Community Water Fluoridation Program Report

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Community Water Fluoridation Program Report


Michigan Department of Community Health- Oral Health Program

This report is to describe activities of the Oral Health Program regarding their Community Water Fluoridation (CWF) Program. The Education/Fluoridation Coordinator is the person most involved in monitoring the objectives for this program and is the author of this report.

Community water fluoridation is the process of adjusting the natural fluoride concentration of a community’s water supply to a level that is best for the prevention of dental caries. In the United States, community water fluoridation has been the basis for the primary prevention of dental caries for many years. Grand Rapids, Michigan was the birthplace of community water fluoridation for the world and for 65 years this preventive practice has been recognized as one of the 10 great achievements in public health of the 20th century. [CDC 1999a].
In 2009 the Michigan population was 9,969,727. A large number of those individuals, 7,616,641, are served by community water systems. There are 551 community water systems providing fluoridated water to 6,898,018 people. Ninety-one percent of people on community water systems have access to fluoridated water.
The goal of the MDCH-Oral Health Community Water Fluoridation Program is to promote a quality Community Water Fluoridation Program through the State of Michigan with the Oral Health Program and the Department of Environmental Quality (DEQ), to reduce dental disease in our state.
There is a three year Interdepartmental Agreement with DEQ and MDCH. This agreement formalizes the collaboration between the two agencies to increase community water fluoridation and fluoridation surveillance measures. Working together, DEQ and MDCH have agreed to meet regularly, collect pertinent information on each water system, promote fluoridation training to all engineers and operators, encourage annual inspections of fluoridation equipment and processes, maintain safety in regards to fluoridation and promote continuation of fluoridation in community water systems.
Of significance for this report is that the State Fluoridation Advisory Committee (FAC) was moved to the Michigan Oral Health Coalition (MOHC) from MDCH for management through the coalition. It was agreed that having the advisory committee comments and recommendations coming from the coalition instead of the state department would gain credibility for the committee. The FAC is crucial for feedback and support to the Oral Health Program’s CWF program.
These were the main objectives/activities for the 09-10 CWF Program:

  1. Develop a State Fluoridation Plan that implements CDC grant requirements and submit requested reports

  2. Monitor fluoride levels on monthly basis consistent with WFRS

  3. Track progress of incorporating CDC EARWF practices

  4. Provide new or replacement equipment to communities looking to add fluoridation

  5. Meet Healthy People 2010/2020 goal of 75% of population on Community Water Fluoridation

  6. Provide education and promotion of Community Water Fluoridation

  7. Participate in Lab Proficiency Testing or equivalent

  8. Maintain all above objectives through management and at a comprehensive level that meets or exceeds Healthy People objectives

  9. Initiate a Fluoridation Coordinator with DEQ

  10. Promote testing of individual wells for fluoride levels

  11. Implement a study on fluorosis levels in the state

  12. Send survey to health departments on private well testing

  13. Develop a CWF Program evaluation plan

This report will describe each objective and give detail on the activities under each, give a time frame activities were carried out, the progress made, and the performance measures. All of these objectives will be monitored and managed by the Fluoridation Coordinator. These objectives are based on the Centers for Disease Control and Prevention (CDC) Cooperative Agreement with MDCH-Oral Health.

Objective A: Develop State Fluoridation Plan that implements CDC grant requirements and submit requested reports
We had developed a CWF workplan listing the requirement objectives but did not realize until the CDC site visit November 2009 that CDC was expecting a State Fluoridation Plan, similar to the State Oral Health Plan, with the workplan as a section of that. The Oral Health Program, with input from key stakeholders, such as the State Advisory Committee, and the DEQ immediately pooled resources and designed a plan which can be found on the Oral Health Program website
This Plan discusses infrastructure, collaborations and partners, evaluation of the program and includes the workplan objectives with activities and time frames clearly addressed. Our performance measure was to have the Plan approved by the State Fluoridation Advisory Committee. This was approved January 2010. The Plan will be updated annually and progress is currently being made to update the 2010-11 Plan. All reports and the status of the State CWF Plan are entered into the CDC reporting system, Management Overview for Logistics Analysis and Reporting, (MOLAR), on a monthly basis.

