Knowledge and Attitudes Towards Fluoride Supplementation: A Survey of Pediatric Medical and Dental Providers in the State of Hawai'i

Hawai'i has the lowest rate of community water fluoridation in the nation, which has contributed to poor oral health for children statewide. When properly prescribed, the benefits of fluoride supplementation for oral health outweigh any potential side effects to the body. Official recommendations give pediatric healthcare providers the authority to prescribe fluoride supplements and guide parents in daily usage. However, knowledge of actual practice and adherence for both providers and patients have never been examined in Hawai'i. This study aims to evaluate pediatric healthcare providers' attitudes, knowledge, and practices, regarding fluoride supplementation. A 37-item survey was developed investigating these domains, and was distributed to pediatric dentists, family practitioners, and pediatricians in the state. One hundred and three responses were collected during the time period of May 2014 through May 2015. Descriptive and bivariate associations with several outcomes were assessed. The majority (87%) reported at least some knowledge of the official guidelines. There was uncertainty in knowledge of fluorosis and the seriousness of the health risk. A recent educational session on fluoride was associated with more knowledge of the guidelines and the signs and symptoms of fluorosis. The majority of providers started fluoride at the recommended age whereas there was more variablility on stopping fluoride. On the patient side, providers reported that 67% of the parents forget to administer and 53% reported that their child does not like the taste. This study provides some information regarding the clinical use of fluoride supplementation in children. More efforts are needed to raise awareness in a consistent manner by both the dental and medical communities on the importance of fluoride supplementation to promote oral health in children while addressing concerns of professionals and the community.

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.

Section On Oral Health. Maintaining and improving the oral health of young children

Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

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.

[External control over the fluoridation of the public water supply in Bauru, SP, Brazil]

OBJECTIVE

To assess the fluoridation of the public water supply and compare these results with previous data.

METHODS

The study was carried out from March 2004-2005 in Bauru, a city of Southeastern Brazil. Every month, on dates established randomly, 60 water samples were collected from the 19 supply sectors of the city, totaling 737 samples. The fluoride concentration in the water samples was determined in duplicate, using an ion-specific electrode (Orion 9609) coupled to a potentiometer. Following analysis, the samples were classified as acceptable or unacceptable according to their fluoride concentration. Descriptive statistical analysis was utilized.

RESULTS

The mean fluoride concentration observed in the different collection months ranged from 0.37 to 1.00 mg/l. Around 85% of the samples were classified as acceptable.

CONCLUSIONS

One year after implementing external control, an improvement in the water fluoridation conditions was observed in comparison with previous results obtained in the city. The implementation of water supply fluoridation monitoring by means of surveillance systems must be stimulated: this is fundamental for controlling dental caries.

Feasibility and costs of water fluoridation in remote Australian Aboriginal communities

BACKGROUND

Fluoridation of public water supplies remains the key potential strategy for prevention of dental caries. The water supplies of many remote Indigenous communities do not contain adequate levels of natural fluoride. The small and dispersed nature of communities presents challenges for the provision of fluoridation infrastructure and until recently smaller settlements were considered unfavourable for cost-effective water fluoridation. Technological advances in water treatment and fluoridation are resulting in new and more cost-effective water fluoridation options and recent cost analyses support water fluoridation for communities of less than 1,000 people.

METHODS

Small scale fluoridation plants were installed in two remote Northern Territory communities in early 2004. Fluoride levels in community water supplies were expected to be monitored by local staff and by a remote electronic system. Site visits were undertaken by project investigators at commissioning and approximately two years later. Interviews were conducted with key informants and documentation pertaining to costs of the plants and operational reports were reviewed.

RESULTS

The fluoridation plants were operational for about 80% of the trial period. A number of technical features that interfered with plant operation were identified and addressed though redesign. Management systems and the attitudes and capacity of operational staff also impacted on the effective functioning of the plants. Capital costs for the wider implementation of these plants in remote communities is estimated at about $US 94,000 with recurrent annual costs of $US 11,800 per unit.

CONCLUSION

Operational issues during the trial indicate the need for effective management systems, including policy and funding responsibility. Reliable manufacturers and suppliers of equipment should be identified and contractual agreements should provide for ongoing technical assistance. Water fluoridation units should be considered as a potential priority component of health related infrastructure in at least the larger remote Indigenous communities which have inadequate levels of natural fluoride and high levels of dental caries.

