1. Fluoridation InitiativeCity of Kalispell Public Works Department
Post Office Box 1997, Kalispell, Montana 59903-1997 - Telephone (406)758-7720, Fax (406)758-7831
MEMORANDUM
August 22, 2002
To: Chris A. Kukulski, City Manager
From: James C. Hansz, PE, Director of Public Works/City
Subject: Fluoridation of Kalispell Water Supply
Over the past several months there has been a steady effort to win public support for the general
fluoridation of the Kalispell water supply. In order to equip the City Council with factual data regarding
costs to implement this proposal I asked staff to research the issue. Copies of their data are attached.
Fluoride compounds are frequently found in water supplies and usually originate from natural
sources. Many Montana communities have fluoride in their water supplies. In western Montana we
usually find small quantities of natural fluoride. In Kalispell the natural concentration is one -tenth part per
million (0.1 PPM). The most often stated optimum level for improved dental health is 1.0 PPM, so the
natural level in Kalispell is roughly one -tenth this recommendation.
The November election ballot will include a question to decide whether the City should
implement a program for general fluoridation of the public water supply. Should this measure pass the
City will incur costs to set up and to operate a fluoride treatment system. The City presently adds a small
amount of chlorine to the water to ensure its safety from the time it leaves the well until it is drawn from
the consumer's tap. This program began a few years ago so we have excellent records of the costs
incurred to construct and maintain the required systems, perform all the required tests, maintain records
and report to regulatory agencies. These are itemized in the accompanying May 13, 2002, memorandum
from Joni Emrick and Ben Van Dyke (Attachment 1). In summary, the costs are as follows:
Equipment and Set Up
$7,368
Construction of Dosing Facilities
$30,750
Annual Operation/Maintenance
$40,740
Approximate First Year Cost
$78,858
Approximate Annual Cost Thereafter
$40,740
Facilities construction costs are significant because each City water source (five sites) must be
equipped to inject the fluoride compound. Unlike larger cities, Kalispell does not have a central water
Fluoridation of Drinking Water
treatment plant where all the process work is done before delivering water to the system. Of the costs
shown above, the initial equipment cost is a semi recurring cost because of the need to replace equipment
items over time. The recurrence interval varies with the item but the approximate annual cost is reflected
in the accompanying itemized estimate for equipment maintenance. Fluoridation is similar to the
chlorination process in that it requires duplication of all the same systems used for chlorination. The
City's existing pumping facilities are presently fully occupied with chlorine equipment and storage tanks.
And, like chlorine (sodium hypochlorite solution), fluoride (fluorosilicic acid) is hazardous and requires
special handling and storage precautions. The American Water Works Association has developed a
manual of practice to guide public water system operators with fluoridation so all these requirements are
well known.
In addition to the dollar costs of setting up and operating a fluoridation system, there are
significant other obligations. Addition of fluoride requires continuous monitoring, significant record
keeping and submittal of reports. USEPA considers fluoride to be a contaminant that we are required to
monitor and report its presence to the public via our annual Consumer Confidence Report (CCR,
attachment 2). The desirable operating range for fluoridation is 0.7 PPM to 1.2 PPM with the AW WA
recommended amount being 1.0 PPM. If an equipment failure or other problem causes an excursion to or
above the action level of 2.0 PPM we are required to notify each customer and issue public notices stating
the problem and the precautionary measures to be taken by water consumers (Attachment 3). This
violation must also be reported in the annual CCR. The approximate costs of this would roughly equal
what we presently pay to deliver an annual CCR to each customer. This is approximately $4,000.00, but
would only be required if the fluoride concentration reached the action level specified by USEPA.
These costs may appear to be high, but they track well with the range of costs suggested by the
National Institute of Health (Attachment 4) for communities the size of Kalispell. Cost is further
influenced by the need to treat 100% of the water delivered to consumers, even though roughly 95% of
the water is used for purposes other than drinking, i.e., bathing, irrigation, sanitation.
