Water fluoridation between public health and public law: an assessment of regulations across countries and their preventive medicine implications

Background

Among health professionals and health policymakers concern is growing as to the difficulty of balancing the prevention of dental caries through cost-effective interventions and the need to limit unnecessary exposure of the population, and especially children, to environmental chemicals. In this respect, the use of water fluoridation to prevent tooth decay epitomizes the dilemma by raising questions relevant to both public health and public law, ranging from the balance of public health and medical self-determination, the division of powers between local or national authorities over water fluoridation, and the need to avoid the adverse effects of socioeconomic inequalities as well as both under- and over-exposure.

Study design

We carried out a narrative review by searching the relevant literature about the laws and rules related to drinking water fluoridation at the community level in the US, UK, and Europe, in order to discuss how the issue is handled from both a public health and public law perspective.

Methods

Sources of data for this review were the biomedical and legal literature retrieved by searching online databases, and websites of public health and legal institutions.

Results and Conclusions

We found that water fluoridation is still largely adopted throughout the US, while in the UK and particularly in the European Union only a minor part of the population is subject to it. In addition, the recommended and maximum allowed amounts of fluoride in drinking water are being adapted to the public health recommendations and the new regulations, within an evolving evaluation of the epidemiologic evidence and the risk assessment currently in progress by two major regulatory agencies, the US National Toxicology Program - NTP and the European Food Safety Authority - EFSA. Under a comparative public law perspective, the three investigated legislations are facing a reassessment of their policies and regulations, to allow for effective and safe public health measures in the field of water fluoridation and more generally for a preferred use of topical fluoride for caries prevention. A consistent trend across these legislations is the choice to centralize at the national level regulatory and management issues related to water fluoridation, and to carefully balance benefits for dental caries prevention in children and the potential risks of systemic overexposure associated with excess fluoride intake, by promptly responding to the evolving indications by the scientific community and the public health professionals.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review

OBJECTIVES

To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis.

METHODS

Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal.

RESULTS

Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis.

CONCLUSIONS

Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Dental Cleaning, Community Water Fluoridation and Preterm Birth, Massachusetts: 2009-2016

Objectives Data on the potential effect of dental cleaning and community water fluoridation (CWF) on pregnancy outcomes are scarce. While numerous studies confirm the cost-effectiveness of fluoride in preventing dental caries, the benefit of CWF during pregnancy has not been well established. Methods This cross-sectional study used data from 2009 to 2016 Massachusetts Pregnancy Risk Assessment Monitoring System and restricted to singleton live births (n = 9234, weighted response rate = 64.3%). Our exposures were: (1) dental cleaning alone during pregnancy; (2) CWF alone; and (3) dental cleaning and CWF combined (DC-CWF). Women without dental cleaning during pregnancy and CWF comprised our reference group. The outcome was preterm birth, (birth < 37 weeks gestation). This study used multivariate logistic regression modeling, controlling for maternal sociodemographic characteristics, previous medical risk and behavioral factors, and calculated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). Results During 2009-2016, the prevalence of preterm birth among women with a singleton live birth was 8.5% in Massachusetts. Overall, 58.7% of women had dental cleaning during pregnancy, and 63.6% lived in CWF. After adjusting for potential confounders, the associations between dental cleaning alone and preterm birth (aRR = 0.74 [95% CI 0.55-0.98]), and DC-CWF and preterm birth (aRR = 0.74 [95% CI 0.57-0.95]) were significant, while the association between CWF alone and preterm birth was not significant (aRR = 0.81 [95% CI 0.63-1.05]), compared to women without dental cleaning and CWF. Conclusions for Practice This study shows that the prevalence of preterm birth was lower among women with DC only and DC-CWF.

Cost-effectiveness analysis of a school-based dental caries prevention program using fluoridated milk in Bangkok, Thailand

BACKGROUND

This study modelled the cost-effectiveness, from a societal perspective, of a program that used fluoridated milk to prevent dental caries in children who were 6 years old at the beginning of the program, versus non-intervention, after 6 years.

