Water Fluoridation and Dental Caries in U.S. Children and Adolescents

Community water fluoride cessation and rate of caries-related pediatric dental treatments under general anesthesia in Alberta, Canada

OBJECTIVE

This study examined the rate of caries-related dental treatments under general anesthesia (GA) in fluoridated and non-fluoridated communities in Alberta, Canada, between 2010 and 2019.

METHODS

This retrospective, population-based study included all children ( < 12 years of age) living in Calgary (non-fluoridated) and Edmonton (fluoridated) who underwent caries-related dental treatments under GA at publicly funded facilities. Demographics and dental data were extracted from health administrative databases for three time periods of 2010/11 (pre-cessation), 2014/15, and 2018/19 (post-cessation).

RESULTS

Among 2659 children receiving caries-related treatments under GA, the mean (SD) and median (IQR) age were 4.8 (2.3) and 4 (3-6) years, respectively, and 65% resided in the non-fluoridated area. The analysis revealed that the cessation of water fluoridation was significantly associated with an increased rate of caries-related GA events per 10,000 children in both age groups (0-5 and 6-11 years), with a more pronounced effect in 0-5-year-olds in non-fluoridated areas. The risk of dental treatments under GA was also positively associated with post-cessation time.

CONCLUSION

Discontinuing water fluoridation appears to negatively affect young children's oral health, potentially leading to a significant increase in caries-related dental treatments under GA and oral health disparities in this pediatric population.

Effect of bottled fluoridated water to prevent dental caries in primary teeth: study protocol for a phase 2 parallel-group 3.5-year randomized controlled clinical trial (waterBEST)

BACKGROUND

Fluoridation of public water systems is known as a safe and effective strategy for preventing dental caries based on evidence from non-randomized studies. Yet 110 million Americans do not have access to a fluoridated public water system and many others do not drink tap water. This article describes the study protocol for the first randomized controlled trial (RCT) of fluoridated water that assesses its potential dental caries preventive efficacy when delivered in bottles.

METHODS

waterBEST is a phase 2b proof-of-concept, randomized, quadruple-masked, placebo-controlled, parallel-group trial designed to estimate the potential efficacy of fluoridated versus non-fluoridated bottled water to prevent dental caries incidence in the first 4 years of life. Two hundred children living in eastern North Carolina, USA, and aged 2-6 months at screening are being allocated at random in a 1:1 ratio to receive fluoridated (0.7 mg/L F) or non-fluoridated bottled water sourced from two local public water systems. Throughout the 3.5-year intervention, study water is delivered monthly in 5-gallon bottles to each child's home with instructions to use it whenever the child consumes water as a beverage or in food preparation. Parents are interviewed quarterly to monitor children's water consumption and health. At annual visits, the presence of dental caries is evaluated with a dental screening examination. Clippings from fingernails and toenails are collected to quantify fluoride content as a biomarker of total fluoride intake. The primary endpoint is the number of primary tooth surfaces decayed, missing, or filled due to dental caries measured by the study dentist near the time of the child's fourth birthday. Tooth decay is assessed at the threshold of macroscopic enamel loss. For the primary aim, a least-squares, generalized linear model will estimate efficacy and its one-tailed, upper 80% confidence limit.

DISCUSSION

waterBEST is the first evaluation of a randomized intervention of fluoridated drinking water in bottles to prevent dental caries in the primary dentition. This innovative method of delivering fluoridated water has the potential to prevent early childhood caries in a large segment of the US population that currently does not benefit from fluoridated public water.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04893681. Registered on March 2022. Last update posted on 10 October 2023. https://clinicaltrials.gov/study/NCT04893681?cond=Dental%20Caries%20in%20Children&term=fluoride&locStr=North%20Carolina,%20USA&country=United%20States&state=North%20Carolina&distance=50&rank=1.

Effect of bottled fluoridated water to prevent dental caries in primary teeth: study protocol for a phase 2 parallel group 3.5-year randomized controlled clinical trial (waterBEST)

Background

Fluoridation of public water systems is known as a safe and effective strategy for preventing dental caries based on evidence from non-randomized studies. Yet 110 million Americans do not have access to a fluoridated public water system and many others do not drink tap water. This article describes the study protocol for the first randomized controlled trial (RCT) of fluoridated water that assesses its potential dental caries preventive efficacy when delivered in bottles.