Attachments:
1. May 13, 2002 Internal Memorandum on Costs
2. CY 2001 Consumer Confidence Report Test Results for Kalispell Water System
3. Example of Notification Letter if Dosages Exceed Recommended Maximum (AW WA)
4. National Institute of Health, NIDCR Statement on Fluoridation, With Cost Ranges
Fluoridation ofDrmking Water
P
MEMORANDUM
DATE: May 13, 2002
TO: Jim Hansz, Public Works Director
FROM: Ben Van Dyke/Joni Emrick(
RE: Costs of fluoridation: set up, operation, and construction; existing fluoride programs;
regulatory and other consequences
The following are estimated costs for chemical (fluoride) feed and testing equipment:
5 pumps $3,581.60
5 - 165 gal. polyethylene tanks with valves & stands 1,632.65
5 — Misc. fittings, injector, tubing 1,083.85
Installation cost, 16 hours @ $45.00/hr. 720.00
1 - Colorimeter testing apparatus 350.00
TOTAL SET UP COST $7,368.10
The costs below are estimates to operate the system on a yearly basis, assuming costs as
stated and no new construction or additional personnel:
Monitoring, observing, recordkeeping: 7 hrs/wk, $30/hr
$10,920.00
Maintenance: 2 hrs/wk, $30/hr
3,120.00
Testing: 3 hrs/wk, $30/hr
4,680.00
Safety & Training: 1 hr/wk, $30/hr
1,560.00
Reporting & Compliance: 2 hrs/wk, $30/hr
3,120.00
Annual maintenance: pump parts, valves, fittings
1,000.00
Reagents for testing: 3,650 tests + standards
3,000.00
Check sample with the State: 1/mo.
240.00
Fluorosilicic Acid @$0.2641 per pound, delivered
13,100.00
YEARLY OPERATING COST
$40,740.00
The above cost assumes use of existing space in the 5 buildings. If modification is
required, the following is the estimated price for the additional space:
City Building Dept. residential structure cost @$61.50 sq.ft.
10 X 10 masonry block buildings at Armory, Depot, Buffalo,
Grandview & NoNsinger
CONSTRUCTION COST $30,750.00
Building cost could be 100% higher due to engineering @15% for design, bidding, and
state approval, containment for chemical, corrosive proof electrical and plumbing,
`- ,
ventilation fans, safety alarms, wash down proof buildings, setting up equipment in a
small space, special corrosion resistant sealants and paints, and connecting and attaching
to existing structures.
Existing fluoride programs:
The State Department of Public Health and Human Services has a once a week program
called "swish day" for kindergarten through 120' grade. They provide fluoride and cups
to the Flathead County Health Department, who in turn has volunteers administering the
0.2% sodium fluoride dosage to the students. The State pays the cost, less than $0.50 per
student per school year. If City fluoridated water is approved, this program will be
dropped.
Regulatory Consequences:
The optimum fluoride level is a target concentration of 1.0 ppm. According to the State
Department of Environmental Quality (DEQ), if Kalispell were to exceed 2 ppm in any
fluoride test, it would be required to issue public notification to effected customers. This
could be by letter or more practically through the news media. Regardless of the method,
the effected public must be notified of the concentration measured and the health effects
as outlined in the attached notification. Kalispell will have an increased chance of such
public notifications because unlike most cities we would have 5 entry points and
therefore 5 measuring points instead of just 1. Exceeding the 4 ppm MCL is, according
to DEQ, still not considered a violation if it is immediately corrected; it does trigger the
above public health notification.
Other options and consequences:
Options for parents: Parents can discuss possible fluoride supplementation for their
children with their doctor and dentist.
A City fluoride program would force customers not wanting to drink fluoridated water to
purchase bottled water. In addition, a very small percentage of the fluoridated water will
be used for children's teeth as most of the water is used by older adults, and for cooking,
toilets, and lawn sprinkling.
2001 Laboratory Testing Results
The table below lists laboratory testing results for the City of Kalispell water during the past
year. The items listed were the only ones detected from a monitoring list of about 80 regulated
substances, which have Maximum Contaminant Levels (MCLs) established by the Safe Drinking
Water Act. Testing is not required for each parameter every year. No substance was detected
at a concentration that exceeded the Environmental Protection Agency limits for safe
water.