METHODS

After 6 years, children in the milk-fluoridation program had a significant (34%) reduction in dental caries experience compared to those in the comparison community (i.e., received school milk without added fluoride) (DMFS: 1.06 vs. 1.60).

RESULTS

This improvement was achieved with an investment of Thailand Baht (THB) 5,345,048 over 6 years (or THB 11.88 per child, per year) (1 US$ = THB(2011) 30.0). When comparing the costs of the operation of the program and dental treatment in the test community with those of the comparison community, the program resulted in a net societal savings of THB 8,177,179 (range 18,597,122 to THB 7,920,711) after 6 years. This investment would result in 40,500 DMFS avoided in a community with a childhood population of 75,000 [DMFS avoided: 75,000 x (- 0.54)].

CONCLUSIONS

While the analysis has inherent limitations due to its dependence on a range of assumptions, the results suggest that, from a societal perspective, when compared with the non-intervention group, the Bangkok Metropolitan Administration intervention appeared to be a more cost-efficient option than current standard oral health care.

[Caries prevention with fluoridated and iodinated salt in school-aged children living in areas with fluoride and iodine deficiency]

The aim of the study was to evaluate the efficacy of dental caries prevention program with 3 years follow-up in children living in areas with fluoride and iodine deficiency. The study involved 625 school-aged children aged 6, 12 and 15 years receiving endogenous prevention with fluoridated and iodinated salt (300±50 mgF/kg and 40±10 mgI/kg). Enamel and dentine concentrations of CA, P, F and I were measured in 98 intact deciduous teeth by X-ray microanalysis before and after prevention program. Enamel and dentin microhardness was assessed in the same 98 teeth by Vickers Hardness Test. Obtained reduction of DMFT growth, positive changes of mineral composition and dental hard tissues microhardness prove high clinical efficacy of applied prevention program.

Fluoride and Oral Health

The discovery during the first half of the 20th century of the link between natural fluoride, adjusted fluoride levels in drinking water and reduced dental caries prevalence proved to be a stimulus for worldwide on-going research into the role of fluoride in improving oral health. Epidemiological studies of fluoridation programmes have confirmed their safety and their effectiveness in controlling dental caries. Major advances in our knowledge of how fluoride impacts the caries process have led to the development, assessment of effectiveness and promotion of other fluoride vehicles including salt, milk, tablets, toothpaste, gels and varnishes. In 1993, the World Health Organization convened an Expert Committee to provide authoritative information on the role of fluorides in the promotion of oral health throughout the world (WHO TRS 846, 1994). This present publication is a revision of the original 1994 document, again using the expertise of researchers from the extensive fields of knowledge required to successfully implement complex interventions such as the use of fluorides to improve dental and oral health. Financial support for research into the development of these new fluoride strategies has come from many sources including government health departments as well as international and national grant agencies. In addition, the unique role which industry has played in the development, formulation, assessment of effectiveness and promotion of the various fluoride vehicles and strategies is noteworthy. This updated version of 'Fluoride and Oral Health' has adopted an evidence-based approach to its commentary on the different fluoride vehicles and strategies and also to its recommendations. In this regard, full account is taken of the many recent systematic reviews published in peer reviewed literature.

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.

Global water fluoridation: what is holding us back?

Artificial water fluoridation was introduced more than 60 y ago as a public health intervention to control dental caries. Despite wide recommendations for its use from the World Health Organization (WHO) and studies showing the benefits of water fluoridation, many countries have opted out. Currently, only 25 countries, including the United Kingdom, the United States, and Australia have schemes for artificial water fluoridation. The issues faced in efforts to promote the global uptake of water fluoridation and the factors that affect the decision to implement it are unique in both developed and developing countries and must be explored. This article addresses the benefits and challenges of artificial water fluoridation. Further, it tackles the complexities faced with uptake of water fluoridation globally, such as ethical and political controversies and the use of alternative fluoride therapies. Potential future strategies to encourage the uptake of artificial water fluoridation are also discussed.