Methods

waterBEST is a phase 2b proof-of-concept, randomized, quadruple-masked, placebo controlled, parallel group, trial designed to estimate the potential efficacy of fluoridated versus non-fluoridated bottled water to prevent dental caries incidence in the first four years of life. Two hundred children living in eastern North Carolina, USA, and aged 2-6 months at screening are being allocated at random in a 1:1 ratio to receive fluoridated (0.7 mg/L F) or non-fluoridated bottled water sourced from two local public water systems. Throughout the 3.5-year intervention, study water is delivered monthly in 5-gallon bottles to each child's home with instructions to use it whenever the child consumes water as a beverage or in food preparation. Parents are interviewed quarterly to monitor children's water consumption and health. At annual visits, the presence of dental caries is evaluated with a dental screening examination. Clippings from fingernails and toenails are collected to quantify fluoride content as a biomarker of total fluoride intake. The primary endpoint is the number of primary tooth surfaces decayed, missing, or filled due to dental caries measured by the study dentist near the time of the child's fourth birthday. Tooth decay is assessed at the threshold of macroscopic enamel loss. For the primary aim, a least-squares, generalized linear model will estimate efficacy and its one-tailed, upper 80% confidence limit.

Discussion

waterBEST is the first evaluation of a randomized intervention of fluoridated drinking water in bottles to prevent dental caries in the primary dentition. This innovative method of delivering fluoridated water has potential to prevent early childhood caries in a large segment of the U.S. population that currently does not benefit from fluoridated public water.

National and Subnational Trend of Dental Caries of Permanent Teeth in Iran, 1990-2017

OBJECTIVE

There are currently no integrated data on the trend of dental caries amongst distinct age groups in Iran. We aimed to assess the national and subnational trend of dental caries of permanent teeth in Iran from 1990 to 2017.

METHODS

A literature search about dental caries and the decayed-missing-filled teeth index (DMFT) was performed in PubMed, Web of Science, Scopus, and 3 national databases (in Persian). All eligible national oral health surveys in these 28 years were included. We categorised and aggregated the DMFT values and their components based on age (5-year-based groups from 5 to 9 to 60+ years), sex, year, and province. The data for missing spots were estimated using the spatiotemporal Bayesian hierarchical model. We used the bootstrap method in multilevel models to predict the uncertainty interval (UI) of the modelled results.

RESULTS

Nationally, the all-ages mean DMFT increased by nearly 58.0% (6.8 [95% UI, 4.1-10.5] in 1990 to 10.8 [95% UI, 7.5-14.5] in 2017). Decayed teeth (DT) and missing teeth (MT) rose by 84.5% and 31.6% during this period, respectively. Filled teeth (FT) showed almost a 2.6-fold increase in the same period from 0.6 (95% UI, 0.01-1.6) in 1990 to 1.7 (95% UI, 0.6-2.8) in 2017. The proportion of DT and FT continuously increased in both sexes. In 2017, the highest DT, MT, and FT were estimated in the 25-29 (4.9 [95% UI, 2.5-7.2]), 60+ (21.5 [95% UI, 17.5-25.4]), and 35-39 (2.6 [95% UI, 1.3-4.0]) year age groups.

CONCLUSIONS

Caries of permanent dentition levies a growing burden on the Iranian population. Considering the continuous increase in caries during the 1990-2017 period, Iranian policymakers should pay heed to these findings and react more proactively to mitigate this perpetuating issue. Implementing nationwide interventions such as sugar consumption management should be encouraged to achieve sustainable outcomes in this regards.

Systems mapping of multilevel factors contributing to dental caries in adolescents

Dental caries is a prevalent chronic disease among adolescents. Caries activity increases significantly during adolescence due to an increase in susceptible tooth surfaces, immature permanent tooth enamel, independence in pursuing self-care, and a tendency toward poor diet and oral hygiene. Dental caries in permanent teeth is more prevalent among adolescents in low-income families and racial/ethnic minority groups, and these disparities in adolescent dental caries experience have persisted for decades. Several conceptual and data-driven models have proposed unidirectional mechanisms that contribute to the extant disparities in adolescent dental caries experience. Our objective, using a literature review, is to provide an overview of risk factors contributing to adolescent dental caries. Specifically, we map the interactive relationships of multilevel factors that influence dental caries among adolescents. Such interactive multilevel relationships more closely reflect the complex nature of dental caries experience among the adolescent population. The methods that we use are two-fold: (1) a literature review using PubMed and Cochrane databases to find contributing factors; and (2) the system dynamics approach for mapping feedback mechanisms underlying adolescent dental caries through causal loop diagramming. The results of this study, based on the review of 138 articles, identified individual, family and community-level factors and their interactions contributing to dental caries experience in adolescents. Our results also provide hypotheses about the mechanisms underlying persistence of dental caries among adolescents.