Detected
Contaminant
Sample
Year
Level
Detected
Range of
Detections
Unit of
Measurement
MCL
MCLG
Violation
Yes/No
Barium
2001
0.1
ND - 0.1
ppm
2
2
No
Copper
2001
0.09
0.02 - 0.11
m
AL = 1.3
1.3
No
Di(2-etbylhexyl)
Phthalate
2001
2.9721
ND- 10
ppb
6
0
No
Fluoride
2001
0.1
ND - 0.1
IYPM
4
4
No
Lead
2001
7
ppb
AL = 15
0
No
Nitrate
(as Nitrogen)
2001
0.94tND
45 - 0.94
m
10
10
No
TTHMS (total
trihalomethanes)
2001
0.73'l
-1.9
ppb
80
N/A
No
1) 90- percentile value
2) Annual average
3) Highest annual average
Key to terms: Level detected is sometimes the highest amount detected and sometimes an average of all detected
amounts from samples tested throughout the year. ND: Not detected at testing limit. ppm: Parts per million or
milligrams per liter, equivalent to 1 penny in $10,000. ppb: Parts per billion or micrograms per liter, equivalent to
1 penny in $10,000,000. MCL (Maximum Contaminant Level): The highest level of a contaminant that is allowed
in drinking water. MCLs are set as close to the MCLGs as feasible using the best available treatment technology.
MCLG (Maximum Contaminant Level Goal): The level of a contaminant in drinking water below which there is no
known or expected risk to health. MCLGs allow for a margin of safety. AL (Action Level): The concentration of a
contaminant which, if exceeded, triggers treatment or other requirements which a water system must follow. N/A:
Not applicable.
Likely sources of contaminants listed in the table:
Barium Discharge of drilling wastes; discharge from metal refineries; erosion of natural
deposits
Copper Corrosion of household plumbing systems; erosion of natural deposits; leaching from
wood preservatives
Di(2ethylhexyl) phthalate Sampling error: plastic bucket used to collect sample
Fluoride Erosion of natural deposits; water additive which promotes strong teeth (not added in
Kalispell); discharge from fertilizer and aluminum factories
Lead Corrosion of household plumbing systems; erosion of natural deposits
Nitrate Rumoff from fertilizer use; leaching from septic tanks, sewage; erosion of natural
deposits
TTHMs By-product of drinking water chlorination
Bacteriological monitoring is performed monthly to test for the presence of coliform bacteria, fecal
coliform, and E.coli. Our system collects 15 samples monthly. No bacteriological contamination was
reported in 2001.
Questions or concerns about your drinking water?
If after reviewing this report you have questions regarding your drinking water, please call Joni Enuick at
758-7817; Write or visit the Department of Public Works, City Hall, P.O. Box 1997, 312 First Avenue
East, Kalispell, Mt. 59903; Attend a regular City Council meeting on the first and third Monday of each
month at 7:00 P.M. in the City Hall.
558 HANDBOOK OF DRINKING WATER QUALITY
Public Notice
Dear User,
The U.S. Environmental Protection Agency requires that we send you this
notice on the level of fluoride in your drinking water. The drinking water in
your community has a fluoride concentration OF __ milligrams per li ter
(mg/L)-
Federal regulations require that fluoride, which occurs naturally in your
water supply, not exceed a concentration of 4.0 mg/L in drinking water. This
is an enforceable standard called a Maximum Contaminant Uwe] (MCL).
and it has been established to protect the public health. Exposure to drink-
ing water levels above 4.0 mg/L for many years may result in some cases of
crippling skeletal fluorosis, which is a serious bone disorder.
Federal law also requires that we notify you when monitoring indicates
that the fluoride in your drinking water exceeds 2.0 ing/L. This is intended
to alert families about dental problems that might affect children under nine
years of age. The fluoride concentration of your water exceeds this federal
guideline.
Fluoride in children's drinking water at levels of approximately 1 mg/L
reduces the number of dental cavities. However, some children exposed to
... levels of fluoride greater than about 2.0 mg/L may develop dental fluorosis
Dental fluorosis, in its moderate anal severe forms, is a brown staining and/or
pitting of the permanent teeth.
Because dental fluorosis occurs only when developing teeth (before thev
erupt from the gams) are exposed !o elevated fluoride levels. households
without children are not expected to be affected by this level of fluoride.
