHEREAS, fluoridation of community water supplies involves the addition of fluoride to the public water supply to an optimal level to reduce the incidence of tooth decay; and WHEREAS, a Seward Fluoridation Study was conducted by Michael L. Foster & Associates, Inc. on April 13, 2009 addressing fluoride forms, corrosion, chemical feed, regulatory requirements, code compliance, operator certification, costs, and fluoride removal; and WHEREAS, according to the Fluoridation Study the approximate cost of fluoridating the water are $130,000 for capital costs and $24,000 for annual costs; and WHEREAS,the Indian Health Service may contribute up to 21%ofthe capital infrastructure costs; and WHEREAS, there are pros and cons to adding fluoride to community water supplies and there is passion among both the proponents and opponents of fluoridation; and WHEREAS, this resolution will place the issue of whether fluoride should be added to the City of Seward water on the ballot as an advisory vote allowing the qualified voters to advise the City Council on whether to fluoridate the water or not; and WHEREAS, the advisory vote on adding fluoride to the City of Seward's water is non binding, the City Council will consider the voting results. NOW,THEREFORE,BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF SEWARD, ALASKA, that: I. CITY OF SEWARD, ALASKA RESOLUTION 2009-043 Section 1. The City Clerk is hereby directed to submit Proposition No.1 as a non binding advisory vote to the qualified voters at the October 6, 2009 regular municipal election in substantially the following form: ADVISORY PROPOSITION NO. I Shall fluoride be added to the City of Seward water to the level (0.7-1.2 parts per million) recommended by the U.S. Public Health Service? Yes No A "Yes" vote advises the Seward City Council that the voters recommend adding fluoride to the level(0.7-1.2 parts per million)recommended by the U.S.Public Health Service to the Seward City Water. A"No" vote advises the Seward City Council that the voters do not recommend adding fluoride to the level (0.7-1.2 parts per million)recommended by the U.S. Public Health Service to the Seward City Water. Section 2. This resolution shall take effect immediately upon its adoption. PASSED AND APPROVED by the City Council of the City of Seward, Alaska. this 2G`" day of May, 2009. THE CITY OF SEWARD, ALASKA 64A, ) Clark Corbridge, Mayo AYES: Dunham, Bardarson, Kellar, Keil, Corbridge NOES: None ABSENT: Valdatta, Smith ABSTAIN: None ATTEST: (a-4' ;� r 7 . .• � ( Vfs4, � moi+ Johanna Dollerhide, CMC 't •• • C>,..!.'111''-°14Z":,.,4%.11 Sd�� Assistant City Clerk V• (City Seal) x • SEAL s 0 ! • • ••., OF AVP`S•`• 'Liml i% Sponsored by: Oates CITY OF SEWARD, ALASKA RESOLUTION 2010-015 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SEWARD, ALASKA, AFFIRMING COUNCIL SUPPORT FOR FLUORIDATION OF THE PUBLIC WATER SUPPLY TO IMPROVE ORAL HEALTH, AND DIRECTING THE CITY MANAGER TO DETERMINE THE REQUIREMENTS AND COSTS FOR SAFELY ADDING FLUORIDE TO THE COMMUNITY WATER SYSTEM AND REPORT ON GRANTS AND OTHER FUNDING SOURCES FOR SUBSIDIZING THOSE COSTS WHEREAS, the Seward City Council is the governing body of the City of Seward and recognizes that there is community support for the fluoridation of the City of Seward public water system; and WHEREAS,the Seward City Council recognizes that dental tooth decay is a chronic disease and that community fluoridation is a public health measure that benefits all individuals; and WHEREAS, fluoridation of community water supplies is supported by numerous professional heath organizations including the American Public Health Association, American Dental Association, World Health Organization and the American Medical Association; and WHEREAS,the Center for Disease Control and Prevention has named water fluoridation as one of the ten greatest public health achievements and in 2005 marked the 60`h anniversary of water fluoridation in the United States; and WHEREAS, SGS (the City's certified lab) conducted a standard water test aimed at detecting fluoride levels of 0.1 parts per million and higher on March 9,2009, and fluoride was not detected in the Seward City water; and WHEREAS,the United States Public Health Service(USPHS) established the position that the optimal concentration for fluoride in the United States should be in the range of 0.7 to 1.2 parts per million; and WHEREAS,fluoridation of community water supplies at an optimal level has been shown to reduce the incidence of tooth decay; and WHEREAS, community water fluoridation simply adjusts the level of fluoride that occurs naturally in water to the level considered optimal in helping to protect against tooth decay as shown in 72.4% of the U.S. population served by public water systems that are optimally fluoridated; and WHEREAS,the Council of State Governments resolution on community water fluoridation supports state efforts to provide community water fluoridation; and CITY OF SEWARD, ALASKA RESOLUTION 2010-015 WHEREAS,the Indian Health Service may contribute up to 21%of the capital infrastructure costs for the fluoridation of community water; and WHEREAS, there are pros and cons to adding fluoride to community water supplies and there is passion among both the proponents and opponents of fluoridation; and WHEREAS,resolution 2009-043 addressed the issue of whether fluoride should be added to the City of Seward water, and authorized placing the question on the ballot as an advisory vote to allow the qualified voters to advise the City Council on whether or not to fluoridate the water; and WHEREAS, resolution 2009-043 advisory ballot was titled as follows: "Proposition 1. (Advisory) Shall fluoride be added to the City of Seward water to the level of(0.7-1.2 parts per million) recommended by the U.S. Public Health Service"; and WHEREAS,the results of the October 6,2008 regular election which included an advisory vote were as follows: Election Day votes (Yes: 229 versus No: 206); after canvass votes (Yes: 50 versus No: 28); and the total votes were (Yes: 279 and No: 234); and WHEREAS, the advisory vote on adding fluoride to the City of Seward's water was non binding; and WHEREAS, at the January 11, 2010 council meeting the Seward City Council was given information concerning the pros and cons of fluoridating the City of Seward water supply in the range of 0.7 to 1.2 parts per million. NOW,THEREFORE,BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF SEWARD, ALASKA, that: Section 1. The city council recognizes and supports the public health benefits of community water fluoridation for preventing dental decay and is committed to the safe and effective practice of water fluoridation as defined by the Centers for Disease Control Preventions' Engineering and Administrative Recommendation to Water Fluoridation. Section 2. The city council directs the city manager to hire a qualified professional engineering firm for an amount not to exceed$50,000,to determine the impacts and requirements in terms of equipment, training, infrastructure, and safeguards of adding fluoride to City of Seward water system. The findings and conclusions from this study, and other requirements for the water system, shall be considered by the city council prior to the appropriation of funds for adding fluoride to the City of Seward water supply. CITY OF SEWARD, ALASKA RESOLUTION 2010-015 Section 3. The city council also directs the city manager to report back to the city council all grants and funding sources that maybe available to subsidize the costs of adding fluoride to the City of Seward water supply. Section 4. Once the city council appropriates funds for the fluoridation of the City of Seward water supply,the city manager will initiate actions for fluoridation of the water supply to a minimum level of 0.7 and not to exceed 1.2 parts per million, the recommended fluoride level of fluoride in public water supplies according to the U.S. Public Health Service. Section 5. This resolution shall take effect immediately upon its adoption. PASSED AND APPROVED by the City Council of the City of Seward, Alaska, this 22nd day of February, 2010. THE CITY OF SEWARD, ALASKA Willard E. Dunham, Mayor AYES: Bardarson, Keil, Shafer, Dunham NOES: Valdatta, Amberg ABSENT: Smith ABSTAIN: None 0ee`so's.gar ov`o F¢y,�*o oIy ATT,ST: .M`< ^;6 . � )..,°r0op J;. Lewis'CM' ' • .1 •• y Clerk . '••,,. ,t.:` (City Seal) ••od'.A `A°" ' '' '' A ruousa rrrrrrarss I TECHNICAL MEMORANDUM Seward Fluoridation Study This study presents information on design criteria,costs, and recommendations associated with fluoridating Seward's City water system. It also identifies related technical, operational, and regulatory constraints that the City will need to address if fluoridation is implemented. Refer to Technical Memoranda 1 and 2 (Refs. 1, 2), as well as the Task 3 Study Report (Ref. 3) for the Water Compliance Study by Michael L. Foster & Associates (MLFA) for additional information on Seward's water systems,including monitoring results. Fluoridation is often promoted by dentists and other health professionals as a way to help protect developing teeth,particularly in children nine years old and younger (Ref. 22). Because the Seward Marine Industrial Center (SMIC) water system is used almost exclusively by adults,we assumed fluoridation of that water was unnecessary and did not address that system. The City may want to review that decision. The scope of this study was to address engineering issues and costs related to equip- ment, chemicals, operation, monitoring, and reporting. However,we would be remiss if we did not alert the City to the fact that this issue can elicit considerable passion among both proponents and opponents of fluoridation. Although 65 percent of Alaskans currently drink fluoridated water (Ref. 4), several communities have consciously chosen not to fluoridate—or have discontinued its practice. No community on the Kenai Peninsula currently fluoridates its water (Ref. 5). The City & Borough of Juneau has invested perhaps the greatest recent effort by any Alaska community into study of fluoridation, produced a report(Ref. 6), reached a conclusion by its Assembly, and discontinued fluoridation of its water on January 15,2007. This report contains these sections: • Fluoride Forms • Corrosion • Chemical Feed • Regulatory Requirements • Code Compliance • Operator Attention • Costs • Fluoride Removal • Closure Seward Fluoridation Study 1 June 10,2009 Michael L.Foster& Associates,Inc. SEWD-SEWD-004-0001 1. Fluoride Forms Fluoride compounds are produced in many different forms, and are used according to availability and application. Sodium fluoride (NaF) and sodium fluorosilicate (Na2SiF6), are two commonly used compounds to fluoridate public drinking water systems in Alaska. Table 1 lists key properties of these two compounds. Table 1 Properties of Fluoride Compounds Property_ Sodium. Sodium Fluoride'. Fiuorosiilcate Form Crystal or Powder powder Commercial Purity 95%± 95%+ Available Fluoride Ion 45% 61% Density 95 lb/cu ft 66 lb/cu ft Solubility in water at 4°C 4.0 g/100 mL 0.5 g/100 mL Amount needed per 20 pounds 15 pounds million gallons of water Volume of saturated solution per million gallons 56 gallons 330 gallons of water pH of saturated solution 7.5 3.6 Cost, delivered, per pound $1.00 $0.70 Note: 1. For a dosage of 1.0 mg/L. Smaller water systems in Alaska that fluoridate almost exclusively use sodium fluoride (NaF). Although Seward is one of Alaska's larger communities, the decentralization of its groundwater sources make each well more like a smaller community source. Sodium fluorosilicate (aka silicofluoride or sodium fluosilicate) is generally less expensive than sodium fluoride,but because of its low solubility, considerably lower pH in solution, and substantial operator experience with and availability of NaF in Alaska, we conclude that sodium fluoride is a better chemical to use in Seward. This decision could be made during design, and is not likely to change the basic question about fluoridation. Fluorosilicic acid (H2SiF6) is commonly used in many water systems elsewhere in the continental United States, but because of the cost and challenge of shipping, and increased handling hazard, is not used by any water system in Alaska, and is not considered appropriate for this application. Sodium fluoride is available from several vendors in Anchorage and elsewhere, including the Alaska Utility Supply Center; Garness Industrial Inc.; and Univar. The costs presented in Table 1 are for chemicals purchased in bulk, and do not include City storage and handling. If purchased in smaller quantities, the unit prices can be expected to be higher. Seward Fluoridation Study 2 June 10,2009 Michael L.Foster&Associates, Inc. SEWD-SEWD-004-0001 global fluoridation discussion and decision. The accompanying drawings show typical layouts for both types of fluoridation equipment. Seward's City water system does not have a common point for chemical injection before water is provided to the consumer. Therefore, fluoridation equipment will need to be provided at each wellhouse. Well House 6 has room for this equipment as well as separation for chemical storage. Space in Well Houses 2,4 and 5 is more limited,but might be able to be arranged. If chemical feed water is softened, backflush water should be removed from the wellhouse,hauled away,and discharged to the sewer system. Mechanical dry feeders meter dry chemical with an auger into a dissolving chamber where it is mixed with water. Although more commonly used for feeding sodium fluorosilicate, they can also be used for sodium fluoride. Like the saturator, the solution is fed from the storage tank to the process line using a metering pump. These feeders require operator attention to ensure they have not"caked" or clogged. The dissolving chamber needs to be checked regularly to ensure the solution is completely dissolved before discharge into the process line and that there is not excessive build-up of un-dissolved chemical in the tank. Because the quantity of sodium fluoride needed for Seward is relatively small, and four well houses are currently in operation, we believe its use is manageable with a saturator, and at this stage of planning have opted for this simpler system,which is used commonly in many smaller communities in Alaska. Although Seward's water system is larger than many of these communities, and the City has a deeper reservoir of operator talent, multiple existing well houses with limited space make this application appealing. 4. Regulatory Requirements The EPA has established criteria for drinking water under the Safe Drinking Water Act and its amendments (1974, 1986, and 1996). Alaska's standards, administered through DEC, must be consistent with this Act. These include the maximum contaminant level goal (MCLG),maximum contaminant level (MCL),and secondary maximum contaminant level (SMCL). Alaska may,with justification, apply more stringent conditions, or otherwise incorporate constraints that recognize unique applications in our State. The MCLG is a goal set to minimize adverse health effects. This goal is advisory, not enforceable by EPA. The MCL is an enforceable standard that is set as close to the MCLG as practicable, considering treatment technology and costs. The SMCL is a non-enforceable secondary standard that for fluoride provides guidance on cosmetic or aesthetic considerations related to tooth enamel fluorosis. In 1986, the EPA established an MCLG and MCL for fluoride at 4 mg/L and an SMCL of 2 mg/L. Seward Fluoridation Study 4 June 10,2009 Michael L.Foster& Associates, Inc. SEWD-SEWD-004-0001 2. Corrosion The pH of water from the City wellfield is 6.93 (see Water Compliance Study, Technical Memorandum No. 1, Appendix E). This water meets the EPA's secondary standard for pH of 6.5 to 8.5. Lower pH waters can be corrosive or contribute to higher lead and copper levels in the distribution system. Corrosivity was a potential concern expressed in Technical Memoranda 1 and 2. Sodium fluoride will have a slight effect on increasing the pH of City water, thereby decreasing its corrosivity, although this may not be measurable. On the other hand,sodium fluorosilicate would have a slight effect on pH depression. In addition, the City could experience corrosion from handling and storage of dry materials that get damp or wet, or from spills of concentrated solutions. Good housekeeping, including prompt washdown, removal, and disposal outside the wellfield protective area should minimize this. 3. Chemical Feed Sodium fluoride is a dry,white chemical commercially available as crystal (preferred) or powder that dissolves in water. It is typically delivered in 50-lb bags or 125-pound drums, is stable,has a long shelf-life,but must be kept dry. If it comes into contact with moisture it can form a hardened cake. Two common options for feeding sodium fluoride are a saturator and mechanical dry feed. A saturator is a free-standing tank (often with 50-55 gallon capacity) that stores a bed of sodium fluoride at the bottom of the tank. On the call for make-up water,water flows through the bed slowly, generating a saturated solution of 4 percent concentration. This solution is then injected into a discharge pipe by a metering pump. Fluoride saturators can be either upflow,in which water enters the bottom of the tank,or downflow, in which water enters the top of the tank. Upflow saturators are more common today and are preferred as they are easier to clean and maintain. The makeup water for a fluoride saturator should have hardness levels less than 50-75 mg/L because calcium and magnesium fluorides will precipitate. Saturator manufacturers recommend that a water softener be included with the chemical feed system if hardness levels are greater than this. City water has a hardness of 94 mg/L (Technical Memorandum No. 1, Appendix E) (Ref. 1), so a water softener for the chemical feed water may be appropriate. Alternatively, the City should count on additional maintenance to clear clogging lines and remove scale. Saturators generally require less operator attention than mechanical dry feed systems. Either will function well. Operation can be automatic or manual. Selection of the type of chemical feed system can be made during design, on the bases of cost, space availability, and operator preference. This choice is not likely to affect a more Seward Fluoridation Study 3 June 10,2009 Michael L.Foster& Associates,Inc. SEWD-SEWD-004-0001 State and federal regulations do not require fluoridation of drinking water systems. However,where it is practiced, they require that fluoride concentrations be measured. DEC has said it will enforce the SMCL of 2.0 mg/L. It has determined public health is threatened or that exceeding this level is not in the public interest(18 AAC 80.300, Refs. 5, 7) because of the toxicity of sodium fluoride and danger of tooth mottling in higher concentrations. The City would want to do this anyway. Good practice in public water systems that fluoridate is to keep fluoride levels between 0.7 and 1.2 mg/L (Refs. 5,8), or possibly somewhat higher (perhaps 1.1 to 1.7 mg/L) in colder climates,like Seward (Refs. 17, 18). Daily sampling and measurement are required for each location where fluoride is injected to ensure that concentrations of fluoride stay within the target levels. A grab sample and measurement with an onsite meter is acceptable (Ref. 5). Continuous online monitoring will also satisfy this requirement, and is recommended. The results of the daily monitoring must be recorded and reported monthly to DEC (Ref. 7,Section 315). The City should also keep records of water production and fluoride consumption at each well house as a cross check on fluoride levels. Although not required, except perhaps in case of equipment malfunction, samples may also be collected and analyzed by a State-certified laboratory to demonstrate the validity of the City's fluoride monitoring. This would be a prudent occasional action by the City anyway to demonstrate the proper application of monitoring procedures and calibration of equipment. In addition,DEC may require the City to modify sampling procedures, increase sampling locations and frequency,and/or change sample-collection locations to ensure representative reporting, fluoridation consistency and protection of public health. The City must notify the DEC when out of compliance and when modifying its water system. According to EPA it must also follow public notification procedures, including reporting in the City's annual Consumer Confidence Report, if the MCL limit of 4.0 mg/L is exceeded. DEC may require public notification, following confirmation by a certified laboratory, if even the SMCL of 2.0 mg/L is exceeded (Ref. 5). Generally, according to DEC, records of measurements on delivered water, especially for inorganics such as fluoride, must be kept at Public Works or City Hall for five years. Like many communities in Alaska, the City of Seward is maintaining its water records essentially indefinitely. In addition to operational and reporting requirements, DEC requires its review of drawings, specifications and calculations (plan review) prepared by an engineer registered in the State of Alaska for water system modifications, such as the addition of a fluoridation unit process (Ref. 7). There is a cost and time for review and response associated with this. Seward Fluoridation Study 5 June 10,2009 Michael L.Foster& Associates, Inc. SEWD-SEWD-004-0001 7. Costs The costs presented in Table 3 assume that all water produced by the City wellfield will be fluoridated, including water delivered to cruise ships and Icicle Seafoods, the two largest summer customers. If these customers do not want their water fluoridated, the City might consider its seasonal discontinuation. Table 3 Costs for Fluoridation Category Cost Capital Chemical feed equipment' $80,0002 Storage 45,0003 Design, DEC review fees, 35.000 observation of installation Total Capital $160,000-220,0004 Annual Chemicals5 $11,000 Operation&maintenance 12,000 (0.15 FTE), parts and supplies Power and heating 3,000 Laboratory tests and reports, 4.000 miscellaneous Total Annual $30,000 Notes: 1. Includes saturator, chemical feed pump,water softener, continuous in-line monitor, redundant pump, spare parts, anti-siphon devices, and controls. 2. Assumes installation in four wellhouses plus redundant parts and wellhouse modifications. 3. Assumes chemical supply stored at a separate Public Works location. 4. If remote monitoring were provided as part of other water system l&C improvements, add$60,000($15,000 per site). 5. Sodium fluoride plus salt(sodium chloride)for water softener. To calculate the total amount of chemical usage a target fluoride concentration of 1.0 mg/L was used (based on the dosage range of 0.7 to 1.2 mg/L recommended by the Centers for Disease Control and Prevention in the U.S. Public Health Service, as supported by the American Water Works Association and DEC, Refs. 5, 8). City water has no detectable background level of fluoride (see Technical Memorandum No. 1, Appendix E, Ref. 1), so all of this would need to be added. If the dosage is increased,so will the cost for the chemicals. The City system will require 20 pounds of sodium fluoride per day (3 bags per week), based on average off-season flows of 1 mgd, and up to 10 bags per week to accommodate summer flows that exceed 3 mgd. If the City is unable to locate appropriate existing storage space,it will either need to construct a new area or Seward Fluoridation Study 8 June 10,2009 Michael L.Foster&Associates, Inc. SEWD-SEWD-004-0001 Table 2 Recommended Overfeed Actions .E 0®1, , ,.Actfonfrecointrleoded' 1.2 to 2.0 mg/L 1. Leave fluoridation on. 2. Determine malfunction and adjust or repair. 2.0 mg/L to 4.0 mg/L 1. Leave fluoridation on. 2. Notify supervisor and report to DEC. Follow instructions. 3. Determine malfunction and repair. 4. Confirm reading by certified laboratory. 5. Provide public notice as directed by DEC.2 4.0 mg/L to 10 mg/L 1.Turn fluoridation off. 2. Notify supervisor and report to DEC. Follow instructions. 3. Determine malfunction and immediately attempt repair. 4. Confirm reading by certified laboratory. 5.Take water samples at several points in the distribution system and test for fluoride. Retest if still high. 6.When repairs have been made, with supervisor's permission, restart fluoridation. 7. Provide public notice as directed by DEC.2 Greater than 10 mg/L 1.Turn fluoridation off immediately. 2. Notify supervisor and report immediately to DEC. Follow instructions. 3.Take water samples at several points in the distribution system and test for fluoride. Retest if still high. Save part of each sample for a certified laboratory to test. 4. Determine malfunction and repair.Then,with supervisor's and DEC permission, restart fluoridation. 