Conclusions

Our findings may contribute to a deeper understanding of the multilevel and interconnected factors that shape the persistence of dental caries experience among adolescents.

The Evolving Microbiome of Dental Caries

Dental caries is a significant oral and public health problem worldwide, especially in low-income populations. The risk of dental caries increases with frequent intake of dietary carbohydrates, including sugars, leading to increased acidity and disruption of the symbiotic diverse and complex microbial community of health. Excess acid production leads to a dysbiotic shift in the bacterial biofilm composition, demineralization of tooth structure, and cavities. Highly acidic and acid-tolerant species associated with caries include Streptococcus mutans, Lactobacillus, Actinomyces, Bifidobacterium, and Scardovia species. The differences in microbiotas depend on tooth site, extent of carious lesions, and rate of disease progression. Metagenomics and metatranscriptomics not only reveal the structure and genetic potential of the caries-associated microbiome, but, more importantly, capture the genetic makeup of the metabolically active microbiome in lesion sites. Due to its multifactorial nature, caries has been difficult to prevent. The use of topical fluoride has had a significant impact on reducing caries in clinical settings, but the approach is costly; the results are less sustainable for high-caries-risk individuals, especially children. Developing treatment regimens that specifically target S. mutans and other acidogenic bacteria, such as using nanoparticles, show promise in altering the cariogenic microbiome, thereby combatting the disease.

Cost-effectiveness of dental caries prevention strategies in South African schools

BACKGROUND

In South Africa, an estimated 85% of the population relies on the public sector for oral health services. With poor infrastructure and inadequate personnel, over 80% of children with dental caries remain untreated. To reduce this burden of disease, one key goal is to promote good oral health and address oral diseases through prevention, screening, and treatment among children. While all policies have been proven to be effective in the control and prevention of dental caries, it is unclear which of those strategies provide value for money. This study evaluated five caries preventative strategies in terms of the cost and benefits among South African school children.

METHODS

The study uses a hypothetical South African population of school aged learners aged 5-15. The context and insights of the strategies utilized at the schools were informed by data from both grey and published literature. Using Markov modeling techniques, we conducted a cost-effectiveness analysis of Acidulated Phosphate Fluoride (APF) application, atraumatic restorative treatment (ART), sugar-reduction and fissure sealants. Markov model was used to depict the movement of a hypothetical patient cohort between different health states over time. We assessed both health outcomes and costs of various interventions. The health outcome metric was measured as the number of Decayed, Missing, Filled Tooth (DMFT). The net monetary benefit was then used to determine which intervention was most cost-effective.

RESULTS

The results showed that school-based caries prevention strategies are cost-effective compared to the status quo of doing nothing. The average cost per learner over the 10-year period ranged from ZAR4380 to approx. ZAR7300 for the interventions considered. The total costs (including screening) associated with the interventions and health outcome (DMFT averted) were: sugar reduction (ZAR91,380, DFMT: 63,762), APF-Gel (ZAR54 million, DMFT: 42,010), tooth brushing (ZAR72.8 million, DMFT: 74,018), fissure sealant (ZAR44.63 million, DMFT: 100,024), and ART (ZAR45 million, DMFT: 144,035). The net monetary benefits achieved for APF-Gel, sugar reduction, tooth brushing, fissure sealant and ART programs were ZAR1.56, ZAR2.45, ZAR2.78, ZAR3.81, and ZAR5.55 billion, respectively.

CONCLUSION

Based on the net monetary benefit, ART, fissure sealant and sugar-reduction appear to be the most cost-effective strategies for preventing caries in South Africa. In a resource-scarce setting such as South Africa, where there is no fluoridation of drinking water, this analysis can inform decisions about service packages for oral health.

