Economic Evaluation of Community Water Fluoridation: A Community Guide Systematic Review

Associations between school-based fluoride mouth-rinse program, medical-dental expense subsidy policy, and children's oral health in Japan: an ecological study

BACKGROUND

Dental caries are a common non-communicable disease among children. As a public health measure at the prefectural level, school-based fluoride mouth-rinse (S-FMR) program, medical/dental expense subsidy policies, and other factors may reduce the incidence of dental caries and tooth loss. Prefectures focusing on promoting oral health policies may promote both, but the interaction effect of implementing both subsidy policies and S-FMR at the prefectural level on caries prevention has not yet been examined.

METHODS

We conducted an ecological study using two-wave panel data, prefecture-level aggregated data in Japan for 2016 and 2018. Coefficient and 95% confidence intervals (CI) were calculated for the dependent variables for oral health using mixed-effects linear regression analysis adjusted for possible confounders. Two dependent variables were used; the standardized claim ratio (SCR) of deciduous tooth extraction and 12-year-olds' decayed, missing, or filled permanent teeth (DMFT). Four independent variables were S-FMR, the SCR of dental sealants, prefectural income per person, and subsidy policy in three models: co-payment until children enter elementary school (n = 23), no co-payment until children enter elementary school (n = 7), and co-payment continuing beyond elementary school (n = 17). The effects of six interaction terms, each representing a unique pairing from the four independent variables, were individually calculated.

RESULTS

S-FMR was negatively associated with the SCR of deciduous tooth extractions and DMFT (coefficient = -0.11, 95% CI -0.20; -0.01 and coefficient = -0.003, 95% CI -0.005; -0.001, respectively). No co-payment until children enter elementary school was positively associated with the SCR of deciduous tooth extraction compared to co-payment until children enter elementary school(coefficient = 11.42, 95% CI 3.29; 19.55). SCR of dental sealants was positively associated with the SCR of deciduous tooth extractions (coefficient = 0.12, 95% CI 0.06; 0.19) but negatively associated with DMFT (coefficient = -0.001, 95% CI -0.003; -0.0001). Per capita prefectural income was positively associated with the SCR of deciduous tooth extractions(coefficient = 0.01, 95% CI 0.001; 0.02). No interaction was found between S-FMR and the subsidy policy at both outcomes.

CONCLUSION

High S-FMR utilization and no co-payment until children enter elementary school were associated with fewer deciduous tooth extractions. Also, S-FMR and dental sealant were associated with decreased DMFT.

Community Water Fluoridation in Focus: A Comprehensive Look at Fluoridation Levels across America

Objective: This study reports on the number and percentage of community water systems (CWSs) meeting fluoride concentration standards set by the U.S. Department of Health and Human Services (DHHS). The study also explored changes in the population exposed to optimally fluoridated water in these systems between 2006 and 2020. Methods: This study analyzed U.S. Centers for Disease Control and Prevention data from 2006 to 2020, tabulating state-specific CWS fluoridation rates, ranking them, and calculating the percent change. Results: In 2020, 72.7% of the US population received CWS water, with 62.9% of those individuals served by a CWS system meeting DHHS fluoridation standards. This compares to 69.2% receiving CWS water in 2006 and 74.6% in 2012. The overall change in those receiving fluoridated water was 1.4%, from 61.5% in 2006 to 62.9% in 2020. State-specific percentages ranged from 8.5% in Hawaii to 100% in Washington DC in 2020 (median: 76.4%). Conclusions: Although endorsed by the American Dental Association, the percentage of individuals receiving fluoridated water did not increase substantially from 2006 to 2020, indicating that there has not been much progress toward meeting the Healthy People 2030 goal that 77.1% of Americans receive water with enough fluoride to prevent tooth decay.

Water fluoridation in Australia: A systematic review

Water fluoridation is considered a safe and effective public health strategy to improve oral health. This review aimed to systematically summarize the available evidence of water fluoridation in Australia, focusing on the history, health impacts, cost effectiveness, challenges, and limitations. A systematic search was conducted on the Ovid Medline, Web of Science, Scopus, ProQuest Central, Cinahl, and Informit databases to identify literature on water fluoridation in Australia. A grey literature search and backward snowballing were used to capture additional literature. Primary studies, reviews, letters, and opinion papers were included in the quantitative analysis and summarized based on the year of publication and geographical location. The data were extracted from primary studies and summarized under three subheadings: history, community health impacts and the limitations and challenges. Water fluoridation in Australia was first implemented in 1953 in Tasmania. Most states and territories in Australia embraced water fluoridation by 1977 and currently, 89% of the Australian population has access to fluoridated drinking water. Studies report that water fluoridation has reduced dental caries by 26-44% in children, teenagers, and adults, benefiting everyone regardless of age, income, or access to dental care. It has been recognized as a cost-effective intervention to prevent dental caries, especially in rural and low-income areas. Water fluoridation as a public health measure has faced challenges, including political and public opposition, implementation and maintenance costs, access and equity, communication and education, and ethical concerns. Variations in research activities on water fluoridation across Australian states and territories over the last seven decades can be due to several factors, including the time of implementation, funding, and support. Ongoing monitoring and research to review and update optimal fluoride levels in drinking water in Australia is warranted to ensure sustainable benefits on oral health while preventing any adverse impacts.

Economic evaluation of fluoride varnish application in preschoolers: A systematic review

BACKGROUND

Fluoride varnish (FV) is a convenient way of professionally applying fluoride in preschoolers. However, its modest anticaries effect highlights the need for economic evaluations.

AIM

To assess economic evaluations reporting applications of FV to reduce caries incidence in preschoolers.

