The relationship between fluoridation, social class and caries experience in 5-year-old children in Newcastle and Northumberland in 1987

Water fluoridation for the prevention of dental caries

BACKGROUND

Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation (CWF) is currently practised in about 25 countries; health authorities consider it to be a key strategy for preventing dental caries. CWF is of interest to health professionals, policymakers and the public. This is an update of a Cochrane review first published in 2015, focusing on contemporary evidence about the effects of CWF on dental caries.

OBJECTIVES

To evaluate the effects of initiation or cessation of CWF programmes for the prevention of dental caries. To evaluate the association of water fluoridation (artificial or natural) with dental fluorosis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and four other databases up to 16 August 2023. We also searched two clinical trials registers and conducted backward citation searches.

SELECTION CRITERIA

We included populations of all ages. For our first objective (effects of initiation or cessation of CWF programmes on dental caries), we included prospective controlled studies comparing populations receiving fluoridated water with those receiving non-fluoridated or naturally low-fluoridated water. To evaluate change in caries status, studies measured caries both within three years of a change in fluoridation status and at the end of study follow-up. For our second objective (association of water fluoridation with dental fluorosis), we included any study design, with concurrent control, comparing populations exposed to different water fluoride concentrations. In this update, we did not search for or include new evidence for this objective.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. For our first objective, we included the following outcomes as change from baseline: decayed, missing or filled teeth ('dmft' for primary and 'DMFT' for permanent teeth); decayed, missing or filled tooth surfaces ('dmfs' for primary and 'DMFS' for permanent teeth); proportion of caries-free participants for both primary and permanent dentition; adverse events. We stratified the results of the meta-analyses according to whether data were collected before or after the widespread use of fluoride toothpaste in 1975. For our second objective, we included dental fluorosis (of aesthetic concern, or any level of fluorosis), and any other adverse events reported by the included studies.

MAIN RESULTS

We included 157 studies. All used non-randomised designs. Given the inherent risks of bias in these designs, particularly related to management of confounding factors and blinding of outcome assessors, we downgraded the certainty of all evidence for these risks. We downgraded some evidence for imprecision, inconsistency or both. Evidence from older studies may not be applicable to contemporary societies, and we downgraded older evidence for indirectness. Water fluoridation initiation (21 studies) Based on contemporary evidence (after 1975), the initiation of CWF may lead to a slightly greater change in dmft over time (mean difference (MD) 0.24, 95% confidence interval (CI) -0.03 to 0.52; P = 0.09; 2 studies, 2908 children; low-certainty evidence). This equates to a difference in dmft of approximately one-quarter of a tooth in favour of CWF; this effect estimate includes the possibility of benefit and no benefit. Contemporary evidence (after 1975) was also available for change in DMFT (4 studies, 2856 children) and change in DMFS (1 study, 343 children); we were very uncertain of these findings. CWF may lead to a slightly greater change over time in the proportion of caries-free children with primary dentition (MD -0.04, 95% CI -0.09 to 0.01; P = 0.12; 2 studies, 2908 children), and permanent dentition (MD -0.03, 95% CI -0.07 to 0.01; P = 0.14; 2 studies, 2348 children). These low-certainty findings (a 4 percentage point difference and 3 percentage point difference for primary and permanent dentition, respectively) favoured CWF. These effect estimates include the possibility of benefit and no benefit. No contemporary data were available for adverse effects. Because of very low-certainty evidence, we were unsure of the size of effects of CWF when using older evidence (from 1975 or earlier) on all outcomes: change in dmft (5 studies, 5709 children), change in DMFT (3 studies, 5623 children), change in proportion of caries-free children with primary dentition (5 studies, 6278 children) or permanent dentition (4 studies, 6219 children), or adverse effects (2 studies, 7800 children). Only one study, conducted after 1975, reported disparities according to socioeconomic status, with no evidence that deprivation influenced the relationship between water exposure and caries status. Water fluoridation cessation (1 study) Because of very low-certainty evidence, we could not determine if the cessation of CWF affected DMFS (1 study conducted after 1975; 2994 children). Data were not available for other review outcomes for this comparison. Association of water fluoridation with dental fluorosis (135 studies) The previous version of this review found low-certainty evidence that fluoridated water may be associated with dental fluorosis. With a fluoride level of 0.7 parts per million (ppm), approximately 12% of participants had fluorosis of aesthetic concern (95% CI 8% to 17%; 40 studies, 59,630 participants), and approximately 40% had fluorosis of any level (95% CI 35% to 44%; 90 studies, 180,530 participants). Because of very low-certainty evidence, we were unsure of other adverse effects (including skeletal fluorosis, bone fractures and skeletal maturity; 5 studies, incomplete participant numbers).