Focus on fluorides: update on the use of fluoride for the prevention of dental caries

Improving the efficacy of fluoride therapies reduces dental caries and lowers fluoride exposure.

BACKGROUND

Fluoride is delivered to the teeth systemically or topically to aid in the prevention of dental caries. Systemic fluoride from ingested sources is in blood serum and can be deposited only in teeth that are forming in children. Topical fluoride is from sources such as community water, processed foods, beverages, toothpastes, mouthrinses, gels, foams, and varnishes. The United States Centers for Disease Control and Prevention (CDC) and the American Dental Association (ADA) have proposed changes in their long standing recommendations for the amount of fluoride in community drinking water in response to concerns about an increasing incidence of dental fluorosis in children. Current research is focused on the development of strategies to improve fluoride efficacy. The purpose of this update is to inform the reader about new research and policies related to the use of fluoride for the prevention of dental caries.

METHODS

Reviews of the current research and recent evidence based systematic reviews on the topics of fluoride are presented. Topics discussed include: updates on community water fluoridation research and policies; available fluoride in dentifrices; fluoride varnish compositions, use, and recommendations; and other fluoride containing dental products. This update provides insights into current research and discusses proposed policy changes for the use of fluoride for the prevention of dental caries.

CONCLUSIONS

The dental profession is adjusting their recommendations for fluoride use based on current observations of the halo effect and subsequent outcomes. The research community is focused on improving the efficacy of fluoride therapies thus reducing dental caries and lowering the amount of fluoride required for efficacy.

Fluoride transport due to injection of reject water from RO process into the ground water through downstream bore well

Fluoride removal using Reverse Osmosis has appreciable amount of fluorine in the reject stream. Disposal of reject water to surface water further contaminates the water body. It is required to dispose of this reject into the environment with minimal pollution. So a study on disposal of fluoride contaminated reject inside the ground water through bore well is done through theoretical modelling using COMSOL multiphysics software. It has been established that the rise in fluoride concentration in ground water due to injection of fluoride contaminated reject through bore well depends on the injection rate of reject inside the bore well and not on the initial background concentration of fluoride in the ground water. It has been found that for reject injection rate of 30 m3/day the rise in fluoride concentration in ground water with respect to initial background concentration of fluoride is less than 10% at a distance above 600m from the injection source after 100 years.

[Long-term results of prevention of dental caries among children using fluoridated milk in city Maikop]

The prevalence of dental caries among preschool and school-age children in Maikop is a consistently high level. The purpose of this study was to examine the state of teeth in children aged 6, 9 and 12 years who drink fluorinated milk during three years they visit kindergartens. The results showed that the irregular production of fluoridated milk due to the economic crisis in the past three years made no possible to achieve adequate antidecay effect in preschool children. Remote prophylactic effect as a result of regular consumption of fluoridated milk registered among children aged 9 and 12 years. It show reducing the decay intensity by 30.9 and 33.2% respectively.

[Influence of topical fluoridation of glass ionomer cements on inhibitory activity on cariogenic bacteria]

Glass ionomer cements are important options in restorative and preventive dentistry due to their adhesion to the tooth surface and fluoride release, which can decrease the risk of recurrent caries. The aim of this study was to define, in vivo, the influence of the topical use of fluoride gel on dental plaque bacteria growing on the glass ionomer cement. Fifteen patients were included into this study. Thirty five class V restorations from the glass ionomer cement (Ketac Molar Aplicap, ESPE Germany) were placed in the patient's one half of the lower jaw. The sound enamel of other side of the lower jaw was treated as a control. After 6 month 72 old dental plaque was collected from the surfaces of restorations and the surfaces of the sound enamel. Total amount of 30 dental plaque samples were investigated according to the previously described method (17). In dental plaque samples the amount of Streptococcus mutans was calculated at the Department of Microbiology, Medical University of Lódź. Next the topical application of fluoride gel (Fluormex) was performed on the surfaces of glass ionomer (Ketac Molar) fillings and the sound enamel. The patients were asked not to clean the teeth for 72 h. After this time the dental plaque was again collected from the surfaces of restorations and sound enamel. Statistical analysis of collected data was accomplished and showed no statistically significant differences in the amount of Streptococcus mutans both on Ketac Molar and the enamel before and after the topical use of fluoride gel. It was concluded that the topical fluoridation of glass ionomer cement did not affect Streptococcus mutans growing in dental plaque.