DESIGN

We included full economic evaluations with preschool participants, in which the intervention was FV and the outcome was related to dentin caries. We searched in CENTRAL; MEDLINE via PubMed; WEB OF SCIENCE; EMBASE; SCOPUS; LILACS; BBO; and BVS Economia em saúde, OpenGrey, and EconoLit. Clinical trial registers, thesis and dissertations, and meeting abstracts were hand searched, as well as 11 dental journals. Risk of bias in the included studies was assessed using the Philips' and Drummond's (full and simplified) tools.

RESULTS

Titles and abstracts of 2871 articles were evaluated, and 200 were read in full. Eight cost-effectiveness studies were included: five modeling and three within-trial evaluations. None of the studies gave sufficient information to allow a thorough assessment using the bias tools. We did not combine the results of the studies due to the great heterogeneity among them. Four studies reported that FV in preschool children was a cost-effective measure, but in one of these studies, sealants and fluoride toothpaste were more cost-effective measures than the varnish, and three studies used limited data that compromised the generalizability of their results. The other four studies showed a large increase in costs due to the application of varnish and/or low cost-effectiveness.

CONCLUSION

We did not find convincing overall evidence that applying FV in preschoolers is an anticaries cost-effective measure. The protocol of this systematic review is available at Open Science Framework (https://osf.io/xw5va/).

Metabolic effect of low fluoride levels in the islets of NOD mice: integrative morphological, immunohistochemical, and proteomic analyses

OBJECTIVES

Fluoride (F) has been widely used to control dental caries, and studies suggest beneficial effects against diabetes when a low dose of F is added to the drinking water (10 mgF/L). This study evaluated metabolic changes in pancreatic islets of NOD mice exposed to low doses of F and the main pathways altered by the treatment.

METHODOLOGY

In total, 42 female NOD mice were randomly divided into two groups, considering the concentration of F administered in the drinking water for 14 weeks: 0 or 10 mgF/L. After the experimental period, the pancreas was collected for morphological and immunohistochemical analysis, and the islets for proteomic analysis.

RESULTS

In the morphological and immunohistochemical analysis, no significant differences were found in the percentage of cells labelled for insulin, glucagon, and acetylated histone H3, although the treated group had higher percentages than the control group. Moreover, no significant differences were found for the mean percentages of pancreatic areas occupied by islets and for the pancreatic inflammatory infiltrate between the control and treated groups. Proteomic analysis showed large increases in histones H3 and, to a lesser extent, in histone acetyltransferases, concomitant with a decrease in enzymes involved in the formation of acetyl-CoA, besides many changes in proteins involved in several metabolic pathways, especially energy metabolism. The conjunction analysis of these data showed an attempt by the organism to maintain protein synthesis in the islets, even with the dramatic changes in energy metabolism.

CONCLUSION

Our data suggests epigenetic alterations in the islets of NOD mice exposed to F levels comparable to those found in public supply water consumed by humans.

Access to community water fluoridation in rural Victoria: It depends where you live…

OBJECTIVE

To explore the water fluoridation status of rural Victorian towns over 1000 population and document the oral health profile in the local government areas (LGAs) currently with no water fluoridation. To assist/inform future LGA planning, we describe a case study of a community-based co-design approach to increase access to fluoridated water in rural communities.

DESIGN

A descriptive design and a case study.

SETTING

Rural Victorian towns over 1000 population.

PARTICIPANTS

Twenty-nine LGAs in rural areas.

MAIN OUTCOME MEASURE(S)

LGA water fluoridation status and oral health profiles.

RESULTS

Sixty-six (33%) of the 203 Victorian rural towns with >1000 population, representing 149 251 people, did not have access to fluoridated water. Towns in 29 rural LGAs were included with 62% without water fluoridation with many having higher than the Victorian average of preventable hospital admissions due to dental conditions in children aged 0-9 years. Over 50% of children aged 0-12 years living in these rural nonfluoridated LGAs had above-the-state average rates of decayed, missing and filled teeth (dmft/DMFT). In those aged 0-5 years, this was the highest with 78% above-the-state average. In the case study, meetings were well attended, and the group resolved to lobby for water fluoridation, which was successful.

CONCLUSION

Many Victorian rural towns do not have access to fluoridated water. A community-based co-design approach can dispel ill-informed concerns about dangers of water fluoridation to successfully lobby the state government to fluoridate the local water supply.

Maintaining and Improving the Oral Health of Young Children

Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries remains greater than 40% among children 2 to 19 years of age. Although dental visits have increased in all age, race, and geographic categories in the United States, disparities continue to exist, and a significant portion of children have difficulty accessing dental care. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of disease, interventions to maintain and restore health, and the social determinants of children's oral health.

Development of small-scale water fluoridation equipment

PURPOSE

A water fluoridation program launched in the United States in 1945 has become a worldwide application for caries prevention. Although such a program is important in Japan, water fluoridation in large communities has not been established. This study aimed to develop safe small-scale water fluoride equipment that can be easily used to carry out water fluoridation programs in areas with children in long-term care facilities, and in developing countries without water supply facilities.

METHODS

Batch-type NaF addition adjustment equipment was manufactured as small-scale water fluoride equipment. The fluoride concentration of the adjusted water with this equipment was measured using an ion meter and a fluoride composite electrode. All 51 water quality standards set by the Ministry of Health, Labour, and Welfare of Japan were tested.

RESULTS

The fluoride ion concentration of the adjusted water was 0.7 mg/L and it was constant and stable. The adjusted water conformed to the water quality standard values of the Japanese Water Supply Law.

CONCLUSION

Water produced with small-scale water fluoridation equipment had a fluoride concentration of 0.7 mg/L, which is the recommended concentration for caries prevention. The fluoride concentration was stable.