Objective B: Monitor fluoride levels on monthly basis consistent with WFRS
The state Fluoridation Coordinator currently receives monthly averages for fluoride levels from each community water system once a year from DEQ usually in February for the previous year. This is then entered into WFRS by the Fluoridation Coordinator or a student assistant. The Fluoridation Coordinator has continued to press DEQ for twice a year submissions with no success. The optimal reporting submission would be to receive these readings on a monthly basis from each water system directly to the Oral Health Program but the DEQ does not want more responsibility added to the already burdensome reports each system is currently submitting.
The Fluoridation Coordinator, after receiving the yearly reports, reviews each water system for high and low levels and reports these systems to the DEQ. It is then the DEQ’s responsibility to contact the water system and determine ways to correct the levels. Michigan fluoride level range was previously set at .9-1.5. This past year we have reset the range in WFRS to reflect .9-1.2 ppm with the optimal range at 1.0 ppm. The performance measures are to increase the number of communities receiving CDC annual awards, especially those with 12 consecutive months of optimal fluoride levels.
Awards: For 2009 we had 55 communities that achieved the CDC award for having optimal levels of fluoride for 12 consecutive months. These communities each received a certificate from CDC and a congratulatory letter from the Oral Health Program Director. Each of these water system names were displayed on a giant poster displayed at the Michigan AWWA meeting in August 2010. The Village of Dexter received the CDC Certificate of Appreciation 2009 Community Initiative Award for beginning a new fluoridation program in their community. Three systems received the Certificate of Appreciation 2009 50 Year Award: Sheridan, Frankenmuth and Yale.
Objective C: Track Progress of incorporating CDC EARWF practices
EARWF is the acronym for Engineering and Administrative Recommendations for Water Fluoridation. The DEQ has the responsibility for monitoring similar standards set by the State of Michigan. The Michigan standards closely follow the EARWF standards. These can be found in Michigan’s Suggested Practice for Water Works Part 10, Section 9- Fluoridation. The Oral Health Program receives the Sanitation Survey Report from DNRE every three years. This includes information about the status of fluoridating water systems. The annual reports from DEQ also include the names of water systems that have discontinued fluoridation or initiated new fluoridation processes.

Objective D: New or Replacement Equipment to communities looking to add fluoridation
Our first activity was to acquire funding to do this. Delta Dental had given the Varnish! Michigan program funds to help promote fluoride varnish programs across the state. Due to this program not utilizing $94,000 of the funds in 2009 we were able to move them into a new project- the Fluoridation Equipment Grant. This had full approval from Delta Dental and the MDCH Budget Department.
Our next activity was to identify all non fluoridated communities with populations over 1000. This was easily accomplished by utilizing WFRS and accessing the report on non fluoridated systems. It was much more difficult to determine which systems were in need of replacement equipment as the DEQ did not have this information. It was decided to just send the RFP out to all systems with the intent to interest those needing replacement equipment.
An RFP was released October 1, 2009 with applications due March 30, 2010. This proposal allowed communities to apply for reimbursement of fluoridation equipment costs purchased between June 1, 2010 and September 30, 2010. The RFP was sent to all systems with 1000 or over populations and with contact names and e-mail addresses. It was also posted on the Oral Health website, the Michigan Section of AWWA website, the State of Michigan website, in the newsletters of the MI AWWA and the Michigan Oral Health Coalition.
Twelve communities sent in applications with one community requesting equipment to initiate a new fluoridation program. A competitive process to review and score the applications took place April 23, 2010. From the scores collected, there were 6 communities that were allocated funds. The one community, Pinckney, that was to initiate a new fluoridation program decided to turn down the funds as it was not the total they requested. Two more communities next in line on the scoring grid were then offered the remaining funds. At the end, we awarded 7 communities fluoridation grants.