5. Provide public notice as directed by DEC.2 Notes: 1 Many of these recommendations come from Ref. 16.Others come from Ref. 5. The remaining are by MLFA. 2 Public notification may prevent or reduce consumption of large volumes of heavily fluoridated water. Monitoring of fluoridation is very important. Because of the layout of the City water distribution system, this should occur at multiple locations. Some customers receive water directly from the distribution system before it has gone to a storage tank. Monitoring in these locations is even more important,as the system will be less forgiving for an overdose. Because of this,wiring in series that ensures shut-off of the fluoridation pump when well pumps are not operating is essential, and is required by DEC. The City may also consider continuous in-line monitoring of fluoride with the capacity to shut-off or adjust the fluoridation pumps when a set level is exceeded. Another safety feature is to size the dosing pumps so their maximum production will not cause substantial overfeeding above the desired control limit. Seward Fluoridation Study 7 June 10,2009 Michael L.Foster& Associates, Inc. SEWD-SEWD-004-0001 5. Code Compliance The Alaska Department of Public Safety,home of the State Fire Marshal,has adopted the 2006 International Building,Fire, and Mechanical Codes. The 2009 Codes are now published, and it is likely the State will adopt them soon. Sodium fluoride is classified by OSHA and the International Fire Code (IFC) as a toxic chemical. Table 2703.1.1(2) of the IFC provides the exempt amounts of hazardous materials that can be stored in a controlled area. If quantities in excess of these are stored, facilities must meet applicable requirements of its Chapters 27 and 31. Generally,limits on storage areas for sodium fluoride are 500 pounds without sprinklers and 1,000 pounds with sprinklers. However, the Code allows some exceptions and adjustments, such as for detached storage. Code interpretation can be complex, and our research was not exhaustive,but we believe this interpretation is close to how it will be enforced by the State of Alaska. Sodium fluoride is non-flammable and does not support combustion. There are no restrictions on extinguishing media in fire situations. However, sodium fluoride will react with acids to form hydrogen fluoride,which is highly toxic. Other requirements also include signage (No Smoking and Chemical Identification) and ventilation. The Occupational Safety and Health Administration (OSHA) has requirements for the safe handling of sodium fluoride, including safety shower and eyewash,protective face shield, gloves, and clothing. 6. Operator Attention Fluoride systems are relatively simple and implementing fluoridation will not require new levels of operator certification for the City's staff(see 18 AAC 74, Ref. 9). However, initial training in fluoridation will be required for operators to ensure effective and safe performance. Additionally,annual training of 6-8 hours will be required. While fluoride is considered safe by EPA, DEC, and several other health authorities when handled properly and kept within regulated levels,an overdose can cause severe sickness, and even be fatal. Alaska was reminded of this in 1992 when fluoridation equipment malfunction and operator error combined to cause the death of one person and illness for several others in Hooper Bay. Thus,it is imperative that operation and maintenance staff be well trained to avoid system overdosing as well as their own accidental direct exposure. On the rare occasion that equipment malfunction or operator error might substantially overdose the water supply, the City will need to act, sometimes very promptly. Table 2 provides recommended actions for responding to various levels of fluoride overfeeding. Seward Fluoridation Study 6 June 10,2009 Michael L.Foster& Associates, Inc. SEWD-SEWD-004-0001 modify an existing space. For our cost purposes, we have assumed that 150 square feet of new space will be needed at$300 per square foot. This will include ventilation, sprinkling, security and other protections to meet Code requirements. Storage of 1,000 pounds will provide a two-week supply in the summer and up to seven weeks in the winter. The chemical will be distributed to wellhouses based on system operation,which currently has Well 6 operating in lead (primary) mode. Saturators are able to store quantities greater than a single 50-pound bag,but they should still be checked regularly,at least every other day,and refilled as necessary. The estimates of capital and annual costs are considered conceptual at this stage (Class 5 cost estimates as defined by the Association for the Advancement of Cost Engineers), made without detailed engineering data. It is normally expected that capital cost estimates of this type are accurate to within plus 50 percent to minus 30 percent. Our estimates have been prepared for guidance in project evaluation and implementation from the information currently available to us, including our own experience with the Seward water system, fluoridation experiences by others, conversations with vendors, catalog and website research, and assumptions we have identified in the report. Actual costs will depend on the project delivery system you choose and its implementation schedule, potential costs and delays from extensive interactions with the interested public,your own Public Works labor costs and assignment of personnel,costs of materials,various market conditions outside our control, and other variables. As a result,your final costs will likely vary from our estimates. Because of this,we suggest that project feasibility and funding needs be carefully reviewed as you advance the project before you make specific financial decisions and commitments. 8. Fluoride Removal The City asked us to address fluoride removal. If the City of Seward decides to fluoridate its water, some of its customers will likely no longer want to drink the water. These customers can purchase non-fluoridated bottled water or can remove fluoride from City water. Alternatively, the City can make non-fluoridated SMIC water available to them, or provide City water before it is fluoridated. The most effective treatment system for fluoride removal is reverse osmosis, and these units are not inexpensive. Small home units sized for removing fluoride from only drinking water (a small component of a household's total water use) cost from$250 to$700 at retail (Ref. 10), plus installation and maintenance expenses. Seward Fluoridation Study 9 June 10,2009 Michael L.Foster& Associates, Inc. SEWD-SEWD-004-0001 9. Closure As it engages in its community dialogue, the City of Seward might consider other options for increasing fluoride intake for young children whose parents want them to have it, without causing the rest of the population that does not want it or does not need it to drink fluoridated water. This could include making fluoride tablets available at little or no cost for families with young children; promoting use of fluoride toothpaste, gels and rinses; or even selectively fluoridating (for example, pre-and elementary schools). Whatever it decides to do,Seward should become well aware of recent experiences elsewhere as it moves forward. Seward Fluoridation Study 10 June 10,2009 Michael L.Foster&Associates, Inc. SEWD-SEWD-004-0001 References 1. Michael L. Foster&Associates, Inc. Technical Memorandum No. 1, Background Investigation, Water Compliance Study, City of Seward, Alaska, February 21,2008. 2. Michael L. Foster&Associates, Inc. Technical Memorandum No. 2, Develop Options, Water Compliance Study, City of Seward,Alaska, August 15,2008. 3. Michael L. Foster&Associates, Inc. Task 3 Study Report: Implementation Plan, Water Compliance Study, City of Seward,Alaska, December 30, 2008. 4. Telephone conversation and email exchanges with Troy Ritter,Environmental Health Specialist,Alaska Native Tribal Health Consortium,March 27 and 31,2009. 5. Telephone conversation with David Litchfield,Drinking Water Compliance,Alaska Department of Environmental Conservation,Soldotna office,Apri11,2009. 6. Juneau Fluoride Study Commission. Report to Assembly of the City and Borough of Juneau, July 11,2006. http://www.juneau.org/clerk/boards/Fluoride/Fluoride Study Commission.php 7. DEC,State of Alaska. Drinking Water Regulations (18 AAC 80). As amended through April 24,2009. 8. American Water Works Association. Position Statement-Fluoridation,May 27,2005. http://www.niawwa.ore nipdf/nj909b.pdf 9. DEC,State of Alaska. Water and Wastewater Operator Certification and Training Regulations (18 AAC 74). As amended through December 3,2006. 10. Pure Water Products,LLC, Countertop Reverse Osmosis Units, http://www.pw&azette.com/ctro.htm,2008. 11. Seward Public Works Department. Interviews, Telephone Conversations, and Correspondence with Staff, November 2007-June 2009. 12. Chapter 4: Installation of Fluoridation Systems,excerpt from reference by South Africa Department of Health. http://www.doh.gov.za/docs/misc/fluoridation/chapter4.pdf 13. Tillman,Glenn. Water Fluoridation, 1993 http://books.google.com/books?id=enclo6vlQVsC&pg=PA18&lpg=PA18&dq=sodium +fluoride+saturator&source=bl&ots=c1MV W5TA5h&sig=Nipp4k8FQkX- SR5w7erIwXNiAKE#PPPI,M1 14. Water Quality and Treatment,A Handbook of Public Water Supplies, by American Water Works Association, Inc.,1971. 15. Lauer,Bill and Frederick Rubel.Water Fluoridation Principles and Practices, American Water Works Association,2004. http://books.google.com/books?id=VRsO8Bx0NjIC&pg=PA2&lpg=PA2&dq=USPHS+f luoridation+goal&source=bl&ots=BKmh3evlx &sig=stKsK10MVPEu7NGjnLsaKWUIN6 Q#PPA2,M1 Seward Fluoridation Study 11 June 10,2009 Michael L.Foster& Associates, Inc. SEWD-SEWD-004-0001 16. Reeves,T.G. Water Fluoridation:A Manual for Engineers and Technicians. U.S. Department of Health and Human Services,Public Health Service,Centers for Disease Control and Prevention,1986. 17. The Updated Plain English Guide to Alaska Drinking Water and Wastewater Regulations. Alaska Department of Commerce,Community&Economic Development;and Department of Environmental Conservations,updated June 2002. 18. Engineering and Administrative Recommendations for Water Fluoridation. U.S.Department of Health and Human Services,Public Health Service,Centers for Disease Control and Prevention, 1995. 19. Inorganic chemical sampling and analytical requirements, 40 CFR Chapter 1, Section 141.23 (a)- (h),July 1,2003. 20. Email communications with James Weise,Drinking Water Program Manager,and Kathaleen(Kathy) Kastens,Statewide Technical Services,DEC,April 1 and 3,2009. 21. Community Water Fluoridation: Frequently Asked Questions. U.S. Department of Health and Human Services,Public Health Service,Centers for Disease Control and Prevention, last reviewed March 9,2009. http://www.cdcgov/fluoridation/faqs.htm 22. Healthy Alaskans 2010- Volume 1, Chapter 13:Oral Health. Alaska Department of Health& Social Services,Division of Public Health,December 2001. 23. Seward Fluoridation Study review letter to Seward City Manager Phillip Oates from Troy Ritter,et al,Alaska Native Tribal Health Consortium,May 21,2009. Seward Fluoridation Study 12 June 10,2009 Michael L. Foster& Associates, Inc. SEWD-SEWD-004-0001 Elc._rr,c,ki wq,r:+, w.,ii 1.1,10.p, ••.,,� - \ . S.014/11.ri t,a 1vede ill Kan r Water Unn r flow ---""- 4--4),"I41 r1_:' - ,� i vV a t e` Iiouo teveid "c. meter swilCh `'Atari`ilrgl 41i.,pntJc iutt,nr)n ■ S.phon11111.1111° i V ,,, , ,,.t{ • .. r --� breaker i of 1,1,r-.:t,<,n • h. She l4 „.,..14,c, .11400, 1..r,.r 0 t I Water '�et:e� .xiiii '�%" --______>)._ softener -` • li r •r � / ---'r Overflow tA Power I i c�;ti �'t_ r+" Connection supply �,.. t •----rz,.._- w ;t `� ' I Floating strainer . ,I ated ..,Ir,rit. - - � I iolutl,:nP ` ---....... ---- Upflow : y�.r{�.i• Saturator Sodium e"by t• e�'„ 111111 fluoride t-•- -":',`-'",:::-..•• ',.. :..3•.}.•-:;"» '„4 ` " Drain Plug Fig. 10. Saturator system for water fluoridation Source: World Health Organization Fluoride . :: :1j:: .l...;:!.......:::3...:.'.:::17'.:".-'.1-' chemical -�� " ::. .,•.-,•. Hopper r :•• Hopper - ;r. agitating Motor -_____ .`:. _ plate : JL • II/ NieRotating reducer '�"► i 0-''� ,A'-,,� •• 0 feed screw Feed rate register and r 1 feed adjusting Water knob '""11111"." " inlet To water supply • ' ; . : •:: • Jet Solution . '. . _ . . - - tank - mixer WHO 85680 Fig. 12. Screw type of volumetric feeder for water fluoridation Source: World Health Or anization ATTACHMENTS Loren D. Leman From: Loren D. Leman Sent: Thursday, June 11, 2009 1:40 PM To: William Casey Subject: Revised Fluoridation Report Attachments: Figure 2 –Typical Mechanical Feeder.pdf; Fluoridation Study 6.10.09.doc; Figure 1 –Typical Saturator Layout.pdf W.C., As I promised yesterday, I am sending our revised report, with revisions.incorporated. Most of these revisions are in response to the ANTHC review comments. The most noticeable change is in Table 3, which summarizes costs. ANTHC expressed concern that we had underestimated costs—and, quite frankly, as we previously told you. we concur. The revised numbers will give you a little more"breathing room" as you plan. We recognize that even this revised report is unlikely to please everyone—but we believe it is fair, accurate, and substantially complete for this level of study. We hope the information in it is helpful as a planning document as Seward considers what it will do with its water. We have tried to respond constructively to review comments—and where these have been specific, we have been specific. The statement in Troy Ritter's cover letter, "The report contains many errors and omissions that would seem to disqualify it for use in determining public policy" is harder to respond to, other than for us to say, "We disagree." Although some of the ANTHC comments were quite constructive, none really resulted in a substantial change to the basic thrust of the document—except for increasing the estimated costs to provide for a more complex, higher technology monitoring system. We take particular exception to the suggestion that seasoned engineers are unable to understand and comment on socio- economic and health impacts, and understand history, particularly as we try to draw attention to work by others who may be more expert in particular applications. We have tried to do so in a fair and balanced way, without saying fluoridation is good or bad. I am particularly personally offended with Troy's suggestion, and do not know if it really represents an official viewpoint of his fine organization, because, as you know—and he probably knows—I have made a substantial investment of my life in formulation of public policy, after careful research, listening to people (often competing in ideas), and analyzing potential impacts and results. Our list of references demonstrates that we have been willing to review materials from many sources, including several from the organization that administers and funds the ANTHC operation. I just realized today that we have been remiss in not sending you the drawings we had promised long ago when we sent you the first draft of this report. I better understand now why the ANTHC reviewers suggested "an idealized sketch" to help understand space requirements. These should have been sent earlier—and should also have been part of the package they received. We are sorry for this oversight. Please include the drawings with your updated copy of the report. The drawings come from a PowerPoint presentation by W. W. Easley, DOS, MPH, from the National Center for Fluoridation Policy & Research in 1999, entitled, "Quick Facts About Fluoridation." Although Dr. Easley did not attribute these drawings to his source(s), I have seen the same figures elsewhere in the literature—and you probably have also. Although he numbers them Figures 10 and 12, for purposes of our report they are Figures 1 and 2. Thanks again for entrusting us to provide guidance to you on this challenging and interesting topic. We hope you are pleased with our work and that it helps Seward make informed and reasoned choices. Loren Leman, P.E. Michael L. Foster&Associates 696-6209 Loren D. Leman From: Loren D. Leman Sent: Wednesday, June 10, 2009 6:00 PM To: William Casey Subject: Fluoridation Study—Response to ANTHC Comments Attachments: ANTHC Review Response (Draft).doc W.C., When we met in Anchorage last week, you asked us to prepare brief responses to the May 21, 2009 review letter to City Manager Phillip Oates from Troy Ritter, ANTHC—and, as appropriate, revise our Fluoridation Study Report. We have done so. We are unaware of what information was shared with the ANTHC reviewers. None of them contacted us during their review. It appears from the substance and tone of some of their comments that they were unaware of the full extent of our scope of work. We have tried not to "over-react" to their more critical comments, particularly the ones that seem more meddling than genuine professional review. Many of their comments are constructive and helpful—and demonstrate that ANTHC's Division of Environmental Health and Engineering has considerable experience with fluoridation. After reviewing all the comments, doing additional research, and responding to them, I'd have to say that the net result isn't substantial change to the report, except for an increase in estimated costs. We had previously mentioned to you that we might be understating costs, but were particularly sensitive to potential criticism from Fluoridation Task Force members or others who might conclude that our view of balanced analysis and report writing is not the same as theirs. ANTHC raises legitimate concerns about costs—and we have adjusted them up in Table 3. I am attaching our draft response to the ANTHC review letter. I'd like you to review it, particularly for tone. We'll do the same, before we release it as final. Tomorrow morning I will have our Word processing editor make a few changes in table format and a few other edits to the report. I hope to send it to you tomorrow so you can review it with our responses. Loren General Comments I. Although this comment is directed to the City of Seward, we believe the work product we produced is responsive to the City's request of us, is fair and balanced, and does not state opinions or make assumptions inappropriate to our scope of work or areas of expertise. 2. The purpose of our report was not to document the decisions reached by the governing authority(in this case the City of Seward). Rather, it was to provide a first cut at identifying costs and constraints as a planning tool to help the City reach its conclusions. Because we were told that fluoridation of the City water supply was being considered to combat dental caries(tooth decay), primarily in adolescent children,we conclude that the SMIC system is an unlikely candidate for fluoridation because almost no children drink its water, none that we are aware of on an exclusive, regular basis. The City certainly can make this call if it disagrees with this assessment,or changes its criteria for fluoridation. 3. These details are valid requirements that will more appropriately be addressed more thoroughly during design, if the City decides to pursue fluoridation. We believe that the space allowances, discussion of some of these features, and estimated costs are adequately addressed at this stage of planning. We had intended to provide drawings showing typical equipment layouts with our original report and are sorry these did not get to the reviewers. 4. Remote monitoring(for example,through SCADA controls) is certainly an option. It would be a good thing for operation and management. However, it comes with a cost. We addressed some of the costs for water system I&C improvements in our Technical Memorandum No. 2(August 15, 2008)and Task 3 Study Report(December 30, 2008). Remote monitoring and reading at a central location could be incorporated into these improvements. We have provided an allowance for this in the revised cost estimate in Table 3. 5. We replaced former Table 2 with recommended and required actions for an overfeed incident. 6. Seward is operating (legally) under an expired permit for its Lowell Point wastewater treatment plant, which is expected to be renewed by DEC under its new primacy authority. The old NPDES permit does not specifically address fluoride levels in the wastewater, perhaps because it was not an issue when the permit was issued. However,the discharged effluent will need to meet Alaska Water Quality Standards for the receiving water,expected to be 4 mg/L for fluoride. Because the fluoride level in the water supply will be much lower than this, it should not be an insurmountable constraint. Specific Comments by Report Section 7. We have revised the discussion,but retain the conclusion that NaF is the preferable chemical form. 8. We added information on chemical cost and availability. 9. This report was not intended as a treatise on the operation of various fluoridation systems at conditions not likely to exist in Seward. Saturators function quite well at producing a maximum concentration of 4% in solution at the temperature of Seward Fluoridation Study 1 Response to ANTHC Review Comments June 12,2009 Michael L.Foster&Associates,Inc. SEWD-SEWD-004-0001 F groundwater from the Fort Raymond wellfield. This temperature does not vary appreciably. 10.Although our interest in this section was in the potential for increased corrosivity in the entire water system,we have added discussion about the potential for damage from corrosion from chemical storage and handling, or spills of concentrated solution. 11. We clarified that a softener may be recommended for the chemical feed system only. The effects of water hardness (clogging and scaling)were already discussed. These can be handled primarily by routine maintenance. 12. This is already said in the first paragraph. 13. Yes. The layout of facilities in the Fort Raymond wellfield means that NaF feed will likely be installed at each wellhouse. Well House 6 has ample room, and any planned new welihouses should also accommodate this. Softener backwash water should be taken offsite—for disposal into the sewer system. 14. Some of these comments are more appropriately addressed during design. However, chemical storage separation is available,as are injection access and separation distances. 15. We have clarified this discussion. 16. Although we believe former Table 2 contained useful information, at the reviewers' suggestion we have removed it. Some of the same discussion remains in the text. Either feed system is expected to serve adequately, depending on the quality of equipment. 17. The point we were making is that(according to ANTHC itself)these NaF saturator systems are commonly used in rural Alaska, with reasonable success. Alaska has substantial operator experience with them. We were not making socio- economic or other infrastructure comparisons of Seward with other communities in Alaska. We have revised this discussion in the text. 18. We believe the information we presented was correct. DEC told us it would enforce the 2.0 mg/L limit—for the reasons stated in its regulations. We still believe this would be good practice for the City,and would be surprised if ANTHC or health professionals would recommend otherwise. We have added lead-in discussion about contaminant level goals, essentially taken from a DHHS website. 19.The DEC regulations had already been referenced, but we added the specific reference to Section 315 in this paragraph. Most of the other comments were already accommodated in our original report. ANTHC may want to discuss with DEC its intent to enforce the SMCL of 2.0 mg/L and when public notice might be triggered if it disagrees with this State policy. 20. This is a good comment, and one we know the City is well aware of. Although we had originally called this out in Table 3,we have added a new paragraph at the end of Section 4 that specifically identifies this requirement. 21. The information presented was from 18 AAC 74. We have reworded the text to clarify that initial and continuing fluoridation education will be required. 22. Yes. 23. We agree that feeding fluoride at the City's water storage tanks would be safer. However, because of the layout of the City's water distribution system,this would Seward Fluoridation Study 2 Response to ANTHC Review Comments June 12,2009 Michael L.Foster&Associates,Inc. SEWD-SEWD-004-0001 mean that some customers would not receive fluoridated water. If the City made this choice, it should notify these customers, in case they want to ingest fluoride from another source. We assumed that because water is currently chlorinated at each wellhouse, installation and operation of the additional fluoridation unit process at each wellhouse would be relatively symbiotic with chlorination. If the City chooses to feed at the tanks,the number of equipment installations would be reduced 24. Yes,we know this. However, because water sales to cruise ships and seafood processors is such a huge business in the summer, we offered this as an option for the City to consider, in case some of the customers did not want to buy fluoridated water. We assumed you would want to retain the sales and cruise ship port calls. 