Oral Health as a Critical Public Health Challenge: Q&A with CDC’s Barbara Gooch
Late last year the Grand Rounds program of the U.S. Centers for Disease Control and Prevention (CDC) held a webinar on water fluoridation, a public health intervention that has been a priority in the United States for nearly seventy years.
Fluoridation, which has been shown to significantly reduce cavities in children, has been recognized by the CDC as one of 10 great public health achievements of the 20th century. Despite the benefits such as cost savings, however, CDC says there are ongoing challenges in promoting and expanding fluoridation.
NewPublicHealth recently spoke with Barbara Gooch, DMD, MPH, Associate Director for Science in the Division of Oral Health at CDC’s National Center for Chronic Disease Prevention and Health Promotion, about the challenges and benefits of water fluoridation and other emerging oral health improvement opportunities.
NewPublicHealth: What has been the historical impact of fluoridating water in the United States?
Dr. Barbara Gooch: All water generally contains fluoride, but usually at a level too low to prevent tooth decay, so community water fluoridation is a controlled adjustment of fluoride in a public water supply to an optimum concentration for the prevention of tooth decay.
That optimal concentration has historically been set at about 1 milligram (mg) of fluoride per liter of water, or 1 part per million. Fluoride was first introduced in the United States in Grand Rapids, Mich., in 1945. For cities that implemented community water fluoridation in the 1940s and 1950s, there was a dramatic reduction in tooth decay among children. Sometimes that reduction was greater than 50 percent. It has really been a major factor leading to the improvement in U.S. oral health.
When we compare the National Health and Nutrition Examination Survey done in the early 1970s with one conducted from 1999 to 2004, we found that the percentage of adolescents with one or more decayed teeth decreased from 90 percent in the early 1970s to 60 percent in the ’99-’04 National Survey. And while the number of teeth affected by tooth decay was an average of six in the 1970s survey, the instance was reduced to fewer than three in the later survey.
NPH: There are other sources of fluoride now, such as toothpaste. Is community water fluoridation still important?
Gooch: Current studies indicate that community water fluoridation increases the prevention of tooth decay by an additional 25 percent despite other sources. But the other very important factor about community water fluoridation is in order to receive its benefits, if you live in a fluoridated community. all you have to do is drink the tap water. And we can also show cost savings. One study estimates that for every dollar spent on community water fluoridation, you save about $38 in dental treatment costs.
NPH: What concerns have been raised?
Gooch: There have been concerns raised regarding adverse health effects related to fluoride in water, and there have been a number of reviews over the years by panels of scientists both in public health and in related fields that have continued to conclude that community water fluoridation is both safe and effective. A very comprehensive review by the National Research Council (NRC) of the Institute of Medicine that looked at much higher levels of fluoride in water than the levels communities add—2-4 mg of fluoride—and concluded that the only adverse health effect related to those higher levels that had strong evidence to report it was severe dental fluorosis—staining and irregularities in the tooth enamel. The vast majority of dental fluorosis that occurs in this country is very mild to mild; the more severe fluorosis the NRC commented on is virtually zero.
And it isn’t just community water fluoridation that has contributed to dental fluorosis. We have noted with this increased availability of other sources of fluoride such as fluoride toothpaste, mouth rinses or supplements that there has been an increase in the prevalence or occurrence of dental fluorosis in younger persons in the United States, and we certainly think that that is associated with the availability of other fluoride sources.
The U.S. Department of Health and Human Services has issued a proposed recommendation that the level of fluoride in water for optimal water fluoridation be set at a new national target of 0.7 mg per liter or parts per million—slightly lower than the current recommendation. Another intervention that also forms part of those plans at the community level is for children to receive dental sealants on their teeth, particularly on the pits and grooves. And we are promoting school-based sealant programs as well.
NPH: Oral health often takes a back seat to other health issues. What benefits do you most often share to point out how important it is?
Gooch: We always maintain here at CDC and throughout dental public health that good oral health—a mouth and teeth without cavities or other oral diseases—is an essential component of good overall health. Having healthy teeth improves our ability to speak and smell, smile, taste, swallow and convey our feelings and emotions, which is very important in terms of interacting with others both professionally and personally. For the most part the oral health of most children and adults in the United States actually is better than ever. But for some of our most vulnerable citizens—certainly families living underneath the federal poverty level and some members of racial and ethnic minority groups—maintaining a healthy mouth and teeth certainly can be challenging.
There are steps in place to improve oral health for children through the Affordable Care Act, and we’re going to be working with our federal partners in the coming year to have a sense of how many more children have been able to receive preventive dental services, including both fluoride and dental sealants. One key partner is the Children’s Dental Health Project, whose board includes industry, academic and public health representatives, and whose goal is to help policymakers and oral health advocates identify innovative, cost-effective strategies for improving children’s oral health.
And, for the first time, the national health objectives for the nation, Healthy People 2020, has chosen an oral health objective as one of the leading health indicators. The leading health indicators are selected to communicate high priority health issues. The selected oral health objective focuses on increasing the use of dental services because currently less than half of Americans aged two and older had a dental visit in the past year. The target for this objective in 2020 is 49 percent.