Benefits of Fluoride
Fluoride has been shown to be effective in reducing tooth decay in permanent teeth when present in the diet of children approximately 5 through 17 years of age. The average diet does not have sufficient fluoride to provide optimum teeth protection. There are a number of ways that fluoride can be increased in the diet. In some communities, fluoride is added to the public water system (PWS) to insure a minimum intake. The rate of fluoride addition to public water supplies in New Hampshire is based on the recommendation of the US Public Health Service, Centers for Disease Control. This rate is 1.1 milligrams per liter (mg/L) which also can be expressed as 1.1 parts per million (ppm).

Legal Requirements When Proposing to Add Fluoride in a Public Water System
The New Hampshire Legislature has specified procedures by which supplemental fluoridation of public water supplies can be accomplished. These procedures are spelled in the following statutes:

For Cities RSA 44:16
For Towns RSA 31:17-a
For Districts RSA 52:23
In addition RSA 485:14 also speaks to the fluoridation issue.

These statutes are set out at the end of this document. In summary, these statutes require that the proposal to fluoridate be subject to a vote and that majority approval is needed. The same procedure could also be used to discontinue fluoridation that is already occurring. Whatever the outcome of the vote, there is a 3-year moratorium before a fluoridation issue can be brought up again.

Exactly how the provisions of RSA 485:14 interact with the other statutes mentioned above is not clear. Therefore, DES is requesting an opinion from the attorney general's office to clarify what is required. What is clear however, is the need for a vote.

Design Review and Operational Oversight
If local voter approval is given, the water system would submit its design for a chemical addition system to the Department of Environmental Services (DES) for approval. The proposal would identify, among other issues: the fluoride chemical to be used, the necessary chemical feed equipment, safety features to prevent an overfeed of chemicals, and the monitoring equipment to be used to assure the proper fluoride concentration is maintained.

Once the fluoride addition begins, a monitoring schedule would be established by DES to ensure that the proper amount of fluoride is being added. This program also requires record keeping and periodic inspection by DES staff. In addition, DES requires that the system operator holds the proper operator certification grade for that treatment process.

Capital And Operational Costs
The typical capital cost of fluoridation for a very small water system is approximately $3000-$5,000 per source assuming the use of the chemical sodium fluoride and the existence of sufficient floor space in the pump building to accommodate the overall equipment. The typical operational cost of water fluoridation ranges from $0.50 to $1.00 per person per year depending on system size. The equipment is simple to install and operate. Some larger water utilities may choose to invest more in the chemical storage and feed systems now to allow the use of lower cost fluoride chemicals through out the future life of the facility.

Public Water Systems That Add Fluoride
As of January 1997, ten New Hampshire municipalities (serving approximately 150,000 people) add fluoride to their public water systems. A list of public water systems that add supplemental fluoride is available from DES on request. This document is entitled WD-WSEB-5-1, "New Hampshire Public Water Systems Adding Fluoride."

Naturally Occurring Fluoride in Water Systems
Fluoride occurs naturally at elevated levels in approximately 3 percent of bedrock artesian/drilled) wells in New Hampshire. Many of the very small public water systems and private homes are served by bedrock wells that have elevated fluoride. Fluoride has no taste or odor and thus only a laboratory test can identify the presence of elevated fluoride.

A list of small public water systems with naturally occurring fluoride is also available from DES on request. This list is entitled WD-WSEB-5-2, "Small Public Water Systems in New Hampshire with Naturally Occurring Fluoride."

Controversy
The intentional fluoridation of drinking water can be a controversial issue. Typical concerns include: the concept of mass medication when other individual methods fluoride supplement are available, the safety of adding a chemical which at very high concentrations is a poison, and the relatively low percentage of water consumed versus that treated. A 1993 study by the National Research Council of the National Academy of Science concerning fluoridation of water supplies confirmed that fluoridation of drinking water is safe and effective. The New Hampshire Division Public Health Services and the New Hampshire Dental Society, along with the US Public Health Service all advocate the fluoridation of drinking water. The NH Department of Public Health Services fluoride advocate is Nancy Martin. She can be reached at 271-4535.