Families with children under the age of nine are encouraged to seek other
sources of drinking water for their children to avoid the possibility of stain-
ing and pitting.
Your water supplier can lower the concentration of fluoride in your water
so that you will still receive the benefits of cavity prevention while the
possibility of stained and pitted teeth is minimized.
Removal of fluoride may increase your water costs. Treatment systcros are
also commercially available for home use. Information on such systems is
available at the address given below. Low fluoride bottled drinking water
that would meet all standards is also commercially available.
For further information. contact'- at your water system.
'PWS shall insert the compliance result which triggered notification under [his Part.
2PWS shall insert the name, address, and telephone number of a contael petsomat the I'WS.
1-4iuu C (rrmter-rnenaty version) Page 1 of 2
National Institute of Dental & Craniofacial Research
Statement on Water Fluoridation
http:llwww.nidcr.nih.gov
June 2000
Community water fluoridation is a public health effort that benefits millions of Americans. For more
than half a century, water fluoridation has helped improve the quality of life in the U.S. through reduced
pain and suffering related to tooth decay, reduced tooth loss, reduced time lost from school and work,
and less money spent on dental care.
The National Institute of Dental and Craniofacial Research continues to support water fluoridation as a
safe and effective method of preventing tooth decay in people of all ages. One significant advantage of
water fluoridation is that anyone, regardless of socioeconomic level, can enjoy its benefits during their
daily lives -- at work, school, and play -- simply by drinking fluoridated water or beverages prepared
with fluoridated water. Within the U.S., fluoridated drinking water is also the most cost-effective
method for preventing tooth decay.
Efficacy. The effectiveness of water fluoridation has been well documented in the scientific literature.
Even before the first community fluoridation program began in 1945, epidemiologic data from the 1930s
and 1940s revealed a lower prevalence of tooth decay in children who consumed naturally occurring
fluoridated water, compared to children who had consumed fluoride -deficient water. Since that time,
numerous studies have proven fluoride's effectiveness in decay prevention in the primary teeth of infants
and children, as well as in the permanent teeth of children, adolescents and adults, including senior
citizens.
Safety. As with other nutrients, fluoride is safe and effective when used and consumed properly. After
more than 50 years of research and practical experience -- as well as data evaluation by the U.S.
government, committees of experts, and national and international health organizations -- the verdict
remains the same: fluoridating community water supplies, at optimal levels, is an effective and safe
method for preventing tooth decay. Moreover, no credible scientific evidence supports an association
between fluoridated water and conditions such as cancer, bone fracture, Down's syndrome, or heart
disease as claimed by some opponents of water fluoridation.
Cost-effectiveness.Community water fluoridation is presently the most cost-effective method for
preventing tooth decay. On average, it costs less than $1 annually per person to fluoridate community
water systems serving most people in this country. The costs range from an average of 68 cents per
person annually in communities with populations larger than 50,000, to an average of $3.00 per person
annually in communities of fewer than 10,000 (1999 dollars).
Equity. Despite a decrease in overall decay rates during the past two decades, tooth decay is still a
significant oral health problem, especially in certain segments of the population. People of low
socioeconomic status suffer from a disproportionate burden of tooth decay. They also have less access
than those with higher incomes to professional oral health services and other sources of fluoride, like
gels and tablets. Water fluoridation helps reduce such oral health disparities.
Back to Fluoride
http://www.nidr.nih.govlscriptslp£asp?ref—�http://www.nidr.nih.govlhealthlwaterFluoridation.... 8/23/02
CDC
/VMWR`�'i
MORBIDITY AND MORTALITY
WEEKLY REPORT
Ac�1,�st 1� 2001 Vol, K No. RR-14
Recommendations
and
Reports
Recommendations for Using Fluoride
to Prevent and Control Dental Caries
in the United States
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention (CDC)
Atlanta, GA 30333
Vol. 50 / No. RR-14 MMWR
3
The safety off I uo ride, which has been documented comprehensively by other scientific
and public health organizations (e.g., PHS [81, National Research Council [91, World
Health Organization [ 101, and Institute of Medicine [ 111) is not addressed.