Fluoride hesitancy: A mixed methods study on decision-making about forms of fluoride

OBJECTIVES

To investigate whether professionally applied topical fluoride-hesitant caregivers are also hesitant about other forms of fluoride for their child.

METHODS

This was a mixed methods study of 56 caregivers hesitant about professionally applied topical fluoride for their child recruited from the University of Washington Center for Paediatric Dentistry and Seattle Children's Hospital's Odessa Brown Children's Dental Clinic. A 32-item semi-structured interview script was piloted and finalized. One-time interviews with caregivers were conducted by phone in 2019. Associations between hesitancy of topical fluoride, fluoridated water and toothpaste were assessed quantitatively via two-tailed chi-squared tests. Qualitative data were coded using an inductive approach and content analytic methods to investigate reasons for hesitancy.

RESULTS

There were significant associations between hesitancy in all three pairwise comparisons of fluoride form (p < .01). Similar proportions of caregivers strongly or somewhat opposed fluoridated water compared with toothpaste (75% and 65%, respectively), but four times as many caregivers strongly or somewhat favoured fluoridated toothpaste compared to water for their child (25% and 7%, respectively). Concerns about harm were the most common reason caregivers opposed both fluoridated water and toothpaste. However, fluoride-hesitant caregivers reported being more comfortable with fluoridated toothpaste because amount and frequency can be controlled, and ingestion can be prevented.

CONCLUSIONS

Professionally applied topical fluoride hesitancy is significantly associated with fluoridated water and toothpaste hesitancy, but caregivers who were hesitant about topical fluoride was more comfortable with fluoridated toothpaste than fluoridated water for their child.

Potential risk factors and genetic variants associated with dental caries incidence in Appalachia using genome-wide survival analysis

OBJECTIVE

The aim of this study was to identify the potential risk factors and genetic variants associated with dental caries incidence using survival analysis.

METHODS

The Center for Oral Health Research in Appalachia recruited and prospectively followed pregnant women and their children. A total of 909 children followed from birth for up to 7 years were included in this study. Annual intra-oral examinations were performed to assess dental caries experience including the approximate time to first caries incidence in the primary dentition. Cox proportional hazards models were used to assess the associations of time to first caries incidence with self-reported risk factors and 4.9 million genetic variants ascertained using a genome-wide genotyping array.

RESULTS

A total of 196 of 909 children (21.56%) had their first primary tooth caries event during follow-up. Household income, home water source, and mother's educational attainment were significantly associated with time to first caries incidence in the stepwise Cox model. The heritability (i.e., proportion of variance explained by genetics) of time to first caries was 0.54. Though no specific genetic variants were associated at the genome-wide significance level (P < 5E-8), we identified 14 loci at the suggestive significance level (5E-8 < P < 1E-5), some of which were located within or near genes with plausible biological functions in dental caries.

CONCLUSION

Our findings indicate that household income, home water source, and mother's educational attainment are independent risk factors for dental caries incidence. We nominate several suggestive loci for further investigation.

Evaluation of the impact of fluoride in drinking water and tea on the enamel of deciduous and permanent teeth

BACKGROUND

Systemic fluoride intake is predominantly derived from drinking water and tea. It's been noted that water and tea containing fluoride, within the boundaries set by the World Health Organization, can lessen the prevalence of dental caries. A review of the literature did not uncover any study that has examined the impact of fluoride in bottled drinking water and tea on enamel of deciduous and permanent teeth. Thus, we assessed the effects of fluoride present in seven different brands of bottled water from distinct geographical regions of Turkey, and a type of tea produced and packaged in Turkey, on the enamel of deciduous and permanent teeth.

MATERIALS AND METHODS

Fluoride analysis was performed on drinking water sourced from seven different regions of Turkey and a brand of tea brewed with these waters. The tea was harvested and packaged in Turkey. The analysis was conducted using an ion-selective electrode. In total, 112 tooth enamel samples (56 deciduous molars and 56 permanent molars) were randomly divided into eight distinct groups. These were kept in water for 15 min and tea for 15 min every day for a month. The eighth group was treated with fluoride gel prior to tea and water applications. The amount of fluoride in the tooth enamel structure was evaluated using an SEM EDX device before and after the experiment.