Fluoride concentration in teas derived from Camellia Sinensis produced in Argentina

To evaluate the fluoride concentration and pH of tea derived from Camellia sinensis produced and commercialized in Argentina. Forty-eight varieties of tea (black (n = 16), green (n = 21), red (n = 7), and white (n = 4)) commercialized in the form of leaves or tea bags were acquired. One bag or 2.0 ± 0.05 g of each product was infused for 5 min in 200 mL of distilled boiled water. The F^- concentration was determined using an ion-selective electrode and pH was measured using a pH meter. The found fluoride concentrations ranged from 0.1 to 9.7 µg/mL and the pH ranged from 2.7 to 5.1. A higher fluoride concentration was observed in the leaves group (2.75 ± 2.65 µg/mL) compared to tea bags (1.10 ± 0.82 µg/mL) (p < 0.05). Regarding the type of tea, green and black tea were richer in F^- than red and white tea. Fluoride and pH appeared not to be correlated (Pearson test). All the studied tea samples presented fluoride concentrations greater than the threshold recommended for drinking water. The pH proved to be low, which could be a risk for erosive tooth wear.

The Impact of Water Fluoridation on Medicaid-Eligible Children and Adolescents in Alaska

Juneau, Alaska, ceased community water fluoridation (CWF) in 2007, and previous research found a substantial increase in dental caries-related procedures and treatment costs for children from low-income families in Juneau between 2003 and 2012. We collected comparable dental caries-related procedures and treatment cost data for the same years for children in Anchorage, Alaska, where CWF has been continuously maintained. This retrospective study analyzed all Medicaid dental claims records in two separate years for caries-related procedures and associated costs among children (aged 0 to 18 years) residing in Anchorage's 99502 zip code and compared these records to data from Juneau. We obtained descriptive statistics and conducted bivariate analyses and binomial logistic regression. Between 2003 and 2012, children in Anchorage experienced a nonsignificant modest decrease in the mean number of caries-related procedures and only small, statistically nonsignificant changes to the mean inflation-adjusted service costs of caries-related restorative care. The lack of significant change in child dental caries-related procedures and treatment costs in Anchorage between 2003 and 2012 contrasted with the substantial increase in caries-related procedures and treatment costs over the same period in Juneau. Our results are consistent with previous research that has demonstrated a significant protective effect of CWF against dental caries.

Promoting support for community water fluoridation: Testing message effects and the role of normative beliefs

BACKGROUND

Despite evidence that community water fluoridation (CWF) protects oral health, improves health equity, is safe and cost-effective, and contributes to social well-being, little is known regarding which of these benefits should be highlighted to effectively influence support for CWF.

METHODS

This within-participants study examines differences in CWF support in response to pro-CWF messages reflecting themes of oral health, health equity, CWF safety, cost-effectiveness, or social well-being among a sample of parents. Prior belief that CWF has health benefits, worry about potential health risks, and normative beliefs were also examined as independent predictors of support for each theme.

RESULTS

Oral health, health equity, and safety messages significantly increased support in comparison with social well-being messages (P < .05). Oral health messages also produced greater support than cost-savings messages. Belief that CWF has health benefits positively predicted support, as did normative beliefs that one's family and physician approve of CWF. Worry about health risks and community and dentist norms were not significant predictors of support. There were no interaction effects of message themes and prior beliefs.

CONCLUSIONS

Messaging focused on oral health, health equity, and the safety of CWF may be the most effective at influencing support for CWF. Preexisting personal beliefs about CWF benefits significantly predict support, but so do normative beliefs-family and physician norms in particular.

PRACTICAL IMPLICATIONS

Findings suggest dental health educators should emphasize the oral health benefits of CWF over cost and social well-being outcomes. They should also consider relevant norms and collaborate with family physicians to promote CWF.

External control of fluoridation in the public water supplies of Brazilian cities as a strategy against caries: a systematic review and meta-analysis

Background

Among the methods currently available to provide fluoride in population levels, fluoridated water is the most successful for presenting high efficacy, safety and good cost–benefit. However, recent studies on external control have shown great variability of fluoride concentrations in the water from treatment stations in Brazilian cities, which must present concentration between 0.6 and 0.8 mg/L to be considered acceptable in most cities. Thus, this study aimed to perform a systematic review of the literature to assess the adequacy of fluoride concentration in the water in Brazilian cities using external control.

Methods

The protocol was registered in PROSPERO. Six databases were used as primary search sources and three databases were used to partially capture the "gray literature". Only observational studies that assessed the fluoride concentration of artificially fluoridated water from the public supply network were included. The JBI Critical Appraisal Tools for Systematic Reviews was used to assess the risk of bias of the studies. A proportion meta-analyses using random-effect models were performed. The heterogeneity between studies was determined by I² statistic. Meta-regressions were conducted to identify relevant moderators to be used in stratified meta-analyses. Publication bias was investigated by Egger’s tests.

Results

The search provided 2038 results, from which 14 met the eligibility criteria and were included in the data extraction of the review. Overall, the water samples were collected from 449 different sources in three Brazilian regions. Thirteen studies presented a low risk of bias. The mean concentration of fluoride ranged from 0.17 to 0.89 ppmF. The meta-analyis demonstrated that more than half of the water samples analyzed had fluoride concentration levels outside the acceptable range (56.6%; 95% CI 45.5; 67.3), with high heterogeneity.

Conclusion

More than half of the public water supply analyzed in the studies selected had fluoride concentration levels outside the acceptable range, which may affect the risk of developing oral diseases in the Brazilian population, having an important impact on public health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01754-2.

Qualitative Analysis of Remineralization Capabilities of Bioactive Glass (NovaMin) and Fluoride on Hydroxyapatite (HA) Discs: An In Vitro Study

Tooth decay is a prevalent disease that initiates when the oral pH becomes acidic. Fluoride and/or bioactive glass (NovaMin) were used to regenerate/repair teeth that had been decalcified. In this present study, we investigated the effect of fluoride and/or bioactive glass (NovaMin) on remineralization of hydroxyapatite (HA) discs, which mimic the enamel surface of natural teeth. HA discs were etched with phosphoric acid and treated with one of the following toothpastes: (1) Sensodyne toothpaste with fluoride; (2) Sensodyne toothpaste with fluoride and bioactive glass (NovaMin); (3) Tom's toothpaste without fluoride or bioactive glass (NovaMin); and (4) Tom's toothpaste with bioactive glass (NovaMin). The toothpastes were applied on the etched discs for two minutes, once a day for 15 days. Scanning electron microscopy (SEM) was used to analyze surface morphologies and X-ray photoelectron spectroscopy (XPS) was used to analyze surface compositions. Tom's toothpaste with only NovaMin demonstrated the most remineralization potential compared with the other groups. In conclusion, incorporating bioactive glass (NovaMin) into toothpastes could benefit the repair and remineralization of teeth.

