Cecil H. Lnde~'ood Joan E.

ObI
Go\ernor Secret3r)"

POLICY STATEMENT
Local Health Departments, Dental Clinics and EPSDT/PHS Providers

FROM: Bureau for Public Health, Children's Public Health .Dentistry

DATE: July 17, 1998

WATER TEST KITS/FLUORIDE DISPENSING

PURPOSE:

The purpose of this memorandum is to fully inform you of ~ the Bureau needsdentIStS,
medical clinicians and the local health departmentsto provide water test kits and them prescrib'e'-
fluoride. In the past, water test kits have beengiven to anyonewho requestedthem, including Head
Starts, WIC and individuals themselves but unlesstrained clinicians/dentists receive the test results,
thesepeople are incapableof interpreting the results, We want to stop this from happeningbecause
if a family needsfluoride, Public Health hasa responsibilityto assurethey receive it. We can't do that
without your help. I

We believe families should be referredb~ Head Stan. WIC or any other agencywho does not
have a clinician on staff. to the local health departmentto obtain the water test kit. Unlessthe family
indicatesto local health that they want the test results sentto their physician or dentist, local health
should advisethem that the test results will be returned to them because they have clinicians who can
interpret the water test results and legally prescribe the fluoride.

The support and cooperation in working with the Children's Public Health Dentistry Program
to resolve the problem of non-cliniciansjust giving familiesfluoride tablets/drops as a matter of office
protocols is very much appreciated. Local healthdepartmentsare located in each c.ountyof the .state
and already have clinicians on staff who can prescribe/dispensethe fluoride.

OFFICE OF MATERNAL AND CHILD HEALTH

Bureau for Public Health
1411 Virginia Street, East
Charleston, West Virginia 25301-3013
Phone: (304) 558-5388 Toll-Free (In WV): 1-800-642-8522 or 1-800-642-9704 FAX: (304) 558-2183
 *Fluoride SuDDlement Dosag:eSchedule

Dietary Fluoride Supplement Dosage Schedule in mg F/day

Water fluoride concentration (com or m2/l)

Age of Child Less than Greater than

<0.30 ppm 0.3-0.6ppm >0.60 ppm
6 months up 0.25 0 0
3 Years of age

3 Years up to 0.50 0.25 0

6 Years of age

6 Years up to 1.00 0.50 0

at least 16 Years

The new dosage schedule now starts fluoride supplements at 6 months of age instead of birth and
changes both the age ranges and the levels of fluoride in drinking water for which supplements are
prescribed.\tV11enwell water test results are below 0.30 parts per million (ppm), children age 6 months
to 3 years of age should get 0.25 milligrams of fluoride; from 3 years to 6 years of, 0.50 milligrams of
fluoride; and 6 to 16 years, 1.00 milligrams of fluoride.

When well water tests results are from 0.30 to 0.60 pp., children from 6 months to 3 years
of age should receiveno fluoride supplement;from 3 years to 6 years of age the dosage should be 0.25"
milligrams of fluoride; and 6 to 16 years,0.50 milligrams of fluoride. Finally, for those whose well water
comes from wells testing above 0.60 ppm, no supplementsare indicated for any age group.

Recent research indicates that fluoride has a greater anti-caries effect on the teeth after they erupt
(topical), rather than when it is incorporated into the developing tooth structure (systemic).
?~g.: 2. '.-1.TE~ TEST KrT"S,FLL"ORIDE DiSPEXSfl';G POLICY STATE;..{E~!

l~STRUCTION:

Water Test Kits and Fluoride DisDensin~:

1) FA~IILIES WHO ARE eS~G FLUORIDATED BOTTLED WATER DO NOT

NEED TO HA \"E THEm \'OA TER TESTED. DO NOT SEND mAW A TER TEST
KIT FOR THESE FA'IILIES.

2) A1~.aysask t~es \vho are on community fluoridated water systems or naturally fluoridated
wells whether they have a water filtering system. If so, ~ test their water ONCE to
make sure their filtering system is not filtering out the fluoride.

3) ~EVER give a \\"ater test kit to a family who only has one child and that child is
younger than six months old.

4) You need to test the family's' drinking water ONLY ONCE unless the familv notifies
vou that thev hate moted and thev are not on a fluoridated water source.

5) Do not disoense fluoride in anv form to a familv whose orimarv source for drinkin~
water has never been tested. We have discovered that some clinicians are providihg-
fluoride without first ha\'ing the water tested, We know this becausethe child's name has
appearedon the dispensinglog sheetbut was never reported on the water test kit log and no
test results were e\'er received by this office,

6) The Medicaid Program still covers fluoride supplements in its drug formulary. Last
year, Medicaid stopped covering Gel-Kam fluoride supplements and said they could be
purchased over-the-counter. Some providers may have incorrectly concluded that the
~1edicaid Program had stopped providing supplements entirely, but they still cover other
fluoride supplements.