Maintenance of Optimal Fluoride Levels in Public Water Systems

OBJECTIVE

This study examines the quality of water fluoridation in public water supplies.

METHODS

An assessment of daily fluoride levels among all communities that fluoridate their public water supplies in New Hampshire was conducted from January 1, 2000, through June 30, 2002. Results were compared against recommendations from the Centers for Disease Control and Prevention.

RESULTS

The fluoride concentration was less than the recommended minimum value on 42.0 percent of days, within the accepted control range on 49.8 percent of days, and above the recommended maximum value on 1.0 percent of days. On 7.1 percent of days, a fluoride concentration was not determined. Only 2 (18.2%) of 11 public water supplies maintained the fluoride concentration in the optimal range > or =80 percent of the days.

CONCLUSIONS

For public water supplies in New Hampshire that fluoridate, suboptimal levels are the most common problem. Water systems need to better maintain recommended fluoride levels if communities are to realize the full benefits of fluoridation.

Dental fluorosis in Brazil: a systematic review from 1993 to 2004

The current article proposes a reflection on several aspect pertaining to dental fluorosis in Brazil, based on a systematic review of epidemiological surveys. The authors assess the prevalence and degrees of severity found in different studies and show that in methodological terms, there is a need for progress in procedures for population-based studies on fluorosis. Despite the different data collection approaches, there is some consensus among the different studies as to the limited severity of fluorosis in Brazil, as well as its association with the independent variables age and socioeconomic status. The authors also highlight the importance of adding subjective aspects to the normative diagnosis as a contribution to public health policy decisions, since the use of exclusively clinical criteria gives dental fluorosis more space than society ascribes to it. There is a lack of empirical evidence to reassess the fluoride content in public water supplies, a method that is known to be necessary to improve dental caries epidemiological indicators.

A comparison of results of fluoride determinations by different laboratories

With water fluoridation imminent in South Africa, the accurate determination of the fluoride content of water is important. The aim of this study was to compare the fluoride content of water reported by 9 laboratories and the laboratory at the South African Bureau of Standards (SABS). The SABS and 9 South African laboratories were asked to determine the fluoride content of five water samples. The fluoride content of the samples was in a range that could be expected in South African waters. The laboratories were requested to disclose their methods for fluoride determination. The results reported by the laboratories were compared to the results reported by the SABS laboratory. Fluoride concentrations of 0.13, 0.22 and 0.58 mg/litre were reproduced to within 0.05 mg/litre by two, six and three laboratories respectively. At the 1.1 and 1.5 mg/litre concentration no laboratory could achieve this accuracy. Four different methods for the determination of fluoride were used. At present laboratories determining fluoride concentrations are not accurate enough to ensure that the process of water fluoridation will be safe. Laboratories will have to check their procedures to ensure better results before water fluoridation can commence.

Vinte e quatro meses de heterocontrole da fluoretação das águas de abastecimento público de Pelotas, Rio Grande do Sul, Brasil

O objetivo deste estudo foi monitorar, mensalmente, os níveis de flúor na água de abastecimento público de Pelotas, Rio Grande do Sul, Brasil, bem como verificar a validade da formação de grupos de heterocontrole. Pelotas foi dividida em 16 pontos geográficos, incluindo as três Estações de Tratamento da água e a coleta foi feita de novembro de 1999 a outubro de 2001, em duplicata. Após a coleta, as amostras foram enviadas ao Laboratório de Vigilância Sanitária de Flúor da Universidade do Vale do Itajaí, onde a análise foi feita utilizando-se o método eletrométrico (Orion 920A/Eletrodo Orion 9609). Após 24 meses, 764 unidades amostrais foram coletadas e verificou-se uma inconstância nos resultados, predominando níveis insuficientes de flúor até o primeiro trimestre de 2001, quando houve um significativo aumento no número de unidades amostrais com uma concentração de flúor ideal (0,6-0,9ppmF), porém, há o surgimento de pontos revelando um excesso de fluoretos (> 1ppmF). Os resultados permitiram concluir que o heterocontrole é fundamental para buscar a manutenção de um correto programa de FAAP.