AUTHORS' CONCLUSIONS

Contemporary studies indicate that initiation of CWF may lead to a slightly greater reduction in dmft and may lead to a slightly greater increase in the proportion of caries-free children, but with smaller effect sizes than pre-1975 studies. There is insufficient evidence to determine the effect of cessation of CWF on caries and whether water fluoridation results in a change in disparities in caries according to socioeconomic status. We found no eligible studies that report caries outcomes in adults. The implementation or cessation of CWF requires careful consideration of this current evidence, in the broader context of a population's oral health, diet and consumption of tap water, movement or migration, and the availability and uptake of other caries-prevention strategies. Acceptability, cost-effectiveness and feasibility of the implementation and monitoring of a CWF programme should also be taken into account.

Global and regional estimates of dental pain among children and adolescents-systematic review and meta-analysis

AIM

We aimed to evaluate the pooled prevalence of dental pain amongst children and adolescents.

METHODS

Studies conducted in children and adolescents up to18 years of age and where prevalence of dental is reported or calculated were included. Search was performed in four major databases from inception to June 1st, 2019. Prevalence estimate at the maximal recall for the dental pain for the individual study was used to calculate the overall pooled estimate.

RESULTS

The prevalence of dental pain ranged from 1.33 to 87.8% in the included publications for quantitative synthesis (n = 97). More than half of the publications reported the lifetime prevalence of dental pain (n = 51) while few studies reported the current prevalence of dental pain (n = 3) and only one study evaluated the dental pain in the past one week. Heterogeneity was high among the included publications (Q = 49,063.12; P < 0.001; df = 96 and I² = 99.8; P < 0.001). Overall pooled prevalence of dental pain was 32.7 (CI = 29.6-35.9). No difference was seen with respect to the trends in prevalence of dental pain (Coefficient: 0.005; 95% CI - 0.001-0.011; P-value: 0.101).

CONCLUSION

Two out of ten children below five years, four out of ten children between 6 and 12 years and three out of ten adolescents between 13 and 18 years would have experienced pain in the past. Overall, three out of ten children or adolescents might have experienced dental pain in the past. There was no difference in the pain prevalence between male and females. Studies from Africa reported highest pooled prevalence (50.1%) with least being from Australia (20.7%). Studies from India (40.4%), China (41.3%) and Iran (42.6%) reported high pooled prevalence estimates of dental pain.

Community Water Fluoridation Benefits US Children From Poor Families More Than Those From More Affluent Families

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Association Between Water Fluoridation and Income-Related Dental Caries of US Children and Adolescents. Sanders AE, Grider WB, Maas WR, Curiel JA, Slade GD. JAMA Pediatr 2019;173(3):288-90.

SOURCE OF FUNDING

National Institute of Dental and Craniofacial Research of the National Institutes of Health under award number UH2DE025494.

TYPE OF STUDY/DESIGN

Cross-sectional study.

Water fluoridation for the prevention of dental caries

BACKGROUND

Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation was initiated in the USA in 1945 and is currently practised in about 25 countries around the world; health authorities consider it to be a key strategy for preventing dental caries. Given the continued interest in this topic from health professionals, policy makers and the public, it is important to update and maintain a systematic review that reflects contemporary evidence.

OBJECTIVES

To evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries.To evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis.

SEARCH METHODS

We searched the following electronic databases: The Cochrane Oral Health Group's Trials Register (to 19 February 2015); The Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2015); MEDLINE via OVID (1946 to 19 February 2015); EMBASE via OVID (1980 to 19 February 2015); Proquest (to 19 February 2015); Web of Science Conference Proceedings (1990 to 19 February 2015); ZETOC Conference Proceedings (1993 to 19 February 2015). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization's WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on language of publication or publication status in the searches of the electronic databases.

SELECTION CRITERIA

For caries data, we included only prospective studies with a concurrent control that compared at least two populations - one receiving fluoridated water and the other non-fluoridated water - with outcome(s) evaluated at at least two points in time. For the assessment of fluorosis, we included any type of study design, with concurrent control, that compared populations exposed to different water fluoride concentrations. We included populations of all ages that received fluoridated water (naturally or artificially fluoridated) or non-fluoridated water.

DATA COLLECTION AND ANALYSIS

We used an adaptation of the Cochrane 'Risk of bias' tool to assess risk of bias in the included studies.We included the following caries indices in the analyses: decayed, missing and filled teeth (dmft (deciduous dentition) and DMFT (permanent dentition)), and proportion caries free in both dentitions. For dmft and DMFT analyses we calculated the difference in mean change scores between the fluoridated and control groups. For the proportion caries free we calculated the difference in the proportion caries free between the fluoridated and control groups.For fluorosis data we calculated the log odds and presented them as probabilities for interpretation.