25. Using fluoride as a tracer would be an interesting application. We continue to believe the City is losing a substantial amount of water from leakage. Testing and repairs have reduced, but not eliminated this. We did not say fluoridation would produce an adverse effect on tourists or fish processors. We just acknowledged that some large customers may not want it. 26. When we delivered the draft report to the Public Works Director,we said that we believed our estimated costs may be low, particularly for storage. If remote monitoring were installed,which we agree would be a good thing, costs could increase further. Because of the demonstrated ability of fluoridation to incite a visceral response,both from its proponents and opponents,and recently reported experience elsewhere in Alaska, we were acutely aware that if we added complexity and its associated costs we could be accused by some proponents of fluoridation that were"sandbagging"the costs. We, of course, did not want to do this but wanted to be totally fair in our analysis and presentation of costs. We agree with the reviewer that it would be wise for the City to plan for additional construction and operation contingencies. We have revised Table 3 accordingly. 27. Yes. It's encouraging when prudence and the law intersect. We have noted these suggestions in the text. 28. This section was included at the specific request of the City. 29. David Litchfield, Drinking Water Compliance, Soldotna(Ref. 5);James Weise, Drinking Water Program Manager; and Kathaleen (Kathy) Kastens, Statewide Technical Services (new Ref. 19). Seward Fluoridation Study 3 Response to ANTHC Review Comments June 12,2009 Michael L.Foster& Associates,Inc. SEWD-SEWD-004-0001 �t. •► Alaska Native Tribal Health Consortium Division of Environmental Health and Engineering 1901 Bragaw Street•Suite 200•Anchorage,AK 99508-3440•Phone:(907)729-3600•Fax:(907)729-4090•www.rnthc.otg May 21, 2009 Mr.Phillip Oates,Manager City of Seward P.O.Box 167 Seward, AK 99664 Dear Mr. Oates, Per your April 28,2009 request, I have reviewed the Seward Fluoridation Study. The Alaska Native TnbaI Health Consortium reviews reports of this nature through the course of our routine activities and has a formal process and expertise for doing so. In addition to me, the report was evaluated by two Professional Engineers with extensive experience in the design, operation and maintenance of fluoridation systems. Our collective comments cart be found in the attachment. In summary, we felt that the report could be improved in a number of areas. The report contains many errors and omissions that would seem to disqualify it for use in determining public policy. In addition, this report is different than others we have reviewed in that it often diverges from the engineering technical aspects of water fluoridation and offers a number of opinions beyond the typical scope of these reports. In particular, issues relating to dental health and toxicology may be best addressed by professionals with specific expertise in those areas. I recommend that the engineering firm be requested to address the issues identified by our comments. Please call me at 907.729.5683 with any questions. Sincerely, Troy L.Ritter, REHS,MPH,DAAS Senior Environmental Health Consultant Seward Technical Report: ANTHC Comments General Comments 1. The authors should be reminded to confine their report to the engineering and technical issues of fluoridation and not to offer opinions or make assumptions not directly related to the fluoridation of public water supplies or their area of expertise. 2: Fluoridation of the Seward Marine Industrial Center water supply is a public policy decision. The merits of fluoridating this public water supply should be decided by governing entities and documented in this report. 3. The report does not discuss basic requirements for a fluoridation site including house keeping pad to deal with spills and overflows, on site disposal of overflows and other liquid wastes (hose down), eye wash station with tempered water,mixing and storage area for dry chemical, flow paced injection by metering, dual safety features to prevent overfeeding the chemical, personal protection gear, ventilation and lighting for mixing chemical, certain waterline injection pressure limitations based on chemical feed capacity and pump. An idealized drawing would help illustrate these features and space requirements. 4. The option of remote monitoring equipment is not discussed; the community should know this option is available for their consideration. 5. Overfeed reaction requirements are not discussed. The city should have this information available for their decision making process. 6. The report does not address whether there is an impact of fluoridation on the waste discharge permits limitations. Specific Comments by Report Section 7. Section 1. Although Sodium Fluoride is probably the better option for Seward, it is the lack of centralized water facility that makes this true. Sodium Fluorosilicate would probably be the typical solution for a population the size of Seward. The conclusion given is poorly rationalized, and unconvincing. 8. Section 1, Table I. The cost reference should be noted as materials only and not in practice. Some mention of vendor and available purchase options would be helpful. 9. Section 1, Table I. Include water temperature as a property. Discussion of water temperature and its effect on various fluoridation systems should be included. 10. Section 2. Concerns about corrosivity usually involve the handling of the dry material and affect of spills and conducting a clean up of a concentrated solution. This is not discussed. 11. Section 3. The report gives the impression that water hardness with the addition of Sodium Fluoride would adversely effect scaling in the entire system. This needs to be clarified to identify only the chemical feed portions of the system would be impacted. Additionally, the report should discuss exactly what effects the water hardness would have on a fluoridation process if a conditioner/softener was not installed. 12. Section 3,paragraph 1. Emphasize the importance of maintaining dry (low humidity) storage conditions where the chemical is stored and transported. 13. Section 3,paragraphs 3-4. Is water softening suggested at each well head site? Clarification is needed for the recommendation and impact on costs to modify well 2 r houses and potential affect of waste stream if disposed of on site(Probably not recommended as part of a Well Head protection program). 14. Section 3,paragraph 4. Space limitations are mentioned, yet the current availability is inadequately defined. Space requirements for the preferred saturator setup are not specified, and the chemical room separation is not mentioned. Available injection point access is also not mentioned. Fluoride should be injected at least 18" downstream of chlorine injections. is the pipe available? 15. Section 3,paragraphs 4-5. Although saturators do not require the chemicals to be weighed, neither do some dry feed applications which are listed as the most economical of all fluoridation systems. The report quickly migrated to a saturator centric discussion, yet uses mechanical dry-feed systems as the comparison, with inaccuracies stated on both. 16. Section 3, Table 2. The table should be removed; it adds nothing to the discussion. There is negligible operator contact difference between the two systems. Both systems may require dust control,both have maintenance requirements, and a cost comparison would offset routine maintenance concerns. 17. Section 3,paragraph 6. Seward has many dissimilarities with Alaska's smaller communities; these are neglected in the report when the comparison is made. 18.Section 4,paragraph /.This information is incorrect. It appears that the terminology, corresponding fluoride levels and associated health effects,have been confused. The Maximum Contaminant Level (MCL)for fluoride is 4.0 Mg/L;this is the health-based limit. The Secondary Drinking Water Standard(SDWS) for fluoride is 2.0 Mg/L. This is a non-health-based,non-enforceable guideline associated only with cosmetic effects. 19.Section 4,paragraph 2. The fluoride section in the DEC Regulations should be referenced, as the monitoring requirements depend on operator monitoring and reporting. Certified lab results are not needed for routine monitoring. Each site, when injecting fluoride, would have to sample and report daily values. It is likely that each site would have to be sampled in the well house. Some records of water production and Fluoride consumption are helpful to calculate applied dose. Values in Excess of 4.0 Mg/L,the primary MCL (not the secondary SDWS of 2.0 Mg/1) would initiate a more severe DEC response, public notice and other Regulatory issues (CCR notice for example). 20. Section 4, paragraph 3. A DEC plan review is necessary for the engineering and system modification for installing fluoridation. 21. Section 6. The DEC should have been consulted and this should be included in the report. It is not a matter of opinion. 22. Section 7,paragraph 2. There are costs at each well house to include necessary housekeeping and safety controls. If automated feed is to occur,the saturator operations would be aligned with the well operations (if SCADA managed or manually). 23. Section 7,paragraph 3. The report mentions water storage tanks, yet the option of feeding fluoride at the tanks instead of at the well house is not discussed. Tanks provide an additional safety feature for a malfunctioning system, as they buffer an overfeed. 3 r 24.Section 7,paragraph 5. Seasonal use of fluoridation is unusual; the start/stopping is tough on the operators and equipment. Fluoridation levels can be tested at any site with the correct equipment. It is best to know what concentrations are at the source to prevent a problem from developing. Continuous monitoring is quick and provides a digital signal, but this includes the additional O&M for instrumentation. 25. Section 7,paragraph 5. Fluoride can also be used as a tracer in tracking down water leaks originating from a city main. There is no adverse affect of fluoridation on tourists or fish processing known. 26. Section 7, Table 3. The cost of fluoridation is listed as a Class 5 cost estimate. There is very little data to evaluate,but the assumptions listed lead to the conclusion that there are many factors unaccounted for. 27. Section 7,paragraph 4. Safety flow switches are listed as essential. It should be noted that this is a requirement by law. Additionally,the engineering safeguards such as proper pump sizing are not discussed. 28. Section 8. The section on fluoride removal should be stricken from this paper. It not within the scope of this paper. 29. References. Was the State Fluoride Officer consulted? What DEC staff were consulted? 4 In.com 1 Pa_4mer to stop adding fluoride to city's public water supply http://www.adn.com/2011/10/30/v-printer/2146684/palmer-to-stop-ad... it ad ii.corn Print Page Close Window Anchorage Daily News Palmer to stop adding fluoride to city's public water supply 6-1 VOTE: Supporters say topical treatments, toothpaste do the job. By ROSEMARY SHINOHARA (10/30/11 21:30:01) Palmer has decided to follow the lead of Fairbanks, and stop adding fluoride to its water system. The Palmer city council voted 6-1 Tuesday to forbid addition of fluoride to the public water system. The federal Centers for Disease Control and Prevention recommends adding fluoride to community water systems, and considers fluoridation of drinking water to be one of 10 great public health achievements of the 20th century. Fluoride, a mineral, reduces tooth decay. Deputy Palmer mayor and councilman Richard Best, who supported the ordinance, said some dentists now say with fluoride available in toothpaste and in topical dental treatments, "We're pretty much getting covered." Plus the Palmer water system has naturally occurring fluoride in it, he noted. There was little controversy over the decision, said Best. One of the Palmer system's three wells naturally contains the nationally recommended amount of fluoride, 0.7 parts per million, but the bulk of the water going to Palmer residents contains only about 0.2 parts per million, said Tom Cohenour, Palmer public works director. Cohenour was in charge of investigating the fluoride issue for the administration, which backed the decision to stop adding fluoride. He went into it open-minded, Cohenour said. "Through investigating, I realized there are moral concerns, ethical and then safety," he said. "What I found is that application of fluoride to the teeth is most effective," said Cohenour. "Why should we add fluoride to the whole body?" A study that a committee of highly educated people -- four Ph.Ds, a dentist and a medical doctor -- produced for Fairbanks last spring was most convincing, Cohenour said. The Fairbanks Fluoride Task Force met periodically over a year's time before concluding, in an April report, that Fairbanks should not add fluoride. Its prime reasons: Fairbanks water naturally contains 0.3 parts per million of fluoride, and "higher concentrations put non-nursing infants at risk." Contrary to that statement, the CDC Web site says, "Scientists have found a lack of evidence to show an association between water fluoridation and a negative impact on people, plants, or animals." The Fairbanks task force report said it's unknown how a reduction in fluoride will affect the level of oft 10/31/2011 10:41 AN idn.com I T.almer to stop adding fluoride to city's public water supply http://www.adn.com/2011/l0/30/v-printer/2146684/palmer-to-stop-ad.. tooth decay in Fairbanks residents. The Fairbanks City Council voted in June to quit adding fluoride to city drinking water. Juneau ended the practice of fluoridating drinking water in 2006. Anchorage still adds fluoride. The last time the issue came up in Anchorage was in 1991 and 1992, said Anchorage Assemblyman Dick Traini, who also served during those years. The issue stirred considerable controversy, Traini said. One lady felt so strongly about it that she told the Assembly she bathed in bottled water, he said. When she used tap water she felt fluoride leaching into her, he said. Unlike some cities, Anchorage has no naturally occurring fluoride in its public water, said Craig Woolard, director of the Anchorage Water and Wastewater Utility. Traini voted to continue fluoridating Anchorage water back in the '90s. Assemblywoman Harriet Drummond earlier this year asked AWWU for information on the cost and status of fluoridation in Anchorage. She was responding to a constituent's concern, she said this week. "We are medicating people whether they need it or not," she said. But she hasn't decided whether to raise the issue at the Assembly. "If I get a lot of public support, I will consider pursuing it," she said. Reach Rosemary Shinohara at rshinohara©adn.com or 257-4340. Print Page Close Window Copyright© Mon Oct 31 2011 10:41:34 GMT-0800 (Alaskan Daylight Time)1900 The Anchorage Daily News (www.adn.com) 2 of 2 10/31/2011 10:41 A Memorandum e of self, kte 4C-.A1 Date: February 27, 2012 To: Jim Hunt, City Manager From: W.C. Casey, Public Works Directors ' Subject: Community Water Fluoridation Costs The Pro's and Con's aside, the Public Policy issue left alone, my message is: As a Public Health official, in my capacity as being in "responsible charge" of the City's water infrastructure, I am proud of the fact that I have been instrumental in "providing safe drinking water for all of Seward's residents and visitors", for the past 32 years. As a State of Alaska Level II Certified Water Treatment Operator, I have confidence in my abilities to continue to provide contaminant free, disinfected water to the City's water utility customers. My number one concern about adding fluoride to the City's drinking water is ...cost. These costs are difficult to completely identify. My experience lends me to believe that the capital costs will exceed $250,000, and the operational costs will more than likely fall into the range of $50,000 per year. With the difficulties (challenges) that I have historically experienced with the "increasing of customer fees" and adjusting water rates to cover the sustainability of the water utility, I must tell you that the expenditure of limited resources to add fluoride to our water system, concerns me from a financial aspect. We are challenged today, and into the future, with financial uncertainty regarding the operation and maintenance of water infrastructure that is reaching the end of its life expectancy. This memo is not intended to elaborate on the details of the costs associated with operating the water utility into the future. We have facility plans, operational plans, maintenance plans, and have spent time identifying high risk, moderate risk, and low risk infrastructure needs, that do that. This information is real, and factual. The financial uncertainties associated with the purchase, storage, safety, and Federal Right to Know legislation associated with hazardous chemicals, lends me to caution you about the unknown financial implications of these things into the future. I have spent an inordinate amount of time attempting to gather real data for your perusal, and hope to have better defined costs in the "not too distant" future. My current focus has been the securing of site control for the New Water Storage Tank and Pumping Facility. That information will be coming to you in the coming weeks. I hope that this memo will be useful in your deliberations regarding the addition of fluoride into the City's Public Drinking water. • William Casey From: American Water Works Association [custsvc©awwa.org] Sent: Monday, February 27, 2012 2:02 AM To: William Casey Subject: AWWA News: Infrastructure needs top $ltrillion Having trouble viewing the email below? Please click her, Note: To ensure delivery to your inbox please add custsvc@awwa.org to y:s_ •• -- AWWA infrastructure report issues call to action The massive investment needed for buried drinking water infrastructure in the United States totals more E. than $1 trillion between now and 2035. The cost of that investment to repair and expand US drinking water infrastructure will be met primarily through higher water bills and local fees, costing some households in small communities as much as $550 more a year, according to a new AWWA report. "Because pipe assets last a long time, water systems that were built in the latter part of the 19th century and throughout much of the 20th century have, for the most part, never experienced the need for pipe replacement on a large scale," the report says. Replacement needs account for about 54 percent of the national total, with the balance attributable to population changes over that period. "Buried No Longer: Confronting America's Water Infrastructure Challenge" is a call to action for utilities, consumers and policy makers and recognizes that the need to replace pipe in the ground "puts a growing stress on communities that will continue to increase for decades to come." They will be affected in different ways depending on their size and geography. Many small communities will face the greatest challenges because they have fewer people to support the expenses. The required national-level investment will double from roughly $13 billion a year today to almost $30 billion (in 2010 dollars) annually by the 2040s. This level of investment will have to be sustained for many years to maintain current levels of water service. IFThe new report extends the study of AWWA's seminal 2001 report, "Dawn of the Replacement Era," which anticipated the extended wave of costs to replace O drinking water infrastructure as it reaches the end of its service life. 1 "Water is a basic necessity of life," said AWWA President Jerry Stevens, general manager of West Des Moines (Iowa) Water Works. "Water utilities are committed to finding fair and equitable rate designs that address affordability issues as they face the increased cost of infrastructure replacement. The good news is that iii there is still time to act. `Buried No Longer' helps us recognize the challenge ahead. Together, we can take the necessary steps to meet that challenge." The new report analyzes many factors, including timing of water main installation and life expectancy, materials used, replacement costs and shifting apj demographics. Some of the key findings in "Buried No Longer" include: • The needs are large. The cost of replacing pipes at the end of their useful lives will total more than $1 trillion nationwide between 2011 and 2035 and exceed $1.7 trillion by 2050. • Household water bills will go up. Although water bills will vary by community size and geographic region, for some communities the infrastructure costs alone could triple the size of a typical family's bill. • The costs keep coming. Infrastructure renewal investments are likely to be incurred each year over several decades. For that reason, many utilities may choose to finance infrastructure replacement on a "pay-as-you-go" basis rather than through debt financing. "The needs uncovered in `Buried No Longer' are large, but they are not insurmountable," said AWWA Executive Director David LaFrance. "When you consider everything that tap water delivers — public health protection, fire protection, support for the economy, the quality of life we enjoy —we owe it to 4100 future generations to confront the infrastructure challenge today." 00100 The report and related information are available on the AWWA website. The report includes more than 35 tables and graphs detailing information by region and utility size. For example, the graphs for utilities in the West show that the investment for growth is consistently greater than that required for replacement through 2050, while just the opposite is true for utilities in the Northeast. Spam Not spam Forget previous vote This email was sent by: American Water Works Association 6666 W. Quincy Ave., Denver CO 80235 This was sent to 00068920 wcasev@citvofseward.net You were added to the system August 2, 2010. For more information click here. Manage Email Preferences 2 Maya Moriarty,Lead Improving Oral Health Subgroup Seward Wellness For All 907.224.3071 work Memo - To: Seward City Council FEB 2 3 2012 From: Maya Moriarty,Lead,Improving Oral Health tJ-rli -� Date: February 22,2012 CITY is; -a� 4 Re: Community Water Fluoridation Resolution Support Attached are additional documents in support of letting Resolution 2010-015 stand as is. Aside from the supporting documents, I firmly believe that it is not in Council's best interest to rescind a resolution that is in support of a public vote—regardless of the topic! You will send a message to the public that their votes do not count. And in this case,there is no new research to support rescinding the resolution. Please do your due diligence and review the information I've provided. Thank you. ATTACHMENT A February 2012 City Council Position Paper outlining the background behind Seward Wellness for All, recent comprehensive studies on fluoridation supporting its safety, what's new and where are we now. ATTACHMENT B January 2010 City Council Position Paper outlining community vote, letters of support,putting research into perspective,economic impact of fluoridation,and funding sources. ATTACHMENT C Commentary by Dr.William Bailey,Dental Abstracts, citing four key drivers for the growth in community water fluoridation: value,ongoing need,public health law,and advocacy. ATTACHMENT D Powerpoint slide: Overview of Water Fluoridatin Safety (and costs) previously presented to Council in 2009 by LCDR Troy Ritter. NOTE the size,design,and costs of a typical system. ATTACHMENT E State of Decay by Dan Lorentz, taken from the Council on State Governments. Article addresses oral health issues in seniors. ATTACHMENT F Effectiveness of Fluoride in Preventing Caries in Adults, Journal of Dental Research. Findings suggest that fluoride prevents cavities among adults of all ages. ATTACHMENT G The Council of State Governments Resolution supporting water fluoridation. The CSG was founded 75 years ago to provide nonpartisan advise to its member states and their elected officials. ATTACHMENT H Facts on Early Childhood Caries (ECC). National Maternal & Child Oral Health Resource Center. ECC can progress rapidly and may have a lasting detrimental impact on a child's health and well-being. ATTACHMENTS I/J ADA brochure on Fluoride: Nature's Cavity Fighter. Seward community brochure: Enhancing Nature's Fluoride: One drop at a time. 1 FEBRUARY 27, 2012 /" ENHANCING NATURE'S FLUORIDE: ti kj ONE DROP AT A TIME "Ir."