RESULTS

Statistically significant differences were found in fluoride content of enamel between water brands and tooth type (deciduous and permanent teeth). Fluoride levels were higher in the enamel of deciduous teeth than in permanent teeth.

CONCLUSION

Regular exposure of enamel samples to black tea and water led to an increase in fluoride levels in the enamel; thus, regular consumption of black tea and fluoride water could help reduce the prevalence of dental caries.

Impact of Fluoride on Associations between Free Sugars Intake and Dental Caries in US Children

OBJECTIVE

Dental caries is the most prevalent chronic disease in US children, with the highest burden among Black and Hispanic youth. Sugars are a primary risk factor, but few studies have specifically measured intakes of free sugars and related this to dental caries or explored the extent to which water fluoride mitigates the cariogenicity of free sugars. Furthermore, the cariogenicity of certain free sugars sources, such as extruded fruit and vegetable products, is unclear.

METHODS

Using cross-sectional data on 4,906 children aged 2 to 19 y in the US National Health and Nutrition Examination Survey 2013-2016, we examined associations of free sugars intake with counts of decayed or filled primary tooth surfaces (dfs) and decayed, missing, or filled permanent surfaces (DMFS) in negative binomial regressions. Stratified models examined these associations in children with home water fluoride above or below the Centers for Disease Control and Prevention (CDC)-recommended level of 0.7 ppm.

RESULTS

Free sugars accounted for 16.4% of energy, primarily contributed by added sugars. In adjusted models, a doubling in the percentage of energy from free sugars was associated with 22% (95% confidence interval [CI], 1%-47%) greater dfs among children aged 2 to 8. A doubling in energy from added sugars was associated with 20% (95% CI, 1%-42%) greater dfs and 10% (95% CI, 2%-20%) greater DMFS in children aged 6 to 19 y. Beverages were the most important source of added sugars associated with increased caries. Other free sugars were not associated with dfs or DMFS. Associations between free sugars and caries were diminished among children with home water fluoride of 0.7 ppm or greater.

CONCLUSIONS

Free sugars intake, especially in the form of added sugars and specifically in sweetened beverages, was associated with higher dental caries. Water fluoride exposures modify these associations, reducing caries risk in the primary dentition of children whose home water meets recommended fluoride levels.

KNOWLEDGE TRANSFER STATEMENT

Intake of free sugars, especially in the form of added sugars and specifically in beverages, was associated with higher dental caries in US children in this study. Water fluoride exposure at CDC-recommended levels protected against caries, especially in the primary dentition. These findings suggest that household water fluoridation at CDC-recommended levels protects against the cariogenic potential of free and added sugars during childhood.

Preventive dental care utilization and dental caries for Medicaid-enrolled adolescents in Oregon

OBJECTIVES

This study aimed to evaluate the relationship between preventive dental care utilization and untreated dental caries for Medicaid-enrolled adolescents and to determine if the relationship is moderated by chronic conditions (CC).

METHODS

This analysis was based on 2015-2016 Medicaid claims files and survey data collected from adolescents ages 12-18 years enrolled in Oregon Medicaid, who received a dental screening between December 2015 and December 2016 (n = 240). To assess the relationship between preventive dental care utilization and untreated dental caries (defined as decayed tooth surfaces), prevalence ratios (PR) and 95% confidence intervals (CI) were generated using log-linear regression models. We also tested for an interaction between preventive dental care utilization and CC.

RESULTS

About 60.4% of adolescents utilized preventive dental care, 21.7% had CC, and 29.6% had ≥1 decayed tooth surfaces. There were no significant differences in untreated dental caries between adolescents who did and did not utilize preventive dental care (PR: 0.73, 95% CI: 0.33-1.60; p = 0.43). There was not a significant interaction between preventive dental care utilization and CC (p = 0.65). Preventive dental care utilization was not significantly associated with untreated dental caries for adolescents with CC (PR: 0.51, 95% CI: 0.10-2.65; p = 0.42) nor among adolescents without CC (PR: 0.79, 95% CI: 0.33-1.91; p = 0.61).

CONCLUSIONS

Preventive dental care was not shown to be associated with lower untreated dental caries for Medicaid-enrolled adolescents or those with CC. Future work that is adequately powered should continue to elucidate this relationship in Medicaid enrollees.

