Community Water Fluoridation

Community water fluoridation is the adjusting of naturally occuring fluoride in public drinking water to a level that best offers maximum protection against tooth decay for all residents. It has been proven to be a safe, effective and inexpensive way to promote good oral health. It's been in practice since 1945 and is considered one of the 10 great health achievements of the 20th century. The CDC states that, "for every $1 a community invests in water fluoridation, $20 are saved in dental treatments." In communities with fluoridated water, residents are encouraged to drink the tap water to benefit from this added protection.

Why Community Water Fluoridation (CWF)? 

Fluoridated water improves the oral health, and therefore the general health, of the people of Louisiana. A Basic Screening Survey (2016-2018) of third grade children in Louisiana revealed that:

  • 26.2% of third grade children had untreated cavities, compared to 16.2% nationally
  • 56% had dental caries experience, compared to 51.7% nationally and
  • 28.7% had sealants present, compared to 40.7% nationally.
  • Only 23.1% of the children were referred to a dentist for early treatment or urgent care. 

In Louisiana, only 44% of residents receive the benefits of community water fluoridation, compared to almost 75% nationally. Here are the parishes with fluoridated water. Act 761, passed in 2008, mandates that water systems with over 5,000 connections initiate water fluoridation. These water systems are eligible for community water fluoridation. 

Because Louisiana's children have poorer oral health than the national average, communities are encouraged to provide the protection of water fluoridation to help prevent tooth decay. Well-Ahead's Oral Health Program works with partners and communities throughout the state to increase access to optimally fluoridated water. 

 

Fluoridation Toolkit for Adjusting Public Water Systems

The purpose of this Fluoridation Toolkit for Adjusting Public Water Systems is to assist public water systems and public water system (PWS) operators in the adjustment and maintenance of fluoride levels to the optimal level within the specified range by helping them to better understand what is required of them by rule and by providing information resources, contact information, procedures and guidance. Hard copy updates and revisions will be supplied as the need arises. PWS operators, health officials and interested residents can also take the CDC's Water Fluoridation Training Course for free.

 

Legislation, Rules and Regulations

In July 2008, the Louisiana Legislature passed Act 761, which mandated that public water systems (PWS) with more than 5,000 service connections fluoridate their water. The mandate was conditional on the State locating and providing funding for the engineering, procurement and construction of the required facilities as well as the fluoride chemical for the first six months of operation. The law also authorized the Louisiana Department of Health (LDH) to rewrite rules and regulations governing fluoridation. Fluoridation rules and regulations can be found in the Louisiana Administrative Code (LAC) Title 48:V.1101, 1303-1315 and LAC 51:XII.317. These rules became effective Jan. 20, 2010.

LA Department of Health Responsibilities

It is the responsibility of the Louisiana Department of Health to promote community water fluoridation with the intent of increasing the number of Louisianans that receive optimally fluoridated drinking water for improving oral health in the state. To that end, LDH promulgates rules and regulations, as authorized by the state legislature, that are intended to ensure that fluoridating public water systems are delivering optimally fluoridated drinking water in a consistent and safe manner.

The current rules: 

  • define optimal fluoride levels 
  • regulate equipment design parameters 
  • require certain operator safety equipment and
  • require daily sampling of fluoride levels and monthly reporting of these samples.

In addition, the rules also define the present mandate concurrent with the state’s responsibility to identify funds for the implementation of the mandate. Louisiana’s CWF Program is housed within the Louisiana Office of Public Health's Well-Ahead Louisiana Oral Health Program, and the Fluoridation Monitor and Program Manager oversee the program's work. It is the program’s responsibility to provide information, grant funding, assistance in plan review, permitting, operator training, technical help and general program oversight. Plan review, permitting and operator training are done in conjunction with the Office of Public Health (OPH) engineering central and district/regional offices.

Fluoridating Public Water Systems Responsibilities

The primary responsibility of any fluoridating public water system (PWS) is to make every effort to ensure the safe, effective and consistent delivery of optimally fluoridated water. This effort should include:

  • proper equipment design and installation
  • correct equipment operation
  • regular equipment maintenance and
  • stocking adequate, properly stored chemical supplies.

PWS management, their technical representatives and operators should be familiar with the Ten State Standards, as well as the additional requirements of LAC Title 48:V.1101, 1303-1315.

A PWS must require that their personnel responsible for the operation the fluoridation equipment be properly trained in:

  • the overall fluoridation process
  • the specifics of their particular equipment
  • the use of required safety equipment
  • the sampling, testing and proper reporting of fluoride levels, and
  • actions to be taken in the event of upsets.

To ensure correct and consistent operation, PWS are encouraged to develop and adopt Standard Operation Procedures (SOPs). SOPs should include not only routine procedures, but also actions to be taken in case of accidents, spills or overfeeds. 

The CDC’s Recommended Fluoride Overfeed Actions for Public Water Systems (adapted for use in Louisiana) provides guidance. PWS management and staff should also become familiar with the real risks/benefits of CWF in such a way that any public concerns, fears or misconceptions can be addressed in an informed manner. The American Dental Association’s Fluoridation Facts is an excellent publication that addresses most questions. A hard copy can be provided upon request.