MAIN RESULTS

A total of 155 studies met the inclusion criteria; 107 studies provided sufficient data for quantitative synthesis.The results from the caries severity data indicate that the initiation of water fluoridation results in reductions in dmft of 1.81 (95% CI 1.31 to 2.31; 9 studies at high risk of bias, 44,268 participants) and in DMFT of 1.16 (95% CI 0.72 to 1.61; 10 studies at high risk of bias, 78,764 participants). This translates to a 35% reduction in dmft and a 26% reduction in DMFT compared to the median control group mean values. There were also increases in the percentage of caries free children of 15% (95% CI 11% to 19%; 10 studies, 39,966 participants) in deciduous dentition and 14% (95% CI 5% to 23%; 8 studies, 53,538 participants) in permanent dentition. The majority of studies (71%) were conducted prior to 1975 and the widespread introduction of the use of fluoride toothpaste.There is insufficient information to determine whether initiation of a water fluoridation programme results in a change in disparities in caries across socioeconomic status (SES) levels.There is insufficient information to determine the effect of stopping water fluoridation programmes on caries levels.No studies that aimed to determine the effectiveness of water fluoridation for preventing caries in adults met the review's inclusion criteria.With regard to dental fluorosis, we estimated that for a fluoride level of 0.7 ppm the percentage of participants with fluorosis of aesthetic concern was approximately 12% (95% CI 8% to 17%; 40 studies, 59,630 participants). This increases to 40% (95% CI 35% to 44%) when considering fluorosis of any level (detected under highly controlled, clinical conditions; 90 studies, 180,530 participants). Over 97% of the studies were at high risk of bias and there was substantial between-study variation.

AUTHORS' CONCLUSIONS

There is very little contemporary evidence, meeting the review's inclusion criteria, that has evaluated the effectiveness of water fluoridation for the prevention of caries.The available data come predominantly from studies conducted prior to 1975, and indicate that water fluoridation is effective at reducing caries levels in both deciduous and permanent dentition in children. Our confidence in the size of the effect estimates is limited by the observational nature of the study designs, the high risk of bias within the studies and, importantly, the applicability of the evidence to current lifestyles. The decision to implement a water fluoridation programme relies upon an understanding of the population's oral health behaviour (e.g. use of fluoride toothpaste), the availability and uptake of other caries prevention strategies, their diet and consumption of tap water and the movement/migration of the population. There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES. We did not identify any evidence, meeting the review's inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries in adults.There is insufficient information to determine the effect on caries levels of stopping water fluoridation programmes.There is a significant association between dental fluorosis (of aesthetic concern or all levels of dental fluorosis) and fluoride level. The evidence is limited due to high risk of bias within the studies and substantial between-study variation.

A historical and undergraduate context to inform interprofessional education for global health

Through a case example of fluoride, this paper examines why dental caries and other 21st century challenges require collaborative practice toward improved health that begins with interprofessional education (IPE). We suggest a theoretical framework for expanding the thinking around IPE for global health and recommend beginning at the undergraduate, or "pre-interprofessional," level where students are still undifferentiated by profession. Our theoretical framework can assist in providing a foundation for curriculum alignment and calibration moving forward to the graduate and professional training levels.

The association between social deprivation and the prevalence and severity of dental caries and fluorosis in populations with and without water fluoridation

BACKGROUND

To determine the association between social deprivation and the prevalence of caries (including caries lesions restricted to enamel) and enamel fluorosis in areas that are served by either fluoridated or non-fluoridated drinking water using clinical scoring, remote blinded, photographic scoring for caries and fluorosis. The study also aimed to explore the use of remote, blinded methodologies to minimize the effect of examiner bias.

METHODS

Subjects were male and female lifetime residents aged 11-13 years. Clinical assessments of caries and fluorosis were performed on permanent teeth using ICDAS and blind scoring of standardized photographs of maxillary central incisors using TF Index (with cases for fluorosis defined as TF > 0).

RESULTS

Data from 1783 subjects were available (910 Newcastle, 873 Manchester). Levels of material deprivation (Index of Multiple Deprivation) were comparable for both populations (Newcastle mean 35.22, range 2.77-78.85; Manchester mean 37.04, range 1.84-84.02). Subjects in the fluoridated population had significantly less caries experience than the non-fluoridated population when assessed by clinical scores or photographic scores across all quintiles of deprivation for white spot lesions: Newcastle mean DMFT 2.94 (clinical); 2.51 (photo), Manchester mean DMFT 4.48 (clinical); 3.44 (photo) and caries into dentine (Newcastle Mean DMFT 0.65 (clinical); 0.58 (photo), Manchester mean DMFT 1.07 (clinical); 0.98 (photo). The only exception being for the least deprived quintile for caries into dentine where there were no significant differences between the cities: Newcastle mean DMFT 0.38 (clinical); 0.36 (photo), Manchester mean DMFT 0.45 (clinical); 0.39 (photo). The odds ratio for white spot caries experience (or worse) in Manchester was 1.9 relative to Newcastle. The odds ratio for caries into dentine in Manchester was 1.8 relative to Newcastle. The odds ratio for developing fluorosis in Newcastle was 3.3 relative to Manchester.