- SE WARD WELLNESS FOR ALL In 2008,Providence Sew- from that,subgroups were The community voted in How MUCH i3 in ard conducted a Commu- formed to include tobacco affirmation of this in 2009 • Typical average capitol costs under nity Health Survey to ob- cessation,healthy choices, and Council issued a reso- $5000 in rural Alaska. tain data on the health and improving oral health, lution in support of com- Seward's costs to be estimated access and awareness, munity water fluoridation from this. healthy behaviors,and in 2010. Along the way of •fostering fitness. The im- public education,relation- - iito Annual expenses for a village of ships were formed with 500 approximately$4595 so 111% proving oral health sub- P Seward's annual expenses are r 4., group met for many stakeholders including the months researching the Alaska Native Tribal estimated under$20,000. mmu- Health Consortium which pros and cons of co -LCDR T,jRitter at City Coundlpresenta- wellness of the people. nity water fluoridation us- has more experience than lion January 2010 From this,Seward Wellness ing the weight-of-evidence any other entity in Alaska for All group was created. approach while studying in the design and imple- Members included repre- scientific peer-reviewed mentation of such systems. 116 , sentatives from public studies related specifically They have pledged support 1116.7 health,PSMC,Seaview, to community water fluori- in trainingPublic Works and other health related dation levels. The recom- staff,have reiterated cost organizations. The results mendation was made for sharing;and have offered Seward's naturally occurring of the survey were corn- - om the City of Seward to im- their engineering depart fluoride level is 0.072 parts per olli million(1993 water test). pared to the Healthy Peo- element a community wa- ter ment services at no cost to the Seward community. pie 2010 initiatives and fluoridation program. What do our neighbors say? - Canada recently completed a comprehensive study on fluoridation which states that mild and very mild dental fluorosis are not considered to be adverse effects and...the weight of iiiii:_-...- evidencefi»m all currently available studies does not support a link between exposure to fluoride in drinking water at 1.5 mg/L and any adverse health effects." (2009 Guidelines for Canadian Drinking Water Quality: Guideline Technical Document) W.. The European Union commissioned a task force in 2011 to also conduct a comprehensive study. The summary conclusion regarding fluoride and water fluoridation found no occurrence of skeletal fluorosis, insufficient evidence linking fluoridation to osteosarcoma,it does not hamper children's neurodevelopment and IQ levels,there is no link to adverse thyroid effects,no adverse influence to the reproductive system,and it does not pose a risk to the environment. What's NEW about fluoride? Where are we now? Minnesota,Mississippi, • California EPA(Prop 65)that fluoride does not cause • U.S.-population served by Nebraska,Nevada,Ohio, Isoi fluoridated public water Puerto Rico,and South cancer and will not be listed as a carcinogenic. increased from 65 %in 2000 Dakota. Add Arkansas to • European Union scientific task force finds no link to 69.2%in 2006 to 72.4%at the st. between fluoride and any adverse health effects. the end of 2008. That's • 42 of the 50 largest U.S. 195,545,109 million people.' cities are supplied with • More Alaska communities have elected to start or fluoridated water. • Since the 2006 census,other continue community water fluoridation than those communities and states have • Data from 2000 to 2008 who have ceased. (ANTHC stats) voted to implement or retain shows that more than 302 fluoridation including Nome communities in 40 states • 2010 Census numbers expect the U.S.population and Bethel. voted to adopt fluoridation served by fluoridated public water to increase from including Los Angeles,Las Statewide mandates: 72.4%to close to 75%. There is a growth trend. • • California,Connecticut, Vegas,San Diego,Salt Lake Delaware,District of City,and Seattle which has • 2011 CDC publication on recent Alaska Native vil- a large cruise ship 4g study � Kentucky,Louisiana, 52 villages or about 25,000 people. Those receiving co. '__ community water fluoridation had fewer and less 1 part per million is equal to 1 I Iii 1 VIO severe cavities than those living without inch in 14 miles! '` h } Seward Wellness For All JANUARY 4,201 O 4 1‘ j ENHANCING NATURE'S FLUORIDE: ONE DROP ATA TIME Majority Voters Approve Water Fluoridation FUNDING SOURCES: For several months,Seward add fluoride to the public • up to 21%capitol • City Council has been re- water supply at levels(0.7- costs Alaska Native Tribal Health Consortium searching the issue of corn- 1.2 parts per million)rec- • Free operator training • State: Village Safe Water munity water fluoridation. ommended by the U.S. • Free engineering re- Program Public Health Service." port,valued at$10,000 • Federal: Indian Health Ser- The proposition passed by to assess a fluoridation .. vices,Sanitation Deficiency a margin of almost 10%! system with Seward's System CommunityCISupport system"as is"and +� PP y • Private grants (i.e.)PSMC Letters of support from with the proposed Community Benefit Strategic Seward PTSA,Qutekcak water storage tank. Investment They have had council and Native Tribe,Dr.s Paul ANTHC wouldn't Forman,Darin Bell,Ray town hall meetings where Robinson,Michelle Hensel, Provide support for they listened to speakers a system that could- and watched presentations Rob Reeg,Glacier Family jr They have reviewed count- Medical Clinic-Brent Ursal, n't be made safe. P A. Dr.Michael P. Safety concerns are less hours of material and Moriarty,Dr.Warren Huss, ails on both the pro and mails and con side of fluoridation. Tim Johnson,P.A.,Jessica olp Ryan,and Matt Gray. foreseeable. Multi- Council decided to let the pie layers of safety community weigh in on the ANTHC Support __gig:41i topic and placed fluorida- Alaska Native Tribal can be built in. - tion on the October 2009 Health Consortium has Troy Ritter,ANTHC ballot. "Should the CitySr.Environmental Cowxltant pledged: Putting Research Into Perspective - After over 60 years of research,there are over 30,000 fluoride-related studies in the National Library of Medicine. One could probably find a study to support any argument,as opponents to fluoride often do. That's when analyzing the research itself becomes confusing. Many opposition arguments are from one study;a study anecdotal in nature;a study based on fluoride 100 times water fluoridation levels;or studies that haven't proven their hypotheses and instead recommend additional studies. The internet,although a great source of information, exacerbates the problem as many sites contain inaccurate or incomplete information about water fluoridation. Like the bulls-eye shown here,what does the majority of generally accepted scientific knowledge show? The preponderance of research continues to confirm the safety, effectiveness, efficiency, cost-effectiveness, and environmental compatibility of community water fluoridation...which have been confirmed by independent scientific studies conducted by a number of nationally and internationally recognized scientific investigators. While opponents of fluoridation have questioned its safety and effectiveness,none of their charges has ever been substantiated by generally accepted science. Delaware,District of Impact of Water Fluoridation Where are we now? Columbia,Georgia,Illinois, Kentucky,Louisiana, • • U.S.-population by Minnesota Mississippi, In Alaska,cost per person is$1-$4 per year fluoridated public water servedNebraska,Nevada,Ohio, • Reduction in tooth decay by 18%-40% increased from 65%in 2000 Puerto Rico,and South to 69.2%in 2006 to 724%at Dakota. • For every dollar spent,savings of$8-$49 dollars in the end of 2008. • 42 of the 50 largest U.S. dental treatment • Since the 2006 census,other cities are supplied with • Estimated savings in the U.S.-$4.6 billion annually communities and states have fluoridated water. voted to implement fluoride: • Data from 2000 to 2008 Metropolitan Water District shows that more than 302 The advisory "YES",there arefundingof Southern CA, San Diego, vote was Nebraska,and Louisiana. communities in 41 states sources,there is technical support, and the sys- voted to adopt fluoridation • Statewide mandates: including Los Angeles,Las tem can be designed to be safe. Please vote YES. California,Connecticut, Vegas,San Diego,and Salt .._ Lake City. a COMMENTARY Water fluoridation status: Where are we? By William Bailey, DDS, MPH, and Karen Sicard, RDH,MPH How is the United States doing with regard to commu- fluoridation of this system alone will add more than 10 mil- nity water fluoridation?Is the practice of adjusting the fluo- lion people to those receiving fluoridation in the United ride concentration in drinking water to a level optimal for States,making it the single largest expansion of fluoridation oral health expanding, declining, or staying relatively the ever.In June 2008,the San Diego City Council voted unani- same?A key strategy of fluoridation opponents is to make mously to implement fluoridation by 2010.Prior to this de- big news of any fluoridation defeat,effectively using newspa- cision,San Diego was the largest nonfluoridated city in the per opinion columns and the Internet to herald every deci- United States. In addition, two states passed legislation in sion where voters, city councils, or other administrative 2008 mandating statewide fluoridation. In April 2008, the bodies such as boards of health have acted to reject or limit Nebraska state legislature overrode a veto by the governor fluoridation.By posting news articles and compiling lists of to pass a measure requiring towns with at least 1,000 resi- communities that have decided to either discontinue or not dents to fluoridate the drinking water supply.This will result implement community water fluoridation,opponents pro- in modest increases to those receiving fluoridation in the duce the impression that fluoridation is on the decline in state. In July 2008, the state of Louisiana passed legislation our country. Even public health advocates sometimes mandating fluoridation for water systems with at least believe this is the case. In reality, however, the practice of 5,000 connections.The Louisiana law has the potential to af- water fluoridation continues to expand,and has been ever fect approximately 110 water systems and just under 2 mil- since 1945,when Grand Rapids,Michigan,became the first lion people. community to adjust fluoride in the public water supply. What is driving this expansion of fluoridation?Although Even more encouraging is the fact that within the last de many factors have contributed to moving this public health cade the rate of growth of this effective public health mea- measure ahead,four key drivers are highlighted below sure is accelerating. • Fluoridation is currently at the highest level ever in the Value.The Guide to Community Preventive Services re United States.According to the most recent national fluorida viewed studies showing that community water fluorida- tion statistics reported by the Centers for Disease Control and tion reduces tooth decay by 18%-40%, even during Prevention (CDC),at the end of 2006,just over 69%of the a time when fluoride toothpaste and other topical fluo U.S.population on community water supplies received opti- ride modalities (rinse, gel, foam, varnish) are readily 1 available. Preventive benefit is imparted to people of mally fluoridated water. This was up from 65%of the popu- all ages and economic strata,including economically dis- lation in 2000 and 62% in 1992. The percentage of the advantaged children,junk food consuming adolescents, population on fluoridated water increased more during the and adults aged 60 and older who more and more are 6 years from 2000-2006 than it did in the previous 8 years keeping most of their natural teeth.3 For adults,the car- from 1992-2000.In just six years,more than 22 million people ies preventive fraction—that is the proportion of caries were added to the U.S.population receiving fluoridated wa prevented from exposure to water fluoridation—is esti- ter—a very significant advancement toward the Healthy Peomated to be 27%.4 Although many public health inter- ple 2010 objective of 75%of the population on community ventions improve quality of life, few offer true cost water supplies being served with optimally fluoridated water. savings; however, fluoridation does result in net More expansion is on the horizon.The MMWR reported economic gains, providing a compelling return on the U.S. fluoridation status through 2006; and since that investment.Every dollar spent on community water fluo- time, a number of large water systems and communities ridation potentially saves from about$8 to$49 in dental have made the decision to adopt water fluoridation.In the treatment costs per person,depending upon the size of fall of 2007,the Metropolitan Water District of Southern Cal- the community,with greater savings in larger communi- ifornia implemented water fluoridation.The "Met,"as it is ties.5 Current savings in dental treatment costs for per- known,is the largest water system in the state of California, sons served by water fluoridation systems in the delivering water to more than 18 million people.While not United States on fluoridated water are estimated to be all the users on this immense water system will be counted over $4.6 billion annually.6 A great number of profes- as new fluoridation recipients, it is anticipated that sional and public health organizations have endorsed 116 Dental Abstracts fluoridation,including the American Dental Association, members of health organizations, representatives from the American Medical Association,and the World Health the bureau of water or local municipalities,child and se- Organization.Because of its remarkable contribution to nior advocates,payers,and business owners.Local coali- reducing tooth decay,CDC listed fluoridation as one of tions can establish a strategy for educating the local 10 great public health achievements of the 20th century population about the benefits of fluoridation as well as Decision makers also are increasingly recognizing the mobilize the local community in the event of an attempt value of fluoridation. Within the past four years, state- to discontinue fluoridation by a council member,water ments supporting community water fluoridation have operator,or a vocal minority of fluoridation opponents. been issued by the National Association of Local Boards We are making strong progress toward reaching the of Health, National Association of County and City Healthy People milestone of 75% of the U.S. population Health Officials,and the Council of State Governments. on community water supplies served by optimally fluori- • Ongoing need.Although dental caries rates continue to dated water. The 2008 National Fluoridation Report, drop for nearly all age groups (the exception being 2-5 expected to be issued by the CDC this coming fall, will year olds), tooth decay remains the most common chronic disease of children aged 6 to 19 years.Dental car- provide insight into the nation's progress. Regardless of ies affects the primary teeth of approximately 42%of chil- progress, challenges will continue. Continued advance dren(2-11 years),59%of adolescents(12-19 years),and ment will require appreciation for and effective utilization 94%of adults(20-64 years).'Fewer than 1 in 3 children of public health law, and strong advocacy efforts at the federal,state,and local level to increase awareness among enrolled in Medicaid received at least one preventive dental service in a recent year and many states provide decision makers and community residents about the ongoing need for and the preventive and economic value only emergency dental services to Medicaid eligible adults.The population of our country is aging,and adults of community water fluoridation. aged 60 and older are developing new decay at a rate sim- William Bailey,DDS,MPH ilar to or higher than the new decay rate in children.8 The Dental Officer,Division of Oral Health,Center for Chronic imperative need for prevention is difficult to ignore. Disease Prevention and Health Promotion, • Public health law.Public health law has also facilitated the Centers for Disease Control and Prevention successful implementation,maintenance,and expansion Atlanta, GA of fluoridation.Over the past 64 years,fluoridation oppo- Karen Sicard, RDH,MPH nents have raised challenges relating to the legality of state Health Education Specialist,Division of Oral Health, or local use of police power;freedom from forced or mass Center for Chronic Disease Prevention and Health medication; privacy; the unauthorized practice of medi- Promotion, Centers for Disease Control and Prevention cine,dentistry and pharmacy; pure water relating to the Atlanta, GA safety and health affects of community water fluoridation; and who has the authority to decide whether a community References will fluoridate.In spite of these challenges and more,the courts continue to uphold community water fluoridation 1. Bailey W, Duchon K, Barker L, Maas W: Populations receiving optimally fluoridated public drinking water—United States, as a constitutional use of police power. They have also sorted through volumes of science and pseudo science 1992-2006.MMWR 57:737-741,2008. to determine that community water fluoridation is a safe 2.Truman BI,Gooch BF,Evans CA Jr.(eds.):The Guide to Commu nity Preventive Services:Interventions to prevent dental caries, and effective method of preventing tooth decay.In addi- oral and pharyngeal cancers,and sports-related craniofacial in- tion to case law,state legislatures have enacted statewide juries.Am J Prey Med 23(1 Supp),2002. fluoridation mandates to prevent and control dental caries 3. Beltran-Aguilar ED, Barker LK, Canto MT, Dye BA, Gooch BF, in California, Connecticut, Delaware, Georgia, Illinois, Griffin SO, et al: Surveillance for dental caries, dental sealants, Kentucky, Louisiana, Minnesota, Nebraska, Nevada, tooth retention,edentulism,and enamel fluorosis.MMWR Sur- Ohio,and South Dakota.While not all of these mandates veillance Summaries 54:1-44,2005. have been funded,in general,they have been shown to ef- 4. Griffin SO,Regnier E,Griffin PM,Huntley VN:Effectiveness of fluo- fectively increase fluoridation.California and Nevada are ride in preventing caries in adults.J Dent Res 86:410-414,2007. examples of states that have realized fluoridation gains 5.Griffin 50,Jones K,Tomar SL:An economic evaluation of torr in recent years because of statewide mandatory laws. munity water fluoridation.J Publ Health Dent 61:78-86, 2001. • Advocacy. Few of the accomplishments related to main- 6. CDC web page,Preventing Dental Caries(in publication). 7. Dye BA,Tan S,Smith V,Lewis BG,Barker LK,Thornton-Evans G, taining and expanding community water fluoridation et al: Trends in oral health status, United States, 1988-1994 could have been done without active local and statewide and 1999-2004.National Center for Health Statistics.Vital Health oral health coalitions.Coalition effectiveness is enhanced Stat 11(248),2007. by a diverse membership that may include, but not be 8.Griffin SO,Griffin PM,Swann JL,Zlobin N:New coronal caries in older limited to, community leaders, health professionals, adults:implications for prevention.J Dent Res 84:715-720,2005. Volume 54 • Issue 3 • 2009 117 (0I Overview of Water _ Fluoridation Safety wqi LCDR Troy Ritter,REHS,MPH,DAAS United States Public Health Service Alaska Native Tribal Health Consortium Senior Environmental Health Consultant Most Basic Fl System Itttr■ Fluoride Solution(4%) 1 NaF(98%) a. 1 Potential Safety Hazard Safer- Option #1 . —. a awn k.,/ Users _ - _ - Water - Storage Fluoride Tank MI Solution NaF(98%) _ Even Safer- Option #2 Even Better- Option #3 iii Water Water Hacrank ter ---.: Storage _ ■ Storage Tank ■� Tank Manualoay rant rni , ,. 2 Last Option #4 Administrative Safety • Operator training/certification -) l F. �> • Daily testing • - • Monthly reporting-review • Laboratory analysis-split samples • Sanitary surveys(3 yrs) f■ -s I ,45 Typical Capital Costs • Upflow saturator(1)-$1,138 Cost Considerations • Chemical pump(1)-$709 • Flow switch(1)-$100 • Test instrument(1)-$398 • Labor,electrician&plumber(10 hrs @$75)-$750 • Other(training, PPE,etc.)-$1,500 - Capital costs(1)-$4,595 3 i z„�, ;c : Typical Annual Operational Costs I t 4:. ` • NaF chemical($0.026/gal x97 mil)-$2,522 f Test ampules(365 days)-$410 4 , � r � • Laboratory testing(12 @$35)-$420 •'h( 7- • Preventative maintenance-$500 a a 1St - Operational costs(1)-$3,852 41.11 4 ti w k. V tri i x State ' ea of , , _ ... I a0)f More Teeth Means Increased Need for Dental Care Fewer seniors are losing all their teeth, but states are not keeping pace with their dental care needs. By Dan Lorentz o If we could get the impetus to try to include some adult dental care in www....§-----arftiM Medicaid (it would be an important first step). - —Arkansas Rep.Tommy G.Roebuck 0 ur bodies are not falling apart as quickly as they once did. For the most part, we're getting As Americans retire, most lose employer-based dental insur- ance. Simultaneously, most see a reduction in their incomes. Medicare, the federal health insurance plan for people 65 and chronic diseases such as heart dis- older or younger people with certain illnesses and disabilities, ease and arthritis later in life and—if doesn't cover routine dental care.Only 22 percent of seniors are we're middle-aged—we're likely to covered by private dental insurance. live much longer and with much less physical misery than ear- Through Medicaid,a program for low-income people who can't Tier generations. That's according to research from around the afford medical care,states have the option of covering dental ser- world summarized in a recent New York Times series on science vices for adults. and aging. According to the survey,however,few states are doing that. But we don't have to look far for proof that our bodies are hold- Among other factors, the survey graded each state based on ing together better than before.Consider the teeth of Americans. how many of its seniors had private dental insurance,the level of In the 1950s,more than half of Americans age 65 and older were adult Medicaid dental coverage provided,and how close to mar- toothless.Now,fewer than a quarter of older Americans have lost ket prices the state's reimbursement rates were for adult Medicaid all their natural teeth. dental services. So,more of us are keeping our teeth into old age.While most The grades were dismal: 15 states got Fs;29 states got Ds and would agree that's good news,there is a catch—more teeth means only seven states received Cs. The highest grade went to Cali- continued need for dental care.And that"catch"becomes a major fornia—a C plus—largely because many residents have private public health policy concern when you take into account that by dental insurance and because the state offers a high level of adult the year 2030,people 65 and older will comprise 20 percent of the Medicaid dental coverage.According to the survey,"27 states are U.S.population and that most seniors have to pay for dental care failing to meet even the most minimal standards of care"for poor out of pocket. seniors. Elizabeth Rogers, communications director of Oral Health America, said the 2003 survey, titled, "A State of Decay: The A State of Decay? Oral Health of Older Americans," would probably not change How is state government responding to this challenge, which much,if at all,if it were conducted again today. developed because we're living longer and healthier lives and "Barring Medicaid reform, there's not much that states are keeping more of our teeth? willing to do right now,"Rogers explained. "And there's nothing Not very well,according to a 50-state survey conducted in Au- much happening with Medicare either. gust 2003 by Oral Health America,a nonprofit advocacy organi- "There's lots of action (improving access to dental care) for zation dedicated to improving the oral health of Americans. kids right now,but I think doing something about oral health for 12 state news october 2006 older Americans is just one of many,many things that Oral Heath for Older Americans: • legislators have to consider. It's a very slow moving train for now" Policy Resources Other Barriers This CDC backgrounder,developed for the American Society Limited income and lack of coverage under federal on Aging, provides an overview about how to prevent oral dis- and state programs are only two of the barriers faced eases among older Americans.The backgrounder is available for by seniors needing dental care. download at www.asaging.org. Other barriers include: Did your state make the grade in terms of providing ac- • Not understanding or seeing the need for regu- cess to oral health care for seniors through private insur- lar dental care; ance and Medicaid? Read Oral Health America's 2003 report, • Fear of dentists and dental care; "A State of Decay:The Oral Health of Older Americans," at • Transportation and mobility difficulties; www•oralheolthamerico.org. In"The State of Aging and Health in America:2004,"the Merck • Limited availability of dental services in certain Institute of Aging& Health,the Centers for Disease Control and urban and rural communities; Prevention,and the Gerontological Society of America assess the • Lack of accessible dental services in nursing health status of the growing number of older Americans and homes.