Risk factors for dental caries in Latin American and Caribbean countries

Identifying the risk factors for dental caries is vital in epidemiology and clinical practices for developing effective preventive strategies, both, at the individual and collective levels. Different causality/determination models have been proposed to understand the development process of dental caries. In the present review, we designed a model inspired by the world-known social determinants models proposed in the 90s and more recently in the 10s, wherein the contextual factors are placed more externally and encompass the individual factors. The contextual factors included those related to the cultural and societal values, as well as the social and health government policies. The individual factors were classified into the following categories: socioeconomic (social class, occupation, income, and education level), demographic characteristics (age, sex, and ethnicity), behavioral factors (non-use of fluoride dentifrice, sugar consumption, poor oral hygiene, and lack of preventive dental care), and biological factors (recent caries experience/active caries lesions, biofilm retentive factors, developmental defects of the enamel, disabilities, saliva amount and quality, cariogenic biofilm). Each of these variables was addressed, while focusing on the current evidence from studies conducted in Latin American and Caribbean countries (LACC). Based on the proposed model, educational aspects were addressed, and individual caries risk assessment and management decisions were proposed; further, implications for public health policies and clinical practice were described. The identification of modifiable risk factors for dental caries should be the basis for multi-strategy actions that consider the diversity of Latin American communities.

Seeking community water fluoridation information on state health department websites

Community water fluoridation (CWF) is the most effective and equitable approach to preventing dental caries (tooth decay). Yet millions of Americans, especially those at highest risk of caries, do not know what CWF is or its preventive benefits. State health departments are responsible for educating their respective populations. Thus, this study assessed health department websites (N = 50) to determine if CWF content existed, the ease of finding it, and if it was written in plain language and for a consumer audience. We used the web component of the HLE2: The Health Literacy Environment of Hospitals and Health Centers (HLE2) to assess how easy or difficult it was to the navigate a website and find information. Forty-one websites had CWF information; 37 states had content written for a consumer audience. HLE2 scores ranged from 0 to 54 points (60 possible). Only five states had websites with a HLE2 score of 50 or higher. SHDs with higher HLE2 scores were easy to navigate and their content was written for a consumer audience. Study findings suggest most SHDs should improve their website’s CWF content and its accessibility to better promote the role of fluoridated water in preventing dental caries.

A cost-effectiveness analysis of community water fluoridation for schoolchildren

BACKGROUND

Community water fluoridation (CWF), the controlled addition of fluoride to the water supply for the prevention of dental caries (tooth decay), is considered a safe and effective public health intervention. The Republic of Ireland (Ireland) is the only country in Europe with a legislative mandate for the fluoridation of the public water supply, a key component of its oral health policy. However, more recently, there has been an increase in public concern around the relevance of the intervention given the current environment of multiple fluoride sources and a reported increase in the prevalence of enamel fluorosis. The aim of this economic analysis is to provide evidence to inform policy decisions on whether the continued public investment in community water fluoridation remains justified under these altered circumstances.

METHODS

Following traditional methods of economic evaluation and using epidemiological data from a representative sample of 5-, 8-, and 12-year-old schoolchildren, this cost-effectiveness analysis, conducted from the health-payer perspective, compared the incremental costs and consequences associated with the CWF intervention to no intervention for schoolchildren living in Ireland in 2017. A probabilistic model was developed to simulate the potential lifetime treatment savings associated with the schoolchildren's exposure to the intervention for one year.

RESULTS

In 2017, approximately 71% of people living in Ireland had access to a publicly provided fluoridated water supply at an average per capita cost to the state of €2.15. The total cost of CWF provision to 5-, 8-, and 12-year-old schoolchildren (n = 148,910) was estimated at €320,664, and the incremental cost per decayed, missing, or filled tooth (d3vcmft/D3vcMFT) prevented was calculated at €14.09. The potential annual lifetime treatment savings associated with caries prevented for this cohort was estimated at €2.95 million. When the potential treatment savings were included in the analysis, the incremental cost per d3vcmft/D3vcMFT prevented was -€115.67, representing a cost-saving to the health-payer and a positive return on investment. The results of the analysis were robust to both deterministic and probability sensitivity analyses.

CONCLUSION

Despite current access to numerous fluoride sources and a reported increase in the prevalence of enamel fluorosis, CWF remains a cost-effective public health intervention for Irish schoolchildren.

Exogenous Intake of Fluorides in Caries Prevention: Benefits and Risks

Caries incidence and prevalence have decreased significantly over the last few decades due to widespread use of fluoride. However, an increase in the prevalence of dental fluorosis has been reported in both fluoridated and non-fluoridated communities. Care must be taken to ensure that a balance between the optimal fluoride preventive effect at the individual and community level and minimal risk of dental fluorosis is maintained. This review describes the main sources of fluoride intake that have been identified: fluoridated drinking water, dietary fluoride supplement, and topical forms comprising toothpastes, rinses, gels and varnishes. The cited data were taken from meta-analytic studies and reports from Cochrane database systematic reviews up to December 2019. Efficiency, but safety, of topically applied fluorides in individual home care is dependent on the degree of compliance of individuals/parents and on the level of competence of providers of preventive counselling. The broad spectrum of these resources allows individualization of fluoride prevention based on risk analysis of caries attack and taking into consideration other preventive measures.

