Water fluoridation

pissing fluoridization ABSTRACT The risklessty and energy of peeing fluoridisation has been a topic of great controversy passim Americas communities. Scientific evidence has shown that ingesting dainty(a) to adjudge directs of fluoride bathroom take in the alveolar fountainheadness of a confederation, especi eachy those races in a community that may be classified as having piteous socioeconomic status. Children in all firmaments, just now oddly those with low SES, ar at greatest guess for develop alveolar consonant cavity and having a community weewee fluoridation program (CWFP) willing alleviate them reduce their alveolar consonant consonant pit. Moderation of fluoride wasting indisposition for individuals is the key. Low to moderate daily inlet of fluoride, averaging 1.0 mg/ liter per twenty-four hour period is optimum. alveolar consonant and skeletal fluorosis laughingstock occur if ingestion levels atomic number 18 great than 3.0 mg/lite r per day for grand periods of term. This is a discussion on the safety and readiness of weewee system fluoridation. INTRODUCTIONThis commentary constitutes the on-going controversy on community water fluoridation in the unite States, and I will attempt to analyze science-based evidence in support of water fluoridation. thither eat up always been questions on the safety and efficacy of fluoride in inebriety water, some school of view believes that fluoridation has some wayward do to exposed human cosmoss, especially in infants and electric razorren. A nonher school of thought believes that water fluoridation is essential in preventing tooth annihilation, and therefore the practice should be sustained. According to the Center for Disease Control and streak (CDC) water fluoridation is champion of the 10 great public wellness achievements of the 20th light speed in the United States (CDC, 1999), which is attributable for increased lifespan of Ameri discharges by 25 lo ng time ( Bunker et al., 1994). This paper will discuss science-based evidence that proves the efficacy and safety of water fluoridation among children as well as learn some recommendations to the various stakeholders. come in STATEMENT Water fluoridation is the valuation account of the submergence level to the optimally regulated level of which the of course occurring fluoride typifys in public or community drinkable water supplies. In approximately cases, deflouridation is needed when the naturally occurring fluoride level exceeds recommended limits. The recommended fluoride assimilation in crapulence water by the U.S. common Health Service (PHS) is 0.7-1.2mg/L, to nucleusively prevent alveolar consonant enclosed space and minimize the occurrence of alveolar fluorosis (NRC, 2006). Low decay order were base to be associated with continuous purpose of water with fluoride content of 1ppm (Meskin, 1995). there has been serious questions as to the efficacy of fluori de intervention in preventing twain tooth decay, as it benefit is said to be merely cosmetic or topical (CDC, 1999). Such topical effect of fluoride kindle be achieved by the use tooth without the pretending the over motion picture from ingested fluoride (NRC, 2006). However, it has similarly been describe that fluoride exposure provides both placementic and topical protection. Ingested fluoride deposited on tooth surface during tooth formation, and fluoride deported in spittle provides long-lasting systemic protection against stand tooth decay than topical application using tooth paste or fluoride foams (CDC, 2001). WHAT IS FLUORIDEFluoride is a naturally occurring element. It is found in rocks and soil everywhere. Fluoride lot be found in fresh water and ocean water. Naturally occurring fluoride levels ranges from 0.1ppm to over 12ppm (NRC, 2006).Fluoride is present in the customary diets of people and in most portable water sources. The comely dietary intake of fluorid e is approximately 0.5mg daily from either naturally occurring fluoride in the water or the fluoride found in produce. It is also a normal comp nonp arilnt of tooth ornament and deck out studies shit shown that the calcified tissues of both grace and bone ar made up of a combination of hydroxyl- and fluor-apatites of alter composition depending on the abundance of fluoride at the site of formation. These tissues are the virtuoso sites of deposition of fluoride (NRC, 2006). HOW FLUORIDE PREVENTS AND CONTROLS DENTAL CARIES disfiguremental caries is an infectious, transmissible disease in which bacterial by-products (i.e., acids) dissolve the hard surfaces of teeth. Unchecked, the bacteria can move into the dissolved surface, attack the underlying dentin, and reach the soft pulp tissue. Dental caries can provide in loss of tooth structure, pain, and tooth loss and can progress to acute systemic infection. Cryogenic bacteria (i.e., bacteria that seduce dental consonant con sonant caries) reside in dental plaque, a sticky organic fertiliser matrix of bacteria, food debris, dead mucosal cells, and spitry components that adheres to tooth ornament. Plaque also represents minerals, in the main calcium and phosphorus, as well as proteins, polysaccharides, carbohydrates, and lipids. Cryogenic bacteria colonize on tooth surfaces and produce polysaccharides that enhance adherence of the plaque to grace. leftfield undisturbed, plaque will grow and harbor increasing numbers of cryogenic bacteria. An initial step in the formation of a carious lesion takes dwelling house when cryogenic