[Water fluoridation and public health]

Fluoridation in Israel was first mooted in 1973 and finally incorporated into law in November 2002 obligating the Ministry of Health to add fluoride to the nation's water supply. Epidemiology studies in the USA have shown that the addition of one part per million of fluoride to the drinking water reduced the caries rate of children's teeth by 50% to 60% with no side effects. Both the WHO in 1994 and the American Surgeon General's report of 2000 declared that fluoridation of drinking water was the safest and most efficient way of preventing dental caries in all age groups and populations. Opposition to fluoridation has arisen from "antifluoridation" groups who object to the "pollution" of drinking water by the addition of chemicals and mass medication in violation of the "Patient's Rights" law and the Basic Law of Human Dignity and Liberty. A higher prevalence of hip fractures in elderly osteoporotic women and osteosarcoma in teenagers has been reported in areas where excess fluoride exists in the drinking water. However, none of the many independent professional committees reviewing the negative aspects of fluoridation have found any scientific evidence associating fluoridation with any ill-effects or health problems. In Israel, where dental treatment is not included in the basket of Health Services, fluoridation is the most efficient and cheapest way of reducing dental disease, especially for the poorer members of the population.

[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.

Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention

Widespread use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries (i.e., tooth decay) in the United States and other economically developed countries. When used appropriately, fluoride is both safe and effective in preventing and controlling dental caries. All U.S. residents are likely exposed to some degree to fluoride, which is available from multiple sources. Both health-care professionals and the public have sought guidance on selecting the best way to provide and receive fluoride. During the late 1990s, CDC convened a work group to develop recommendations for using fluoride to prevent and control dental caries in the United States. This report includes these recommendations, as well as a) critical analysis of the scientific evidence regarding the efficacy and effectiveness of fluoride modalities in preventing and controlling dental caries, b) ordinal grading of the quality of the evidence, and c) assessment of the strength of each recommendation. Because frequent exposure to small amounts of fluoride each day will best reduce the risk for dental caries in all age groups, the work group recommends that all persons drink water with an optimal fluoride concentration and brush their teeth twice daily with fluoride toothpaste. For persons at high risk for dental caries, additional fluoride measures might be needed. Measured use of fluoride modalities is particularly appropriate during the time of anterior tooth enamel development (i.e., age <6 years). The recommendations in this report guide dental and other health-care providers, public health officials, policy makers, and the public in the use of fluoride to achieve maximum protection against dental caries while using resources efficiently and reducing the likelihood of enamel fluorosis. The recommendations address public health and professional practice, self-care, consumer product industries and health agencies, and further research. Adoption of these recommendations could further reduce dental caries in the United States and save public and private resources.

Fluoride concentrations in bottled water

Bottled water use and lack of adequate labeling have given rise to questions regarding fluoride intake. This study examined fluoride concentration of commercially available bottled water products, determined if significant differences existed among the products, and explored packaging date as a variable on the concentration of fluoride. The values were compared to the ADA guideline for optimally fluoridated water and the American Academy of Pediatric Dentistry recommended schedule for fluoride supplementation. Five commercial brands were chosen for the study. Three bottles of each brand, each with different batch dates, were purchased. Following calibration, six tests were conducted on each bottle using the Hach DR-100 Colorimeter System for fluoride analysis and the values were recorded. Data were analyzed using a two-tailed ANOVA and Tukey's HSD Test (p = 0.05). The results showed that significant differences in fluoride concentrations existed among the five brands. For three brands, significant differences existed between the batches. All products had fluoride concentrations that fell below the ADA accepted standards for optimally fluoridated water. Due to the significant variability in fluoride concentration between products and batches, dental providers should advise their patients that bottled water might not contain optimal levels of fluoride.