(While 80 percent of nursing homes say make recommendations to improve their mental and physical services are available in their facilities, studies health.The report includes a section on oral health for seniors.It have found that only 19 percent of residents ac- can be accessed at:wwwcdc.gov/aging. tually received dental care.) Read a succinct summary of how demographic trends are in- tersecting with oral health care realities for older Americans in Oral Health at Risk "Oral Health for Older Americans,"part of CDC's National Cen- The policy train for dealing with the oral health ter for Health Statistics series of publications on aging trends.Find needs of older Americans may be moving slowly,but the report at www.cdc.gov/nchs/data/ogingtrends. the oral health risks they face are real and present. For access to a variety ofresources related to oral health According to Dr. Barbara F. Gooch, DMD, MPH, from the Centers for Disease Control and Prevention in general, visit CDC's Oral Health Resources Web site at (CDC), seniors are challenged by an array of oral www.cdc.gov/OralHealthlindex.htm. health problems,including: To learn about best practices in state and community oral Tooth decay.Cavities don't just affect kids.Nearly health, go to the Association of State and Territorial Dental Di- one in five adults have untreated cavities that in the rectors Web site at www.astdd.org. absence of timely dental care can result in extensive and costly treatment or tooth loss. Periodontal (gum) diseases. Left untreated, gin- givitis—the mildest form of gum disease—may lead Oral cancers.Oral cancers,which include cancers of the mouth,tongue, to more severe periodontal disease,an infection of the lips and throat,kill about 7,200 Americans every year.If caught early enough, tissues and bones that support the teeth.This can lead however,there is a five-year survival rate of over 80 percent. to tooth loss. Loss of teeth. While many older Americans are keeping their teeth,a significant number are still los- Help for States from the C D C ing all of them.Even with dentures,maintaining good Even though oral health for seniors may not yet be on the top of the public nutrition can become more difficult as those with- health agenda for many, states are getting help from the CDC to promote out their natural teeth tend to avoid fresh fruits and improved oral health for Americans,including older Americans. vegetables in favor of softer, more chewable foods. In 2005,Arizona,Iowa and Rhode Island received funds from the CDC to Low-income seniors are more likely to lose all their implement pilot oral health programs for seniors who get their meals deliv- teeth than their counterparts with higher incomes. ered at home or who go to meal centers.With the funds,the states will learn In Kentucky and West Virginia, about 40 percent of more about the oral health needs of these seniors—most of whom are low older residents have lost all their teeth—the highest income and from minority communities. The pilot programs used a variety percentages among the states. of approaches—including the use of fluoride products,health education and Dry mouth.Too little saliva in the mouth,throat referrals to dental care providers—to raise awareness about oral health and and lips will increase risk for tooth decay and mouth effective prevention strategies for older adults. infections and may cause difficulties with chewing, The CDC has also directed an additional $3.8 million since 2003 to tasting, swallowing and even talking. Hundreds of help strengthen state oral health programs in 12 states—Alaska Arkan- medications,including diuretics and common antide- sas,Colorado,Illinois,Michigan,Nevada,New York,North Dakota,Or- pressants and allergy drugs—can cause dry mouth, egon,Rhode Island,South Carolina and Texas. as can some medical treatments like chemotherapy Some state programs provide examples of best practices regarding and head and neck radiation. oral health. the council of state governments www.csg.org 13 - ; - • t� •. v. • I ` •r • -try ` AN • A)1„ • "" What Works in Oral Health: • ••"i as Proven Prevention Strategies • it for Kids and Seniors • Drink fluoridated water and use a fluoride tooth- ' paste. Fluoride's protection against dental decay is : ', not just for kids. • Brush and floss. Take care of your teeth and gums. ' 1 r Z - '� Thorough tooth brushing and flossing to reduce den- tal plaque can prevent gingivitis, a gum disease. t • Avoid tobacco. Smokers have seven times the risk In Arkansas, for example, the CDC funding is being of developing gum disease compared to non smok used to reduce disparities in oral diseases in the state ers. Tobacco use in any form cigarette, pipes, and and to promote the expansion of water fluoridation—the smokeless (spit) tobacco—increases the risk for most cost-effective way to prevent cavities in both the gum disease, oral and throat cancers, and oral fungal young and old. Colorado continues to use its funds to infections. implement a preventive oral health program targeting high-risk children and adults,and to work with local pro- • Limit alcohol. Heavy use of alcohol is also a risk fac- grams to establish oral health infrastructure at the corn- tor for oral and throat cancers. When used alone, munity level. alcohol and tobacco are risk factors for oral cancers, In North Dakota, funds are being used to boost the awareness of both the public and policymakers of the im but when used in combination the effects are even portance of oral health. greater. Additionally, the CDC supports information-sharing • Eat wisely. Avoiding sugars and starches when systems. An example is the National Oral Health Sur- snacking applies to adults as well as children. Limit veillance System,www.cdc.gov/nohss,which links oral the number of snacks eaten throughout the health data from state systems,such as the adult-focused g day. Behavioral Risk Factor Surveillance System—a database The recommended five-a-day helping of fiber-rich that contains essential information about the oral health fruits and vegetables stimulates salivary flow to aid of older Americans. remineralization of tooth surfaces with early stages of tooth decay. Prospects for the Future The CDC's efforts to help strengthen state oral health • Go to the dentist. Check-ups can detect early signs programs promise to generate important information for of oral health problems and can lead to treatments policymakers to use in developing effective policies to that will prevent further damage and in some cases improve the oral health of older Americans. But major reverse the problem. Professional tooth cleaning state efforts to ensure broad access to needed dental care for all seniors likely won't occur in the near future° also is important for preventing problems, especially In Arkansas,for example,even a projected$700 mil- when self-care is difficult. lion budget surplus in 2007 isn't getting state Rep.Tom- my G.Roebuck too excited about the prospects for swift Adapted from CDC's fact sheet on oral health for adults,www.cdc.gov/ action to address the oral health needs of seniors. OralHealth/factsheets/adult.htm. Roebuck, a practicing dentist and a legislative leader in improving oral health in his state,recognizes that oral Continued on page 32 14 state news october 2006 State of Decay continued from pg 14 health care for seniors is an important issue especially for those "A lot of other groups want that money also,"he explained. with lower incomes."In Arkansas,the median income is well be- "It would be good for the general health of these patients to low the national average,"Roebuck says."Medicaid in Arkansas receive these services.If you let it go,it gets worse.If we don't get does not cover adult dental care,not even for relief of pain,which it early,it's going to get worse,no question about it." is ludicrous." At the national level, advocates for dental care have been "If we could get the impetus to try to include some adult dental championing legislation to require states to provide more oral care in Medicaid(it would be an important first step),"Roebuck health services to seniors either through the Medicaid program says.But he acknowledges that it"would take a pretty good effort or by adding dental benefits to Medicare.So far,Congress hasn't to get that passed. taken action. Rogers,from Oral Health America,however, sees some positive signs for the future,too. Oral Health Links fo r Yo u r Constituents: "Health insurance companies are detecting and noticing the links"between providing pre- Help Connect Senior Citizens With Expert ventive dental care for seniors and saving on more expensive treatment for preventable oral Advice health problems, Rogers said. "I'd say within the next three to five years, you'll see a lot This CDC fact sheet on oral health for older Americans provides easy-to-follow more research that will show why and how it advice on how to prevent oral health problems.Link your constituents to the fact pays to address the health care needs of seniors sheet at www.cdc.gov/OralHealth/factsheets/adult-older.htm early. That will help legislators defend dental For answers to questions about oral cancer,direct constituents to this CDC care programs for seniors." Web page: www.cdc.gov/OralHealth/topics/cancer.htm The American Dental Association's"Your Oral Health"Web page offers useful —Dan Lorentz is editor of Healthy States information for the general public about a wide range oral health topics.Link to Quarterly, a publication of the Healthy States this page at www.ada.org/public/index.asp. Initiative. Wired for Success continued from pg 22 Thomas, director of the Southern Regional Education Board. 'Just Do It' "They can be used to fill gaps in curricula, whether it is with Advanced Placement courses,core subjects or things people re- To Reg Weaver,president of the National Education Associa- fer to as electives." tion,it's as simple as this:If education is a top priority,policy- Thomas said 12 of the 16 SREB states already provide Web- makers have to provide for better technology in the classroom. based courses, with Florida leading the pack. Florida's pro "When America decides something is important,they find the gram began in 1997, and this year alone, more than 40,000 money,"said Weaver."I'd say to policymakers,when it comes to high school student are taking online courses.The program is making America strong,when it comes to making sure America funded by the state. has the people to make sure we are the country we are today,to "Schools only get money from the state if a student has suc- have a quality public education, they need to be like Nike and cessfully completed the course,"said Thomas,noting that Flor- just do it to make sure schools have the money they need." ida requires that students pass the class. Success rates in Florida range from 90 to 92 percent. Of the —Laura Coleman is the associate editor of State News 137 students who took Advanced Placement courses through magazine. Florida's virtual school in 2000-2001, more than half earned imm scores of 4 or 5—on a five-point scale—on the exams.About 65 percent of the students earned scores of 3 or higher—besting the • national average of 61 percent. "We see these programs as good economics," said Thomas. .;• • "Why should everybody create all courses?Once online cours '' -,*• es are developed,teachers can teach the same course and make ' • * copies of it.You could have five or 50 algebra teachers teaching } ** that course" 111 The best part of virtual schools, said Thomas,is that the pro- grams are closely monitored no matter where the students are. "Rural kids or inner city kids who have never had access to a qual- ity teacher can have a nationally board certified teacher,"he said. 32 state news october 2006 fir RESEARCH REPORTS Clinical S.O. Griffin'*, E. Regnier2, Effectiveness of Fluoride in P.M. Griffin3, and V. Huntley' 'Centers for Disease Control and Prevention/Division of Oral Preventing Caries in Adults Health,4770 Buford Highway,MSFIO,Chamblee,GA 30341, USA; 'Defense Resources Management Institute,Naval Postgraduate School,699 Dyer Road,Monterey,CA 93943, USA;and 3H.Milton Stewart School of Industrial and Systems Engineering,Georgia Institute of Technology,Atlanta,GA 30332-0205,USA;*corresponding author,sigl@cdc.gov INTRODUCTION J Dent Res 865):410 415,2007 'n systematic reviews on the effectiveness of fluoride in preventing/arresting caries, most of the studies included have been conducted among children (CDC, 2001; National Institutes of Health Consensus Development ABSTRACT Conference Statement,2001).For example,the National Institutes of Health To date, no systematic reviews have found Consensus Development Conference on Diagnosis and Management of fluoride to be effective in preventing dental caries Dental Caries Throughout Life noted that evidence on the effectiveness of in adults. The objective of this meta-analysis was fluoride in preventing dental caries was limited to studies involving to examine the effectiveness of self- and populations of children between six and 15 yrs of age. professionally applied fluoride and water The reviews included in the consensus conference generally emphasized fluoridation among adults. We used a random- the professional application of fluorides (Treasure, 2001), and not self- effects model to estimate the effect size of fluoride applied fluoride or water fluoridation. Moreover, the Centers for Disease (absolute difference in annual caries increment or Control and Prevention's(CDC)2001 Recommendations for Using Fluoride relative risk ratio) for all adults aged 20+ years to Prevent and Control Dental Caries in the U.S. found that, "Few studies and for adults aged 40+ years. Twenty studies evaluating the effectiveness of fluoride toothpaste, gel, rinse, and varnish were included in the final body of evidence. among adult populations are available", and called for further research on Among studies published after/during 1980, any the effectiveness of different fluoride modalities on dental caries, including fluoride(self-and professionally applied or water adults over 50 yrs old(CDC,2001). fluoridation)annually averted 0.29 (95%CI: 0.16- Documenting the effectiveness of fluoride in preventing/managing dental 0.42)carious coronal and 0.22(95%CI:0.08-0.37) caries among adults is important.Although literature reviews suggest that the carious root surfaces. The prevented fraction for incidence of caries among adults is as high as that in children—about 1 new water fluoridation was 27% (95%CI: 19%-34%). carious coronal tooth surface per year(Garcia, 1989; Griffin et al., 2005) — These findings suggest that fluoride prevents with the exception of water fluoridation, virtually all primary preventive caries among adults of all ages. programs target children and youth (Association of State and Territorial Dental Directors, 2002). One possible reason for the lack of preventive KEY WORDS: caries, fluoride, adults, meta- programs for adults may be the lack of evidence on their effectiveness for this analysis. population. To compete successfully for resources to support primary prevention,programs must not only establish the importance of the problem, but also provide evidence that interventions are effective(Gooch et al.,2006). For this present study,we analyzed the topical effectiveness of fluoride (self- and professionally applied and in drinking water) in preventing/reversing caries in all adults (aged 20+yrs) and in older adults (aged 40+ yrs). Because several clinical trials on the effectiveness of fluoride were conducted in the 1950s and 1960s,we expanded our search to include articles published before 1980, the earliest year in the National Institutes of Health search for systematic reviews (Rozier, 2001). We specifically addressed the following questions: (1) Is fluoride effective in preventing coronal caries in all adults and in older adults (?40 yrs) and in preventing root caries in the older group? and (2) How effective are the different fluoride delivery modes in preventing caries? METHODS Search Strategy Received May 14, 2006; Last revision October 20,2006; We searched three electronic databases to locate primary studies and systematic Accepted December 19,2006 reviews relating to the topical effectiveness of fluoride(i.e.,fluoridated water or A supplemental appendix to this article is published fluoride-containing toothpaste, gel,varnish, or rinse) in preventing or arresting electronically only at http://www.dentalresearch.org. caries among adults: 410 J Dent Res 86(5)( ) 2007 Fluoride Affects Adults 41 ) (1) MEDLINE from 1966 to week 42 of 2004A endix Table ( pp yrs). We also estimated the root caries increment for adults, aged 1)identified 1044 records; 40+yrs. We chose 40 yrs as the cut-point age to balance age with (2) EMBASE from 1988 to week 43 of 2004(Appendix Table 2) the need to have a sufficient number of studies. identified 56 records;and The reader should note that, for the cross-sectional studies (3) in the Cochrane Control Register of Controlled Trials with lifetime exposure to fluoridated/non-fluoridated water, (CENTRAL),we used MEDLINE search strategy to identify DMFT/S prevalence measures lifetime caries increment or, if 148 records, divided by the number of teeth/surfaces (assumed to be 28 Two reviewers (VH and SG) independently reviewed the teeth/128 surfaces),estimates the lifetime attack rate(%of teeth or abstract and title of each record for relevant articles; records surfaces attacked by caries). deemed relevant by at least one reviewer were examined. In Adjustment of Outcome Measures addition,the references of each retrieved article were searched for relevant articles.In total,489 articles were examined and screened When adjusting data, we used conservative methods that would with a form developed for this review(Appendix Table 3).We also bias the results against a statistical finding of a benefit of fluoride. For studies that reported the absolute difference in caries increment contacted the American Dental Association, the Food and Drug Administration,and manufacturers of topical fluoride products for for the same population for different time intervals(e.g., 12 and 30 unpublished clinical trials(Appendix Table 4),but these inquiries mos), we used the results for the follow-up examination that was did not yield additional studies. closest to,but at least 1 yr after,the first examination, so that the method used to annualize the variance would have minimal Study Selection and Validity Assessment influence. For studies whose selected follow-up period exceeded 1 A study was eligible for abstraction if it was published in English, yr, we annualized the outcome measure by assuming that caries lasted 1 yr or longer, and examined the association between increment was constant,and therefore independent of the duration fluoride and caries in intact human teeth in study populations that of the time since the first examination. Thus, we annualized the included adults. In all,we reviewed 50 studies(Appendix Fig. 1). reported caries increment by dividing it by the number of yrs in the Studies were excluded from the final body of evidence if the mean reported interval, and estimated the annual standard error by age of the study population was less than 20 yrs,they did not have dividing the reported standard error for the interval by the square a concurrent control group,or there was insufficient information to root of the number of years in the interval. If the caries increment both extrapolate the benefits of fluoride to all 28 teeth and to were higher in the first year and the caries increment in the control calculate a standard error(Appendix Tables 5,6). group were higher than in the treatment group (as expected), the We used an algorithm designed by the Guide to Community above method would underestimate the absolute difference in Preventive Services to determine the type of study design(Zaza et caries increment attributable to fluoride exposure. al., 2000). To examine the effectiveness of self- or clinically Quantitative Data Synthesis applied fluoride,we included only longitudinal studies with random To examine if any fluoride is effective,we used Fisher's inverse chi- assignment of participants or of split-mouth design. For studies square method (Hedges and O1kin, 1985) to calculate whether examining the effectiveness of water fluoridation, we included combined p-values were statistically significant.This test statistic was cross-sectional studies if their participants lived most of their lives calculated for studies examining the effectiveness of any mode of (hereafter referred to as 'lifetime residency') in fluoridated/non- fluoride delivered to all and older adults.We also applied Fisher's test fluoridated communities,or they estimated the effect of exposure to to the water fluoridation studies, because they also had different water fluoridation controlling for potential confounding factors. outcome measures and used different statistical methods. Because water fluoridation is a community intervention, it is To measure the size of the effect of water fluoridation, we difficult to assign participants randomly to a treatment or control calculated the relative risk ratio for each of the cross-sectional group, and thus other systematic reviews of the effectiveness of studies that excluded participants without continuous residency, water fluoridation have not excluded non-randomized studies where (McDonagh et al.,2000).Other measures of validity(drop-out rate and examiner/participant blinding) were also examined and %teeth or surfaces that are DMFFruoridadon Relative risk= reported for included studies,but were not used to exclude studies. %teeth or surfaces that are DMFCoutroI Data Abstraction All four authors pilot-tested an abstraction form developed for this We used the relative risk ratio because it is more invariant to project(Appendix Table 7). To calibrate the reviewers, all four differences in unit of measurement (teeth vs. surfaces), baseline reviewers abstracted the same five articles and then met to discuss and caries risk status, and age (length of exposure), which were all compare their completed abstraction forms. After a consensus had possible confounding factors. To calculate the standard error for been reached on how the form should be completed,each article was the relative risk ratio,we assumed perfect correlation among teeth randomly assigned to two reviewers.All four reviewers independently (the most conservative assumption),and thus the effective sample abstracted their assigned articles and then compared abstraction forms size became the number of participants; we used this value in with the other reviewer to whom the article had been assigned;finally, calculating the pooled standard error. For the remaining studies,we used the absolute difference in the two reviewers completed a consensus abstraction form. annual caries increment between the control and the treatment Outcome Measures groups to measure the effect size. The primary outcome of interest was coronal caries increment,as For those studies where the standard error had to be extracted measured by the number of teeth/surfaces becoming decayed or from reported p-values,or it was necessary to pool standard errors filled (DFT/S) or decayed, filled, or missing (DMFT/S). We to make comparisons similar across studies, we used standard examined this outcome in all adults (20+yrs) and in adults (40+ statistical techniques,which are described in the Notes Section of 412 Griffin et al. J Dent Res 86(5) 2007 Table 1.Characteristics of Included Studies Design;Number of Subjects; Study Duration;Drop-out Rate Location;Mean Age in Yrs(Range) Mode of Fluoride Delivery Burt et al.,1986; Cross-sectional;315;NA";NA New Mexico;41.6(27-65) Community water system(3.5 ppm"vs.0.7 ppm) Eklund et al.,1987 DePaola, 1993 Randomized controlled trial;71;1 yr;14% Northeastern US;71 (NR') Gel(1.2%)professionally applied for 2 min every 4 mos,and daily self-application of neutral sodium fluoride gel(0.5%) Englander and Cross-sectional;1831;NA;NA Illinois;33(18-59) Community water system(1.2 ppm vs.0.1 ppm) Wallace,1962 Fure et al.,1998 Randomized controlled trial;81;2 yrs;6.8% Sweden;71.5(NR) Rinse(0.05%)twice daily o Not applicable. b Parts per million. • Not reported. Grembowski Cross-sectional;595;NA;NA Washington;30.6(20-34) Community water system et al.,1992 Hunt et al.,1989 Prospective cohort(random sample); Iowa;75(NR) Community water system(0.7 to 1.5 ppm vs.