bacteria in dental plaque metabolize a substrate from the diet (e.g., sugars and another(prenominal)wise fermentable carbohydrates) and the acid produced as a metabolic by-product demineralizes (i.e., begins to dissolve) the adjacent decorate crystal surface (CDC,2009). demineralisation involves the loss of calcium, phosphate, and carbonate. These minerals can be capture d by surrounding plaque and be available for reuptake by the enamel surface. Fluoride, when present in the let out, is also retained and concentrated in plaque. Fluoride works to control early dental caries in several ways. Fluoride concentrated in plaque and saliva inhibits the demineralization of strong enamel and enhances the remineralization (i.e., recovery) of demineralized enamel (Featherstone, 1999 Koulourides, 1990). As cryogenic bacteria metabolize carbohydrates and produce acid, fluoride is released from dental plaque in response to lower pH at the tooth-plaque interface. The released fluoride and the fluoride present in saliva are then taken up, along with calcium and phosphate, by de-mineralized enamel to establish an alter enamel crystal structure. This amend structure is more than acid repelling and contains more fluoride and less carbonate (Featherstone, 1999). Fluoride is more readily taken up by demineralized enamel than by sound enamel. Cycles of demineral ization and remineralization hap passim the lifetime of the tooth. Fluoride also inhibits dental caries by affecting the operation of cryogenic bacteria. As fluoride concentrates in dental plaque, it inhibits the process by which cryogenic bacteria metabolize carbohydrates to produce acid and affects bacterial deed of viscous polysaccharides. In laboratory studies, when a low submersion of fluoride is constantly present, one type of cryogenic bacteria, Streptococcus mutans, produces less acid. Whether this reduced acid production reduces the carcinogenicity of these bacteria in domain is unclear (Van Loveren, 1990). Saliva is a major(ip) carrier of topical fluoride. The con inexorableion of fluoride in ductal saliva, as it is secreted from salivary glands, is low approximately 0.016 parts per million (ppm) in areas where inebriety water is fluoridated and 0.006ppm in non fluoridated areas. This concentration of fluoride is non likely to affect cryogenic activity. Howeve r, drinking fluoridated water, copse with fluoride toothpaste, or using other fluoride dental products can raise the concentration of fluoride in saliva present in the mouth 100- to 1,000-fold. The concentration returns to introductory levels within 12 hours but, during this time, saliva serves as an important source of fluoride for concentration in plaque and for tooth remineralization (Murray,1993). Applying fluoride gel or other products containing a racy concentration of fluoride to the teeth leaves a temporary layer of calcium fluoride-like actual on the enamel surface. The fluoride in this material is released when the pH drops in the mouth in response to acid production and is available to remineralize enamel. In the soonest days of fluoride research, investigators hypothesized that fluoride affects enamel and inhibits dental caries only when incorporated into developing dental enamel (i.e., pre pyrogenicly, before the tooth erupts into the mouth) (Murray,1993). Evidenc e supports this hypothesis, but distinguishing a on-key preeruptive effect after teeth erupt into a mouth where topical fluoride exposure occurs regularly is difficult. However, a high fluoride concentration in sound enamel cannot exclusively explain the marked reduction in dental caries that fluoride produces . The prevalence of dental caries in a population is not inversely related to the concentration of fluoride in enamel, and a higher(prenominal) concentration of enamel fluoride is not necessarily more efficacious in preventing dental caries (Mcdonagh etal.,2000). The laboratory and epidemiologic research that has led to the reform understanding of how fluoride prevents dental caries indicates that fluorides predominant effect is post eruptive and topical and that the effect depends on fluoride being in the right bill in the right place at the right time. Fluoride works primarily after teeth have erupted, especially when small inwardnesss are keep constantly in the mout h, specifically in dental plaque and saliva (Mcdonagh etal., 2000). Thus, adults also benefit from fluoride, rather than only children, as was previously assumed. happen FOR DENTAL CARIES The prevalence and severity of dental caries in the United States have decreased substantially during the preceding 3 decades. topic surveys have report that the prevalence of whatsoever dental caries among children decrepit 1217 years declined from 90.4% in 19711974 to 67% in 19881991 severity (measured as the hateful number of decayed, missing, or filled teeth) declined from 6.2 to 2.8 during this period (Burt, 1989). These decreases in caries prevalence and severity have been uneven across the general population the effect of disease now is concentrated among certain groups and persons. For example, 80% of the dental caries in permanent teeth of U.S. children aged 517 years occurs among 25% of those children. Populations believed to be at increased find for dental caries are those with low socioeconomic status (SES) or low levels of parental education, those who do not seek regular dental care, and those without dental insurance or feeler to dental services (Meskin,1995). Persons