7) We have revised the Patient Fluoride DispensingLog to allow local health clinics to record
the names of the child's parents AND the child's Medicaid Identification Number.

8) No fonD of fluoride supplementation should be given to infants until they are 6 months
of age or older. Note: Please remember that no water tests should .be submitted on
children under the age of six months.

*9) Your clinic is still responsible for completing the Fluoride Dispensing Log AND/OR the
Water Test Kit Log in accordancewith the instructions in this memorandum.

*These may be fa.xedto the attention of Tammy Vickers at (304) 558-1524

Pag~ 3 \,VATER TEST KlIS/FLL:OR1DE D[S?E~SL\:G POLICY STA TE:-"1E~l

\VATER TEST LOGS/PA TIE~T LOGS

PROCESS FOR FOLLOW-UP WHE~ PARE~TS DO ~OT FOLLOW-THROUGH:

The follo~ing stepshave beenput into placeto try to assurethat parents of children who may
need fluoride supplementationfollow through with the water testing before any fluoride is dispensed:

HEAD START/\\l1C clinics should refer parents of children whose primary water source is
)
a welVcistern to their local health department with instructions they should request a water
test kit.

Local healthdepartmentsshould provide the parents with the water test kit and they should
2)
explain to them how the process works, e.g., how to fill the test tube with the child/ren's
water they drink regularly. If the child/ren are kept by a babysitter, the babysitter's water
should be tested rather than their drinking water from home because the child/ren will be at
the babysitter's for the longestperiod of the day. The provider should advise the parents how
they are supposed to fully complete the form inside the water test kit (NOTE: ALL
REQUESTED ffiFORi'\fA nON ON THE FORJ.'\1MUST BE COMPLETED) and mail
it to the addresson the box, indicating to them that no postageis required becausethe Bureau
has prepaid the postage. (A Fluoride Instruction Fact Sheet is attached and copies can
be given to the parents.) , --

Local health departments must send Tammy Vickers (Materials Management Office) the
3) Water Test Kit Log monthly and the data from the Water Test Kit Log will be entered into
a database.
The Water Lab will completethe testing and will send Tammy Vickers the test results and she
4)
w.ill enter the resultsinto the database. Tammy Vickers will immediately send the water test
resultsback to the clinician or to the local health department where a fluoride prescription or
the fluoride supplementscan be given to the parents for the child/ren.

On a monthly basis, Tammy Vickers will download the database and print a listing of those
5) parentswho were given a water test kit but no test result was received in her office. (These
will be the parents we will need to contact to detennine whether they sent in the water test
kit and, if not, whether they need help in doing it.)

Dentists/Clinicians who have given patients a water test kit will receive a'monthly listing of
9)
those patients who did not return their water test kits.
 Pag~.; I;.°ATER TEST i<..:"TSIFL"L:ORIDEDISPE~S~G POLICY STATE~fEm

PLEASE ~OT~ THAT THE FOLLOWTh"G LOCAL HEALTH DEPARTMENTS

ARE THE PR.L\IlARY tOUNTIES WHERE WATER FLUORIDATION IS NEEDED AND
SHOLLD TAKE NOltE OF THE ABOVE DESCRIBED rnSTRUCTION. HOWEVER,
CO~[MU~ITIES WI~HIN THESE COUNTIES THAT HAVE BEEN FLUORIDATED
~EED NOT SEND IN WATER TEST KITS.

BOO~E MONROE
CLAY MORGAN
FAYETTE NICHOLAS
G R.\NT PENDLETON
GREENBRIER POCAHONTAS
HA~lPSHIR.E PRESTON
HARDY RITCHIE
JACKSON TUCKER
LOGAN WETZEL
~lASON WYOMING
MCDOWELL
MTh"ERAL
MlliGO

Questions concerning this memorandum may be directed to the Children's Public Heakft-
Dentistry Program at 1-800-642-8522. Your cooperation in complying with these new guidelines
is appreciated.