<0.5 ppm) 275;1.5 yrs;13% Jensen and Randomized controlled trial;810;1 yr;11% Iowa;68(54-93) Dentifrice(1.1%)used twice daily Kohout,1988 Lu etal.,1980 Randomized controlled trial;1105;1 yr;17% Oregon;33(18-78) Dentifrice(stannous fluoride-calcium pyrophosphate, pH=4.5;fluoride content NR) Morgan et al.,1992 Cross-sectional;104;NA;NA Australia;NR(20-24) Community water system(fluoride content NR) Muhler et al.,1956 Randomized controlled trial;322;1 yr;10% Indiana;NR(17-36) Dentifrice(4 mg stannous fluoride; frequency not reported') Muhler,1958 Randomized controlled trial;435;1 yr;NR Indiana;NR(17-38) Aqueous solution professionally applied(10%), single application o Results stratified by good(>_3 times daily)or bad brushers(<_2 times daily),but numbers in each group not reported. Muhler et al.,1967 Randomized controlled trial;168;1 yr;17% Indiana;NR(NRC) Topical professionally applied every 6 mos preceded by prophylactic paste(%NR)and dentifrice(%NR) Murray,1971 Cross-sectional;3902;NA;NA Great Britain;findings presented Community water system(1.5-2.0 ppm vs.0.2 ppm) by age group(20-60+) Rickles and Becks,1951 Controlled trial(split-mouth);25;2 yrs;NR USA;27(22-34) Topical professionally applied(2%)eveery 3 mos Ripa et al.,1987 Randomized controlled trial;731;3 yrs;27% New York;39.9(20-65) Rinse(0.05%)swished for 60 sec daily Scala,1970 Randomized controlled trial;120;2 yrs;NR USA;20.7(18-22) Topical(8.9%)professionally applied once yearly pre- ceded by prophylaxis paste(8.9%)and dentifrice(0.4%) o Age was assumed to be greater than 20 yrs because participants were all dental students. Stamm et al.,1990) Cross-sectional;967;NA;NA Canada;41.5(18-60+) Community water system(1.6 ppm vs.0.2 ppm) Thomas and Cross-sectional;649;NA;NA Great Britain;NR(20-32) Community water system(0.9 ppm vs.NR) Kassab, 1992 Wallace etal.,1993 Randomized controlled trial;466;4 yrs; Alabama;NR(aged 60+) Gel(1.2%in trays kept in place for 4 min)applied semi- 11.8%in year 1 and 22.7%in year 4 annually or rinse(0.05%)used daily Wiktorsson et al.,1992 Cross-sectional;496;NA;NA Sweden;NR(30-40) Community water system(fluoride content NR) relevant studies in Appendix Table 6. square test(QW)(Normand, 1999).Because we had a small number We estimated summary measures for the various modes of of studies in many cases,we estimated the quantity 12(Higgins and fluoride by age group if there were five or more studies for that Thompson,2002)for effect sizes that failed the heterogeneity test. mode. We used a random-effects model, which assumes that each study was randomly selected from a hypothetical population of RESULTS studies (DerSimonian and Laird method, referenced in Normand, 1999). Because we included many studies published before 1980, Quality Assessment we also estimated summary measures for studies conducted during Twenty studies representing 13,551 participants were included or after 1980.We tested for homogeneity of effect size using a chi- in the final body of evidence (Table 1 and Appendix Table 6). • J Dent Res 86(5) 2007 Fluoride Affects Adults 413 Eleven studies examined the Table 2.P Values for Combined Results effectiveness of self- or clinically applied fluoride. Of these studies, 10 Measure(Number of Studies;Number of Participants;References) Combined p-value were randomized clinical trials, and 1 was a controlled trial (split-mouth) Any fluoride,all adults,coronal caries(18 studies;11,649 participants;Eklund <0.001 that did not specify whether the eta,1987;Englander and Wallace,1962;Fure et at,1998;Grembawski at, treatment had been randomly assigned. 1992;Hunt et at,1989;Jensen and Kohout,1988;Lu et at,1980;Morgan et at, Nine studies examined the 1992;Muhler et al.,1956;Muhler,1958;Muhler at,1967;Murray,1971; effectiveness of water fluoridation— Rickles and Becks,1951;Ripa et at,1987;Scala, 1970;Stamm et at, 1990; one was a prospective cohort trial that Thomas and Kassab,1992;Wiktorsson et at,1992) examined caries increment among randomly selected lifelong residents of Any fluoride,alder adults,coronal caries(6 studies;2290 participants;Eklund et al, <0.001 fluoridated and non-fluoridated 1987;Fure et at,1998;Hunt et at,1989;Jensen and Kohout,1988;Murray,1971; communities, and 8 were cross- Stamm et at,1990) sectional studies. In this last group, 7 compared caries prevalence between Any fluoride,older adults,root caries(7 studies;2112 participants;Burt et al.,1986; <0.001 lifelong residents of fluoridated and De Paola,1993;Fure et at,1998;Hunt et al.,1989;Jensen and Kohout,1988; non-fluoridated communities, and 1 Ripa stat,1987;Wallace et al,1993) used linear regression analysis to estimate averted caries increment Water fluoridation,all adults,coronal caries(9 studies;7853 participants;Eklund <0.001 attributable to 1 yr of exposure to et al., 1987;Englander and Wallace,1962;Grembowski et at,1992;Hunt et at, water fluoridation. Among the 12 1989;Morgan et al.,1992;Murray,1971;Stamm et al.,1990;Thomas and Kassab, longitudinal studies, 9 reported the 1992;Wiktorsson et at,1992) drop-out rate (mean drop-out rate for one yr [weighted by sample size] = 10.9%), 5 reported that examiners were blinded, and 8 reported using a placebo. with 4809 participants; Fig. 1). The summary difference was 0.64 surfaces (95%CI: 0.35-0.94). Heterogeneity was present. Is Any Fluoride Effective in Preventing Caries? Eighteen studies (11,649 participants) compared coronal caries There were enough studies to estimate an effect measure for among adults of all ages by fluoride exposure(Table 2). Caries studies published during/after 1980 (6 studies with 3573 was always higher in the control group than in the treatment participants). The summary difference in annual caries group.With Fisher's inverse chi-square method,the combined p- increment for these studies was 0.29 coronal surfaces (9 Z%CI: values were less than 0.001. Six studies (2290 participants) 0.16-0.42). Both the chi-square test, p > 0.05, and the I test, 0.38,indicated that heterogeneity was not an issue. compared coronal caries among adults aged 40+ yrs. Again, The difference in annual root caries increment by any caries was always higher in the control group than in the fluoride exposure for adults aged 40+ranged from 0.05 to 0.50 treatment group, and the combined p-values were less than (5 studies all published after/during 1980,with 1894 participants; 0.001.Finally,7 studies(2112 participants)compared root caries Fig. 2). The summary difference was 0.22 (95%CI: 0.08-0.37). among adults aged 40+yrs by fluoride exposure(Table 2);in all Both the chi-square test, p> 0.05, and the quantity I2, equaling studies,caries was higher in the non-fluoride than in the fluoride 0.15,indicated that heterogeneity was not significant. group,and the combined p-values were less than 0.001. For self-applied fluoride, the difference in annual coronal How Effective is Community Water Fluoridation caries increment between exposed and not-exposed adults in Preventing Caries? ranged from 0.02 to 2.17(Appendix Fig.3;7 studies with 3503 The combined results of the 9 studies (7853 participants) participants). The summary difference was 0.72(95%CI: 0.20- examining the effectiveness of water fluoridation were 1.24). Heterogeneity was present. When we restricted the significant at p < 0.001 (Table 2). Among the 7 studies analysis to the 5 studies that included solely self-applied including only lifelong residents of control or fluoridated-water fluoride(3049 participants),the summary difference decreased communities (5409 participants; Appendix Table 8 and to 0.30 surfaces(95%CI:0.09 to 0.51).Although the chi-square Appendix Fig. 2), the summary relative risk ratio was 0.654 test indicated that heterogeneity was not an issue, the quantity (95% confidence interval [CI]: 0.490-0.874); this is equivalent I2 indicated that about 53%of the difference among studies was to a prevented fraction of 34.6% (95%CI: 12.6%-51.0%). due to heterogeneity as opposed to random chance. Heterogeneity was present. Heterogeneity was not an issue Because only 2 studies examined the effectiveness of when we pooled the 5 fluoridation studies published after 1979 professionally applied fluoride without another fluoride (2530 participants);the summary-prevented fraction was 27.2% modality, we did not calculate summary measures for this (95%CI: 19.4%-34.3%). mode of delivery. How Effective are the Different Modes of Fluoride in Preventing Caries? DISCUSSION The difference in annual coronal caries increment between One limitation of this review is the quality and the quantity of exposed and not-exposed adults of all ages for all modes of studies on fluoride effectiveness among adults. Recent meta- fluoride delivery ranged from 0.02 to 2.17 surfaces(11 studies analyses of fluoride rinses and toothpastes among children 414 Griffin et al. J Dent Res 86(5) 2007 No effect • No effecta 0.35 0.64 0.94 0.08 0.22 0.37 f Rickles and Becks. 1951t 9 6 Wiliam Nal.,1093 e • —A--Masher.1958 A AA • —4—Mahler 1967 i O O O • 4-Ripa of el.,1987' 0 - t I $Scola.1970 Q I 0 O 0 Jensen and Kdaul,19881 • • • ( -e-Muhler et al.,1956 0 0 1 0 • $Pure eta/.,1998' • • • —Q—Jansen1988' ane Kohout 0 o Vj _e_Lu et al..1980' Q 0,, Q -El—Hunt C ...1099' C - a _e—Fere et al.,1988' O 0 -0.400 -0.200 0.000 0.200 0.400 0.800 0.800 1.000 1.200 .. Ripa et al.,1987' Figure 2. Absolute reduction in root caries increment attributed to fluoride exposure.'Indicates study published during or after 1980. --e—Hunt et al.,1989' C o Values to the right of the 'no effect' line (difference in caries increment is positive)indicate fluoride effective,and values to the left (negative difference)indicate fluoride ineffective. ❑ Community water fluoridation. '-+ Grerobowskietal, a i 0 Self-applied fluoride. 1992' �.L. ! 0 Combination of self-applied and professionally applied fluoride. -0.50 0.00 0.50 1.00 1.50 2.00 2.50 3.00 Figure 1. Absolute reduction in coronal caries increment that was we found that exposure to any mode of fluoride reduced caries attributed to fluoride exposure. 'Indicates study published during or by about 25%. This value is similar to the prevented fraction for after 1980. community water fluoridation.When we restricted the analysis of Values to the right of the 'no effect' line (difference in caries the effect of self-applied fluoride to 4 studies published after 1979, increment is positive)indicate fluoride effective,and values to the left the prevented fraction again equaled 25% (data not shown). A (negative difference)indicate fluoride ineffective. recent meta-analysis conducted amongchildren and youth also ❑ Community water fluoridation. Y O Self-applied fluoride. found preventive fractions of fluoride rinse(26%)and toothpaste O Combination of self-applied and professionally applied fluoride. (24%)close to 25%(Marinho et aL,2003a,b). ♦ Professionally applied fluoride. On a population basis,caries is becoming a more important health issue among adults,especially older adults,because they are more likely to retain their natural teeth than in previous included 36 and 74 randomized or quasi-randomized controlled generations.A comparison of the National Health and Nutrition trials (Marinho et al., 2003a,b), respectively, whereas this Examination Survey (NHANES III) conducted in 1988-1994 review could locate only 8 such studies from which to estimate with that conducted in 1999-2002 indicates that the mean the size of the effect. Because of the paucity of studies, we number of missing teeth among adults aged 40+has decreased were not able to exclude studies without blind outcome by 22% (Beltran-Aguilar et al., 2005). In addition, the assessment, as was done in the recent meta-analysis for percentage of the population that is older is increasing. Thus, children. In addition, our findings on the effectiveness of self- there are more at-risk teeth,making population-based efforts at applied fluoride may not be generalizable to the current prevention even more important. generation of adults; there were only 4 studies published after Although adults are as likely to experience new caries as 1979 (the summary measure, however, was significant). children, certain segments of the U.S. adult population—those Finally, we also included cross-sectional studies to evaluate with low incomes and the elderly—may have little or no access water fluoridation. Thus, there is a clear need for further well- to restorative or preventive clinical care. At present, designed studies on the effectiveness of fluoride among adults. approximately 15% of state Medicaid programs provide no One interesting finding, however, was the consistency of the adult dental benefits at all, and approximately 45%cover only effect size for the various modes of fluoride delivery among adults, tooth extraction and emergency services(Oral Health America, and their similarity to findings for children. Using findings from 2003). Routine dental care is one of the few health areas not studies published after 1979,and assuming that the annual coronal covered by Medicare. Limited access to restorative care caries increment among adults is 1 surface(Griffin et aL, 2005), increases the need for effective prevention; complications and J Dent Res 86(5) 2007 Fluoride Affects Adults 415 pain and suffering are more likely if caries remains untreated. stannous fluoride-calcium pyrophosphate dentifrice in an adult The proportion of the U.S. population comprised of older population:one-year results.Pharmacol Ther Dent 5:11-16. adults is increasing,most of these persons are likely to be dentate Marinho VC, Higgins JP, Sheiham A, Logan S (2003a). Fluoride and at risk for dental caries,and many lower-income adults lack toothpastes for preventing dental caries in children and adolescents. access to timely restorative care. Our finding that fluoride is Cochrane Database Syst Rev 1:CD002278. effective among all adults supports the development and Marinho VC, Higgins JP, Logan S, Sheiham A (2003b). Fluoride implementation of fluoride programs to serve this population. mouthrinses for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 3:CD002284. ACKNOWLEDGMENTS McDonagh MS,Whiting PF,Wilson PM,Sutton AJ,Chestnutt I,Cooper J, et al. (2000). Systematic review of water fluoridation.BMJ This research was funded by the Division of Oral Health, 321:855-859. Centers for Disease Control and Prevention (CDC); the Morgan MV,Stonnill A,Laslett AM(1992).Dental caries amongst Royal Defense Resources Management Institute, Naval Postgraduate Australian Navy recruits,1988.Aust Dent J37:201-204. School;and the National Science Foundation(DMI-0113881). Muhler JC(1958). The effect of a single topical application of stannous We also acknowledge input from Drs. William Kohn and fluoride on the incidence of dental caries in adults.JDent Res 37:415- Barbara Gooch,Division of Oral Health,CDC. 416. Muhler JC,Radike AW,Nebergall WH,Day HG(1956).The effect of a REFERENCES stannous fluoride-containing dentifrice on dental caries in adults.J Dent Res 35:49-53. Association of State and Territorial Dental Directors and Centers for Muhler JC,Spear LB Jr,Bixler D,Stookey GK(1967).The arrestment of Disease Control and Prevention(2002). Synopses of State and incipient dental caries in adults after the use of three different forms of Territorial Dental Public Health Programs. [accessed March 2006] SnF2 therapy: results after 30 months.J Am Dent Assoc 75:1402- Available from http://www2.cdc.gov/nccdphp/doh/synopses/ 1406. index.asp Murray JJ(1971).Adult dental health in fluoride and non-fluoride areas. 1. Beltran-Aguilar ED,Barker LK,Canto MT,Dye BA,Gooch BF,Griffin Mean DMF values by age.Br DentJ 131:391-395. SO,et al.(2005).Surveillance for dental caries,dental sealants,tooth National Institutes of Health Consensus Development Conference retention,edentulism,and enamel fluorosis-United States, 1988- Statement,March 26-28(2001).Diagnosis and management of dental 1994 and 1999-2002.MMWR Surveill Summ 54(3):1-43. caries throughout life.JDent Educ 65:1162-1168. Burt BA, Ismail AI, Eklund SA(1986). Root caries in an optimally Normand ST(1999). Tutorial in biostatistics meta-analysis: formulating, fluoridated and a high-fluoride community.JDent Res 65:1154-1158. evaluating,combining,and reporting.Stat Med 18:321-359. Centers for Disease Control and Prevention(2001).Recommendations for Oral Health America(2003). Keep America smiling:2003 oral health using fluoride to prevent and control dental caries in the Unites States. report card. Chicago: Oral Health America. MMWR Recomm Rep 50(RR-14):1-42. http://www.oralhealthamerica.org/pdf/2003ReportCard.pdf DePaola PF(1993).Caries in our aging population:what are we learning? (accessed April 2007). In: Cariology for the nineties. Bowen WH, Tabak LA, editors. Rickles NH,Becks H(1951).The effects of an acid and a neutral solution Rochester,NY:University of Rochester Press,pp.25-35. of sodium fluoride,on the incidence of dental caries in young adults.J Eklund SA,Burt BA, Ismail AI, Calderone JJ(1987). High-fluoride Dent Res 30:757-765. drinking water,fluorosis and dental caries in adults.JAm Dent Assoc Ripa LW,Leske GS,Forte F,Varma A(1987).Effect of a 0.05%neutral 114:324-328. NaF mouthrinse on coronal and root caries of adults.Gerodontology Englander HR,Wallace DA(1962).Effects of naturally fluoridated water 6:131-136. on dental caries in adults.Public Health Rep 77:887-893. Rozier RG(2001).Effectiveness of methods used by dental professionals Fure S,Gahnberg L,Birkhed D(1998).A comparison of four home-care for the primary prevention of dental caries.J Dent Educ 65:1063- fluoride programs on the caries incidence in the elderly. 1072. Gerodontology 15:51-60. Scola FP(1970).Self-preparation stannous fluoride prophylactic technique Garcia AI(1989). Caries incidence and costs of prevention programs.J in preventive dentistry: report after two years.JAm Dent Assoc Public Health Dent 49(5 Spec No 2):259-271. 81:1369-1372. Gooch BF,Griffin SO,Malvitz DM(2006).The role of evidence in form- Stamm JW,Banting DW,Imrey PB(1990). Adult root caries survey of ulating public health programs to prevent oral disease and promote two similar communities with contrasting natural water fluoride oral health in the United States.JEvid Based Dent Pract 6:85-89. levels.JAm Dent Assoc 120:143-149. Grembowski D,Fiset L, Spadafora A(1992).How fluoridation affects Thomas FD,Kassab JY(1992).Fluoridation in Anglesey:a clinical study adult dental caries.JAm Dent Assoc 123:49-54. of dental caries in mothers at term.Br Dent J173:136-140. Griffin SO,Griffin PM,Swann JL,Zlobin N(2005).New coronal caries Treasure ET(2001). Methods of stopping or reversing early carious in older adults:implications for prevention.JDent Res 84:715-720. lesions fluoride:a European perspective.JDent Educ 65:1073-1077. Hedges LV,01kin I(1985). Statistical methods for meta-analysis,New Wallace MC,Retief DH,Bradley EL(1993).The 48-month increment of York:Academic Press,pp.37-39. root caries in an urban population of older adults participating in a Higgins JP,Thompson SG(2002).Quantifying heterogeneity in a meta- preventive dental program.JPublic Health Dent 53:133-137. analysis.Stat Med 21:1539-1558. Wiktorsson AM, Martinsson TR, Zimmerman M (1992). Caries Hunt RJ,Eldredge JB,Beck JD(1989).Effect of residence in a fluoridated prevalence among adults in communities with optimal and low water community on the incidence of coronal and root caries in an older fluoride concentrations.Community Dent Oral Epidemiol 20:359-363. adult population.JPublic Health Dent 49:138-141. Zaza S, Wright-DeAguero LK, Briss PA, Truman BI, Hopkins DP, Jensen ME,Kohout F(1988).The effect of a fluoridated dentifrice on root Hennessy MH, et al. (2000). Data collection instrument and and coronal caries in an older adult population.J Am Dent Assoc procedure for systematic reviews in the Guide to Community 117:829-832. Preventive Services.Task Force on Community Preventive Services. Lu KH,Hanna JD, Peterson JK(1980). Effect on dental caries of a Am JPrev Med 18(1 Suppl):44-74. THE COUNCIL OF STATE GOVERNMENTS RESOLUTION ON COMMUNITY WATER FLUORIDATION Resolution Summary Tooth decay, also known as dental caries, causes pain and disability for millions of Americans every year. There are safe and effective methods to prevent tooth decay; one of the most cost-effective is community water fluoridation. Fluoridation of community water supplies involves adjusting the naturally occurring fluoride levels in drinking water to 0.7-1.2 parts per million, the optimal fluoride level recommended by the U.S. Public Health Service for the prevention of tooth decay. According to the Centers for Disease Control and Prevention, community water fluoridation is the single most effective public health measure to prevent tooth decay and is one of 10 great public health achievements of the 20th century. Studies conducted over the last 60 years have demonstrated that community water fluoridation is safe and effective in preventing dental decay in both children and adults. This resolution seeks to encourage states to support and adopt community water fluoridation initiatives which have been shown to be effective in reducing dental caries and saving costs associated with tooth decay. Additional Resource Information American Dental Association http://www.ada.org/prof/resources/positions/statements/fluoride anniversary.asp List of National and International Organizations That Recognize the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay http://www.ada.org/public/topics/fluoride/facts/compend i um.asp Water Fluoridation Facts from the CDC http://www.cdc.gov/oralhealth/waterfluoridation/benefits.htm CDC Oral Health Resources http://www.cdc.gov/oralhealth/ Association of State and Territorial Dental Directors(ASTDD)Best Practices http://www.astdd.org/index.php?template=practice exam p1es.html&shell=best http://www.astdd.org/docs/BPAF luoridation.pd f CSG Healthy States web conference: Protecting Precious Smiles: How States Prevent Oral Diseases and Curb Costs http://www.healthy states.csg.org/Events+and+Conferences/Web+C onferences/Oral+Heal th+Web+Conference.htm Communih Water Fluoridation Management Directives > Management Directive #1: Support state efforts to provide community water fluoridation. ➢ Management Directive #2: CSG staff will post approved resolution on CSG's Web site and make available through its regular communication venues at the state and local level to ensure its distribution to the state government and policy community. THE COUNCIL OF STATE GOVERNMENTS Resolution on Community Water Fluoridation WHEREAS, community water fluoridation benefits everyone, especially high-risk populations. It is the most efficient way to prevent one of the most common childhood diseases-dental decay (five times as common as asthma and seven times as common as hay fever in 5- to 17- year-olds). Without fluoridation, there would be many more than the estimated 51 million school hours lost each year in this country because of dental- related illnesses; WHEREAS, states need to reduce expenditures in Medicaid budgets and studies have proven that communities benefiting from fluoridated water use fewer Medicaid dollars to treat dental decay; WHEREAS, the average cost for a community to fluoridate its water is estimated to range from approximately $3 a year per person in small communities to approximately 50 cents a year per person in large communities. For most cities, every $1 invested in water fluoridation yields $38 savings in dental treatment costs; WHEREAS, with more than 60 years of research and practical experience, the overwhelming weight of credible scientific evidence has consistently indicated that fluoridation of community water supplies is safe; WHEREAS, the Centers for Disease Control and Prevention has proclaimed community water fluoridation (along with vaccinations and infectious disease control) as one of 10 great public health achievements of the 20th century. Fluoridation of community water supplies is the single most effective public health measure to prevent tooth decay; WHEREAS, more than 125 national and international health, service and professional organizations recognize the public health benefits of community water fluoridation for preventing tooth decay; WHEREAS, community water fluoridation simply adjusts the level of fluoride that occurs naturally in water to the level considered optimal in helping protect against tooth decay. More than two-thirds of the population of the United States is served by public water systems that are optimally fluoridated; WHEREAS, simply by drinking water, everyone, especially those without access to regular dental care, can benefit from fluoridation's cavity protection whether they are at home, work or school. Studies prove water fluoridation continues to be effective in reducing dental decay by 20-40 percent, even in an era with widespread availability of fluoride from other sources, such as fluoride toothpaste; WHEREAS, the maximum reduction in tooth decay is achieved when fluoride is available before teeth erupt so that it can be incorporated while teeth are forming and after teeth erupt to help repair enamel damaged by acid from decay-causing bacteria; BE IT THEREFORE RESOLVED,that due to the devastating consequences of tooth decay, The Council of State Governments urges state and local policymakers to consider the effectiveness of community water fluoridation as an economical public health measure in preventing tooth decay—particularly among those at greatest risk. BE IT FURTHER RESOLVED,that The Council of State Governments urges state and local policymakers to favorably consider policies related to the important oral health benefits of optimally fluoridated community water systems. Adopted this 10th Day of May,2006 at the CSG Spring National Committee and Task Force Meetings In White Sulphur Springs,West Virginia CYn4-4/.4..: Governor Jim Douglas Senate President Earl Ray Tomblin 2006 CSG President 2006 CSG Chair IA Promoting Awareness, Preventing Pain: Facts on Early Childhood Caries (ECC) Early childhood caries(ECC)is an infectious disease that can start as soon as an infant's teeth erupt.ECC can progress rapidly and may have a lasting detrimental impact on a child's health and well-being.ECC is a serious public health problem. In a child age 71 months or younger,the presence t ` of one or more decayed teeth,missing teeth(result- -.