CONCLUSIONS

Water fluoridation appears to reduce the social class gradient between deprivation and caries experience when considering caries into dentine. However, this was associated with an increased risk of developing mild fluorosis. The use of intra-oral cameras and remote scoring of photographs for caries demonstrated good potential for blinded scoring.

The water fluoridation debate

Water fluoridation schemes have been employed for over 50 years. Water fluoridation has been a source of continuous debate between those who advocate its use as a public health measure and those who oppose it. There have been no new fluoridation schemes in the U.K. for nearly 30 years owing to principally legislative, but also geographic, financial, and political reasons. However, in early 2008, the U.K. Secretary of State for Health promoted the use of water fluoridation schemes for areas in England with the highest rates of decay. This article, the third and final article of three, aims to discuss the arguments surrounding water fluoridation and its continued relevance as a public health measure.

CLINICAL RELEVANCE

This article aims to provide an update for general practitioners for the background and the current status of the water fluoridation debate and to enable them to answer non-clinical questions raised by patients.

Enquête épidémiologique sur la santé buccodentaire d'enfants âgés de 4 ans scolarisés en école maternelle

The departmental service of maternal and infantile protection (PMI) of Moselle (Lorraine region), together with the Paediatric Dentistry Department from Nancy University, organized a study of the dental health of 4-year-old children.

AIMS OF THE STUDY

To assess the children dental health; to evaluate parental knowledge of dental health; to identify the factors associated with caries amongst children.

MATERIAL AND METHODS

The study was a cross sectional observation. A random sample of 4-year-old children was selected among 11 586 children in nursery schools. The study was based on a clinical examination performed by a dentist and a structured questionnaire completed by parents.

RESULTS

The overall proportion of children affected by caries was 37.5%. The mean dmft score was 1.51 (sd = 2.82) and 11.6% of the children had caries which affected their upper incisors, a sign of early childhood caries. Only 6.2% had received dental treatment on at least 1 occasion. There was a clear disparity in dental health: 1 child out of 3 suffered from caries but 1 out of 2 children in priority education districts was affected, compared with only 1 out of 4 children coming from a rural area. The questionnaires completed by parents showed a lack of knowledge of dental health and inadequate use of current prevention facilities. The multivariate logistic regression analysis showed that the variables that were significantly associated with caries in 4 year-old children were the mother's education, the low social background, the level of consumption of drinks containing sugar by both children and parents, the consumption of fluoride, and the level of knowledge about fluoride.

CONCLUSION

Preventive measures must be developed in close relationship between pediatricians and dentists. Initial training of health care professionals has to be reinforced. Health care professionals in paediatrics are far more likely to meet mothers and young children than are dentists.

The interrelationship between diet and oral health

Diet and nutrition impact on many oral diseases, in particular dental caries. Consumption of fluoridated water coupled with a reduction in non-milk extrinsic sugar intake is an effective means of caries prevention. However, studies on the fluoride concentration of bottled waters suggest increased consumption of these waters, in preference to fluoridated tap water, would lead to a marked decrease in caries protection. Concerns have been raised about the bioavailability of fluoride from artificially-fluoridated water compared with naturally-fluoridated water. This issue has been addressed in a human experimental study that has indicated that any differences in fluoride bioavailability are small compared with the naturally-occurring variability in fluoride absorption. Research has unequivocally shown sugars to be the main aetiological factor for dental caries, and information on intakes guides health promotion. Repeat dietary surveys of English children over three decades indicate that levels of sugars intake have remained stable, while sources of sugars have changed considerably, with the contribution from soft drinks more than doubling since 1980. Dental caries eventually leads to tooth loss, which in turn impairs chewing ability causing avoidance of hard and fibrous foods including fruits, vegetables and whole grains. A very low intake (<12 g/d) of NSP and fruit and vegetables has been found in edentulous subjects. Provision of prostheses alone fails to improve diet. However, initial studies indicate that customised dietary advice at the time of denture provision results in increased consumption of fruits and vegetables, and positive movement through the stages of change. Feasible means of integrating dietary counselling into the dental setting warrants further investigation.

Caries Prevalence in a Rural Chilean Community after Cessation of a Powdered Milk Fluoridation Program

OBJECTIVE

The milk fluoridation scheme established in Codegua, Chile, between 1994 and 1999 demonstrated the effectiveness of powdered milk as a community-based vehicle for fluoride to prevent dental caries. The present study aimed to compare caries prevalence in both the Codeguan control and test communities, three years after ending fluoride distribution through the powdered milk fluoridation scheme, to assess whether the benefits of such milk fluoridation were still present in the test community.