can be at high risk for dental caries even if they do not have these recognise factors. Children and adults who are at low risk for dental caries can maintain that status through frequent exposure to small amounts of fluoride (e.g., drinking fluoridated water and using fluoride toothpaste). Children and adults at high risk for dental caries baron benefit from additional exposure to fluoride (e.g., mouth rinse, dietary supplements, and professionally applied products). All available information on risk factors should be postulateed before a group or person is identified as being at low or high risk for dental caries. However, when classification is uncertain, treating a person as high risk is heady until further information or experience allows a more hi-fi assessment. This assumpti on increases the immediate cost of caries taproom or handling and might increase the risk for enamel fluorosis for children aged NATIONAL GUIDELINES FOR FLUORIDE use PHS recommendations for fluoride use include an optimally ad erected concentration of fluoride in community drinking water to maximize caries legal community and limit enamel fluorosis. This concentration ranges from 0.7ppm to 1.2ppm depending on the average maximum daily air temperature of the area (PHS, 1991). In 1991, PHS also issued policy and research recommendations for fluoride use. The U.S. environmental Protection role (EPA), which is responsible for the safety and quality of drinking water in the United States, sets a maximum allowable limit for fluoride in community drinking water at 4ppm and a secondary limit (i.e., non-enforceable guideline) at 2ppm (EPA,1998). The U.S. victuals and Drug Administration (FDA) is responsible for approving prescription and over-the-counter fluoride products marketed in t he United States and for setting standards for noticeing bottled water and over-the-counter fluoride products (e.g., toothpaste and mouth rinse) (adenosine deaminase,2007). Nonfederal agencies also have published guidelines on fluoride use. The American Dental Association (ADA) reviews fluoride products for caries prevention through its voluntary Seal of Acceptance program accepted products are listed in the ADA Guide to Dental Therapeutics (ADA, 2007). A dosage inventory for fluoride supplements for infants and children aged 16 years, which is scaled to the fluoride concentration in the community drinking water, has been jointly recommended by ADA, the American Academy of Pediatric Dentistry (AAPD), and the American Academy of Pediatrics (AAP) (Meskin,1995). In 1997, the Institute of Medicine published age-specific recommendations for congeries dietary intake of fluoride. These recommendations list adequate intake to prevent dental caries and tolerable upper intake, defined as a level unlikely to pose risk for adverse effects in approximately all persons. COST-EFFECTIVENESS OF FLUORIDE MODALITIES Documented effectiveness is the most basic requirement for providing a wellness-care service and an important prerequisite for preventive services (e.g., caries-preventive modalities). However, effectiveness alone is not a sufficient reason to initiate a service. new(prenominal) factors, including cost, must be considered. A mode is more cost-effective when deemed a less expensive way, from among competing alternatives, of meeting a stated objective (Garcia,1989). In public health planning, determination of the most cost-effective alternative for prevention is essential to using scarce resources efficiently. Dental-insurance carriers are also interested in cost-effectiveness so they can help purchasers use funds efficiently. Because half of dental expenditures are out of pocket (Garcia, 1989), this topic interests patients and their dentists as well. Potentia l receipts to quality of life is also a consideration. The contribution of a wholesome dentition to quality of life at any age has not been quantified, but is probably valued by most persons. Although solid info on the cost-effectiveness of fluoride modalities alone and in combination are needed, this information is scarce. In 1989, the Cost Effectiveness of Caries Prevention in Dental Public Health shop, which was attended by health economists, epidemiologists, and dental public health professionals, attempted to assess the cost-effectiveness of caries-preventive approaches available in the United States (Downer et al., 1981). biotic community Water fluoridation Health economists at the 1989 workshop on cost-effectiveness of caries prevention calculated that the average annual cost of water fluoridation in the United States was $0.51 per person (range $0.12$5.41) (Burt, 1989). In 1999 dollars, this cost would be $0.72 per person (range $0.17$7.62). Factors report to influenc e the per capita cost included size of the community (the larger the population reached, the lower the per capita cost) number of fluoride injection points in the water translate system amount and type of system feeder and monitoring equipment used amount and type of fluoride chemical used, its price, and its cost of transportation and storage and expertise of staff office at the water plant. When the effects of caries are repaired, the price of the homecoming is based on the number of tooth surfaces affected. A tooth can have caries at 1 location (i.e., surface), so the number of surfaces saved is a more appropriate measure in calculating cost-effectiveness than the number of teeth with caries. The 1989 workshop participants concluded that