Caries risk assessment-related knowledge, attitude, and behaviors among Chinese dentists: a cross-sectional survey

OBJECTIVES

To investigate caries risk assessment (CRA)-related knowledge, attitudes, and practices among dentists in China, to describe their subjective ratings of the significance of specific caries risk factors and to identify factors associated with the level of knowledge, attitudes, and use of CRA in routine clinical practice.

MATERIALS AND METHODS

A cross-sectional anonymous online questionnaire survey was performed. The questionnaire was distributed via WeChat (Tencent, Shenzhen, China) to practicing dentists between November 25 and December 25, 2021. For participant recruitment, we employed purposive and snowball sampling techniques. Data were collected using a specialized web-based survey tool ( www.wjx.cn ) and analyzed with descriptive statistics and regression analyses.

RESULTS

A total of 826 valid questionnaires were collected. Only 292 (35.4%) respondents used CRA in routine practice, among whom a majority (243, 83.2%) did not use a specific CRA tool. The routine use of CRA was associated with the type of practicing office, attendance of caries-related lectures, the habit of reading caries-related literature, geographic location, and the total knowledge score. The mean total knowledge score was 3.13 (score range: 0 to 6). Knowledge levels were related to several sociodemographic characteristics, including geographic location, the type of practicing office, attendance of caries-related lectures and the habit of reading caries-related literature. The risk factor deemed most important was "current oral hygiene."

CONCLUSIONS

Caries risk assessment has not widely entered clinical practice in China. The level of CRA-related knowledge among dentists was generally suboptimal.

CLINICAL RELEVANCE

Strengthening CRA-related education may allow practitioners to develop a better understanding of caries risk assessment and hence promote its implementation.

Red Marine Algae Lithothamnion calcareum Supports Dental Enamel Mineralization

The current management of oral conditions such as dental caries and erosion mostly relies on fluoride-based formulations. Herein, we proposed the use of the remaining skeleton of Lithothamnion calcareum (LC) as an alternative to fluorides. LC is a red macroalgae of the Corallinales order, occurring in the northeast coast of Brazil, whose unique feature is the abundant presence of calcium carbonates in its cell walls. Two experimental approaches tested the general hypothesis that LC could mediate enamel de-remineralization dynamics as efficiently as fluorides. Firstly, the effect of LC on enamel de-mineralization was determined in vitro by microhardness and gravimetric measurements to test the hypothesis that LC could either prevent calcium/phosphate release from intact enamel or facilitate calcium/phosphate reprecipitation on an artificially demineralized enamel surface. Subsequently, an in situ/ex vivo co-twin control study measured the effect of LC on the remineralization of chemical-demineralized enamel using microhardness and quantitative light-induced fluorescence. With this second experiment, we wanted to test whether outcomes obtained in experiment 1 would be confirmed by an in situ/ex vivo co-twin control model. Both experiments showed that LC exhibited equivalent or superior ability to modulate enamel de-remineralization when compared to fluoride solution. LC should be explored as an alternative to manage oral conditions involving the enamel demineralization.

Maintaining and Improving the Oral Health of Young Children

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

Risk perceptions of drinking bottled vs. tap water in a low-income community on the US-Mexico Border

Background

Previous studies have shown that low-income Latinos generally drink bottled water over tap water and might be at increased risks for cavities from unfluoridated bottled water. In order to better design interventions, it is important to understand the risk perceptions of this unique high-risk yet historically marginalized group.

Methods

We interviewed low-income Latino households (n = 90) from Nogales, Arizona who primarily drink bottled water and asked them to evaluate potential health risks of drinking tap water compared to 16 other voluntary activities. Unpaired t-tests were used to determine if statistically significant (α = 0.05) differences occurred in perceived risk by drinking-water source and differences among demographic groups in their level of (dis)agreement with statements regarding tap or bottled water safety. To assess significant differences (α = 0.05) in perceived risks and voluntariness to engage in a number of activities, including drinking local tap water and drinking water in different geographic regions, a one-way analysis of variance (ANOVA) followed by Scheffe’s post-hoc test (a conservative post-hoc test) with adjustment for the number of pairwise comparisons was used.