The Association between Community Water Fluoridation and Bone Diseases: A Natural Experiment in Cheongju, Korea

The present study aimed to investigate the association between bone diseases and community water fluoridation (CWF). An ecological study with a natural experiment design was conducted in Cheongju, South Korea, from 1 January 2004 to 31 December 2013. The community water fluoridation program was implemented in Cheongju and divided into CWF and non-CWF areas. To observe adverse health effects related to bone diseases, we conducted a spatio-temporal analysis of the prevalence of hip fracture, osteoporosis, and bone cancer in residents who have lived in CWF and non-CWF areas using National Health Insurance Service data. First, we used standardized incidence ratios to estimate the disease risk. Second, the hierarchical Bayesian Poisson spatio-temporal regression model was used to investigate the association between the selected bone diseases and CWF considering space and time interaction. The method for Bayesian estimation was based on the R-integrated nested Laplace approximation (INLA). Comparing the CWF area with the non-CWF area, there was no clear evidence that exposure to CWF increased health risks at the town level in Cheongju since CWF was terminated after 2004. The posterior relative risks (RR) of hip fracture was 0.95 (95% confidence intervals 0.87, 1.05) and osteoporosis was 0.94 (0.87, 1.02). The RR in bone cancer was a little high because the sample size very small compared to the other bone diseases (RR = 1.20 (0.89, 1.61)). The relative risk of selected bone diseases (hip fractures, osteoporosis, and bone cancer) increased over time but did not increase in the CWF area compared to non-CWF areas. CWF has been used to reduce dental caries in all population groups and is known for its cost-effectiveness. These findings suggest that CWF is not associated with adverse health risks related to bone diseases. This study provides scientific evidence based on a natural experiment design. It is necessary to continue research on the well-designed epidemiological studies and develop public health prevention programs to help in make suitable polices.

Social media conversations about community water fluoridation: formative research to guide health communication

OBJECTIVES

Community water fluoridation (CWF) is one of the greatest public health achievements of the 20th century. Despite this achievement, there are still misunderstandings about the safety of water fluoridation. Previous communication campaigns advocating CWF have been unsuccessful in combating these misunderstandings, suggesting a need for a new way to promote CWF. The goal of this article is to guide research for future campaigns by analyzing the digital conversation regarding community water fluoridation and other forms of fluoride in the state of Texas.

METHODS

NUVI software extracted tweets from Twitter, and SAS Text Miner 12.1 software revealed topics related to water fluoridation.

RESULTS

The results uncovered eight topics related to water fluoridation. Overall, the analysis showed mixed reactions toward water fluoridation, fluoride toothpaste, and children's dental health.

CONCLUSIONS

The findings of the text analysis will guide future research, with the goal of building a pro-CWF effort in Texas.

Associations between Household Water Fluoridation Status and Plain Tap or Bottled Water Consumption

INTRODUCTION

The benefits of community water fluoridation for preventing dental caries are attenuated if people do not consume tap water.

OBJECTIVES

We examined associations between household water fluoride content and consuming plain tap or bottled water among US youth.

METHODS

We used National Health and Nutrition Examination Survey data for 2013 to 2016 for 5,193 youth aged 2 to 19 y. Fluoride content in youth's household tap water samples was measured electrometrically with ion-specific electrodes and designated low (<0.6 mg/L) or about optimal (0.6 to 1.2 mg/L). Plain tap and bottled water consumption was obtained from one 24-h dietary recall. We used binomial regression models to estimate adjusted prevalence ratios (APRs) and 95% CIs for consuming plain tap water (including tap only or both tap and bottled) and consuming only bottled water as related to household water fluoride content (low or about optimal) and sociodemographic characteristics.

RESULTS

On a given day, 52.6% of youth consumed plain tap water (43.8% exclusively and 8.8% both tap and bottled) and 28%, only bottled water. Neither tap water (APR, 0.96; 95% CI, 0.84 to 1.10) nor only bottled water (APR, 1.03; 95% CI, 0.86 to 1.22) consumption was associated with household water fluoride content. Non-Hispanic Black youth and Hispanic youth were about 30% relatively less likely to consume tap water and 60% to 80% relatively more likely to consume only bottled water than non-Hispanic Whites. Low income, low parental education, and no past-year dental visit were associated with not consuming tap water.

CONCLUSION

Half of youth consumed plain tap water on a given day. Consuming plain tap water was not associated with community water fluoridation status. This study is the first to find that up to 50% of the population served by fluoridated water may not receive its full caries-preventive benefits due to not consuming plain tap water.

KNOWLEDGE TRANSFER STATEMENT

Half of US youth consumed plain tap water on a given day. Consuming plain tap water was not associated with community water fluoridation status. This finding suggests that up to 50% of the population served by fluoridated water systems may not receive its full caries-preventive benefits due to not consuming plain tap water. Our findings add support for the need to identify and address barriers to tap water consumption and promote health benefits of fluoridation.

Effects of low-level fluoride exposure on glucose homeostasis in female NOD mice

Water fluoridation is an important public health measure for the control of dental caries. Recent animal studies have shown that low doses of fluoride (F) in the drinking water, similar to those found in public water supplies, increase insulin sensitivity and reduce blood glucose. In the present study we evaluated the effects of low-level F exposure through the drinking water on glucose homeostasis in female NOD mice. Seventy-two 6-week mice were randomly divided into 2 groups according to the concentration of F in the drinking water (0-control, or 10 mg/L) they received for 14 weeks. After the experimental period the blood was collected for analyses of plasma F, glucose and insulin. Liver and gastrocnemius muscle were collected for proteomic analysis. Plasma F concentrations were significantly higher in the F-treated than in the control group. Despite treatment with fluoridated water reduced plasma levels glucose by 20% compared to control, no significant differences were found between the groups for plasma glucose and insulin. In the muscle, treatment with fluoridated water increased the expression of proteins related to muscle contraction, while in the liver, there was an increase in expression of antioxidant proteins and in proteins related to carboxylic acid metabolic process. Remarkably, phosphoenolpyruvate carboxykinase (PEPCK) was found exclusively in the liver of control mice. The reduction in PEPCK, a positive regulator of gluconeogenesis, thus increasing glucose uptake, might be a probable mechanism to explain the anti-diabetic effects of low doses of F, which should be evaluated in further studies.