Fluoride concentration in foods from Iran

Knowledge of fluoride intake is important in optimizing the caries-preventive role of fluoride, and the measurement of fluoride intake usually requires information on the fluoride concentration in foods and drinks. Most information comes from developed countries and there are no data on fluoride concentration in foods in Middle Eastern countries including Iran. The aim of the study was to: (a) describe a modification to the silicon-facilitated diffusion method for determining fluoride concentration, (b) provide information on fluoride content of foods in Iran to supplement food tables for the Middle East, and (c) determine the effect of variation in the fluoride concentration of drinking water on the fluoride concentration of prepared foods. Five hundred and ten samples of 84 popular foods and drinks were collected from three areas of Iran where water fluoride concentrations were 0.32, 0.58 and 4.05 mg/L. The mean recovery of fluoride added to food samples before diffusion was 98 +/- 5%. Values for duplicate analysis of 20 food samples were within 0.03 microgram F/g. Most of the samples of foods and drinks came from the area with 0.32 mg F/L in water supplies. For 30 of the 84 items, fluoride concentration was below 0.1 microgram/g. Fluoride concentrations in the cereals group (which constituted much of the diet) were mainly between 0.2 and 0.3 microgram/g, when prepared for consumption. It was concluded that: (a) modification of a published method for determining fluoride concentration of foods appeared to be an advance, (b) values for fluoride concentration of foods commonly consumed in Iran showed variation between groups but were in broad agreement with published data, and (c) concentration of fluoride in water influences positively fluoride concentration in foods cooked in water, but the increase in foods was less than the increase in fluoride concentration in water.

Risk factors for enamel fluorosis in optimally fluoridated children born after the US manufacturers' decision to reduce the fluoride concentration of infant formula

This case-control study investigated risk factors for enamel fluorosis in optimally fluoridated children, born after the US infant formula industry voluntarily reduced the fluoride content of their products. Analysis was performed on 233 children, aged 10-14 years. Case-control status was determined using the Fluorosis Risk Index (FRI). Risk factor exposure was ascertained via a mailed questionnaire. Logistic regression analyses revealed a strong association between mild-to-moderate enamel fluorosis on early forming (FRI classification I) enamel surfaces and both fluoride supplement use (odds ratio (OR)=5.95, 95% confidence interval (CI) 1.06-33.53), and early fluoride toothpaste use (OR=6.35, 95% CI 1.21-33.40). The authors found a suggestive, but nonsignificant, association between fluorosis on these enamel surfaces and infant formula in the form of powdered concentrate (OR=4.33, 95% CI 0.73-25.66). There was a strong association between mild-to-moderate fluorosis on later forming (FRI classification II) enamel surfaces and infant formula use in the form of powdered concentrate (OR=10.77, 95% CI 1.89-61.25), fluoride supplement use (OR=10.83, 95% CI 1.90-61.55), and early fluoride toothpaste use (OR=8.37, 95% CI 1.68-41.72). No association was observed between the use of ready to feed infant formula and enamel fluorosis.

Estimation of optimal concentration of fluoride in drinking water under conditions prevailing in Chile

The purpose of this comparative study of caries and dental fluorosis experience in Chilean children was to estimate the optimal range of fluoride concentration in tap water under conditions currently prevailing in Chile. The sample included 2431 schoolchildren 7, 12 and 15 years old, life-long residents of five communities with fluoride concentrations in their tap water in the range 0.07-1.1 mg/L. The study population received an oral clinical examination including caries experience and an enamel fluorosis evaluation of the permanent dentition (Dean's scoring system). For 15-year-old children, the DMFT index changed from 5.06 to 2.60, and for 12-year-olds it changed from 3.10 to 1.36 when fluoride water concentration changed from 0.07 to 1.10 mg/L. For 7-year-old children the dmft index correspondingly changed from 3.67 to 1.59. The relationship between DMFT for 12-year-olds and water fluoride concentration was best fitted by a logarithmic function (r2=0.98). The Community Fluorosis Index (CFI) was used to assess enamel fluorosis in the study population, and it showed a linear relationship (r2=0.983) with increasing fluoride concentration of water for the 12-year-old group. Results obtained suggest that under current Chilean conditions, the optimal range of fluoride concentration in potable water should lie in the 0.5-0.6 mg/L range.

[Water fluoridation in the Region of Murcia]

BACKGROUND

The purpose of this study is that of expounding upon the natural fluoride ion concentrations in the public water supplies of all of the municipalities in the Region of Murcia in 1991, in addition to the trend in said concentrations throughout the 1992-1996 period, this being a time during which fluoride was added to the water supply as a public health measure.