� - ing from caries),or filled tooth surfaces in any pri- mary tooth is known as ECC.1 Early childhood caries. Caries is a multifactorial disease process initiated by bacteria(primarily Streptococcus mutans).When food is consumed,bacteria are able to break down carbohydrates,producing acids that cause mineral loss from teeth.This mineral loss results in cavities when the attack is prolonged and exceeds an individual's resistance and ability to heal.Resistance and healing ability are determined partly by physiology and partly by health behaviors. Because poor feeding and eating practices alone do not cause caries,terms such as"baby bottle tooth decay,""bottle mouth,"and"nursing decay"are misleading.ECC is a term that better reflects the many factors involved in the disease process.1 ECC should be prevented to the extent possible and should be treated if it occurs.2 Who Is at Risk Among children in the United States,the number of teeth with treated or untreated caries for ECC? has declined substantially since the 1970s.2 However,ECC remains a significant problem for some children. Among children from families with incomes at or below the federal poverty level,the amount of caries in the primary teeth remained unchanged from the early 1970s to the early 1990s.2 For children ages 2 to 5,75 percent of caries is found in 8 percent of the population.3 .l ,,, e Children ages 2 to 5 who have not had a dental visit within the past 12 months are more likely to experience caries in primary teeth than children who have.4 t Mexican-American children ages 2 to 5 are more likely than their non-Hispanic black and non-Hispanic white peers to experience caries in primary teeth.4 For children ages 2 to 5 from families with incomes above the federal poverty level,the likeli- hood of experiencing caries in primary teeth is significantly greater among those who do not eat breakfast daily or who eat fewer than five servings of fruit and vegetables per day than among those who do.4 What Are the Costs Children diagnosed with ECC may be highly susceptible to future caries development.5 of ECC? Manifestations of ECC may go beyond pain and infection.ECC has the potential to affect speech and communication,nutrition,productivity,and quality of life,even into adulthood. ECC has significant financial consequences.Many children with ECC require restorative treatment in an operating room under general anesthesia.State Medicaid expenditures for restorative dental care delivered under general anesthesia range from$1,500 to$2,000 per child per year.6'7 • Ei National Maternal&Child ■4Oral)Health RESOURCE CENTER How Can ECC Risk The infectious nature of ECC,its early onset,and the potential of early interventions all Be Reduced? point toward an emphasis on preventive oral health care. Fluoride is safe and effective for preventing caries in children.Community water fluoridation is a major factor responsible for the decline in caries during the second half of the 20th cen- tury.8 Fluoride toothpastes,varnishes,mouthrinses,gels,and dietary supplements can also help prevent caries.9 Preventing ECC requires good dietary and oral hygiene practices and access to preventive and restorative dental care.10 Ili Programs directed toward families with young children,such as the Special Supplemental "441111 Nutrition Program for Women,Infants and Children(WIC),can contribute to the preven- tion of ECC.11 Other programs such as Head Start can also help prevent ECC. Nutrition education and counseling for the purpose of preventing ECC aims to teach parents the importance of reducing their infant's or child's high-frequency exposures to foods con- r taining sugar.l0 The Early and Periodic Screening,Diagnosis and Treatment(EPSDT)component of the The knee-to-knee position,being used Medicaid programcould be apowerful tool for identifyingand ECC early.However, by an oral health professional and treating caregiver to perform an oral health Healthy People 2010 baseline data indicate that only 20 percent of children eligible for dental screening. services under Medicaid/EPSDT received a single preventive dental service.12 What Can Health As part of any routine health supervision visit,primary care health professionals should per- Professionals Do? form an oral health screening that includes the lips,tongue,teeth,gums,interior surface of the cheeks,and roof of the mouth. Health professionals can help ensure that infants and young children receive the care they need by referring infants to a dentist for an oral examination within 6 months of the eruption of the first primary tooth,and no later than age 12 months,and by establishing the child's dental home.1 Health professionals can provide parents with anticipatory guidance on oral development, caries transmission,gum/tooth cleaning,feeding and eating practices,and fluoride.Since caries is an infectious disease that may be transmitted from the parent,especially the mother, to an infant or child,13 anticipatory guidance on oral health should also be provided to preg- nant women,new mothers,and other caregivers. References 1. American Academy of Pediatric Dentistry,American children with early childhood caries following treat- 10.Tinanoff N,Palmer CA.2000.Dietary determinants Board of Pediatric Dentistry,College of Diplomates ment under general anesthesia.Pediatric Dentistry of dental caries and dietary recommendations for of the American Board of Pediatric Dentistry.2003. 22(4):302-306. preschool children.Journal of Public Health Dentistry Policy on early childhood caries(ECC):Unique 6. Griffin SO,Gooch,BF,Beltran E,Sutherland JN, 60(3):197-206. challenges and treatment options.Pediatric Dentistry Barsley R.2000.Dental services,costs,and factors 11. Nurko C,Skur P,Brown JP.2003.Caries prevalence 24(7):27-28. associated with hospitalization for Medicaid-eligible of children in an infant oral health educational pro- 2. Brown LJ,Wall TP Lazar V.2000.Trends in total children,Louisiana 1996-97.Journal of Public Health gram at a WIC clinic.Journal of Dentistry for caries experience:Permanent and primary teeth. Dentistry 60(1):21-27. Children 70(3)231-234. Journal of the American Dental Association 131(2): 7. Kanellis MJ,Damiano PC,Momany ET.2000. 12. U.S.Department of Health and Human Services. 223-231. Medicaid costs associated with the hospitalization of 2000.Healthy People 2010:Volume II(2nd ed.). 3. Macek MD,Heller KE,Selwitz RH,Manz MC. young children for restorative dental treatment under Washington,DC:U.S.Department of Health and 2004.Is 75 percent of dental caries really found in general anesthesia.Journal of Public Health Dentistry Human Services. 25 percent of the population?Journal of Public Health 60(1):28-32. 13. Li Y,Dasanayalce AP,Caufield PW,Elliott RR, Dentistry 64(1):20-25. 8. Centers for Disease Control and Prevention.1999. Butts JT,3rd.2003.Characterization of maternal 4. Dye BA,Shenkin JD,Ogden CL,Marshall TA, Achievements in public health,1990-1999:Fluori- mutans streptococci transmission in an African Levy SM,Kanellis MJ.2004.The relationship dation of drinking water to prevent dental caries. American population.Dental Clinics of North America between healthful eating practices and dental caries Morbidity and Mortality Weekly Report(48(41):933- 47(1):87-101. in children ages 2-5 years in the United States, 940. 1988-1994.Journal of the American Dental Association 9. U.S.Preventive Services Task Force.2004. 135(1):55-66. Prevention of dental caries in preschool children: 5. Almeida AG,Roseman MM,Sheff M,Huntington Recommendations and rationale.Rockville,MD: N,Hughes CV.2004.Future caries susceptibility in Agency for Healthcare Research and Quality. This fact sheet was produced by Jolene Bertness and National Maternal and Child Oral Health Resource National Maternal and Child Oral Health Katrina Holt of the National Maternal and Child Oral Center,Georgetown University. Resource Center Health Resource Center under its grant(H47MC00048) Georgetown University from the Maternal and Child Health Bureau,Health Permission is given to photocopy this fact sheet.Requests Box 571272 Resources and Services Administration. for permission to use all or part of the information con- Washington,DC 20057-1272 tamed in this publication in other ways should be sent to (202)784-9771•(202)784-9777 fax Promoting Awareness,Preventing Pain:Facts on Early the National Maternal and Child Oral Health Resource E-mail:info@mchoralhealth.org Childhood Caries(ECC)(2nd ed.)©2004 by the Center. Web site:www.mchoralhealth.org rill11 Sponsored by: Oates CITY OF SEWARD,ALASKA RESOLUTION 2009-043 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SEWARD, ALASKA,SUBMITTING AN ADVISORY BALLOT PROPOSITION TO THE QUALIFIED VOTERS AT THE OCTOBER 6,2009 REGULAR MUNICIPAL ELECTION REGARDING WHETHER FLUORIDE SHOULD BE ADDED TO THE CITY OF SEWARD WATER WHEREAS, SGS (City's certified lab)conducted a standard water test,that measures 0.1 parts per million and higher, on March 9, 2009 and fluoride was not detected in the Seward City water; and WHEREAS, the United States Public Health Service (USPHS) established the optimum concentration for fluoride in the United States in the range of 0.7 to 1.2 parts per million; and WHEREAS, fluoridation of community water supplies involves the addition of fluoride to the public water supply to an optimal level to reduce the incidence of tooth decay; and WHEREAS, a Seward Fluoridation Study was conducted by Michael L. Foster & Associates, Inc. on April 13, 2009 addressing fluoride forms, corrosion, chemical feed, regulatory requirements, code compliance, operator certification, costs, and fluoride removal; and WHEREAS, according to the Fluoridation Study the approximate cost of fluoridating the water are $130,000 for capital costs and $24,000 for annual costs; and WHEREAS,the Indian Health Service may contribute up to 21%of the capital infrastructure costs; and WHEREAS, there are pros and cons to adding fluoride to community water supplies and there is passion among both the proponents and opponents of fluoridation; and WHEREAS,this resolution will place the issue of whether fluoride should be added to the City of Seward water on the ballot as an advisory vote allowing the qualified voters to advise the City Council on whether to fluoridate the water or not; and WHEREAS, the advisory vote on adding fluoride to the City of Seward's water is non binding,the City Council will consider the voting results. NOW,THEREFORE,BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF SEWARD,ALASKA,that: , CITY OF SEWARD,ALASKA RESOLUTION 2009-043 Section 1. The City Clerk is hereby directed to submit Proposition No.1 as a non binding advisory vote to the qualified voters at the October 6, 2009 regular municipal election in substantially the following form: ADVISORY PROPOSITION NO. 1 Shall fluoride be added to the City of Seward water to the level (0.7-1.2 parts per million) recommended by the U.S. Public Health Service? Yes No A "Yes" vote advises the Seward City Council that the voters recommend adding fluoride to the level(0.7-1.2 parts per million)recommended by the U.S.Public Health Service to the Seward City Water. A"No"vote advises the Seward City Council that the voters do not recommend adding fluoride to the level(0.7-1.2 parts per million)recommended by the U.S. Public Health Service to the Seward City Water. Section 2. This resolution shall take effect immediately upon its adoption. PASSED AND APPROVED by the City Council of the City of Seward, Alaska,this 26th day of May,2009. THE CITY OF SEWARD, ALASKA Clark Corbridge, Mayor AYES: Dunham, Bardarson, Kellar,Keil, Corbridge NOES: None ABSENT: Valdatta, Smith ABSTAIN: None ATTEST: Johanna Dollerhide, CMC Assistant City Clerk (City Seal) ' Sponsored by: Oates CITY OF SEWARD,ALASKA RESOLUTION 2010-015 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SEWARD, ALASKA, AFFIRMING COUNCIL SUPPORT FOR FLUORIDATION OF THE PUBLIC WATER SUPPLY TO IMPROVE ORAL HEALTH, AND DIRECTING THE CITY MANAGER TO DETERMINE THE REQUIREMENTS AND COSTS FOR SAFELY ADDING FLUORIDE TO THE COMMUNITY WATER SYSTEM AND REPORT ON GRANTS AND OTHER FUNDING SOURCES FOR SUBSIDIZING THOSE COSTS WHEREAS, the Seward City Council is the governing body of the City of Seward and recognizes that there is community support for the fluoridation of the City of Seward public water system; and WHEREAS,the Seward City Council recognizes that dental tooth decay is a chronic disease and that community fluoridation is a public health measure that benefits all individuals; and WHEREAS, fluoridation of community water supplies is supported by numerous professional heath organizations including the American Public Health Association, American Dental Association, World Health Organization and the American Medical Association; and WHEREAS,the Center for Disease Control and Prevention has named water fluoridation as one of the ten greatest public health achievements and in 2005 marked the 60th anniversary of water fluoridation in the United States; and WHEREAS, SGS (the City's certified lab) conducted a standard water test aimed at detecting fluoride levels of 0.1 parts per million and higher on March 9,2009,and fluoride was not detected in the Seward City water; and WHEREAS,the United States Public Health Service(USPHS)established the position that the optimal concentration for fluoride in the United States should be in the range of 0.7 to 1.2 parts per million; and WHEREAS,fluoridation of community water supplies at an optimal level has been shown to reduce the incidence of tooth decay; and WHEREAS, community water fluoridation simply adjusts the level of fluoride that occurs naturally in water to the level considered optimal in helping to protect against tooth decay as shown in 72.4%of the U.S.population served by public water systems that are optimally fluoridated;and WHEREAS,the Council of State Governments resolution on community water fluoridation supports state efforts to provide community water fluoridation; and CITY OF SEWARD,ALASKA RESOLUTION 2010-015 WHEREAS,the Indian Health Service may contribute up to 21%of the capital infrastructure costs for the fluoridation of community water; and WHEREAS, there are pros and cons to adding fluoride to community water supplies and there is passion among both the proponents and opponents of fluoridation; and WHEREAS,resolution 2009-043 addressed the issue of whether fluoride should be added to the City of Seward water, and authorized placing the question on the ballot as an advisory vote to allow the qualified voters to advise the City Council on whether or not to fluoridate the water;and WHEREAS, resolution 2009-043 advisory ballot was titled as follows: "Proposition 1. (Advisory) Shall fluoride be added to the City of Seward water to the level of(0.7-1.2 parts per million)recommended by the U.S. Public Health Service"; and WHEREAS,the results of the October 6,2008 regular election which included an advisory vote were as follows: Election Day votes (Yes: 229 versus No: 206); after canvass votes (Yes: 50 versus No: 28); and the total votes were (Yes: 279 and No: 234); and WHEREAS, the advisory vote on adding fluoride to the City of Seward's water was non binding; and WHEREAS, at the January 11, 2010 council meeting the Seward City Council was given information concerning the pros and cons of fluoridating the City of Seward water supply in the range of 0.7 to 1.2 parts per million. NOW,THEREFORE,BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF SEWARD,ALASKA,that: Section 1. The city council recognizes and supports the public health benefits of community water fluoridation for preventing dental decay and is committed to the safe and effective practice of water fluoridation as defined by the Centers for Disease Control Preventions' Engineering and Administrative Recommendation to Water Fluoridation. Section 2. The city council directs the city manager to hire a qualified professional engineering firm for an amount not to exceed$50,000,to determine the impacts and requirements in terms of equipment, training, infrastructure, and safeguards of adding fluoride to City of Seward water system. The findings and conclusions from this study, and other requirements for the water system,shall be considered by the city council prior to the appropriation of funds for adding fluoride to the City of Seward water supply. • CITY OF SEWARD, ALASKA RESOLUTION 2010-015 Section 3. The city council also directs the city manager to report back to the city council all grants and funding sources that may be available to subsidize the costs of adding fluoride to the City of Seward water supply. Section 4. Once the city council appropriates funds for the fluoridation of the City of Seward water supply,the city manager will initiate actions for fluoridation of the water supply to a minimum level of 0.7 and not to exceed 1.2 parts per million, the recommended fluoride level of fluoride in public water supplies according to the U.S. Public Health Service. Section 5. This resolution shall take effect immediately upon its adoption. PASSED AND APPROVED by the City Council of the City of Seward,Alaska,this 22nd day of February, 2010. THE CITY OF SEWARD, ALASKA Willard E. Dunham, Mayor AYES: Bardarson, Keil, Shafer, Dunham NOES: Valdatta, Amberg ABSENT: Smith ABSTAIN: None ATTEST: Jean Lewis, CMC City Clerk (City Seal) 11111•1111111111111•111•1111.L...,...._ IIMENIMINIMINNIIII Related U.S. Healthy People a • 2010 Objectives Enhancing CD CD� Increase percentage of the population on public water E N a t U r e s Fluoride O r l d e receiving fluoridated water to 75%. Z vi z aa ¢ a One drop at a time Alaska-only 59.5%of the population on public y water receives fluoridated water. Community Water Fluoridation U.S.- populations served by fluoridated public "one of the 10 great public health water has increased from 65%in 2000 to 69.2%in 2006. achievements of the twentieth century."cvc Worldwide—over 300 million people in more +' than 40 countries are receiving fluoridated water. What is fluoride? Fluoride is a mineral that occurs •� naturally in all water sources. It is nature's decay Where can I get additional,reliable information°', preventing supplement. Over 60 years of research about fluoridation? The Internet can be a great -0 has shown that fluoride helps strengthen teeth,pre- 1. source of information but there are many sites that ccs a` vents cavities,and helps repair the early stages of contain inaccurate or incomplete information about 3 tooth decay even before the decay is visible. Maxi- fluoride. Those that provide scientifically accurate I mum benefit is achieved when fluoride is available and reliable information include: both systemically and topically. as What is fluoridation? Water fluoridation is the ad- The Centers for Disease Control& Prevention Ui justment of the natural fluoride concentration of http://www.cdc.gov/fluoridation/ fluoride deficient water to the level recommended for optimal health. That level is 0.7-1.2 parts per million U.S. Public Health Service per the U.S. Public Health Service. It is the equiva- lent lent of one inch in 14 miles. Is fluoridation safe? Yes. A few small research American Dental Association projects have questioned whether increased rates of http://www.ada.org/public/topics/fluoride/ certain health problems were associated with fluori- fluoride links.asp dation but these theories have not been confirmed by larger,well designed studies. With over 60 years of References,Data,and Statistics: N experience with water fluoridation in communities 1. American Dental Society,Fluoride and Fluoridation. u 4 cv with large populations,no legitimate large-scale epi- 2. State of AK,Department of Health&Social Services, Q no Women's,Children,and Family Health. R, o rn demiological,laboratory,or clinical study has dem- 3. Alaska Native Tribal Health Consortium x °` onstrated that long term ingestion of fluoride at opti- 4. Centers for Disease Control and Prevention ccizi - mal levels in water causes illness or disease. 5. U.S.Department of Health and Social Services,Healthy < a People 2010. o "Ti gi u) v Seward's naturally occurring fluo- R1") ride level is 0.072 parts per million Paid for by the Dentists of Alaska A Political Action Committee (1993 water test). , -, What is the public health issue? Good oral health is Healthy People 2010 In the U.S., tooth decay affects: systemically linked to good overall health. Although National Initiative preventable,tooth decay is a chronic disease affecting d 42%of elementary school children all age groups. In fact,it is the most common chronic Goal 1: Increase Quality and Years of Healthy Fir, Life for individuals of all ages. d 59%of adolescents disease and unmet healthcare need among children 6-19 yrs. Left untreated,tooth decay can cause needless Goal 2: Eliminate Health Disparities among d 94%of adults +', pain,tooth loss,or far worse. Toothaches affect every different segments of the population. What is enamel fluorosis? During tooth de- day living activities including eating,sleeping,learning, Whatand working. Prevention is a key element. The nation- acid,chosen because they dissolve completely velopment,higher than recommended levels of fluoride have been shown to cause some wide goal to prevent cavities through community water in water and break down into harmless corn- fluoridation is similar to previous public health efforts pounds, leaving none of the original chemical. discoloration of teeth but this might occur in a very small percentage of the population and is to prevent other common health problems. These in- Research shows that there is no difference in of the mildest form in optimally andfluois dude adding iodine to salt to prevent thyroid problems the effects between the fluoride ions in artifi- mostlydated It is readily apparent to the i- or adding Vitamin D to milk to prevent rickets. As a cially fluoridated water and naturally occur- dafedcted areas.It is notual or casual aopparent Teeth result of these programs thousands of cases of illnesses, ring fluoride. that have erupted are not at risk. The U.S. disability,and death are prevented each year with no harm to the rest of the population. 