2010 Fluoridation Equipment Grantees:

Name of Community:

Award Amount Allocated:

Award Amount Used:

























The grantees have 6 months from the date of invoice submission for reimbursement to have the equipment installed, operational, and their report sent in to MDCH. As of September 30, 2010, 3 of the grantees had everything completed. The Fluoridation Coordinator is following through with the rest of the grantees to insure compliance and reporting within the allotted timeframe.

Objective E: Meet Healthy People 2010/2020 goal of 75% of population on Community Water Fluoridation
According to the 2009 WFRS 510 report for Michigan, we had 91.2% of the population in community water systems drinking fluoridated water. The DEQ reported having 91.7% of the population for this same year. We continue to exceed the target for the Healthy People Objective. Michigan continues to promote and support community water fluoridation in those areas currently not fluoridating. Through the Michigan Oral Health Coalition we had identified those communities not fluoridating and had sent information packets with studies promoting fluoridation and a copy of the Fluoridation Equipment RFP.
Objective F: Education and Promotion of Community Water Fluoridation
One of the activities under this objective was to integrate oral health education into the state trainings for operators, engineers, local water treatment directors, and utility organizations. The Fluoridation Coordinator was able to present at 5 regional meetings across the state in the spring of 2009 and presented on the benefits of a fluoridation program for their water systems. There are currently discussions to include the Fluoridation Coordinator into the state trainings on a yearly basis.
Another activity under this objective is to send at least one state district engineer each year to the CDC fluoridation training offered two times a year. We allow funding for this through the CDC Cooperative Agreement. This is an ongoing project until all district engineers in the state have taken the national training. Two Oral Health Program (OHP) contractors, Jill Moore and Lynda Horsley, were sent to the CDC training in the fall of 2009.
In the spring of 2010 we were able to send Michael Bolf, District Engineer, Grand Rapids District. Here is what Michael had to comment on the training: “As a water supply engineer, I found the training very informative and relevant to my job. The two biggest benefits of the training for me personally were a) the comprehensive examination of unsupported claims from the anti-fluoridating community and b) the explanation of how fluoride is beneficial or detrimental to the body at various concentrations. I feel much better prepared to field questions from the general public, municipal officials, or utility personnel as a result.”
In October of 2010 our new Oral Health Program Director, Chris Farrell, attended as well as Tom Kochheiser from the Michigan Dental Association.
The Oral Health Program developed a CWF brochure in 2008. In conjunction with another activity the brochures were sent to all local health departments in Michigan stating they were free while available to these health departments to distribute to the community. The Fluoridation Coordinator has distributed over 2000 of these brochures through requests from health departments, individual dental offices, and numerous conferences. There are continued requests to continue to provide these for public education.
As another ongoing activity the OHP continues to update CWF fact sheets as needed. We have a special folder in our data base that keeps current research resources, bullet point fact sheets and pertinent information that communities and the public can use to promote CWF. They are reviewed on an annual basis and updated if necessary by the OHP and the State Fluoridation Advisory Committee.
The State Fluoridation Advisory Committee is crucial for promotion and education of community water fluoridation. Our objective was to meet at least twice a year with one of those meetings face to face. The FAC has its own workplan that does, to some extent, follow the OHP workplan. We met twice in the 09-10 year and decided to better promote CWF and step that up to 4x/year for the 10-11 year. Face to face meetings will be in conjunction with the Michigan Oral Health Coalition meeting in June of each year.
Along with the State Fluoridation Advisory Committee, the OHP will continue to give support and education to communities and the public dealing with anti fluoridation issues. This is an ongoing activity depending on the needs of each community. For the 09-10 year the Fluoridation Coordinator and the FAC had representation at a Mt. Pleasant Fluoridation Task Force meeting and a city council meeting. Mt. Pleasant has a history of fighting the fluoridation program and in the summer of 2009 developed a Task Force to spend a year researching all aspects of fluoridation. The Fluoridation Coordinator attended a Task Force meeting in November 2009 and gave each member research materials and addressed questions. The Task Force then issued a report on their findings to the city council on June 14, 2010 with the Fluoridation Coordinator and three members of the FAC present. The city council heard from numerous individuals on the pros and cons of the report and yet, voted to reduce the level of fluoride in their drinking water from 1.0ppm to .4ppm. Letters from MDCH and the FAC were sent describing our disappointment in their decision.
No progress has been made to update the OHP website to include more information on CWF. There is a heading for CWF with a few resources. The 2009-10 RFP was posted as well under Grant Opportunities. Future plans would include a direct box link to store fluoridation resources and FAC agendas and minutes.