METHODS

Children 3-6 years old living in Codegua (test community) and La Punta (control community) were examined for dental caries at their educational facilities by three trained and calibrated examiners using natural light, dental mirrors, and sickle probes. Differences in caries prevalence (dmfs) by year of the study were tested for statistically significant differences using the Mann-Whitney U test.

RESULTS

Findings from Codegua (1999-2002) indicate that the dental caries experience increased in all age groups following the termination of powdered milk fluoridation. These differences reached levels of statistical significance in the 3-, 4-, and 5- year old group (P < .03). Comparing results from Codegua and La Punta (2002), no statistically significant differences were found.

CONCLUSIONS

Termination of the powdered milk fluoridation scheme resulted in a deterioration of the dental health of children. After three years, dental caries prevalence was higher than that reached at the end of the scheme and equivalent to that of the control community without fluoride exposure. These results emphasize the need to establish and maintain an alternative mechanism of community-based fluoridation of proven effectiveness for the prevention of dental caries in communities where water fluoridation is not available.

Inequality of water fluoridation in Southern Brazil—the inverse equity hypothesis revisited

The purpose of this ecological study was to investigate the association between social and economic indicators at the municipal level and the presence of water fluoridation and time when water fluoridation was implemented in the 293 municipalities of Santa Catarina State in Southern Brazil. Several social and economic indicators were obtained from official Brazilian agencies as well as from UNICEF. Questionnaires were sent to local authorities and to the local government water supply Company to obtain information about the presence or not of a fluoridated water supply and the year when fluoridation was implemented. Differences in social and economic indicators between municipalities with and without fluoridated water and between those that have had this service for different lengths of time were compared by the Mann-Whitney U test. In addition, multiple logistic regression analyses was performed to identify associations between social and economic indicators at the municipal level and presence and time of implementation of water fluoridation. Results indicated that larger populations are associated with municipalities with fluoridated water. Larger populations, higher child development indexes and low illiteracy rates are associated with a longer time since the implementation of water fluoridation. The finding that less developed municipalities delayed the provision of water fluoridation corroborates the inverse equity hypothesis.

Fluoridation and social equity

The overall reduction in caries prevalence and severity in the United States over recent decades is largely due to widespread exposure to fluoride, most notably from the fluoridation of drinking waters. Despite this overall reduction, however, caries distribution today remains skewed, with the poor and deprived carrying a disproportionate share of the disease burden. Dental caries, like many other diseases, is directly related to low socioeconomic status (SES). In some communities, however, caries experience has now diminished to the point where the need for continuing water fluoridation is being questioned. This paper argues that water fluoridation is still needed because it is the most effective and practical method of reducing the SES-based disparities in the burden of dental caries. There is no practical alternative to water fluoridation for reducing these disparities in the United States. For example, a school dental service, like those in many other high-income countries, would require the allocation of substantial public resources, and as such is not likely to occur soon. But studies in the United States, Britain, Australia, and New Zealand have demonstrated that fluoridation not only reduces the overall prevalence and severity of caries, but also reduces the disparities between SES groups. Water fluoridation has been named as one of the 10 major public health achievements of the 20th century by the Centers for Disease Control and Prevention, and promoting it is a Healthy People objective for the year 2010. Within the social context of the United States, water fluoridation is probably the most significant step we can take toward reducing the disparities in dental caries. It therefore should remain as a public health priority.

Why reduce health inequalities?

It is well known that social, cultural and economic factors cause substantial inequalities in health. Should we strive to achieve a more even share of good health, beyond improving the average health status of the population? We examine four arguments for the reduction of health inequalities.1 Inequalities are unfair. Inequalities in health are undesirable to the extent that they are unfair, or unjust. Distinguishing between health inequalities and health inequities can be contentious. Our view is that inequalities become "unfair" when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health (for example, unequal opportunities in education or employment).2 Inequalities affect everyone. Conditions that lead to marked health disparities are detrimental to all members of society. Some types of health inequalities have obvious spillover effects on the rest of society, for example, the spread of infectious diseases, the consequences of alcohol and drug misuse, or the occurrence of violence and crime.3 Inequalities are avoidable. Disparities in health are avoidable to the extent that they stem from identifiable policy options exercised by governments, such as tax policy, regulation of business and labour, welfare benefits and health care funding. It follows that health inequalities are, in principle, amenable to policy interventions. A government that cares about improving the health of the population ought therefore to incorporate considerations of the health impact of alternative options in its policy setting process.3 Interventions to reduce health inequalities are cost effective. Public health programmes that reduce health inequalities can also be cost effective. The case can be made to give priority to such programmes (for example, improving access to cervical cancer screening in low income women) on efficiency grounds. On the other hand, few programmes designed to reduce health inequalities have been formally evaluated using cost effectiveness analysis. We conclude that fairness is likely to be the most influential argument in favour of acting to reduce disparities in health, but the concept of equity is contested and susceptible to different interpretations. There is persuasive evidence for some outcomes that reducing inequalities will diminish "spill over" effects on the health of society at large. In principle, you would expect that differences in health status that are not biologically determined are avoidable. However, the mechanisms giving rise to inequalities are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.