For public water systemss that are initiating CWF, the program will notify appropriate health professionals in the distribution area. It is up to the PWS, however, to inform the public as it sees fit. Well-Ahead's Oral Health program can provide guidance and assistance with public notification and strongly recommends that the PWS utilize the Oral Health team to help develop the process.

Operator Responsibilities

The operator is a critical link in the safe, effective and consistent delivery of optimally fluoridated drinking water. It is the responsibility of the operator to completely understand and safely operate his/her system for consistent results within regulated limits. The operator should be aware of all hazards whether to him/her personally, to the environment (as in the case of a spill), to the public, or in the event of a misfeed. 

Although it is designed to be fail-safe and/or redundant, equipment does malfunction. It is the responsibility of the operator to:

  • Identify problems as they develop
  • Notify management and
  • Assist in the planning of corrective actions.

The operator is also responsible for their personal safety; they should understand the specific dangers of mishandling fluoridation chemicals and should know and use the required safety equipment. The operator should be properly trained in the sampling and, as required, the testing and reporting of fluoride levels to the program.

Operators should be very familiar with procedures, SOPs and emergency procedures, as well as statute requirement. Operators should also become familiar with the real risks and benefits of CWF in such a way that any public concerns, fears or misconceptions can be addressed in an informed manner. The American Dental Association’s Fluoridation Facts addresses most questions. A hard copy can be provided upon request.

Continued Operation; Engineering & Operational Guides

Requirement for Continued Operation

Public water systems that have more than 5,000 service connections that were fluoridating prior to Act 761 are required by rule to continue until a public referendum is held in accordance with the Act's provisions. PWS that do not fall under the mandate are required to continue fluoridation, unless the PWS governing body resolves to discontinue in accordance with the Act’s provisions. Grant funds may be available to assist public water systems to continue fluoridation. 

Engineering and Operational Guides

Any new fluoridation installation or modification of an existing installation must be designed in accordance with the Recommended Standards for Water Works, 2003 Edition (aka the “Ten State Standards”). Additional requirements are put forth in LAC Title 48:V.1101, 1303-1315.

Other excellent sources of information are the CDC’s Morbidity and Mortality Weekly Report Engineering and Administrative Recommendations for Water Fluoridation 1995 and the American Water Works Association's (AWWA) Water Fluoridation Principles and Practices M4, Fifth Edition.

Optimal Fluoride Level

The optimal level for fluoride was determined by over 70 years of scientific study, which has shown that people who consume optimally fluoridated water have between 20% and 40% fewer cavities than those who do not consume optimally fluoridated water. 

The optimal fluoride level for the state is 0.7 mg/L or ppm, or as determined by the CDC. Any daily value between 0.6 and 1.2 mg/L or ppm is considered to be in the optimal range. Should the fluoride level exceed 4.0 mg/L or ppm, the level violates the Environmental Protection Agency's (EPA) Maximum Contaminant Level (MCL), and Safe Drinking Water regulations mandate that the violation be reported. Should the level of fluoride exceed 4.0 mg/L or ppm, the EPA requires that the level be reduced to 2.0 mg/L or ppm prior to consumption. The Secondary Maximum Contaminant Level is 2.0mg/L or ppm.

Reporting and Inspections

Reporting

Daily reporting of fluoride levels shall be measured and recorded each day at a location that is representative of the distributed water. These daily records shall be kept and reported to the program on the Fluoride Monthly Monitoring Report Form (MMR). The report should be sent to LAOralHealthCoalition@la.gov each month before the 10th day after the close of the month.   

Also once per month, the public water system shall provide a split sample result. Half of the sample shall be tested for fluoride level by a LDH-certified laboratory: the other half shall be tested by the PWS’s standard practice. The results shall be submitted (emailed or sent) on the Fluoride MMR, which may be submitted online. If the monthly report is emailed to the fluoridation engineer/monitor, it is suggested that a “read receipt” is requested. Each month, the Oral Health program enters reported data into the CDC’s national database, the Water Fluoride Reporting System (WFRS). The public has limited access to this data through a webpage entitled, My Water’s Fluoride.

Each year, the CDC presents a certificate to each PWS that maintains fluoride levels within the optimum range (0.6-1.2 ppm) for the previous 12 consecutive months. These reporting requirements are specific only for fluoride levels below the EPA’s MCL of 4.0 mg/L.

Inspections

Louisiana Department of Health's Safe Drinking Water program is responsible for conducing inspections of public water systems for safe operation of systems. However, Well-Ahead Louisiana's Oral Health program also conducts periodic inspections to public water systems to assess fluoridation facilities and activities. The inspections results are reported on the Fluoride Inspection Report and provided to public water systems.

If there are conditions discovered that indicates out of compliance, a PWS is notified, and corrective action assistance is provided. Any system upgrade or modification must go through the same approval process as a new installation. The water system should not modify an existing system without prior approval.

Actions in Case of Overfeeds or Ingestion

Actions In Case of Overfeeds
Refer to the Louisiana-specific CDC’s Recommended Overfeed Actions for Public Water Systems. A public water system should list their particular contact information on the form where required.

Actions in Case of Ingestion
Refer to the CDC’s Recommended Emergency Actions for Persons Who Ingest Fluorosilicic Acid and Recommended Emergency Actions for Persons Who Ingest Dry Fluoride Chemicals.
 

For more information, contact Mechaune Butler, Oral Health program manager, at mechaune.butlter@la.gov