Community Water Fluoridation

Communities Can Take the Lead in Improving Oral Health

Improving Oral Health through the Fluoridation of the Community Water Supply

Water fluoridation is the single most effective and inexpensive public health measure to fight bacteria in the mouth and prevent tooth decay. Acid from bacteria eats away minerals from the tooth’s surface, making the tooth weaker and increasing the chance of developing cavities. Fluoride helps to rebuild and strengthen the tooth’s surface, or enamel.1

Through community water fluoridation, the amount of fluoride in public water supplies can be adjusted to the level optimal for preventing tooth decay. Many Louisiana residents do not have access to regular dental care4 which only heightens the importance of expanding community water fluoridation in the state. In communities with fluoridated water, residents are encouraged to drink the tap water to benefit from this added protection. 

In addition to the health benefits of community water fluoridation, there’s also an economic benefit. For every dollar spent on community water fluoridation, up to $27 is saved in treatment costs for tooth decay.3  

Only 39% of Louisiana residents receive the benefits of community water fluoridation, compared to almost 75% nationally. Does your parish have fluoridated water? 

Adjusting Public Water Systems for Community Water Fluoridation

Well-Ahead aims to help public water systems and public water system operators in the adjustment and maintenance of fluoride levels to the optimal level within the specified range. We provide information and grant funding, and in conjunction with the Office of Public Health (OPH) engineering central and district or regional offices, we provide assistance in plan review, permitting, operator training, technical help and general program oversight.

Public water system operators, health officials and interested residents can also take the free CDC Water Fluoridation Training Course designed to build the capability of state fluoridation programs and help increase knowledge and refine skills to implement and maintain community water fluoridation.

Legislation, Rules and Regulations

In July 2008, the Louisiana Legislature passed Act 761, which mandated that public water systems (PWS) with 5,000 or more 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.

The Network for Public Health Law released a summary of all state laws and regulations regarding water fluoridation in each U.S. state and select jurisdictions in Aug. 2020.

Louisiana Department of Health disseminates rules and regulations, as authorized by the state legislature, which 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.

The primary responsibility of any fluoridating public water system 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
  • Stocking adequate, properly stored chemical supplies

Public water system 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 public water system must require that their personnel responsible for the operation the fluoridation equipment be properly trained in:

  • Overall fluoridation process
  • Specifics of their particular equipment
  • Use of required safety equipment
  • Sampling, testing and proper reporting of fluoride levels
  • Actions to be taken in the event of upsets

To ensure correct and consistent operation, public water systems are encouraged to develop and adopt standard operation procedures. They 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. Public water system management and staff should also become familiar with the real risks or benefits of community water fluoridation 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 systems that are initiating community water fluoridation, Well-Ahead will notify appropriate health professionals in the distribution area. It is up to the public water system to inform the public as it sees fit. We strongly recommend using Well-Ahead for guidance and assistance with public notification.

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 the system for consistent results within regulated limits. The operator should be aware of all hazards whether to themselves, 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 or redundant, equipment does malfunction. It is the responsibility of the operator to:

  • Identify problems as they develop
  • Notify management
  • 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, standard operation procedures and emergency procedures, as well as statute requirement. Operators should also become familiar with the real risks and benefits of community water fluoridation 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.

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. Public water systems that do not fall under the mandate are required to continue fluoridation, unless the public water system 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 Water Fluoridation Principles and Practices M4, Fifth Edition.

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

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, the public water system shall provide a split sample result once per month. Half of the sample shall be tested for fluoride level by a LDH-certified laboratory, and the other half shall be tested by the public water system’s standard practice. The results shall be submitted (emailed) on the Fluoride MMR. When the monthly report is emailed LAOralHealthCoalition@la.gov, it is suggested that a “read receipt” is requested.

Each month, Well-Ahead enters reported data into the Center for Disease Control and Prevention (CDC) 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 public water system that maintains fluoride levels within the Louisiana 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 conducting inspections of public water systems for safe operation of systems. However, Well-Ahead 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 public water system 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
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.