Predictive tool for estimating the potential effect of water fluoridation on dental caries

OBJECTIVE

To provide a tool for public health planners to estimate the potential improvement in dental caries in children that might be expected in a region if its water supply were to be fluoridated.

BASIC RESEARCH DESIGN

Recent BASCD (British Association for the Study of Community Dentistry) dental epidemiological data for caries in 5- and 11-year-old children in English primary care trusts in fluoridated and non-fluoridated areas were analysed to estimate absolute and relative improvement in dmft/DMFT and caries-free measures observed in England. Where data were sufficient for testing significance this analysis included the effect of different levels of deprivation.

RESULTS

A table of observed improvements was produced, together with an example of how that table can be used as a tool for estimating the expected improvement in caries in any specific region of England. Observed absolute improvements and 95% confidence intervals were: for 5-year-olds reduction in mean dmft 0.56 (0.38, 0.74) for IMD 12, 0.73 (0.60, 0.85) for IMD 20, and 0.94 (0.76, 1.12) for IMD 30, with 12% (9%, 14%) more children free of caries; for 11-year-olds reduction in mean DMFT 0.12 (0.04, 0.20) for IMD 12, 0.19 (0.13, 0.26) for IMD 20, 0.29 (0.18, 0.40) and for IMD 30, with 8% (5%, 11%) more children free from caries.

CONCLUSIONS

The BASCD data taken together with a deprivation measure are capable of yielding an age-specific, 'intention to treat' model of water fluoridation that can be used to estimate the potential effect on caries levels of a notional new fluoridation scheme in an English region.

Retention of KOH-soluble fluoride on enamel and dentine under erosive conditions—A comparison of in vitro and in situ results

OBJECTIVES

Aim of the study was to investigate the stability of CaF(2)-like precipitates on enamel and dentine under neutral or acidic conditions and to compare in vitro and in situ results.

METHODS

Human enamel and dentine specimens were fluoridated (Elmex fluid, 5 min) and subjected to erosive demineralisation (Sprite light: 3/day each; 30 s in vitro, 2 min in situ) or stored under neutral conditions for 4 (in vitro) or 7 (in situ) days. KOH-soluble fluoride was determined using an ion selective electrode. Between the acid attacks, specimens were stored in remineralisation solution (in vitro) or retained in the oral cavity (four volunteers for enamel and dentine each).

RESULTS

Initially, high amounts of KOH-soluble fluoride were gained (between 77.9+/-12.3 and 96.0+/-46.4 microg/cm2). Under neutral conditions in vitro, a significant decrease on enamel (16.2+/-5.0 microg/cm2) and dentine (18.6+/-10.5 microg/cm2) was found, which was more severe under acidic conditions (6.3+/-3.0 and 5.1+/-2.1 microg/cm2, respectively). Under in situ conditions, KOH-soluble fluoride was strikingly stable on enamel under neutral (42.3+/-12.6 microg/cm2) as well as under acidic conditions (54.1+/-17.4 microg/cm2). On dentine, the dissolution kinetics of KOH-soluble fluoride was similar to the in vitro conditions, but the loss was less severe (45.3+/-12.9 microg/cm2 under neutral and 8.8+/-6.4 microg/cm2 under acidic conditions).

CONCLUSIONS

In vitro, more KOH-soluble fluoride was lost under erosive compared to neutral conditions. The intra-oral environment was considerably protective for CaF2-like precipitates especially on enamel.