HOW FLUORIDE PREVENTS AND CONTROLS DENTAL CARIES
Dental caries is an infectious, transmissible disease in which bacterial by-products
(i.e., acids) dissolve the hard surfaces of teeth. Unchecked, the bacteria can penetrate the
dissolved surface, attack the underlying dentin, and reach the soft pulp tissue. Dental
caries can result in loss of tooth structure, pain, and tooth loss and can progressto acute
systemic infection.
Cariogenic bacteria (i.e., bacteria that cause dental caries) reside in dental plaque, a
sticky organic matrix of bacteria, food debris, dead mucosal cells, and salivary compo-
nents that adheres to tooth enamel. Plaque also contains minerals, primarily calcium and
phosphorus, as well as proteins, polysaccharides, carbohydrates, and lipids. Cariogenic
bacteria colonize on tooth surfaces and produce polysaccharides that enhance adher-
ence of the plaque to enamel. Left undisturbed, plaque will grow and harbor increasing
numbers of cariogenic bacteria. An initial step in the formation of a carious lesion takes
place when cariogenic bacteria in dental plaque metabolize a substrate from the diet
(e.g,, sugars and other fermentable carbohydrates) and the acid produced as a metabolic
by-product demineralizes (i.e., begins to dissolve) the adjacent enamel crystal surface
(Figure 1). Demineralization involves the loss of calcium, phosphate, and carbonate.
These minerals can be captured by surrounding plaque and be available for reuptake by
the enamel surface. Fluoride, when present in the mouth, is also retained and concen-
trated in plaque.
Fluoride works to control early dental caries in several ways. Fluoride concentrated
in plaque and saliva inhibits the demineralization of sound enamel and enhances the
remineralization (i.e., recovery) of demineralized enamel (12,13). As cariogenic bacteria
metabolize carbohydrates and produce acid, fluoride is released from dental plaque in
response to lowered pH atthe tooth -plaque interface (14). The released fluoride and the
fluoride present in saliva are then taken up, along with calcium and phosphate, by de -
mineralized enamel to establish an improved enamel crystal structure. This improved
structure is more acid resistant and contains more fluoride and less carbonate (12,15-
19) (Figure 1). Fluoride is more readily taken up by demineralized enamel than by sound
enamel (20). Cycles of demineralization and remineralization continue throughout the
lifetime of the tooth.
Fluoride also inhibits dental caries by affecting the activity of cariogenic bacteria. As
fluoride concentrates in dental plaque, it inhibits the process bywhich cariogenic bacte-
ria metabolize carbohydrates to produce acid and affects bacterial production of adhe-
sive polysaccharides (21). In laboratory studies, when a low concentration of fluoride is
constantly present, one type of cariogenic bacteria, Streptococcus mutans, produces
less acid (22-25). Whether this reduced acid production reduces the cariogenicity of
these bacteria in humans is unclear (26).
Saliva is a major carrier of topical fluoride. The concentration of fluoride in ductal
saliva, as it is secreted from salivary glands, is low — approximately 0.016 parts per
million (ppm) in areas where drinking water is fluoridated and 0.006 ppm in nonfluoridated
areas (27). This concentration of fluoride is not likely to affect cariogenic activity. How-
ever, drinking fluoridated water, brushing with fluoride toothpaste, or using otherfluoride
4 MMWR August 17, 2001
FIGURE 1. The demineralization and remineralization processes lead to remineralized
enamel crystals with surfaces rich in fluoride and lower in solubility
Demineralization
Acid
A}Calcium
Enamel Crystal- /phosphete
Carbonated Apatite
10001"
�� Carbonate
Partly Dissolved
Enamel Crystal
Remineralization
Calcium
iS111>:1Y�1�1�11Phosphate
111�1111111V �Nl
111Y w
Fluoride
illgl.
_ Enamel Crystal
�11��11V ♦,
���.
11l�"
�1111�>.•11 �1 i1N11�
�1N111N A11.1111`
�)111111�11J111J`
i1111��1i111�Gti1�,
��
Fluors
i� .. .. W
ii1ii11ilvii\111i1
Source: Adapted from Featherstone JDB. Prevention and reversal of dental caries: role of low
level fluoride. Community Dent Oral Epidemiol 1999;27:31-40. Reprinted with permission
from Munksgaard International Publishers Ltd., Copenhagen, Denmark.
dental products can raise the concentration of fluoride in saliva present in the mouth 100-
to 1,000-fold. The concentration returns to previous levels within 1-2 hours but, during
this time, saliva serves as an important source of fluoride for concentration in plaque and
for tooth remineralization (28).