Objective G: Participate in Lab Proficiency Testing or Equivalent
The activity of this objective was to acquire the results of the state lab proficiency testing on an annual basis. This is only done in Michigan sporadically so no report was available for the 09-10 year. CDC decided to discontinue this objective for the 10-11 year.

Objective H: Maintain all above objectives through management and at a comprehensive level that meets or exceeds Healthy People objectives
The main activity under this objective was to maintain the Oral Health Program Fluoridation Coordinator position to make sure someone was responsible for carrying out the objectives. We received continued funding through the CDC Collaborative Agreement to further fund this position through 2010. Having a dedicated person follow through with the activities for each objective has been the success of our CWF program. Building relationships with DEQ, the MOHC and the FAC has been crucial to maintaining our high status for populations served from CWF.
Objective I: Fluoridation Coordinator with DEQ
This is one objective that has been a dream of the OHP. We wish there was state funding that would support the hiring of a full time fluoridation engineer with the DEQ. Other states have this position. This makes it easier to coordinate with the Oral Health program, maintain optimal fluoride levels and monitor the safety of equipment and administration. At this point no funds are available and the state budget for the foreseeable future does not appear to make this objective a reality. This objective may be removed for 2010-11 as not feasible at this time.
Objective J: Testing of individual wells for fluoride levels
Even though the majority of Michigan residents are on community drinking water systems, there are still over 2 million people living in rural areas that may not have access to fluoridated water. In order to encourage private well testing for the public we have encouraged all health departments to carry individual chemical test sample bottles to hand out to the public. A link to the state lab to obtain these sample kits is posted on the Oral Health Program website and on the Michigan Oral Health Coalition website. We sent out a survey in 2009 asking each health department whether they stock these sample kits. (See Objective L). Over 94% of health departments said they do carry these kits.
Another activity we need to pursue is to initiate a public awareness campaign to promote individual well testing in the state. The FAC has initiated some discussion on designing a brochure to inform the public on the importance of this. An informal survey was taken at the Infant Oral Health Summit October 1, 2010 to assess dental and medical care provider’s knowledge regarding their practice use of fluoride. Some of the questions asked included:

  • Are you aware what percentage of your patients drink regularly from fluoridated or from non-fluoridated water sources?  

  • Do you regularly evaluate a patient’s fluoride intake (water, toothpaste, fluoride vitamins, fluoride rinses) and discuss with the patient?

  • Do you feel well-informed enough to make recommendations to your patients regarding their (systemic or topical) fluoride exposure?

  • Do you ever prescribe fluoride drops for babies?

Presently, this information is being compiled and will be discussed at the next FAC meeting to help plan next steps. Discussion will also include ways to address this topic with the public such as newspaper articles, letters to legislators, etc.

Objective K: Study on fluorosis levels in the state
First thing we did was add questions regarding fluorosis into the 2010 Count Your Smiles Survey of 3rd graders across Michigan. Screeners were trained in identifying fluorosis and the Dean’s fluorosis index was used. Results from the 2010 Count Your Smiles Survey are not available at this time. If we discover that fluorosis is higher than the national average (28.5%- very mild) than we will determine whether a future study just on fluoride intake in the state is warranted for our state. This objective will be projected into the new 2010-11 workplan.

