Dr Charles Gardner Medical Officer of Health Muskoka

Dr. Charles Gardner, Medical Officer of Health, Muskoka Simcoe Dental Society May 11 th, 2017 Community Water Fluoridation Pursuing a Legacy of Healthy Teeth in Simcoe Muskoka

Overview • Public Health and Community Water Fluoridation (CWF) • Status of CWF in Simcoe Muskoka • Advocacy for Provincially mandated CWF

Decay has a substantial burden of illness • Tooth decay is the most common childhood health condition – Recent Ontario study: there are more ER visits for non-traumatic dental problems than for diabetes and high blood pressure diseases 1 – Dental and other infections – not only affect teeth and gums, but there’s potential for spread to other parts of mouth and face • Studies have shown that poor oral health impacts children’s development: • • • 1 Community Limits food choices Impairs speech development Repeated absences from school Trouble concentrating or learning Loss of self-esteem (appearance and poor school performance) Dentistry and Oral Epidemiology, August 2009 University of Toronto, Faculty of Dentistry. Water Fluoridation; Questions and Answers (April 2012).

What is fluoride and fluoridation? • Fluoride is a mineral that naturally occurs in rocks, soil, and water. • Hydrofluorosilicic acid used for CWF. Produced during phosphate production – National Sanitation Foundation standards. • Fluoridation: adding fluoride to municipal water supply to the concentration range to optimize dental benefits while avoiding adverse effects. • Health Canada • Maximum Allowable Concentration is 1. 5 parts per million. (mg/L) • Recommended 0. 7 mg/L for dental benefits. • Supported by measurements of fluoride consumption rates for children and adults.

The Effectiveness and Safety of CWF: Systematic Reviews • Water fluoridation to prevent tooth decay • Health effects of water fluoridation: An evidence review • Water fluoridation: Health monitoring report for England 2014 • Health effects of water fluoridation: A review of the scientific evidence • Guidelines for Canadian Drinking Water Quality: Guideline Technical Document - Fluoride Iheozor-Ejiofor et al. Cochrane Database of Systematic Reviews, 2015 Health Research Board, 2015 Public Health England, 2014 Prepared by The Royal Society of New Zealand TA, 2014 Prepared by the Federal-Provincial-Territorial Committee on Health and the Environment, 2010 • • Health Canada Expert Panel, 2007. • A Systematic Review of the Efficacy and Safety of Fluoridation Water Fluoridation: An Analysis of the Heath Benefits and Risks Institut National de Sante Publique Du Quebec, 2007 National Health and Medical Research Council, Australian Government, 2007

Effectiveness of CWF • Review of studies comparing communities with and without community water fluoridation, meeting selection criteria for relevance and quality • Outcomes: – 35 original studies (2 systematic reviews): before-after, cross sectional, prospective / retrospective cohort, time series studies – 14. 3% - 15. 5% increase in children free of dental decay – Reduction of 2. 61 decayed / missing / filled teeth per child A Systematic Review of the Efficacy and Safety of Fluoridation. National Health and Medical Research Council, Australian Government, 2007

CWF: Tooth Decay and Social Deprivation British Fluoridation Society, One in a Million: the facts about water fluoridation. 3 rd Ed. March 2012. www. bfsweb. org/onemillion 2012. html

Prevalence of Tooth Decay: Simcoe Muskoka

CWF Safety • The evidence does not support a link between exposure to fluoride in drinking water at 1. 5 ppm and any adverse health effects, including: – – – Cancer Immunotoxicity Reproductive / developmental toxicity Genotoxicity Fractures / skeletal fluorosis Neurotoxicity / intelligence • Studies of communities in China, Mexico – high fluoride concentrations, other causal factors (eg. lead, iodine) not reported • “There are significant concerns regarding the available studies, including quality, credibility, and methodological weaknesses. ” Fluoride in Drinking Water. Prepared by the Federal-Provincial-Territorial Committee on Drinking Water. Health Canada. Comment period ended November 27, 2009: http: //www. hc-sc. gc. ca/ewh-semt/consult/_2009/fluoride-fluorure/draft-ebauche-eng. php#t 5 Critical review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridating agents of drinking water. Scientific Committee on Health and Environmental Risks. European Commission. 2010.

Dental fluorosis Proportion of population with fluorosis of aesthetic concern by water fluoride concentration (plotted on untransformed scale because of linear association between this and log (odds) of “aesthetic fluorosis”). Each circle represents a study area in which the proportion of people with fluorosis is estimated—the larger the circle, the higher the precision of the estimate. Source: Systematic review of water fluoridation. BMJ 2000; 321; . Mc. Donagh, M. et al.

Support for community water fluoridation Ontario • • Chief Medical Officer of Health of Ontario Royal College of Dental Surgeons of Ontario Canada International • Health Canada • • Public Health Agency of Canada World Health Organization (WHO) • Canadian Association of Public Health Dentistry Pan American Health Organization (PAHO) • Centers for Disease Control and Prevention (CDC) • • Ontario Dental Association • Ontario Association of Public Health Dentistry • Canadian Dental Association • College of Dental Hygienists of Ontario • Canadian Dental Hygienists Association • Recent US Surgeon General’s Report • Ontario Medical Association • Canadian Pediatric Society • • Canadian Cancer Society Federation Dentaire Internationale (FDI) Association of Local Public Health Agencies (al. PHa) • Canadian Public Health Association • American Cancer Society • American Medical / Dental Associations •