Water Fluoridation Strategies

Nearly all public health, medical and dental organizations recommend community water fluoridation. Together, Well-Ahead and the Louisiana Oral Health Coalition increase fluoridation through the following strategies:

  • Educate communities, water system operators, local municipalities, and community and civic organizations throughout Louisiana about the importance of community water fluoridation.
  • Perform annual inspections to current fluoridating water systems to ensure safe delivery protocols.
  • Ensure systems are adhering to the regulations established in the LAC, Title 78, Subpart 5.
  • Report optimal water levels as well as all levels of fluoride in each fluoridating community to the CDC on a monthly basis.
  • Oversee the Annual Water Fluoridation Quality Award process.
  • Collaborate with Louisiana’s Safe Drinking Water Program to secure possible funding.
  • Work with state leadership for support to obtain state funding to initiate more community fluoridation.

Community Water Fluoridation Past Accomplishments

The Assumption Parish Water Works District #1 received $35,000 in 2019 from the Louisiana Department of Health Office of Public Health. The funds were used for replacing aging equipment to re-initiate fluoridation for the parish’s water system that benefitted approximately 23,000 residents.

Well-Ahead, through the National Association of County Health Officials (NACHO), contributed to water fluoridation efforts in Jefferson Parish and helped the West Jefferson Parish Public Water System receive a $14,002 grant during the second round of funding from the Centers for Disease Control and Prevention (CDC) via NACHO for aging equipment replacement.

Well-Ahead, through the National Association of County Health Officials, contributed to water fluoridation efforts in Jefferson Parish and helped the East Jefferson Parish Public Water System receive $28,610 to replace aging equipment.

Five additional Louisiana community water systems received the Annual Water Fluoridation Quality Award from the CDC, bringing the total to 18.

Thirteen Louisiana community water systems received the Annual Water Fluoridation Quality Award from the CDC.

Between 2012 and 2015, through Health Resources and Services Administration (HRSA) grant funding, Well-Ahead was able to contribute to the water fluoridation efforts in two large Louisiana communities.

  • The City of Sulphur received $100,000 to purchase the required equipment to reinitiate water fluoridation for 7,500 residents.
  • The City of Gonzales received $90,000 for necessary modifications for two wells in the city, as well as the initiation of fluoridation at a third well. This provided water fluoridation to 10,300 residents.

Legislative Mandate

Act 761 of the Louisiana 2008 Regular Session required the Louisiana Department of Health to provide funding (when available) to assist communities to initiate water fluoridation. The program depends on federal grant support, which ended in August, 2015. Currently, there is no funding to support this mandate.

Frequently Asked Questions

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Currently, there are 49 total water systems with 5,000+ water connections. Of the 49 systems, 32 systems include fluoride. There are 17 systems that include no fluoride.  

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Currently, there are 48 total water systems with 5,000+ water connections. Of the 48 systems, 31 systems do not include fluoride and 17 systems do include fluoride. In addition to the 17 systems with 5,000 or more service connections, there are 13 systems with less than 5,000 service connections that add fluoride.

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Those groundwater systems with wells containing 0.6-1.2 ppm of natural fluoride and   the ground and surface water systems that adjust their levels to the optimum as well as those consecutive systems that purchase water from systems with optimal fluoride levels.

Resources

Citations

1 Water Fluoridation Basics, Centers for Disease Control and Prevention. https://www.cdc.gov/fluoridation/basics/index.htm

2 Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries, Centers for Disease Control and Prevention.  https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm

3 An economic evaluation of community water fluoridation. Griffin SO, Jones K, Tomar SL. J Public Health Dent. 2001;61(2):78–86. https://pubmed.ncbi.nlm.nih.gov/11474918/

4 Closing the Gap on Dental HPSAs: Louisiana Oral Health Workforce Assessment, August 2018. Louisiana Department of Health. http://ldh.la.gov/assets/oph/pcrh/OH_Assessment_Report_8_31_18_final_.pdf