Trends and determinants of drinking water practices among North Carolina children

OBJECTIVES

To identify trends and determinants of drinking water practices [bottled (BW) versus community water (CW) consumption] among families of pediatric patients presenting to an academic dental institution over 15 years.

METHODS

Electronic health record data were obtained for all first-time routine-care patients ages 0-16 presenting to UNC-Chapel Hill's Pediatric Dentistry Clinics from 2002 to 2016, including families' primary drinking water source and patient demographics (e.g., age, gender, residence, insurance status). Data analyses included descriptive and bivariate methods and multivariable modeling using a P < 0.05 statistical significance criterion.

RESULTS

BW consumption has increased over time, from 17 percent in 2004 to 42 percent in 2016 (n = 2,920; P < 0.05). Medicaid-enrolled children [prevalence ratio (PR) = 2.1; 95% confidence interval (CI) = 1.8-2.4] and residents of rural counties (PR = 1.3, 95% CI = 1.1-1.5) were significantly more likely to consume BW versus CW.

CONCLUSIONS

BW consumption among NC children has been increasing and is most prevalent among low-income families and in rural areas.

Teeth: Small but Mighty and Mighty Important. A Comprehensive Review of Children's Dental Health for Primary Care Clinicians

Healthy teeth allow us to eat and stay well-nourished. Although primary care clinicians receive limited training about teeth, given the common nature of dental problems, it is important that they understand and recognize normal and abnormal dental conditions and can implement primary and secondary prevention of dental conditions in their practice. PubMed has been used to search the scientific literature for evidence on the following topics: normal dental development, dental abnormalities, malocclusion, teething, dental caries and related epidemiology and prevention, fluoride, dental injury and its management and prevention; and identification, prevention and treatment of gingivitis and periodontal disease. Literature review relied on randomized controlled trials, meta-analyses, systematic reviews, and Cochrane reviews when relevant and available. Other sources of evidence included cohort and case-control studies. Consensus statements and expert opinion were used when there was a paucity of high-quality research studies. The literature has been synthesized on these topics to make them relevant to pediatric primary care clinicians, and as available, the strength of evidence has been characterized when making clinical recommendations.

Princípios invocados numa política intersetorial de saúde: o caso da fluoretação da água no Brasil

Resumo O objetivo foi identificar princípios invocados numa política intersetorial de saúde, tomando como caso uma proposta legislativa de revogação da fluoretação da água no Brasil apresentada em 2003. Realizou-se estudo descritivo por meio de pesquisa documental, na qual foram selecionados registros gerados na tramitação do Projeto de Lei nº 510/2003 na Câmara dos Deputados. Buscou-se destacar estratégias discursivas utilizadas pelos atores conforme o jogo de interesses e o contexto conflitivo, utilizando-se o institucionalismo histórico como referencial teórico. O Projeto de Lei tramitou 13 meses, passando pelo Plenário, por três comissões, e sendo arquivado. Três deputados de partidos distintos, órgãos do Poder Executivo federal, agências reguladoras e entidades representativas da categoria odontológica, da saúde pública/coletiva, da engenharia sanitária e das empresas de saneamento participaram diretamente do debate em que emergiram os princípios da segurança da intervenção, dos custos econômicos e do direito à saúde. Em relação às estratégias discursivas utilizadas, os principais elementos invocados no debate da política intersetorial de saúde foram o princípio da incerteza, criando-se falsas categorias científicas a fim de sobrevalorizar os efeitos desfavoráveis e sustentar a implementação de medidas individualizantes; e os princípios morais que definem diferentes tipos de bens econômicos e dimensões de liberdade associadas ao exercício de direitos.

Guidelines on the use of fluoride for caries prevention in children: an updated EAPD policy document

AIM

To update the exisitng European Academy of Paediatric Dentistry (EAPD) 2009 fluoride guidelines.

METHODS

Experts met in Athens, Greece duirng November 2018 for the following groups: I Fluoride toothpastes, II Fluoride gels, rinses and varnishes, III Fluoridated milk, fluoridated salt, tablets/lozenges and drops, IV Water fluoridation. Systematic reviews and meta-analyses were reviewed and discussed for each of the groups. The GRADE system was used to assess the quality of evidence which was judged as HIGH, MODERATE, LOW or VERY LOW based on the assessment of eight criteria which can influence the confidence of the results. Following the quality assessment, GRADE was then used to indicate the strength of recommendation for each fluoride agent as STRONG or WEAK/CONDITIONAL.

RESULTS

Parents must be strongly advised to apply an age-related amount of toothpaste and assist/supervise tooth brushing until at least 7 years of age. The EAPD strongly endorses the daily use of fluoride as a major part of any comprehensive programme for the prevention and control of dental caries in children. Regardless of the type of programme, community or individually based, the use of fluoride must be balanced between the estimation of caries-risk and the possible risks of adverse effects of the fluorides. Fluoride use is considered safe when the manufacturer's instructions are followed. Preventive programmes should be re-evaluated at regular intervals and adapted to a patient's or population's needs and risks.

CONCLUSIONS

For the majority of European Countries, the EAPD recommends the appropriate use of fluoride toothpaste in conjunction with good oral hygiene to be the basic fluoride regimen.