water fluoridation is one of the few public health measures that results in true cost conservations (i.e., the measure saves more bills than it costs to operate) in the United States, water fluoridation cost an estimated average of $3.35 per carious surface saved ($4.71 in 1999 dollars). Even under the to the lowest degree favorable assumptions in 1989 (i.e., cities with populations A Scottish study conducted in 1980 reported that community water fluoridation resulted in a 49% saving in dental treatment costs for children aged 45 years and a 54% saving for children aged 1112 years (Downer et al., 1981). These savings were hold even after the secular decline in the prevalence of dental caries was recognized. The effect of community water fluoridation on the costs of dental care for adults is less clear. This topic cannot be fully explored until the generations who grew up drinking optimally fluoridated water are older. School Water Fluoridation Costs for school water fluoridation are similar to those of any public water supply system serving a small population (i.e., Assessment of the Adverse Health Effects of fluorideEvidence of the adverse health effects of prolonged exposure to high concentrations of fluoride are well documented by several peer reviewed studies, which are examined in this paper. higher(prenominal) concentrations of total ingested fluoride from potential sources like drinking water, food and beverages, dental-hygiene products such as toothpaste, and pesticide residues can have adverse health effects on humans (NRC, 2006). Some of the adverse health effects of fluoride in drinking water are enamel fluorosis, skeletal fluorosis, bone cancer and bone die. (NRC, 2006, PHS, 1991). Fluorosis is caused chiefly by the ingestion of fluoride in drinking water (Viswanathan et al., 2009). Fluoride has high rachis affinity for developing enamel and as such high concentration of cumulative fluoride during tooth formation can lead to enamel fluorosis, a dental condition from mild to laborious form characterized by brown stains, enamel loss and surface pitting (DenBesten Thariani, 1992). These dental effects are believed to be caused by the effects of fluoride on the breakdown rates of early-secreted matrix proteins, and on the rates at which the degraded by-products are withdrawn from the maturing enamel (Aoba Fejerskov, 2002). Children are much more at risk of enamel fluorosis, especially in their critical period from 6 to 8 years of age, than adults. Fluoride uptake into enamel is possible only as a result of concomitant enamel dissolution, such as caries development (Fejerskov, Larsen, Richards, Baelum, 1994). There is a 10% prevalence of enamel fluorosis among U.S. children in communities with water fluoride concentrations at or well-nigh the EPAs MCLG of 4 mg/L (NRC, 2006). The CDC estimates that 32% of U.S. children are diagnosed with dental fluorosis (CDC, 2005). Today, there are convincing evidence that enamel fluorosis is a toxic effect of fluoride intake, and that its severe forms can produce adverse dental effects, and not just adverse cosmetic effects in humans (NRC, 2006). Burt and Eklund (1999) states The most severe forms of fluorosis manifest as heavily stained, pitted, and friable enamel that can result in loss of dental function. Epidemiological data from both observational and clinical studies have been examined. Sowers, Whitford, Clark Jannausch (2005) investigated prospectively for four years bone fracture in relation to fluoride concentrations in drinking water in a cohort study, by meter serum fluoride concentrations and bone density of the hip, radius, and spine. The authors reported higher serum fluoride concentrations in the communities with fluoride concentrations at 4 mg/L in drinking water and higher osteoporotic fracture rates in the high fluoride areas that were similar to those in their previous studies in 1986 and 1991. It is unclear in their recent study whether existing factors in the population like smoking rates, hormone replacement and physical activity were examined as potential cofounders for fractures. continence serum fluoride concentrations are considered a good measure of long-term exposure and of bone fluoride concentrations (Whitford, 1994 Clarkson et al., 2000). Findings by the Sowers studies were complemented in several ways by Li et al. (2001) in a retrospective cohort ecologic study. The combined findings of Sowers et al. (2005) and Li et al., (2001) lend support to the biological gradients of exposures and fracture risk between 1 and 4 mg/L of fluoride concentration. Evidently, the physiological effect of fluoride on bone quality and the fractures observed in the referenced animal studies are tenacious with the effects found in the observational studies. RECOMMENDATIONSBefore promoting a fluoride modality or combination of modalities, the dental-care or other health-care provider must consider a persons or groups risk for dental caries, current use of other fluoride sources, and potential for enamel fluorosis. Although these recommendations are based on assessments of caries risk as low or high, the health-care provider might also evidence among patients at h igh risk and provide more intensive interventions as needed. Also, a risk category can change over time the type and frequency of preventive interventions should be adjusted accordingly. Continue and plow Fluoridation of Community Drinking Water Community water fluoridation is a safe, effective, and inexpensive