Inequalities in oral health: a review of the evidence and recommendations for action

Reducing inequalities in health has become one of the main health policy issues in the late 1990s. The Labour Government set up an independent inquiry into inequalities in health under Sir Donald Acheson to make recommendations on approaches to reducing health inequalities. This paper reviews the evidence on inequalities in oral health in Britain. Dramatic improvements in dental health in children and young adults have taken place in the past 30 years. The levels of caries in permanent teeth of children is low. Widening inequalities in oral health however exist between social classes, regions of England, and among certain minority ethnic groups in pre-school children. The main social class and minority ethnic differences in dental caries is in pre-school children. Wide district and regional differences also exist in prevalence of caries in young children. The area differences relate very strongly to deprivation. In adults the differences in decay experience is less unequal than in children but there are marked social class inequalities in edentulousness. Dental caries decreased in all social classes in the United Kingdom. The main causes of the inequalities are differences in patterns of consumption of non milk extrinsic sugars and fluoridated toothpaste. Improvements in oral health that have occurred over the last 30 years have been largely a result of fluoride toothpaste and social, economic and environmental factors. Oral health inequalities will only be reduced through the implementation of effective and appropriate oral health promotion policy. Treatment services will never successfully tackle the underlying cause of oral diseases.

Fluoride exposure and dental fluorosis in Newburgh and Kingston, New York: policy implications

OBJECTIVES

This analysis was conducted to determine the changes in the effect of exposure to fluoridation and other sources of fluoride on dental fluorosis in children attending Newburgh and Kingston school districts in New York State.

METHODS

Data for this analysis were obtained from two surveys conducted in the 1986 and 1995 school years. Analyses were limited to 3500, 7-14-year-old lifelong residents of a fluoridated or a nonfluoridated community. Dean's classification and DMFS index were used for recording dental fluorosis and caries, respectively. A questionnaire was used to collect fluoride exposure data. Regression procedures were used to estimate the effect of fluoridation, fluoride supplements, and brushing before the age of 2 years on dental fluorosis.

RESULTS

Children examined in 1996 were at higher risk for both questionable and very mild to severe dental fluorosis if they received fluoride from water or daily tablet use, or started brushing before the age of 2 years. The increase in risk from 1986 to 1995 was greater for African-American children.

CONCLUSION

This analysis showed that the risk of developing dental fluorosis did not decline over time in these communities. Continuous exposure to water fluoridation had an observable effect on dental fluorosis. However, implementation of fluoridation in Newburgh Town did not result in an increase in dental fluorosis prevalence.

The relationship between water fluoridation and socioeconomic deprivation on tooth decay in 5-year-old children

AIM

To examine the relationship between water fluoridation, socioeconomic deprivation and tooth decay in 5-year-olds.

SETTING

10,004 children: 1,051 in naturally fluoridated Hartlepool in 1991/92, 3,816 in fluoridated Newcastle & North Tyneside and 5,137 in non-fluoridated Salford & Trafford in 1993/94.

OUTCOME MEASURES

Correlations between mean electoral ward dmft and ward Townsend Scores from the 1991 census.

RESULTS

Regardless of the level of water fluoridation significant correlations were found between deprivation and tooth decay. Multiple linear regression models for dmft showed a statistically significant interaction between ward Townsend score, and both types of water fluoridation, confirming the more deprived the area the greater the reduction in tooth decay. At a Townsend score of zero (the English average) there was a predicted 43% reduction in decay in 5-year-olds in fluoridated areas.

CONCLUSIONS

Tooth decay is strongly associated with social deprivation. The findings confirm that the implementation of water fluoridation has halved tooth decay in 5-year-old children and that the dental caries divide between rich and poor is reduced.

Changes in dental fluorosis and dental caries in Newburgh and Kingston, New York

OBJECTIVES

This study sought to determine whether the prevalence of dental fluorosis and dental caries had changed in a fluoridated community and a nonfluoridated community since an earlier study conducted in 1986.

METHODS

Dental fluorosis and dental caries data were collected on 7- to 14-year-old lifelong residents (n = 1493) of Newburgh and Kingston, NY.

RESULTS

Estimated dental fluorosis prevalence rates were 19.6% in Newburgh and 11.7% in Kingston. The greatest disparity in caries scores was observed between poor and nonpoor children in nonfluoridated Kingston.

CONCLUSIONS

The prevalence of dental fluorosis has not declined in Newburgh and Kingston, whereas the prevalence of dental caries has continued to decline.