Fluoride in drinking water and its removal

Excessive fluoride concentrations have been reported in groundwaters of more than 20 developed and developing countries including India where 19 states are facing acute fluorosis problems. Various technologies are being used to remove fluoride from water but still the problem has not been rooted out. In this paper, a broad overview of the available technologies for fluoride removal and advantages and limitations of each one have been presented based on literature survey and the experiments conducted in the laboratory with several processes. It has been concluded that the selection of treatment process should be site specific as per local needs and prevailing conditions as each technology has some limitations and no one process can serve the purpose in diverse conditions.

Milk helps build strong teeth and promotes oral health

A great deal of research into the benefits of milk consumption has gone largely under the radar for many decades. There is a wealth of studies both in the United States and abroad to suggest that milk consumption is largely anti-cariogenic when combined with a typical routine of oral hygiene. This effect can be mostly attributed to several factors: tooth remineralization, inhibition of bacterial colonization, and biofilm inhibition. These abilities have been studied in detail and are likely due to numerous proteins found in milk. An attractive feature of milk from the community health perspective is its widespread consumption throughout the world. For this reason, studies have been initiated to investigate the possibilities of using milk to deliver fluoride and antibacterial antibodies to high-risk populations worldwide. This review will focus on the various components of milk, which promote oral health, and will also discuss common approaches to improve upon the oral health benefits of milk consumption.

[Efficient methods of prevention and treatment of permanent first molars before completion of root formation]

Examination of first molars among 124 children, age range 7-8 years, showed high intensity of caries disease. Detection and prevention of risk factors, also practical use of prevention and treatment methods existed in clinical stomatology, especially before completion of root formation of permanent teeth, is extremely important. Results showed that deep fluoridation of fissures of permanent teeth with enamel Hermetisation Liquid (A. Knappfost) is very effective method for preventing dental caries. Caries was reduced in 96% of cases. Cultivation of cavity with above-mentioned solution, right before restoration prevents reoccurrence of caries and pulpal complications that is very important for future growth and formation of roots of permanent teeth and for functional value of permanent teeth themselves.

Salt fluoridation--an alternative in automatic prevention of dental caries

Despite great improvements in terms of reduced prevalence and amount of dental caries in populations worldwide, problems still persist particularly among the underprivileged groups of both developed and developing countries. Research and practical experience gained in several countries have demonstrated however, that dental caries can be prevented effectively through establishment of fluoride programmes. Water fluoridation, salt fluoridation, milk fluoridation and use of affordable fluoridated toothpastes play the major roles in public health. The present paper outlines the relevance and some practical aspects in relation to implementation of salt fluoridation programmes. The World Health Organisation Oral Health Programme provides technical assistance to countries in the process of planning, implementing and evaluating salt fluoridation projects.

Blood lead concentrations in children and method of water fluoridation in the United States, 1988-1994

Some have hypothesized that community water containing sodium silicofluoride and hydrofluosilicic acid may increase blood lead (PbB) concentrations in children by leaching of lead from water conduits and by increasing absorption of lead from water. Our analysis aimed to evaluate the relation between water fluoridation method and PbB concentrations in children. We used PbB concentration data (n=9,477) from the Third National Health and Nutrition Examination Survey (1988-1994) for children 1-16 years of age, merged with water fluoridation data from the 1992 Fluoridation Census. The main outcome measure was geometric mean PbB concentration, and covariates included age, sex, race/ethnicity, poverty status, urbanicity, and length of time living in residence. Geometric mean PbB concentrations for each water fluoridation method were 2.40 microg/dL (sodium silicofluoride), 2.34 microg/dL (hydrofluosilicic acid), 1.78 microg/dL (sodium fluoride), 2.24 microg/dL (natural fluoride and no fluoride), and 2.14 microg/dL (unknown/mixed status). In multiple linear and logistic regression, there was a statistical interaction between water fluoridation method and year in which dwelling was built. Controlling for covariates, water fluoridation method was significant only in the models that included dwellings built before 1946 and dwellings of unknown age. Across stratum-specific models for dwellings of known age, neither hydrofluosilicic acid nor sodium silicofluoride were associated with higher geometric mean PbB concentrations or prevalence values. Given these findings, our analyses, though not definitive, do not support concerns that silicofluorides in community water systems cause higher PbB concentrations in children. Current evidence does not provide a basis for changing water fluoridation practices, which have a clear public health benefit.