Review of Fluoride Intake and Appropriateness of Current Guidelines

Since the classical epidemiological studies by Dean, it has been known that there should be an optimum level of exposure to fluoride that would be able to provide the maximum protection against caries, with minimum dental fluorosis. The "optimal" daily intake of fluoride for children (0.05-0.07 mg per kilogram bodyweight) that is still accepted worldwide was empirically determined. In the present review, we discuss the appropriateness of the current guidance for fluoride intake, in light of the windows of susceptibility to caries and fluorosis, the modern trends of fluoride intake from multiple sources, individual variations in fluoride metabolism, and recent epidemiological data. The main conclusion is that it is very difficult to think about a strict recommendation for an "optimal" range of fluoride intake at the individual level in light of existing knowledge of 1) the mechanisms of action of fluoride to control caries, 2) the mechanisms involved in dental fluorosis development, 3) the distinct factors that interfere in the metabolism of fluoride, and 4) the windows of susceptibility to both dental caries and fluorosis development. An "optimal" range of fluoride intake is, however, desirable at the population level to guide programs of community fluoridation, but further research is necessary to provide additional support for future decisions on guidance in this area. This list includes the effect of factors affecting fluoride metabolism, clinical trials on the effectiveness of low-fluoride dentifrices to prevent caries in the primary dentition, and validation of biomarkers of exposure to fluoride.

Dental caries experience in children of a remote Australian Indigenous community following passive and active preventive interventions

Objectives

To report on changes in dental caries experience in children of a remote Indigenous community following 6 years of passive preventive intervention (PPI) and 2 years of active preventive intervention (API).

Methods

Five consecutive cross‐sectional surveys were conducted on 4‐ to 15‐year‐old school going children between 2004 and 2017 following phases of Community Water Fluoridation (CWF), post‐cessation of CWF and API. Following treatment of any cavities present, API included selective placement of fissure sealants (FS) and an annual application of povidone‐iodine (PI) and fluoride varnish (FV). The World Health Organization's (WHO) “Oral Health Surveys – Basic Methods (4th Edition)” methodology was used in the first two and the International Caries Detection and Assessment System (ICDAS‐II) in the latter three surveys. ICDAS‐II codes of 3‐6, representing advanced caries, were combined to allow comparison to the decayed component of the DMF caries index.

Results

Age‐weighted mean dmft decreased by 37.7% in the deciduous (DD) and DMFT by 35% in the permanent (PD) dentitions between the pre‐ and post‐CWF surveys, followed by increases of 25% and 7.7%, respectively, between the 1‐year and 4‐year post‐CWF surveys. After 2 years of API, mean dmft decreased by 14.3% and DMFT by 7.1%. Untreated dental caries however remained a concern in the DD and PD during both phases of PPI and of API. The decline in caries experience for both dentitions following 2 years of API exceeded that for the 6‐year period of PPI.

Conclusions

The annual reductions in caries experience of 7.2% (DD) and 8% (PD) during the phase of API exceeded annual decreases of 4.7% (DD) and 4.6% (PD) during the phase of PPI. Due to remoteness, cost and logistics in ensuring long‐term viability of API programmes, CWF remains necessary in this type of community.

Low-level fluoride exposure reduces glycemia in NOD mice

Water fluoridation is the most widespread measure to prevent dental caries but its relationship with the development of type-1 diabetes (T1D), which has been increasing by 2-5% worldwide, is not quite well understood.

AIM

This study evaluated if fluoride (F) administered in the drinking water can prevent or reduce the development of T1D in non-obese diabetic (NOD) mice, as well as to explore the underlying mechanisms.

MATERIALS AND METHODS

Twenty-four weaning NOD mice received water containing 0, 10 or 50 ppm F for 21 days. Plasma glucose and insulin were analyzed. Quantitative proteomic analysis was conducted in the liver and gastrocnemius muscle.

RESULTS

Animals treated with 10 ppm F had significantly lower glucose levels than the control group, but there was no significant difference among the groups in relation to insulin. The % of β-cell function was significantly higher in the 10 ppm F group. Changes in the proteomic profile of muscle and liver were seen among the groups. In the muscle, the 10 ppm F group presented, when compared with control, increased expression of proteins involved in energy metabolism. The 50 ppm F group, compared with control, presented increased expression of proteins related to muscle contraction, differentiation of brown adipose tissue and apoptosis. For the liver, the 10 ppm F group had increase in proteins involved in energy metabolism and protein synthesis, in respect to control. There was also an increase in isoforms of Glutathione S transferase, which was confirmed by Western blotting. In the group treated with 50 ppm F, proteins related to ROS metabolism and energetic metabolism were altered.

CONCLUSION

Increased expression of antioxidant proteins by treatment with low F concentration may possibly help to explain protection against the development of T1D, which should be better explored in future mechanistic studies.

Age-sex specific and sequela-specific disability-adjusted life years (DALYs) due to dental caries preventable through water fluoridation: An assessment at the national and subnational levels in Iran, 2016

We assessed disability-adjusted life years (DALYs) due to dental caries preventable through water fluoridation apportioned by sex, age group, sequela, province, and community type in Iran, 2016. The burden of disease due to dental caries was extracted from the Global Burden of Disease Study 2016 (GBD 2016) and the caries preventive effect of water fluoridation was calculated using a database of fluoride levels in drinking water. All the preventable DALYs were caused by years lived with disability (YLDs) because of the non-fatal character of dental caries. DALYs and DALY rate (per 100,000 people) preventable through water fluoridation at the national level in 2016 were 14,971 (95% uncertainty interval 7348- 24,725) and 18.73 (9.19-30.93), respectively. The national population preventable fraction (PPF) of dental caries by water fluoridation was determined to be as high as 0.176 (0.141-0.189). The share of sequelae in the preventable DALYs at the national level were estimated to be 76.8% for edentulism and severe tooth loss, 21.4% for caries of permanent teeth, and 1.8% for caries of deciduous teeth. The national DALYs and DALY rate preventable through water fluoridation exhibited no difference by sex, but considerably increased by age from 110 (37-223) and 1.5 (0.5-3.1) for the age group 0-4 y to 4331 (2334-6579) and 88.9 (47.9-135.1) for the age group 65 y and older, respectively. Over 80% of the national preventable DALYs occurred in urban areas due to higher population and lower coverage of fluoridated drinking water. The highest provincial DALYs and DALY rate preventable by water fluoridation were observed in Tehran and Gilan to be 3776 (1866-6206) and 37.2 (18.6-60.8), respectively. The results indicated that water fluoridation can play a profound role in the promotion of dental public health and compensate the spatial inequality and increasing temporal trend of health losses from dental caries at the national level.