Influence of exposure to fluoridated water on socioeconomic inequalities in children's caries experience

This study aimed to evaluate inequalities in children's dental caries experience among socioeconomic status (SES) groups and to investigate effects of exposure to fluoride in water on those inequalities. Cross-sectional data were obtained from 6704 Queensland children aged 5-12 years and 6814 South Australian children aged 5-15 years. School dental therapists and dentists recorded dmfs and DMFS data. A questionnaire to parents sought information about household SES and each child's lifetime exposure to fluoridated drinking water. SES fluoride exposure and multiplicative interactions between the two were used as explanatory variables in least squares models in which dmfs and DMFs were dependent variables. Additive interactions were evaluated by calculating the excess rate of disease. In both states, children from low SES groups (categorized by household income or parental education) had higher mean dmfs and DMFS values than children from high SES groups (P < 0.01). Independent effects of income and education remained significant (P < 0.01) after controlling for exposure to fluoride in drinking water. In Queensland, there was a significant multiplicative interaction whereby SES inequalities were lower among children exposed to fluoride: dmfs ratios between low- and high-income groups ranged among ages from 1.54 to 3.56 for children with no exposure to fluoride and from 0.84 to 2.07 for children with lifetime exposure to fluoride. Multiplicative interactions were not statistically significant in South Australia or when DMFS was the dependent variable. However, additive interactions were consistent and most pronounced for deciduous teeth in both States. Absolute differences in caries experience between low and high SES children were greater among non-exposed groups due to the higher underlying levels of caries experience of children with no exposure to fluoride in water.

[Dental health status of students living in places supplied with drinking water of very high and very low levels of fluorides]

The results of a cross sectional epidemiological survey for the purpose of evaluating the state of dental health of schoolchildren (aged 6-7 and 12-13) living in Sampacho and Porteña, two towns in the Province of Córdoba (Argentina), supplied with drinking water containing quite different levels of fluoride, are described and analized. In Sampacho, F- level is 9.05 mg/l. while in Porteña the concentration is of 0.19 mg/l. The proportion of schoolchildren (aged 6-7 and 12-13) without caries was significaticantly higher in Sampacho than in Porteña, while the dmf-t, dmf-s, DMF-T and DMF-S indexes were considerably higher in the latter place. The severity of caries in children (age 12-13) living in Sampacho ranged from low to moderate (DMF-T = 2.53), whilst in Porteña the range went from moderate to high (DMF-T = 4.41). No cases of dental fluorosis were recorded in Porteña; but in Sampacho, there was a high proportion of children with mild fluorosis (aged 6-7) and mild or severe fluorosis (aged 12-13). Calcium, phosphate, thiocyanate, protein and secretory Ig A salivary levels were similar not only among schoolchildren of both towns but also among those with different experience of caries and different degrees of severity of fluorosis. It is concluded that urgent (preventive and/or curative) sanitary measures are necessary for the purpose of reducing or controlling caries in Porteña as well as dental fluorosis in Sampacho.

Caries experience in Latvian nursery school children

In 1993 the dental health was assessed in 631 Latvian 3--4-yr-old nursery school children. Forty-eight percent of the 3-yr-olds and 26% of the 4-yr-olds were caries free. The mean dmft for the total sample was 3.2 (2.2 and 3.8 in the 3-and 4-yr-olds, respectively). Molar caries, accounting for 66% of the total dmft score, was dominant in both age groups. Sixteen percent of the children had received restorations, 38% of which manifested recurrent caries. Recurrent caries was relatively more frequent in the younger children. Concomitant with a general increase in caries level, the polarization of the disease was less pronounced in the older children. The upper 25% of the distribution for 3- and 4-yr-olds contained 74% and 40% of the dmft, respectively. Daily toothbrushing was reported for 60% of the children. Of those, 38% used fluoride-containing dentifrice. No significant associations were found between caries experience and toothbrushing frequency, use of fluoride dentifrice or parents' education.

Relationship of caries with socioeconomic status in 14-year-old children from communities with different fluoride histories

The aim of this study was to describe the caries prevalence of 14-yr-old children living in two fluoridated communities, a non-fluoridated community, and a community that discontinued fluoridation 5 yr before the children were examined and to relate the caries prevalence to socio-economic status. Clinical examinations were completed on 413 children of whom 227 had been continuously resident in their towns. Children living in the fluoridated communities had significantly lower mean DMFT and DMFS scores than those in the non-fluoridated town. The children from the town that had discontinued fluoridation 5 yr earlier had mean DMFT and DMFS scores that occupied an intermediate position. The differences were greater when only the continuous residents were examined. There were significant differences in the mean DMFT and DMFS when comparing socioeconomic status and fluoridation of the water supply. No interaction effect was demonstrated between these two factors.