The effect of Pt and Pd alloying additions on the corrosion behavior of titanium in fluoride-containing environments

In this study, we examined the corrosion behaviors of pure titanium, the alloys Ti-6Al-4V and Ti-6Al-7Nb, and the new experimental alloys Ti-Pt and Ti-Pd using anodic polarization and corrosion potential measurements in an environment containing fluoride. Before and after immersion in the test solutions, we made observations using a scanning electron microscope. The test solutions included an artificial saliva containing 0.2% NaF (corresponding to 905 ppm F) and an artificial saliva with a low concentration of oxygen. Although the surfaces of the Ti-Pt and Ti-Pd alloys were not affected by an acidic environment containing fluoride, the surfaces of the pure titanium, the Ti-6Al-4V alloy, and the Ti-6Al-7Nb alloy were markedly roughened by corrosion. The surfaces of the pure titanium, the Ti-6Al-4V alloy, and the Ti-6Al-7Nb alloy were microscopically damaged by corrosion when they were immersed in the solution containing a low concentration of dissolved oxygen, even with a fluoride concentration included in the commercial dentifrices. In this situation, however, the surfaces of the new Ti-Pt and Ti-Pd alloys were not affected. These alloys are expected to be of use in dental work as new titanium alloys with high corrosion resistances.

Influence of fluoridated mouthwashes on corrosion resistance of orthodontics wires

The aim of the present study was to classify the different alloys commonly used to make orthodontic wire according to their corrosion resistance in different media. The four materials analysed were titanium-based alloys: TMA, TiNb, NiTi and CuNiTi, which were tested in three fluoride mouthwashes: Elmex, Meridol and Acorea as well as in Fusayama Meyer artificial saliva. The electrochemical study showed that the alloys could be divided into two groups. In one group were the NiTi-based alloys which were subject to strong corrosion in the presence of monofluorophosphate found in Acorea solution. In the other group were TiNb, which was the most resistant to corrosion, and TMA, which corroded strongly with the stannous fluoride found in Meridol mouthwash. The results obtained in the present study will enable us to provide attending practitioners with advice concerning fluoride mouthwash to recommend, depending on the treatment phase and the alloy used. So we can advise Elmex mouthwash for patients with TMA and NiTi-based orthodontics wires but we suggest Acorea or Meridol mouthwashes for patients with TiNb orthodontics wires.

[Optimal fluoride level in drinking water and public health]

Water fluoridation is a safe, efficient, and well-proven way of preventing dental decay in the community. In countries such as Israel, where dental care is not covered by the national insurance law, this has an important role in reducing social inequalities in health care. For toddlers and children, water fluoridation is the only way of promoting dental health without a need for regular visits to dental clinics, and without regard to parent awareness and motivation. The other methods of fluoride supplementation do not succeed in reaching the level of safety and cost-efficiency of water fluoridation, and their use is successful only among upper socio-economic classes. Water fluoridation has been defined by the US CDC as one of the main achievements in health care during the 20th century. In spite of the legal difficulties raised by various activist groups, the use of water fluoridation is growing steadily among developed as well as third world countries. The Israeli bylaw of national water fluoridation that is in effect will enable the safe improvement of the overall dental health status of the population at an extremely low cost.

Health and fitness series--2. Dental decay and the case for fluoride

A former Chief Dental Officer explains the use of fluoride in preventing dental caries. He discusses the causes and process of dental caries and the basic health education messages to communicate to the public. Although the incidence of dental caries has reduced in the UK, mainly due to greater use of fluoride, decay remains prevalent among socially and economically disadvantaged groups. Dental health promotion is also needed for young parents who, having good teeth themselves, do not always realise that their children are still at risk of caries. Parents are not always aware of how to prevent dental caries in their children.