METHODS

The methods employed for the findings were those of potentiometer-based gauging by means of standard addition and direct findings using a potentiometer equipped with an ion-selective electrode.

RESULTS

The findings indicate that major fluctuations have taken place in the amounts of fluoride in these waters throughout the initial years during which fluoride was added to the water supply, without it being possible to establish broad-scope geographical patterns, to later tend toward stabilization during the final years of the time period in question, in which solely the municipalities supplied by the Letur treatment plant (which supplies the central and northwestern areas of the Region) showed levels nearing 0.8 mg/l, been maintained, which are those stipulated under the regulations resolving in favor of the addition of fluoride.

CONCLUSIONS

We can conclude that only a portion of the municipalities of the Murcia Region has reached the optimum value for the concentration of fluoride in drinking water proposed by the Autonomous Community (0.8 mg/liter), or values close to it (0.6-0.7 mg/liter) during the period studied.

[Evaluation of fluoride content of bottled drinking waters in Brazil]

The utilization of a systemic fluoride method must be controlled in terms of risks and benefits. The reason for this is that while a small dose will not be effective in preventing dental caries, a larger dose may cause dental fluorosis. Therefore the knowledge of the fluoride concentration found in the bottled mineral waters sold throughout the Brazilian market the consumption of which has increased lately, is of great concern. The objective of the study was the analysis of the concentration of fluoride found in the bottled mineral waters. A hundred and four brands coming from different regions of Brazil were analysed using an Orion 96-09 ion specific electrode and an Orion EA 940 ionanalyser. previously calibrated with standard fluoride solutions. Different concentrations of fluoride ranging from 0.0 to 4.4 were found. It was discovered that specific bottled waters contained: 1) Significant concentrations of fluoride not reported by the producer; 2) Fluoride concentrations of no preventive effect, although the producer had advertised the water as a Fluoridated Mineral Water; 3) Fluoride concentrations high enough to cause dental fluorosis, although the producer did not alert the consumer to this fact. It is to be concluded, therefore, that a sanitary regulatory system for the control of the level of fluoride in the bottled mineral waters marketed is necessary. Such reputation should be formulated in terms of benefits as well as in terms of risks.

Prevalence and severity of fluorosis in the primary and permanent dentition using the TSIF

This paper reports on the prevalence and severity of dental fluorosis in the primary and permanent teeth and the tooth surfaces of 262 school children aged 6-18 years from two communities in KwaNdebele (South Africa), the first with 8-9 ppm F-, and the second with 0.6-1.6 ppm F- in the drinking water. The Tooth Surface Index of Fluorosis (TSIF) was used to measure the degree of fluorosis. In both areas, the population prevalence, for primary and permanent teeth was more than 90 per cent. For the lower F- area, 40 per cent of tooth surfaces were free of fluorosis compared with only 22 per cent in the high F- area. Of the surfaces affected by fluorosis in the high F- area, 37 per cent scored in the categories 4-7, compared with 6 per cent in the lower F- area. This difference in severity was found to be statistically significant (P<0.001). This study has shown that, in two areas with significantly different levels of fluoride in the water supply, the population prevalences of fluorosis were similar, but significant differences existed in severity. The World Health Organization 1984 guidelines for Drinking-water Quality recommend that 1.5 ppm F- is the maximum acceptable concentration in drinking water but this may not be appropriate for South Africa.

Appropriate uses of fluorides for children: guidelines from the Canadian Workshop on the Evaluation of Current Recommendations Concerning Fluorides

OBJECTIVE

To prevent fluorosis caused by excessive fluoride ingestion by revising recommendations for fluoride intake by children.

OPTIONS

Limiting fluoride ingestion from fluoridated water, fluoride supplements and fluoride dentifrices.

OUTCOMES

Reduction in the prevalence of dental fluorosis and continued prevention of dental caries.

EVIDENCE

Before the workshop, experts prepared comprehensive literature reviews of fluoride therapies, fluoride ingestion and the prevalence and causes of dental fluorosis. The papers, which were peer-reviewed, revised and circulated to the workshop participants, formed the basis of the workshop discussions.