Professional References for Fluoridation

PRINCIPLE STATUTES GOVERNING FLUORIDATION OF DRINKING WATER

STATUTE PERTAINING TO CITY WATER SYSTEMS
"44:16 Public Water Supplies. Upon the written application of 10 percent of the voters in any city, presented to the city clerk prior to the municipal election, the city clerk shall insert on the ballot to be used at said election the following question: "Shall permission be granted to introduce fluorides into the public water system?" Beside the question shall be printed the word "yes" and the word "no" with the proper boxes for the voter to indicate his choice. If a majority of voters at said election do not approve the use of fluorides in the public water system for said city, no fluorides shall be introduced into the public water system. If fluorides have, prior to said vote, been so introduced, such use shall be discontinued until such time as the voters of the city shall, by majority vote, approve the use of fluorides. After such popular referendum, the city clerk shall not insert the aforementioned question relative to the use of fluorides in the public water system on the ballot to be used at the municipal election for a minimum period of 3 years from the date of the last popular referendum, and only upon written application at the time of not less than 10 percent of the registered voters of said city."

STATUTE PERTAINING TO TOWN WATER SYSTEMS
"31:17A Referendum. Upon the written application of 10 percent of the voters in a town, presented to the selectmen or one of them at least 15 days before the day prescribed for an annual town meeting, the selectmen shall insert in their warrant for such meeting an article relative to the use of fluorides in the public water system for said town. If the town has an official ballot, the town clerk shall insert on such ballot the following question: "Shall permission be granted to introduce fluorides into the public water system?" Beside the question shall be printed the word "yes" and the word "no" with the proper boxes for the voter to indicate his choice. If a majority of voters do not approve the use of fluorides in the public water system, no fluorides shall be introduced into the public water system for said town; or if fluorides have prior to said vote been introduced, such use shall be discontinued until such time as the voters of the town shall, by majority vote, approve the use of fluorides. After such popular referendum, the selectmen shall not insert an article relative to the use of fluorides in the public water system in the warrant nor shall such question be inserted on the official ballot for a minimum period of 3 years from the date of the last popular referendum and only upon written application at the time of not less than 10 percent of the registered voters of said town."

STATUTE PERTAINING TO DISTRICT WATER SYSTEMS
"52:23 Public Water. Upon the written application of 10 percent of the voters in any village water district, presented to the commissioners or one of them at least 15 days before the day prescribed for an annual meeting of the district, the commissioners shall insert in their warrant for such meeting an article relative to the use of fluorides in the water system for said district, and the district clerk shall prepare a ballot for said meeting with the following question: "Shall permission be granted to introduce fluorides into the district water system?" Beside the question shall be printed the word "yes" and the word "no" with the proper boxes for the voter to indicate his choice. If a majority of voters do not approve the use of fluorides in the district water system, no fluorides shall be introduced into the district water system; or if fluorides have, prior to said vote, been so introduced, such use shall be discontinued until such time as the voters of the district shall, by majority vote, approve of the use of fluorides. After such popular referendum, the commissioners shall not insert an article relative to the use of fluorides in the district water system in the warrant nor shall the district clerk prepare such a ballot for a minimum period of 3 years from the date of the last popular referendum of the district and only upon written application at the time of not less than 10 percent of the registered voters of said district."

OPINION BEING SOUGHT FROM THE ATTORNEY GENERALS OFFICE
"485:14 Use Of Fluorine. No fluorine shall be introduced into the water of any lake, pond, reservoir or stream tributary from which the domestic water supply is taken unless and until the municipality using said waters has held a public hearing as to the introduction of fluorine into the public water supply of said municipality, and the voters of such municipality have approved such action pursuant to RSA 44:16 or 52:23."

FOR FURTHER INFORMATION
Should you have technical questions relative to the fluoridation of water supplies, you may call DES's Water Supply Engineering Bureau at 271-3139. For brochures relating to dental benefits and concerns regarding fluoride safety, please contact any of the groups noted above. We would appreciate your suggestions concerning this fact sheet. For a complete list of water supply fact sheets, please request fact sheet WD-WSEB-15-2. 11/98