way to prevent dental caries. This modality benefits persons in all age groups and of all SES, including those difficult to reach through other public health programs and private dental care (CDC, 2001a). Community water fluoridation also is the most cost-effective way to prevent tooth decay among populations living in areas with adequate community water supply systems. subsequence of community water fluoridation for these populations and its adoption in additional U.S. communities are the foundation for sound caries-prevention programs. In contrast, the appropriateness of fluoridating stand-alone water systems that supply individual schools is limited. Widespread use of fluoride toothpaste, availability of other fluoride modalities that can be delivered in the school setting, and the current environment of low caries prevalence limit the appropriateness of fluoridating school drinking water at 4.5 measure the optimal concentration for community drinking water. Decisions to initiate or continue school fluoridation programs should be based on an assessment of present caries risk in the target school(s), alternative preventive modalities that might be available, and periodic evaluation of program effectiveness (CDC, 2001a). Frequently physical exercise Small Amounts of Fluoride All persons should receive frequent exposure to small amounts of fluoride, which minimizes dental caries by inhibiting demineralization of tooth enamel and facilitating tooth remineralization. This exposure can be readily accomplished by drinking water with an optimal fluoride concentration and brushing with fluoride toothpaste twice daily(CDC, 2001a). Supervise Use of Fluo ride Toothpaste among Children Aged Childrens teeth should be cleaned daily from the time the teeth erupt in the mouth. Parents and caregivers should consult a dentist or other health-care provider before introducing a child aged Use an Alternative Source of Water for Children Aged 8 Years Whose Primary Drinking Water Contains 2 ppm Fluoride In some regions in the United States, community water supply systems and home wells contain a natural concentration of fluoride 2ppm. At this concentration, children aged 8 years are at increased risk for developing enamel fluorosis, including the moderate and severe forms, and should have an alternative source of drinking water, preferably one containing fluoride at an optimal concentration. In areas where community water supply systems contain 2ppm but 8 years. For families receiving water from home wells, testing is necessary to get word the natural fluoride concentration (CDC, 2001a). Label the Fluoride Concentration of Bottled Water Prod ucers of bottled water should label the fluoride concentration of their products. Such labeling will allow consumers to make informed decisions and dentists, dental hygienists, and other health-care professionals to appropriately advise patients regarding fluoride intake and use of fluoride products (CDC, 2001). CONCLUDING POSITION STATEMENTWhen used appropriately, fluoride is a safe and effective agent that can be used to prevent and control dental caries. Fluoride has contributed profoundly to the improved dental health of persons in the United States and other countries. Fluoride is needed regularly throughout life to protect teeth against tooth decay. To ensure additional gains in oral health, water fluoridation should be extended to additional communities, and fluoride toothpaste should be used widely. Adoption of these and other recommendations in this paper could lead to substantial savings in public and private resources without compromising fluorides substantial benefit o f improved dental health. What is consistent from the literature review is the fact that infants and children are much more at risk of overexposure and the development of adverse health effects. A community water fluoridation program (CWFP) is very safe and efficient, not only in terms of reducing dental caries, but also on the communitys budget (CDC, 2001a). A CWFP can especially help those communities who have populations in the low SES category. These populations have children whose parents or guardians dont always have access to dental insurance and so regular dental checkups to substantiation the dental caries is not always an option. Reducing dental caries before they lead into more extreme oral morbidity can be very beneficial to these children. Implementing a fluoridated water program can also be beneficial to a whole community in terms of saving communities thousands and millions of dollars. Implementing a water program would follow strict guidelines set by the EPA, so th e optimum level of fluoride would be followed, staying in the range of 0.7 to 1.2, where people would ingest no more than an average of 1 mg/liter of fluoride per day. Moderation is the key. There are studies confirming that ingestion of fluoride greater than the optimum level could produce dental fluorosis. Though unconfirmed by studies, individual reports have even suggested that ingestion of fluoride 8 mg/liter per day over a long period of time could produce skeletal fluorosis. However, with proper surveillance and reporting of fluoride in water systems, the greater population could be served, increasing the dental health of all individuals, especially the youth and saving dollars from excessive health care costs (ADA, 2009). Remember, a little prevention now can go a long way later. 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