Applying fluoride gel or other products containing a high concentration of fluoride to
the teeth leaves a temporary layer of calcium fluoride -like material on the enamel sur-
face. The fluoride in this material is released when the pH drops in the mouth in response
to acid production and is available to remineralize enamel,(29 ).
In the earliest days of fluoride research, investigators hypothesized that fluoride af-
fects enamel and inhibitsdental caries only when incorporated into developing dental
enamel (i.e„ preeruptively; before the tooth erupts into the mouth) (30,39 ). Evidence
supports this hypothesis (32-34 ), but distinguishing a true prear4ptive effect after teeth
erupt into a mouth where topical fluoride exposure occurs regularly is difficult. However,
a high fluoride concentration in sound enamel cannot alone explain the marked reduction
in dental caries that fluoride ,produces (35,36), The prevalence of dental caries in a
Population is not inversely related to the concentration of luonde`in enamel (3� ), and<a
higher concentration of enamel fluoride is not necessarily more efficacious in preventing
dental caries (38).
depends
(07). Thils, adults also benefit
t . 19U�{ffsassumed.
erupted,
&Wty in
26 MMWR August 17, 2001
Public Health and Clinical Practice
Continue and Extend Fluoridation of Community Drinking Water
Community water fluoridation is a safe, effective, and inexpensive way to prevent
dental caries. This modality benefits persons in all age groups and of all SES, including
those difficult to reach through other public health programs and private dental care.
Community water fluoridation also is the most cost-effective way to prevent tooth decay
among populations living in areas with adequate community water supply systems.
Continuation of community water fluoridation for these populations and its adoption in
additional U.S. communities are the foundation for sound caries -prevention programs.
In contrast, the appropriateness of fluoridating stand-alone water systems that sup-
ply individual schools is limited. Widespread use of fluoride toothpaste, availability of
other fluoride modalities that can be delivered in the school setting, and the current
environment of low caries prevalence limit the appropriateness of fluoridating school
drinking water at 4.5 times the optimal concentration for community drinking water.
Decisions to initiate or continue school fluoridation programs should be based on an
assessment of present caries risk in the target school(s), alternative preventive modali-
ties that might be available, and periodic evaluation of program effectiveness.
Counsel Parents and Caregivers Regarding Use of Fluoride Toothpaste
by Young Children, Especially Those Aged <2 Years
Fluoride toothpaste is a cost-effective way to reduce the prevalence of dental caries.
However, for children aged <6 years, especially those aged <2 years, an increased risk
for enamel fluorosis exists because of inadequately developed control of the swallowing
reflex. Parents or caregivers should be counseled regarding self -care recommendations
fortoothpaste use for young children (i.e., limit the child's toothbrush ing to <2 times a day,
apply a pea -sized amount to the toothbrush, supervise toothbrushing, and encourage the
child to spit out excess toothpaste).
For children aged <2 years, the dentist or other health-care provider should consider
the fluoride level in the community drinking water, other sources of fluoride, and factors
likely to affect susceptibility to dental caries when weighing the risk and benefits of using
fluoride toothpaste.
Target Mouthrinsing to Persons at High Risk
Because fluoride mouthrinse has resulted in only limited reductions in caries experi-
ence among schoolchildren, especially astheir exposureto other sources of fluoride has
increased, its use should be targeted to groups and persons at high risk for caries (see
Riskfor Dental Caries). Children aged <6 years should not use fluoride mouthrinse with-
out consultation with a dentist or other health-care provider because enamel fluorosis
could occur if such mouthrinses are repeatedly swallowed.
Judiciously Prescribe Fluoride Supplements
Fluoride supplements can be prescribed for children at high risk for dental caries and
whose primary drinking water has a low fluoride concentration. For children aged <6
years, the dentist, physician, or other health-care provider should weigh the risk for
caries without fluoride supplements, the caries prevention offered by supplements, and
the potential for enamel fluorosis. Consideration of the child's other sources of fluoride,