Objective L: Survey to Health Departments on Private Well Testing
We worked with a University of Michigan Dental Hygiene student who designed a survey to assess the current knowledge and procedures of all Michigan local health departments regarding fluoride levels and well water testing. The survey consisted of questions which assessed the knowledge of fluoride levels and well water testing, types of questions asked by the public to health departments regarding water testing, and the availability of the public to obtain water sample bottles and results.
“The residents of Michigan will benefit from this project because it will be identified and promoted where people need to go to gain access to well water testing kits, how to use the kits, and obtain results. The MDCH will benefit because it specifically aligns with the Michigan’s Oral Health Plan’s strategies for preventing oral diseases and their community water fluoridation work plan that has an objective, “Testing of individual wells for fluoride levels.” (From the cover letter to the health departments accompanying the survey October 2009). The survey was mailed to all local health departments in October of 2009 accompanied with a CWF brochure described in objective F. The survey was also offered online through Survey Monkey.

Some Results:

This information was shared with the Advisory Committee and the DNRE. No epidemiological support was available at the time to make conclusions or recommendations.

Objective M: CWF Program Evaluation
The activity for this objective was to get an evaluation plan in place for the CWF program. Evaluation objectives were developed for the Oral Health Community Water Fluoridation Program by an Oral Health Program Coordinator and currently our evaluation person. The 09-10 CWF Evaluation Plan was ready by September 2010 and is based on the MDCH- OHP evaluation plan. There are 11 evaluation objectives with three general questions to answer as a summary. Updates to the Plan are under way for 2010-11.
Each objective describes:

  • What type of data is needed

  • Where the data will come from

  • How the data will be collected

  • When the data will be collected

  • What will be done with the data

  • How and when results will be shared

  • Who is responsible for each evaluation objective

  • If and when evaluation objective was completed and by whom

Our performance measure was to have this plan in place by September 2010 and that has been accomplished. In the new 2010-11 CWF workplan more detailed evaluation activities will be described.

Changes to Community Water Fluoridation in Michigan for the 2009-2010 fiscal year: (From the DEQ Fluoride Progress Report November 2010)

  • The City of West Branch started feeding fluoride again in 2010. They had stopped feeding in 2008 when they connected their system to the West Branch Township system, which was non fluoridating.

  • Marine City resumed feeding fluoride in September 2010 after having stopped feeding in May 2009.

  • Mt. Pleasant did not stop feeding fluoride but reduced the feed rate to 0.4 mg/l on the recommendations of a task force.

  • Munising stopped feeding fluoride during a major water system construction project in 2009. The city council has recently voted to resume feeding fluoride but first it will need to purchase new feed equipment.

  • Forsyth Township/Gwinn officially stopped feeding fluoride by council vote. They have not feed fluoride for several years.

Looking Ahead:
The work plan for the Oral Health Program Community Water Fluoridation Program for 2010-11 will have similar objectives as this past year:

  • We are currently updating the CWF Plan

  • We are continuing to collaborate with the Michigan Department of Environmental Quality, the Michigan Oral Health Coalition and the State Fluoridation Advisory Committee

  • We will continue to work with DEQ on acquiring fluoride levels for each water system and monitoring of safety issues

  • We do have funding for another fluoridation equipment RFP that was released October 1, 2010

  • Efforts will continue to exceed the Healthy People objective of 75% population on fluoridated drinking water

  • Promotion and education of CWF will continue to remain a top focus

  • Plans to begin a public awareness campaign to educate on testing private wells have begun.

  • We will determine if a further study to address fluorosis levels in the state needs to be developed.

  • From the evaluation of the 09-10 program adjustments and changes will be made to better enable the OHP to improve its CWF program

For further information on the Michigan Oral Health Community Water Fluoridation Program please check our website: or contact:

Susan Deming, RDH, RDA, BS

Education/Fluoridation Coordinator

MDCH- Oral Health

P.O. Box 30195

Lansing, MI 48909

517 373-3624

Fluoridation Program Report 09-10

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