[Operational control of water fluoridation in Niterói, Rio de Janeiro, Brazil]

The aim of this study was to evaluate the operational control of water fluoridation at the city water supply plant in Niterói, Rio de Janeiro, Brazil, from January to December 2000. The water treatment supervisor filled out a questionnaire on the control of water fluoridation. In addition, water samples were collected every two weeks for fluoride analysis before and after treatment. Samples were analyzed by an independent laboratory using an ion-specific electrode. According to the water treatment supervisor, the entire process for controlling fluoride concentration in the water was rigorous and complied with Brazilian guidelines, but according to testing, 96% of samples were inadequate in terms of risks/benefits of fluoride use from water. The information obtained from the plant supervisor and the test data were thus mutually inconsistent. Based on these data, an independent water fluoride concentration control program is needed to ensure the benefits of dental caries prevention for the population.

US drinking water: fluoridation knowledge level of water plant operators

OBJECTIVES

We determined the knowledge level of water plant operators who fluoridate drinking water, and we compared small and large water plants.

METHODS

A pretested survey was sent to 2,381 water plant operators in 12 states that adjust the fluoride concentration of drinking water. A z-test for proportion was used to test for statistical difference between small and large plants at alpha = 0.05. Small water plants were those treating less than 1 million gallons of water daily.

RESULTS

Eight hundred small and 480 large water plant operators responded, resulting in a response rate of 54 percent. Two-thirds of water plant operators correctly identified the optimal fluoride level, but more than 20 percent used a poor source for choosing the optimal level. Only one-fourth of operators were able to maintain the fluoride concentration to within 0.1 mg/L of the optimal concentration. A significantly greater proportion of operators at large water plants than at small water plants reported that they were able to maintain a fluoride concentration to within 0.1 mg/L of the optimal concentration (33.5% vs 21.3%, z = 4.74, P < .05).

CONCLUSIONS

Although most operators correctly identified the optimal fluoride level, small water plant operators were less likely to use accurate reasoning for choosing that level and in maintaining fluoride concentrations within 0.1 mg/L of that level than large water plant operators.

The effects of water filtration systems on fluoride: Washington, D.C. metropolitan area

According to the U.S. Environmental Protection Agency (EPA), approximately one in eight Americans is exposed to potentially harmful microbes, pesticides, lead, or radioactive radon whenever they drink a glass of tap water or take a shower. One reason for this exposure is that the water plants are aging or ill equipped to process the huge amounts of raw sewage and agricultural pollutants that are still being discharged into our drinking-water sources. Other compounds such as fluoride and chloride have been added to the community water supplies for health benefits. Water filtration systems are becoming more popular as people become concerned with pollutants in the public water supply and questions are being raised as to whether fluoride is affected by these filters. The aim of this pilot study was to assess the efficacy of three types of water filtration systems and to determine their impact on fluoride content of the water in the Washington, D.C. metropolitan area. One sample of water was collected daily for fourteen days, from one location. The sample was divided to use as a control and the test samples which were processed through various filter systems. With the use of a fluoride ion specific electrode, the fluoride concentration level was tested in all samples in order to determine the percentage of fluoride removed. This study was intended to prove that the water filtration systems did not affect the advantage offered by optimum water fluoride levels. The experimental samples were ascertained and compared to the control group, resulting in three of the four carbon filters showing statistically significant amounts of fluoride removed from the water. Both Reverse Osmosis and Distillation, as expected, removed the fluoride at a high rate.

Recommendations for fluoride use in children. A review

Fluoride has played a significant role in the improvement of the oral health of all Americans. Because of its effectiveness, cost and frequency of exposure, water fluoridation is the preferred method of delivery. Today, many products containing fluoride are available over the counter and as prescription items. The potential for exposure to multiple sources of fluoride has increased. Therefore, practitioners should prescribe fluoride therapy based on an understanding of patients' total exposure to fluoride and the need for additional amounts.