Community water fluoridation online: an analysis of the digital media ecosystem

OBJECTIVES

Research demonstrates the safety and efficacy of community water fluoridation (CWF). Yet, the digitization of communication has triggered the spread of inaccurate information online. The purpose of this study was to analyze patterns of CWF information dissemination by a network of sources on the web.

METHODS

We used Media Cloud, a searchable big data platform of over 550 million stories from 50 thousand sources, along with tools to analyze that archive. We generated a network of fluoridation publishers using Media Cloud's keyword identification from August 1, 2015 to July 31, 2016. We defined the media type and sentiment toward CWF for each source and generated a network map of the most influential sources during our study period based on hyperlinking activity.

RESULTS

Media Cloud detected a total of 980 stories from 325 different sources related to water fluoridation. We identified nine different media types participating in the dissemination of information: academic, government, scientific group, natural medicine, blogs, mainstream media, advocacy groups, user-generated (e.g., YouTube), and "other." We detected five sub-networks within the overall fluoridation network map, each with its own characteristics. Twenty-one percent of sources were pro-fluoridation, receiving 57 percent of all inlinks, 22 percent of sources were anti-fluoridation, and the rest were neutral (54 percent).

CONCLUSIONS

The dominant neutral sentiment of the network may signify that anti- and pro-sides of the debate are viewed as balanced, not just in number but also in quality of information. Despite high inlinks to pro-sources, anti-fluoridation sentiment maintains influence online.

Costs And Savings Associated With Community Water Fluoridation In The United States

The most comprehensive study of US community water fluoridation program benefits and costs was published in 2001. This study provides updated estimates using an economic model that includes recent data on program costs, dental caries increments, and dental treatments. In 2013 more than 211 million people had access to fluoridated water through community water systems serving 1,000 or more people. Savings associated with dental caries averted in 2013 as a result of fluoridation were estimated to be $32.19 per capita for this population. Based on 2013 estimated costs ($324 million), net savings (savings minus costs) from fluoridation systems were estimated to be $6,469 million and the estimated return on investment, 20.0. While communities should assess their specific costs for continuing or implementing a fluoridation program, these updated findings indicate that program savings are likely to exceed costs.

Adjusted fluoride concentrations and control ranges in 34 states - 2006-2010 and 2015

To inform selection of a control range around the Public Health Service's recommended 0.7 mg/L drinking water fluoride concentration to prevent tooth decay, CDC's Water Fluoridation Reporting System data for 2006-2010 and 2015 were analyzed. Monthly average concentration data from 4,251 fluoride-adjusted community water systems for 191,266 of 255,060 system-months (2006-2010) were compared to control ranges 0.6 mg/L to 0.2 mg/L wide. Percentages of system-months within control ranges ≥0.4 mg/L wide (e.g., ±0.2 mg/L) were >83% versus 68% for 0.2 mg/L wide (±0.1 mg/L). In 2015, 70% of adjusted systems maintained averages within ±0.1 mg/L of their system's annual average for 9 of 12 months, 67% used the 0.7 mg/L target and 45% used it with a ±0.1 mg/L control range. Adoption of the 0.7 mg/L target was underway but not completed in 2015. Control ranges narrower than ±0.2 mg/L may be feasible for monthly average fluoride concentration.

Science, Politics, and Communication: The Case of Community Water Fluoridation in the US

Community water fluoridation (CWF) and its effect in reducing the burden of dental caries (tooth decay) is considered one of the 10 public health achievements in the 20th century. In the U.S., three-quarters (74.4%) of people on community water supplies have optimally fluoridated water, and each year approximately 90 communities actively consider starting or discontinuing CWF. CWF exists within the policy environment and includes actions taken by local community councils, health and water boards, and groups; state legislatures and health departments; national regulatory and science agencies; independent science entities; and professional and nonprofit organizations. Epidemiologists have been in the forefront of CWF. Experience with the past 70 years reveals that the coming decades will bring additional questions, recommendations, and challenges for CWF. The continued involvement of epidemiologists as part of multidisciplinary teams is needed in research, surveillance, peer review of studies, assessment of systematic review findings, and in the translation and communication of science findings to audiences with limited science/health literacy. This chapter's purpose is to 1) examine how epidemiologic evidence regarding CWF has been translated into practice and policy, 2) examine how recommendations for and challenges to CWF have affected epidemiologic research and community decision-making, and 3) identify lessons learned for epidemiologists.

Using Registered Dental Hygienists to Promote a School-Based Approach to Dental Public Health

We examine a strategy for improving oral health in the United States by focusing on low-income children in school-based settings. Vulnerable children often experience cultural, social, economic, structural, and geographic barriers when trying to access dental services in traditional dental office settings. These disparities have been discussed for more than a decade in multiple US Department of Health and Human Services publications. One solution is to revise dental practice acts to allow registered dental hygienists increased scope of services, expanded public health delivery opportunities, and decreased dentist supervision. We provide examples of how federally qualified health centers have implemented successful school-based dental models within the parameters of two state policies that allow registered dental hygienists varying levels of dentist supervision. Changes to dental practice acts at the state level allowing registered dental hygienists to practice with limited supervision in community settings, such as schools, may provide vulnerable populations greater access to screening and preventive services. We derive our recommendations from expert opinion.