Attachments: Fluoride Patient Log. Fluoride Supplement Dosage Schedule and

111stntctionsforTestingWaterfor Fhloride

cc: Ms. Chris Gordo~

Ms. Pat Moss I
Ms. Joan Faris
Ms. Tammy Vickers
Dr. F rank Lambert
Ms. Charlotte Billingsly
:-"1s.Becky Crowder
Mr. Wayne Morganroth
l\:lr. James Kay

....... .
...... ..... ..
PJgt: 5 \\"ATER TEST K..7SI'FLL"ORlDE
DrSPE:"-SL'-"G
?OL;CY STATE~tE~-r

MEMOR.\-"DU~I OF UNDERSTA~DTh'G

I understand the instructions contained in the memorandum dated July 17, 1998, "Water Test
Kits/Fluoride Dispensing Policy Statement," and I will do my best to tl]" to comply with these
guidelines implemented by the Bureau for Public Health's, Children's Dentistry Services
Program with regard to water testing procedures for fluoride when I become aware that my
patient may need to have their water tested so that I can prescribe adequate fluoride
supplements.

Please sign and return this page to the following address:

Office of Maternal and Child Health

Materials Management Office
151 11th Avenue
South Charleston, WV 25303

PROVIDER/CLmIC ADMTh'ISTRATOR SIGNATURE DATE

PROVIDER/CLINIC NAME:

PROVIDER/CLINIC ADDRESS:
 I A.\-f REQUESTL\"G THE FOLLO\v'l'."G

FLL-ORIDE T.-\BLETS

FLL"ORIDE DROPS

\VATER TEST KrrS

THESE FLUORIDE Su7PLE~1E!\."TS/\VATER TEST KrrS Wn..L BE DISPENSED IN MY

OFFICE/CL'ThiIC TO CHn..DREN IN ACCORDAL'iCE WrrH THE "WATER TEST
KrrS/FLUORIDE DISPENSING POLICY STA TEM:E..'\1TGUIDELINES," ISSUED BY THE
OFFICE OF Y!ATE~~AL ,~~"DCHll..D HE.~TH'S (OMCH'S). MY OFFICE WILL
PROVIDE OMCH THE N.~"1ES OF ALL CHll..DREN WHO RECEIVED FLUORIDE
SUPPLEMENTSI\VATER KITS PROVIDED BY THIS AGENCY.

PLE.~SEMAn.. THEM TO THE FOLLOV/ING STREET ADDRESS

Office of Y1:atemal and Child Health

Materials Management
151 11 titAvenue
South Charleston. West Virginia 25303

Provider Signature Date

Provider/Agency Name

Street Address*

~OTE: Oi\ICH ~laterials Manag~ment Office reservesthe right to reduce fluoride orders
basedupon availability and/or funding.

If you do not have a street address,provide delivery directions.

-~-- WV D H HRiB PH;'O~1CH/ICH/7 .98 FORM 217

v.-\ TE: .~LG~ST 12, 1998
TO: DE~T AL HE.~L TH PROFESSIO~.~LS
FRO'!: CHILDRE~'S DENTISTR\'" PROGR~-'I,
Bl"RE.~l. FOR PUBLIC HEALTH

CHILDRE~ NEED FLUORIDE SUPPLEMENTS 6 .~IONTHS

ST.~RTING.;:\ T J.J:\.GE
L-~LESS THEIR PRIMARY DRINKING W.J:\.TER SOURCE IS .;\ FLUORIDATED
CO'[ylU~ITY
--- WATER S"STE~[.
"

To help you, we have a 'system' in place and would ask that you take note of these recommendatiO'ns:

A TER FROM...
.-\ WEI..L?..
.-\. Cistern? . When the answer is "yes", please adhere to these guidelines:
S
A ..prIng.
.? 1.) Refer the family to their local county health
department to obtain a water test kit. There
is no charge for the test kit and the postage
is prepaid for returning the water sample to
the Office of Laboratory Services in
Charleston.

2.) Provide the family with a copy of the

attached "Instructions for Testing Your
Water for Fluoride". This instruction
sheetadvisesthe family ~ to properly
fill the test tube in the Water Test Kit so
the lab can get an accurate result.

If you want the test results sent to your

3)
office, you need to tell the family to be sure
to put your office address on the
identification form included in the Water
Test Kit.
FluorideAlert
Page 2

4) The fluoride test results will be

provided within a month and if the
child/ren need supplements:
Medicaid-Eligible Children-Simply
write a prescription. OR Non-
Medicaid Children-Fluoride drops
and tablets are availablefrom the
Bureau. Simply call or fax in your
request for drops/tabletsand they will
be sent to you via UPS.

Telephone:(304) 558-3417
FAX: (304) 558-1524
Attention: TammyVickers

5) Dispensing fluoride supplementsto

Non-Medicaid Eligible children
involves some basic compliance
'rules' and those will be sentto you
immediately after you call or fax your
request for drops/tablets.

Fluoride dally dosesgivenin mg.

Questions concerning the Fluoride .SupplementationProgram should be directed to Dr. Gregory Black,
Dental Consultant @ (304)558-3017 or Kay Medley, Dental Coordinator @ (304) 558-5388.