2007-Alaska awarded State Fluoridation Environmental Protection Agency, in a deci- Quality Award for maintaining the quality sign supported by the U.S. Surgeon General, How is Alaska/Seward doing? of fluoridation. has determined enamel fluorosis as a cosmetic In 2004,65%of Alaska's 3rd graders had experienced tooth effect with no known health effects. decay. Seward is in the Gulf Coast region which had a Will fluoridated water taste different? No. "The preponderance of research continues higher rate of 68.5%of 3rd graders who had experienced The color and taste of the water will not be to confirm the safety, effectiveness, tooth decay. affected. Fluoride already occurs naturally in Seward's water at 0.072 ppm. efficiency, cost-effectiveness, and Who pays for water fluoridation? environmental compatibility of Why is fluoridation necessary rather than just giving Sources of funding for a water fluoridation community water fluoridation." people fluoride drops/tablets? Fluoride drops/tablets system have been identified on both state and are given to children. Also,there are affordability and federal levels. The Village Safe Water Pro- What is the impact of fluoridation? This compliance issues. Fluoridation reaches everyone in the p n' gram has a capitol improvements program and preventative health measure has been around community. the Indian Health Services has a Sanitation since 1945 and has repeatedly been shown to Is fluoridation safe for my pet? Yes Deficiency System program. Also,due to the be a safe, inexpensive,and extremely effective What is the process for fluoridating our public water high cavity experience in Alaska Natives and method of preventing tooth decay.It benefits supply? A fluoridation program would not happen a 21%Native population,the AK Native everyone,regardless of age and socioeco- overnight. Operators would be thoroughly trained and Tribal Health Consortium has pledged up to nomic status by reducing tooth decay by 18%- certified. Fluoridated water is tested/monitored fre- 21% of capital costs. Lastly,there are several 40%,even with other available fluoride prod- uentl accordingto DEC guidelines. With the advent ucts around. In Alaska,cost per person per quently private grant opportunities available. year is estimated at$1-$4. Every dollar spent of 9/11,our water supply systems are thoroughly pro- tected,have redundant safety measures in place,have The arrows on fluoridation potentially saves about$8-$49 point out safety alert systems that call directly into the local po- mild dental in dental treatment costs per person. Current lice department,and operators who are on call24/7. fluorosis. savings in dental treatment costs for persons What are the chemicals used in fluoridating water served by fluoridation systems in the U.S. is supplies? The compounds most commonly used for estimated to be over$4.6 billion annually, fluoridating water are sodium fluoride and fluorosolicic Memorandum sof SFt9 16 q�SSP Date: February 6, 2012 To: Jim Hunt, City Manager From: W.C. Casey, Public Works Director J Subject: Request for Information Regarding Fluoride Implementation I believe that I have answered the questions that Councilmember Casagranda had emailed the Clerk's Office, on January 25, 2012. I will hand deliver the supporting documents, and the following will be my specific answers to her questions. This is the first time that I have been asked for information pertaining to fluoride, from a Councilmember. Question: Did the engineering firm study (fluoridation) ever happen, and do I have the results? (Per Resolution 2010-015) Answer: No, there was a study done in April, 2009 by M.L. Foster & Associates that Phillip had forgotten about, and he reviewed it and decided to save $50,000. Furthermore, when the engineering for the new water storage tank is done, it will Incorporate a more precise cost analysis. I have done some independent research, and will compile those costs in the following days. Question: What grant, funding sources were found/available to subsidize the costs of adding fluoride to the water? Answer: A 1.9 million dollar direct State of Alaska Appropriation, and we appear to have received a Municipal Grant in the 2.7 million dollar range. The Alaska Native Tribal Health Consortium has "indicated" verbally, to a contribution of $21,000. I have not followed up with them about this possible contribution. Page 2 Question: What are the annual costs of adding fluoride to the water, including implement- tation ? Answer: There several variables, most of which would be a swag, until such time as the engineer begins the design. I am willing to provide my best guess estimate, if you so desire. Additional Information Requested (not in the email, but Councilmember Casagranda asked me for additional information, since the email request). Those items are as follows: 1. Photo of PPE 2. Insurance coverage (are we covered by AML/JIA) ? 3. Toxicity Chart 4. Copy of M.L. Foster Engineering Study TECHNICAL MEMORANDUM Seward Fluoridation Study This study presents information on design criteria, costs, and recommendations associated with fluoridating Seward's City water system. It also identifies related technical, operational, and regulatory constraints that the City will need to address if fluoridation is implemented. Refer to Technical Memoranda 1 and 2 (Refs. 1, 2), as well as the Task 3 Study Report (Ref. 3) for the Water Compliance Study by Michael L. Foster & Associates (MLFA) for additional information on Seward's water systems, including monitoring results. Fluoridation is often promoted by dentists and other health professionals as a way to help protect developing teeth, particularly in children nine years old and younger. Because the Seward Marine Industrial Center (SMIC) water system is used almost exclusively by adults, we assumed fluoridation of that water was inappropriate and did not address that system. The scope of this study was to address engineering issues and costs related to equip- ment, chemicals, monitoring, and reporting. However,we would be remiss if we did not alert the City to the fact that this issue can elicit considerable passion among both proponents and opponents of fluoridation. Although 65 percent of Alaskans currently drink fluoridated water (Ref. 4), several communities have consciously chosen not to fluoridate—or have discontinued its practice. No community on the Kenai Peninsula currently fluoridates its water (Ref. 5). The City & Borough of Juneau has invested perhaps the greatest recent effort by any Alaska community into study of fluoridation, and discontinued fluoridation of its water on January 15, 2007. Its report is available at http://www.juneau.org/clerk/boards/Fluoride/Fluoride Study Commission.php (Ref. 6). The key issues addressed by this report are: • Fluoride forms • Corrosion • Chemical feed • Regulatory requirements • Code compliance • Operator certification • Costs • Fluoride removal Seward Fluoridation Study 1 April 13,2009 c.nnrrl AAA nnni 1. Fluoride Forms Fluoride compounds are produced in many different forms, and are used according to availability and application. Sodium fluoride (NaF) and sodium silicofluoride (Na2SiF6) are two commonly used compounds to fluoridate public drinking water systems in Alaska. Table 1 lists key properties of these two compounds. Table 1 Properties of fluoride Compounds Property Sodium Sodium Fluoride Fluorosilicate Form Crystal or Powder powder Commercial Purity 95%± 95%+ Available Fluoride Ion 45% 61% Density 95lb/ft3 ft 66 lb/ 3 Solubility in water at 4°C 4.0 g/100 mL 0.5 g/100 mL Amount needed per 20 pounds 15 pounds million gallons of water' Volume of saturated 56 gallons 330 gallons solution per million gallons of water pH of saturated solution 7.5 3.6 Cost,delivered, per pound $1.00 $0.70 Note: 1. For a dosage of 1.0 mg/L. Smaller water systems in Alaska that fluoridate almost exclusively use sodium fluoride. Silicofluoride (aka sodium fluorosilicate or sodium fluosilicate) is generally less expensive than sodium fluoride, but because of its low solubility and considerably lower pH in solution, we conclude that sodium fluoride is a better chemical to use in Seward. Fluorosilicic acid (H2SiF6) is commonly used in many water systems elsewhere in the continental United States, but because of the cost and challenge of shipping, and increased handling hazard, is not used by any water system in Alaska, and is not considered appropriate for this application. 2. Corrosion Impacts The pH of water from the City wellfield is 6.93 (see Water Compliance Study, Technical Memorandum No. 1, Appendix E). This water meets the EPA's secondary standard for pH of 6.5 to 8.5. Lower pH waters can be corrosive or contribute to higher lead and copper levels in the distribution system. Corrosivity was a potential concern expressed in Technical Memoranda 1 and 2. Sodium fluoride will have a slight effect on increasing the pH of City water, thereby decreasing its corrosivity, although this may not be measurable. On the other hand, sodium fluorosilicate would have a slight effect on pH depression. Seward Fluoridation Study 2 April 13, 2009 •,r:,.r._..r r n_,..__ o_ w____._�_.. r.... 01-'11 Irl crnirrr /IAA nnni 3. Chemical Feed Sodium fluoride is a dry, white, colorless chemical commercially available as crystal (preferred) or powder that dissolves in water. It is typically delivered in 50-lb bags or 125-pound drums, is stable, has a long shelf-life, but must be kept dry. If it comes into contact with moisture it can form a hardened cake. Two common options for feeding sodium fluoride are a saturator and mechanical dry feed. A saturator is a free-standing tank (often with 50-55 gallon capacity) that stores a bed of sodium fluoride at the bottom of the tank. On the call for make-up water, water flows through the bed slowly, generating a saturated solution of 4 percent concentration. This solution is then injected into a discharge pipe by a metering pump. Fluoride saturators can be either upflow, in which water enters the bottom of the tank, or downflow, in which water enters the top of the tank. Upflow saturators are more common today and are preferred as they are easier to clean and maintain. The makeup water for a fluoride saturator should have hardness levels less than 50-75 mg/L because calcium and magnesium fluorides will precipitate. Saturator manufacturers recommend that a water softener be included with the system if hardness levels are greater than this. City water has a hardness of 94 mg/L (Technical Memorandum No. 1, Appendix E) (Ref. 1), so a water softener may be appropriate. Alternatively, the City should count on additional maintenance to clear clogging lines and remove scale. Saturators require less operator attention than mechanical dry feed systems and eliminate the need to weigh the chemical to form the desired solution strength. Operation can be automatic or manual. The accompanying drawings show a typical layout for a saturator and pump. Seward's City water system does not have a common point for chemical injection before water is provided to the consumer. Therefore,fluoridation equipment will need to be provided at each wellhouse. Well House 6 has room for this equipment. Space in Well Houses 2, 4 and 5 is more limited, but might be able to be arranged. Mechanical dry feeders produce a desired fluoride concentration in a storage tank by metering dry chemical with an auger into a dissolving chamber where it is mixed with water. Like the saturator, this solution is fed from the storage tank to the process line using a metering pump. These feeders require operator attention to ensure they have not"caked" or clogged. The dissolving chamber needs to be checked regularly to ensure the chemical is completely dissolved before discharge and that there is not excessive build-up of un-dissolved chemical in the tank. Seward Fluoridation Study 3 April 13,2009 01-n17rr c,r.117r1 /IAA nnni These feed systems are compared in Table 2. TABLE 2 Fluoride Feed Comparison Feeder Type Advantages Disadvantages Saturator •Less mechanically •More operator contact complex with chemical • Requires less routine maintenance Mechanical Dry Feed •Reduced operator •More mechanically contact with chemical complex •Requires more routine maintenance •May require dust control (for powder form) Because the quantity of sodium fluoride needed for Seward is relatively small, and four well houses are currently in operation, we believe its use is manageable with a saturator, and we have opted for this simpler system,which is used commonly in many smaller communities in Alaska. 4. Regulatory Requirements State and federal regulations do not require fluoridation of drinking water systems. However, where it is practiced, they require that fluoride concentrations be measured. DEC will enforce the secondary maximum contaminant level (MCL) of 2.0 mg/L. It has determined public health is threatened or that exceeding this secondary MCL fluoride is not in the public interest (18 AAC 80.30) (Refs. 5, 7) because of the toxicity of sodium fluoride and danger of tooth mottling in higher concentrations. The City would want to do this anyway. Good practice in public water systems that fluoridate is to keep fluoride levels between 0.7 and 1.2 mg/L (Ref. 8). Daily sampling and measurement are required for each location where fluoride is injected to ensure that concentrations of fluoride stay within the required levels. The results of the daily monitoring must be recorded and reported monthly to DEC. This can be done by grab sampling at representative locations in the water distribution system. Continuous online monitoring will also satisfy this requirement, and is recommended. Samples may also be collected and analyzed by a State-certified laboratory to demonstrate the validity of the City's fluoride monitoring. This would be a prudent action by the City to demonstrate the proper application of monitoring procedures and calibration of equipment. In addition, DEC may require the City to modify sampling procedures, increase sampling locations and frequency, and/or change sample-collection locations to ensure representative reporting, fluoridation Seward Fluoridation Study 4 April 13,2009 11A:.,4...,1 T T....a..— O. A........:..�.... 1... OTAI/Tl r'.ST77-1 /IAA AAAI public and protection of health.The City must notify the DEC i n out of compliance and when modifying its water system. t must al o follow public P MCL mg/L is notification procedures if EC recorde s secondary measurements on delivered water, Generally, according to DEC, especially for inorganics such as fluoride, must be kept at PubliicvW Works or Ciis ty Hall ng for five years. Like many communities indefinitely. Alaska, the City of its water records essentially 5. Code Compliance The Alaska Depar tment of Public Safety,home of the State Fire Marshal, has 9 adopted the 2006 International Building, Fire, and Mechanical Codes. The 200 are now published, and it is likely the State with adopt o(IFC)hem os na toxic Codes Fire fluoride is classified by OSHA andIFCeprovides nthe exempt amounts of hazardous chemical. Table 2703.1.1(2) of the materials that can be stored in a controlled area. If quantitiesChapters 27 and these are stored,facilities must meet applicable requirements of Geny, the erall ,limits on storage areas for sodium fluoride are 50 ode allows some pounds without sprinklers and 1,000 pounds with sprinklers. However , exceptions and adjustments, such as for detached storage.be Code this interpretation interpretation t be complex, and our research e aznfco c d by flee State of Alaska. is close to how it will fluoride is non-flammable and does not supportoe However,tion.sodiThm ere e no Sodium media in fire situations. H restrictions on extinguishinghighlytoxic. Other will react with acids to form hydrogen fluoride,an cChcal dentification) and requirements also include signage (No Smoking ventilation. The Occupational Safety and Health Administration (OSHA) safety shower and requirements for the safe handling of sodium °d d clo hinge including eyewash, protective face shield, gloves, 6. Operator Certification implementing fluoridation is not Fluoride systems are relatively simple certifiation for the City's staff (see 18n saCfe expected to require additional operator to 9 Still, training will be necessary for operators DEC, urend seeffective other 74) Ref ) performance.While fluoride is considered safe by EPA, regulated levels, an health authorities when handled properly and pt fatal.within i hi Alaska w s reminded ofn this overdose can cause severe sickness, and evenand operator error combined to P in 1992 when fluoridation equipment malfunction to avoids stem of one person and illness for several others in Hooper Bay. Thus, it cause theera death is imperative that operation and maintenance direct exposure�a overdosing as well as their own accidental April 13,2009 Seward Fluoridation Study 7- 7. Costs To calculate the total amount of chemical usage a target fluoride concentration of 1.0 mg/L was used (based on the dosage range of 0.7 to 1.2 mg/L recommended by the Centers for Disease Control and U.S. Public Health Service, as supported by the American Water Works Association and DEC) (Refs. 5,8). City water has no detectable background level of fluoride (see Technical Memorandum No. 1, Appendix E) (Ref. 1), so all of this would need to be added. The City system will require 20 pounds of sodium fluoride per day (3 bags per week), based on average off-season flows of 1 mgd, and up to 10 bags per week to accommodate summer flows that exceed 3 mgd.If the City is unable to locate appropriate existing storage space, it will either need to construct a new area or modify an existing space. For our cost purposes, we have assumed that 150 square feet of new space will be needed at$300 per square foot. This will include ventilation, sprinkling, security and other protections to meet Code requirements. Storage of 1,000 pounds will provide a two-week supply in the summer and up to seven weeks in the winter. The chemical will be distributed to welihouses based on system operation,which currently has Well 6 operating in lead (primary) mode. Saturators are able to store quantities greater than a single 50-pound bag, but they should still be checked regularly, at least every other day, and refilled as necessary. Monitoring of fluoridation is very important. Because of the layout of the City water distribution system, multiple locations should be monitored. Some customers receive water directly from discharge pipes, before water has gone to a storage tank. Monitoring in these locations is even more important, as the system will be less forgiving for an overdose. Because of this, wiring that ensures shut-off of the fluoridation pump when well pumps are not operating are essential. The City may also consider continuous in-line monitoring of fluoride with the capacity to shut-off or adjust the fluoridation pumps when a set level is exceeded. The costs presented in Table 3 assume that all water produced by the City wellfield will be fluoridated, including water delivered to cruise ships and Icicle Seafoods, the two largest summer customers. If these customers do not want their water fluoridated, the City might consider its seasonal discontinuation. Seward Fluoridation Study 6 April 13,2009 PT`11Yr\ 1111( (111\1 Table 3 Costs for Fluoridation Category Cost Capital Chemical feed equipment' $60,0002 Storage 45,0003 Design, DEC review fees, 25.000 observation of installation Total Capital $130,000 Annual Chemicals4 $11,000 Operation&maintenance 8,000 (0.1 FTE), parts and supplies Power and heating 3,000 Laboratory tests and reports, 2.000 miscellaneous Total Annual $24,000 Notes: 1. Includes saturator,chemical feed pump,water softener, continuous in-line monitor, redundant pump, spare parts,anti-siphon devices,and controls. 2. Assumes installation in four wellhouses plus redundant parts. 3. Assumes chemical supply stored at a separate Public Works location. 4. Sodium fluoride plus salt(sodium chloride)for water softener. These estimates of capital and annual costs are considered conceptual at this stage (Class 5 cost estimates as defined by the Association for the Advancement of Cost Engineers), made without detailed engineering data. It is normally expected that capital cost estimates of this type are accurate to within plus 50 percent to minus 30 percent. Our estimates have been prepared for guidance in project evaluation and implementation from the information currently available to us, including our own experience with the Seward water system, fluoridation experiences by others, conversations with you and vendors, catalog and website research, and certain assumptions we have identified in the report. Your actual costs will depend on the project delivery system you choose and its implementation schedule, potential costs and delays from extensive interactions with the interested public, your own Public Works labor costs and assignment of personnel,costs of materials, various market conditions outside our control, and other variables. As a result, your final costs will likely vary from our estimates. Because of this, we suggest that project feasibility and funding needs be carefully reviewed as you advance the project before you make specific financial decisions and commitments. Seward Fluoridation Study 7 April 13,2009 .�__t.__i T T`.,_a_- O_ •....- 7.... C'rtl,r C'T 1T nn nnnI 8. Fluoride Removal If the City of Seward decides to fluoridate its water, some of its customers will likely no longer want to drink the water. These customers can purchase non-fluoridated bottled water or can remove fluoride from City water. Alternatively, the City can make non-fluoridated SMIC water available to them. The most effective treatment system for fluoride removal is reverse osmosis, and these units are not inexpensive. Small home units sized for removing fluoride from only drinking water (a small component of a household's total water use) cost from$250 to $500 at retail (Ref. 10), plus installation and maintenance expenses. As it engages in its community dialogue, the City of Seward might consider other options for increasing fluoride intake for young children whose parents want them to have it, without causing the rest of the population that does not want it or does not need it to drink fluoridated water. This could include making fluoride tablets available at little or no cost for families with young children; promoting use of fluoride toothpaste, gels and rinses; or even selectively fluoridating (for example, pre- and elementary schools). Whatever it decides to do, Seward should become well aware of the recent experience in Juneau on this issue. Seward Fluoridation Study 8 April 13,2009 PT117T PT11/T nnA INA/1i References 1. Michael L. Foster &Associates, Inc. Technical Memorandum No. 1, Background Investigation, Water Compliance Study, City of Seward, Alaska, February 21,2008. 2. Michael L. Foster &Associates,Inc. Technical Memorandum No. 2, Develop Options, Water Compliance Study, City of Seward,Alaska, August 15, 2008. 3. Michael L. Foster &Associates, Inc. Task 3 Study Report: Implementation Plan, Water Compliance Study, City of Seward, Alaska, December 30,2008. 4. Telephone conversation and email exchanges with Troy Ritter, Environmental Health Specialist,Alaska Native Tribal Health Consortium,March 27,2009. 5. Telephone conversation with David Litchfield,Alaska Department of Environmental Conservation,Soldotna office, April 1, 2009. 6. Juneau Fluoride Study Commission. Report to Assembly of the City and Borough of Juneau, July 11,2006. http://www.juneau.org/clerk/boards/Fluoride/Fluoride Study C.:ominission.php 7. DEC,State of Alaska. Drinking Water Regulations (18 AAC 80). As amended through November 9, 2006. 8. American Water Works Association. Position Statement-Fluoridation, May 27, 2005. http://www.njawwa.org/njpdt/nj9U9b.pdf 9. DEC,State of Alaska. Water and Wastewater Operator Certification and Training Regulations (18 AAC 74). As amended through December 3,2006. 10. Pure Water Products,LLC, Countertop Reverse Osmosis Units, http://www.pwgazette.com/ctro.htm, 2008. 11. Seward Public Works Department. Interviews, Telephone Conversations, and Correspondence with Staff, February-March 2008. 12. Chapter 4: Installation of Fluoridation Systems,excerpt from reference by South Africa Department of Health.http://www.doh.gov.za/docs]mise/fluoridation/chapter4.pdf 13. Tillman,Glenn. Water Fluoridation,1993 http://books.google.com/books?id=enclobvlQVsC&pg=PA18&lpg=PA18&dq=sodium +fluori de+satura tor&source=hklrc)ts=cI MvW5TA5h&sib=Ni12P4k8FQkX- SR5w7eriwXNiAKE#PPP1,M1 14. Water Quality and Treatment,A Handbook of Public Water Supplies, by American Water Works Association, Inc., 1971. 15. Lauer,Bill and Frederick Rubel. Water Fluoridation Principles and Practices, American Water Works Association, 2004. http://books.google.com/books?id=VRsOBBx0Nj1C&pg=PA2&lpg=PA2&dy=USP1 IS+f luoridation+goal&source=b1&ots=BKmh3evlx &sig=stKsKI UM VPEu7NGjn LsaKW U IN 6 Q#PPA2,M1 Seward Fluoridation Study 9 April 13,2009 07'11 TT (AA1