[The monitoring of the level of body fluoride intake in children participating in 3 milk fluoridation projects in Russia]

In Russia three milk fluoridation projects have been implemented since 1994 (cities Smolensk, Voronezh and Maykop) covering more than 10,000 children living in low fluoride areas and having high risk of caries development both in temporary and permanent dentitions. Both preliminary and monitoring studies of fluoride excretion with urine and fluoride consumption were done. Total number of subjects--663 children 3-6-years of age attending kindergartens in these three cities; 2602 urine samples were collected, twice analyzed for fluoride content and processed in accordance with the method approved by the Russian Ministry of Health. 24-month monitoring of milk fluoridation projects in Russia did really show and confirm three main facts: the concentration of fluoride 2.5 mg/l in F-milk products for children 2-6 year-olds in low fluoride areas of Russia is really optimal concentration when daily milk consumption is about 200 ml; there is no such phenomena as detectable accumulation of metabolic fluoride under physiological conditions even after 2 years of regular fluoridated milk consumption; developed technique of fluoride consumption determination proved to be a very useful tool for planning and monitoring preventive programmes based on systemic use of fluoride.

Technical aspects of water fluoridation in the United States and an overview of fluoridation engineering world-wide

This paper summaries the technical aspects of water fluoridation in the United States, and gives an overview of the engineering aspects of water fluoridation world-wide. The status of water fluoridation in the USA is summarised. Fluoride chemicals used in the USA are discussed, as well as the equipment used to deliver these chemicals. A brief overview of fluoridation engineering world-wide is also presented.

Should we use milk fluoridation? A review

This article presents the argument that because of several demonstrated advantages, milk fluoridation provides a valid alternative to water fluoridation when the latter is not possible. Extensive literature describing study of fluoride compounds administered with calcium-rich food, as well as clinical trials and laboratory experiments with fluoridated milk, have demonstrated its effectiveness in caries prevention. The main criticisms of milk fluoridation are decreased bioavailability of the fluoride, the cost and administrative burden involved, and (in some cases) lack of sound clinical conclusions regarding its preventive efficacy. These criticisms are reviewed in the light of evidence now available.

Update in systemic fluoride therapy

The dental literature abounds with articles demonstrating drastic reductions in dental caries activity as a result of fluoride therapy. Recently, there has been concern over the number of fluorosis cases being seen. The prudent dental practitioner will utilize only approved products for systemic fluoride therapy, be aware of other possible sources of fluoride, and known the patient's fluoride intake before prescribing supplementation in order to avoid fluorosis and possible litigation.

Fluoride overfeeds in public water supplies

A description of the fluoride overfeed in Hooper Bay, Alaska, that resulted in the first reported death due to fluoride toxicity caused by drinking water from a community water system.

The Venturi Fluoride Saturator project

This study was conducted to determine whether Venturi Fluoride Saturator (VFS) systems could be used to fluoridate small community and school water supply systems with an acceptable level of maintenance. VFS systems were installed and operated at four school and six community well sites according to state and federal regulations and recommendations. School VFS systems were unable to maintain optimum fluoride residuals even with substantial maintenance. All six community well site VFS systems performed acceptably, with only a few short lapses. VFS system maintenance was labor intensive. Recurring problems were caused by lengthy equipment delivery delays, the unavailability of timely technical assistance to support the VFS system, and the inadequate quality of VFS equipment and design. Based upon these findings, further expansion of the use of VFS systems either for community or school fluoridation cannot be recommended. Additional study of and improvements in the VFS system are indicated. Three major recommendations appear appropriate: (1) extensive laboratory testing of the VFS system concept under controlled conditions should be performed to determine the functioning parameters of this equipment under different hydrodynamic conditions; (2) additional research and development of the VFS unit to improve the quality of operations and the quality control of manufacturing and assembly should be undertaken; and (3) a VFS equipment distribution network should be developed, with sufficient logistical and technical support to supply equipment parts and expertise for installation, monitoring, and maintenance in a timely and efficient manner.