Factors affecting caries experience in French adolescents

Three hundred French 14-15-yr-old adolescents were randomly selected. They were examined clinically and caries experience was determined by using the DMFS index. The aim of this investigation was to evaluate children's habits using a self-administered questionnaire, to clarify the actual influence of well-known factors such as fluoride exposure, diet, oral hygiene and socioeconomic factors on caries experience and to stress those factors of primary importance. A multiple regression analysis revealed the variables which significantly contributed to explain DMFS scores in a final model: Age, sex, frequency of sweet consumption, use of standard or high fluoride toothpastes, bleeding during toothbrushing, living in St Yorre (F- = 0.45 mg/l). At a time when caries experience is decreasing, it seems that fluoride supply, snacking and oral hygiene are still independent and significant determinants of caries experience in French adolescents.

Dental status of 12-year-olds treated in private practice and a school dental service

Different ways of service provision frequently lead to different services being provided. In the School Dental Service (SDS) in Western Australia, all 5-15-yr-olds are eligible for care free of charge and most avail themselves of the service. The parents of some children choose to use private dentists (typically copaying about 50% of the cost) and their children do not attend the SDS. This study aimed to compare the dental status of 12-yr-olds who attended private dentists with that of matched children enrolled in the SDS. Non-enrolled 12-yr-olds in Perth (F- 0.8 mg/l) were identified and asked to provide background information and participate in clinical examinations. Each non-enrolled participant was matched with a classmate of the same sex. Of 184 non-enrolled children, 100 actually participated. Data on caries experience (DMFT and DMFS), fissure sealants and gingival health (CPITN) were collected by clinical examination. Analyses used Wilcoxon's signed rank, categorical and t-tests and simple linear regression. Caries prevalence was lower in non-enrolled children (0.31) than in enrolled (0.47). Caries experience was also lower in non-enrolled children (mean DMFT 0.71 vs. 0.95, ns). Enrolled children had more FT than non-enrolled (Wilcoxon, P = 0.059) but the mean number of DT in each group was 0.14. Enrolled children had somewhat fewer fissure sealants than non-enrolled children but in enrolled children there was an apparent (P = 0.056) inverse relationship between number of fissure sealants and DMFT scores; this was not the case in the non-enrolled group, suggesting better targeting of fissure sealants in the SDS.(ABSTRACT TRUNCATED AT 250 WORDS)

Socioeconomic disadvantage and child morbidity: an Australian longitudinal study

While an extensive body of literature has demonstrated an association between socioeconomic status and child mortality, there have been relatively few papers which discuss the impact of socioeconomic inequality on child morbidity. This absence of data is partly attributable to methodological problems (need for large samples, the difficulty of assessing morbidity) and partly to the absence of relevant official health statistics. This paper reports results from the Mater-University of Queensland Study of Pregnancy (MUSP) and its outcomes. The sample comprises 8556 consecutive pregnancies, of which over 90% were followed up to birth. Of those mothers giving birth, approx. 70% of children were successfully given a health assessment five years after the birth (mothers report of the child's health using a set of standard indicators). The results indicate a consistent pattern with the children of the most socioeconomically disadvantaged mothers manifesting the worst health. Thus children living in socioeconomic disadvantage have a higher rate of health service utilisation, more chronic health problems and poorer dental health. The paper discusses some social policies for redressing these inequalities.

Fluoride in the prevention of caries in the preschool child

The use of fluorides has benefited greatly the dental health of preschool children. Water fluoridation cuts caries by half in the deciduous dentition as it does in the permanent dentition. In the absence of water fluoridation, fluoride dietary supplements can be used and are effective. For practical reasons it may be useful to limit their use to those at risk from caries and those seen to be prone to caries. There has been some concern over links between early use of fluoride toothpastes and the occurrence of very mild fluorosis. Although this is not perceived as a problem by parents or the community, it is prudent to recommend that parents clean their children's teeth with a pea-size amount of toothpaste. Fluoride varnishes are effective and are useful for preventing caries in young children.

Epidemiology of dental caries

The most recent epidemiological data on the prevalence of dental caries in children indicate a halting of the increasing levels in many developing countries and a continuing decrease in many highly industrialized countries of the world. However, a further fall in caries levels predicted for 5-yr-old children in the U.K. has not occurred and the decline in caries may have begun to level out. 'Polarization' of caries to a minority of high-risk individuals is occurring in the developed world, with 20-25% of children accounting for more than 50% of the disease. Socio-economic factors are important in determining the proportion of high-risk children in these countries. The multifactorial aetiology of caries allows a number of different interpretations to account for changes in the prevalence of the disease with time, in both the developing and developed countries. These changes are variously ascribed to alterations in dietary habits, especially the consumption of sugar; variations in the patterns of oral hygiene; increased contact with trace elements, especially fluoride, in the environment; changes in the ecology and/or virulence of oral and dental plaque microflora and alterations in the oral protective mechanisms including the immune status. The epidemiological evidence available on the relationship of all these social, environmental and other factors to changes in the prevalence levels of caries does not, however, fully explain all the changes that have been observed. The claim that caries is no longer a public health problem is premature, as it ignores the still high proportion of individuals with tooth decay throughout the world.