VALUES

Recommendations to limit fluoride intake were vigorously debated before being adopted as the consensus opinion of the workshop group.

BENEFITS, HARMS AND COSTS

Decrease in the prevalence of dental fluorosis with continuing preventive effects of fluoride use. The only significant cost would be in preparing new, low-concentration fluoride products for distribution.

RECOMMENDATIONS

Fluoride supplementation should be limited to children 3 years of age and older in areas where there is less than 0.3 ppm of fluoride in the water supply. Children in all areas should use only a "pea-sized" amount of fluoride dentifrice no more than twice daily under the supervision of an adult.

VALIDATION

These recommendations are almost identical to changes to recommendations for the use of fluoride supplements recently proposed by a group of European countries.

SPONSORS

The workshop was organized by Dr. D. Christopher Clark, of the University of British Columbia, and Drs. Hardy Limeback and Ralph C. Burgess, of the University of Toronto, and funded by Proctor and Gamble Inc., Toronto, the Medical Research Council of Canada and Health Canada (formerly the Department of National Health and Welfare). The recommendations were formally adopted by the Canadian Dental Association in April 1993.

Provider compliance with recommended dietary fluoride supplement protocol

Proper dosage of dietary fluoride supplements is important for children without access to optimally fluoridated water to balance dental caries prevention and risks of dental fluorosis. Subsequent to water fluoride assay, compliance by physicians and dentists with the recommended dietary fluoride supplement dosage schedule was determined for 446 children. Approximately one third of child patients and 42% of siblings did not receive the recommended supplement dosage.

Changes in dental caries experience of 12-year olds in low fluoride urban and rural areas of Tanzania

This report is a 2-year follow-up of a baseline study conducted in Tanzania in 1984. 377 and 448 twelve-year old primary school children were examined in Dar es Salaam (urban) and rural areas respectively. The same criteria and examiners were employed to replicate conditions in 1984 as closely as possible. The mean DMFT score has remained stable over the 2-year period in both the urban (1984: 0.67 (s.d. 1.20); 1986: 0.64 (s.d. 1.32) and rural (1984: 0.51 (s.d. 1.07); 1986: 0.40 (s.d 0.93) areas. However, a significant decrease in the mean DMFS score in Dar es Salaam from 1.19 (s.d. 2.71) in 1984 to 0.81 (s.d. 1.96) in 1986, and in rural areas from 0.78 (s.d. 1.98) in 1984 to 0.48 (s.d. 1.44) in 1986 was observed. In 1986 significantly fewer children with caries had more than 5 involved surfaces in both urban and rural areas than in 1984. In the two areas the difference in caries prevalence observed between 1984 and 1986 affected different surfaces types to varying extents. The results do not support the finding that caries is increasing in all developing countries.

Caries prevalence in the deciduous dentition of a Tanzanian urban and rural child population in relation to levels of fluoride in drinking water in 1984, 1986 and 1988

A mixed-longitudinal study to determine the prevalence of caries in the deciduous dentition of a Tanzanian child population was carried out in Morogoro Region between 1984 and 1988. Since 1978 shallow wells have been constructed in the study areas which contained water in the range of the assumed optimal fluoride level in tropical countries (0.5-1.0 ppm). Three areas were distinguished, urban, rural and villages in rural areas with an average fluoride concentration of 0.5 ppm or more in all drinking water sources present. There were no fluoridated toothpaste for sale nor were organised oral health programmes implemented in the study areas. The following background parameters were studied; age, locality, socioeconomic status and sex. School children aged 7- to 9-year (= 694), 7- to 11-year (n = 652) adn 7- to 13-year (n = 555) were examined in 1984, 1986 and 1988 respectively. For all three years of investigation, children living in villages with naturally fluoridated water were found to have significantly lower mean number of dentinal lesions than those living in urban and/or rural areas. There were no restorations found. Over the three years of investigation the mean dft*-scores were low and varied between 1.67 (urban area in 1984) and 0.79 (naturally fluoridated rural areas in 1984). No SES and sex effect on the dft-condition were found. It is recommended that water samples be collected from all drinking water sources in all regions of Tanzania and to map the results of the fluoride analyses for use in prioritization setting in planning oral health services at national and regional level.