CWF Public Support in Simcoe Muskoka

Opposition issues – 1950 to today • Health Allegations: – – • Fluoride accumulates in the body; Allergies, environmental toxicity; Carcinogenic, cause of cancer, kidney disease, skeletal fluorosis; Damages intelligence Industrial Allegations: – It’s a “toxic hazardous waste product of the aluminum and fertilizer industries”; a means for industry to get rid of toxic waste which is very expensive to get rid of properly • Civil Libertarian Issues: – A conflict between individual rights and the common good; – Forced “medication” without consent (legal challenges raised) • Led by: (a minority of) doctors, dentists, researchers; alternative medical practitioners; health food store operators; members of religious and political minority groups

Declining Fluoridation Coverage in ON • 1945: First Canadian City – Brantford, Ontario • 2016: 67. 3% of Ontario’s population received fluoridated community water (Ontario Ministry of the Environment) – 1945 - 1962: Brantford – Stratford – Sarnia study Reviewed and Maintained • • • Atikokan Norfolk County Toronto Hamilton Peel Halton London Carleton Place Cornwall West Nipissing • • Petrolia Lambton Shores Point Edward Warwick Georgian Bay Township Muskoka Lakes Township Gravenhurst Reviewed and Not Commenced • • • Thunder Bay Dryden Orillia CWF Discontinued • • • Niagara Region Waterloo Lakeshore Amherstburg Windsor Tottenham Muskoka District Lake of Bays Township Huntsville

Simcoe Muskoka: Oral Health Concerns in 2009 Data Sources: Dental Indices Survey, extracted August 2008 and SMDHU Screening Data (2009 -2011) Results from the 1993 -94 Ontario Dental Health Indices Survey. PHERO 1996: 355 -35. Ontario Association of Public Health Dentistry (OAPHD) Survey of Ontario Health Units, August 2008.

Fluoridation / Dental Caries in Ontario: 2009

CWF in Simcoe Muskoka: 2009 vs 2014 • Please place a map with the coverage in 2008, showing its presence in the following locations – Tottenham – Base Borden – All of Muskoka

Losing Fluoridation in Tottenham • Only CWF ever in Simcoe (apart from federal Base Borden) • Commenced in Tottenham in 1973 – Advocacy local dentist, Dr. Gerry Ross • 2009: CWF opposition by a New Tecumseth councilor, after reading our focus report – Initial council support for CWF discontinuation – CWF successfully defended by SMDHU, Dr. Ito (with local data), Dr. Keith Morley, Dr. Peter Cooney • 2013: Challenged again by same councilor – Unsuccessful joint response (including Dr. Gerry Ross) – Discontinued on October 15, 2013

Comparison of Dental Decay in 7 -Year-Olds from Tottenham and rest of New Tecumseth 2007 -08 Dental Index Tottenham New Tecumseth (N = 24) (excluding Tottenham) (N = 87) DMFT 1. 67 2. 16 % Caries Free 16 54% 49%

Not Gaining Fluoridation in Orillia • Orillia never fluoridated; – Unsuccessfully promoted by community dentists in 1960’s and 1980’s • March 9, 2009 City of Orillia motion to review CWF • SMDHU presentation to new council – Tour of Gravenhurst facility – June 27, 2011 – endorsed review process with City staff • Community engagement and consultation +++ (SMDS Jan/12) • Orillia staff report and motion supportive of CWF – Council defeated motion in July 16 th, 2012

Orillia’s high rate of child dental decay

Elevated severe dental decay in Orillia

Muskoka: Losses and Successes • Local fluoridation commenced between 1988 and 2004 – District bylaw, 2003 • SMDHU presentations to District Council in response to challenge in April 2011, and October 21, 2013 – Oct 21 Council decision to strike District CWF bylaw • Engagement of Area Municipalities – January 20, 2014 District Council Bylaw NO. 2014 -2 – continued CWF in Bracebridge, Gravenhurst, Townships of Georgian Bay and Muskoka Lakes • September, 2016 – motion to Muskoka Lakes Council to discontinue CWF – Presentations (SMDHU and Dr. Eric Luks) successful in overturning, September 16

Protecting CWF: Mandated by State/ National Governments • Jurisdictions that have legislated fluoridation at the state, territorial or national level of government have been much more effective in providing CWF to their respective municipal populations – with resulting reductions in dental decay. • USA – 13 States, DC, Puerto Rico mandate CWF – California: increase in population coverage from 17% in 1995 to 62. 5% in 2011 • Australia – 7 of 9 States mandate CWF. 80% population fluoridated – Queensland increased population coverage from 5% in 2008 to 86% in 2012 – has since discontinued state mandated CWF resulting in 18 municipalities discontinuing CWF. Countries Mandating CWF: • • • Brazil Hong Kong Singapore Ireland Malaysia Israel (until 2014)

Motion of the SMDHU Board of Health / al. PHa: 2014 • NOW THEREFORE BE IT RESOLVED THAT the Province of Ontario should amend regulations of the Safe Drinking Water Act requiring community water fluoridation for all municipal water systems (when source-water levels are below the Health Canada-recommended level of 0. 7 mg/L) to prevent dental caries; • AND FURTHER THAT the Province should provide the funding and technical support to municipalities required for community water fluoridation.

Provincial Statements of Support • January 7, 2016, Minister of Health and Chief Medical Officer of Health letter of support to municipal councils for CWF • October 06, 2016 private member’s motion (MPP Bob Delaney) ongoing “That, in the opinion of this House, the Province of Ontario… …act to replace the outdated Fluoridation Act with an updated section of the Health Protection and Promotion Act… …the Province of Ontario work with municipalities to provide financial and technical assistance… …to begin water fluoridation”.

Conclusions • CWF is a safe and effective way to reduce dental caries, particularly for vulnerable children • It is increasingly difficult to maintain CWF with rising organized and dedicated opposition • Ontario has had a high population coverage of CWF – but is losing coverage in recent years • In the past decade, Simcoe Muskoka has been losing its very limited CWF coverage, despite our collective best efforts • Many have made the case for CWF to be provincially mandated