Results

Participants viewed bottled water to be significantly safer to consume than tap water (p < 0.001). On a Likert scale from 1 (low risk) to 5 (high risk), “drinking tap water in Nogales, Arizona” received an average score of 4.7, which was significantly higher than the average perceived risk of drinking San Francisco, California tap water (µ = 3.4, p < 0.001), and as risky as drinking and driving (µ = 4.8, p = 1.00) and drinking Nogales, Sonora, Mexico tap water (µ = 4.8, p = 1.00). Ninety-eight percent of participants feared that drinking local tap water could result in illness, 79% did not drink their water because of fear of microbial and chemical contamination and 73% would drink their water if they knew it was safe regardless of taste.

Conclusions

These results suggest that fear of illness from tap-water consumption is an important contributing factor to increased bottled water use. Future efforts should focus on the development of educational and outreach efforts to assess the safety and risks associated with tap-water consumption.

Mothers' Sources of Child Fluoride Information and Misinformation From Social Connections

IMPORTANCE

Fluoride delivered either topically (eg, fluoride varnish) or systemically (eg, water fluoridation, prescription fluoride supplements) is widely used as a caries preventive agent in children. The widespread existence of misinformation, including inaccurate information that attaches negative values or suspicion to fluoride treatments, raises concerns that misinformation will lead to underutilization of fluoride and contribute to avoidable increases in caries prevalence.

OBJECTIVE

To describe the social relationships from which mothers obtain child fluoride information and misinformation.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study analyzed 126 mothers with children aged 3 to 5 years to explore how their social networks were associated with their child's oral health. Mothers were recruited from community-based sites in Pittsburgh, Pennsylvania, and throughout the state of West Virginia from 2018 to 2020. In-person, semi-structured qualitative interviews were conducted. Data were transcribed, coded, and analyzed using Nvivo 12. Three investigators analyzed data using template analysis, a qualitative technique that combines inductive and deductive approaches to identify patterns until primary themes are identified.

MAIN OUTCOMES AND MEASURES

Sources of information regarding fluoride from the mother's social relationships.

RESULTS

Of the 126 mothers with children aged 3 to 5 years in Pittsburgh and West Virginia, 120 (95%) identified as non-Hispanic White and 5 (4%) identified as Hispanic White; 38 (30%) had a bachelor's degree, 77 (61%) had private dental insurance for their child, and 52 (41%) had an income less than $50 000; 82 (65%) reported that they discussed child fluoride information with members of their social network. Mothers described that they obtained fluoride information from family members, health care clinicians, and community members. The receipt of inconsistent child fluoride information from multiple sources resulted in confusion and difficulty assessing whether fluoride information was accurate.

CONCLUSIONS AND RELEVANCE

This qualitative study found that mothers received inconsistent child fluoride information from multiple sources, which resulted in confusion and difficulty assessing the accuracy of the fluoride information. These findings suggest that social relationships can be a potential target for interventions to communicate fluoride information related to children.

Comparing oral health systems for children in six European countries to identify lessons learned for universal oral health coverage: A study protocol

Background: Oral diseases have the highest global prevalence rate among all diseases, with dental caries being one of the most common conditions in childhood. A low political priority coupled with a failure to incorporate oral health within broader health systems has contributed to its neglect in previous decades. In response, calls are emerging for the inclusion of oral health within the universal healthcare domain (UHC). This protocol outlines the methodology for a cross-country comparative analysis of publicly funded oral health systems for children across six European countries, reporting on oral health status in line with the indicators for UHC. Methods: This study will follow Yin's multiple case study approach and employ two strands of data collection, analysis, and triangulation: a systematic documentary analysis and semi-structured interviews with elite participants local to each country. The countries chosen for comparison and providing a representative sample of European dental systems are Denmark, Hungary, the Republic of Ireland, Germany, Scotland, and Spain. A systematic search of five electronic databases and four additional electronic resources will be undertaken, in addition to grey literature and other publicly available sources, with the outcomes verified and further informed by local experts. The WHO Universal Health Coverage Cube will be used to guide data collection and analysis. Conclusions: This research will provide policy makers with an in-depth analysis and comparison of publicly funded oral health systems for children in Europe, including consideration of effective preventive strategies, oral health system reform, and indicators of universal oral health coverage. It is anticipated that the outcomes may help in positioning oral health on governmental health agendas and support its integration into wider health systems' reform in an accessible and affordable manner.

Impact of water fluoridation on dental caries decline across racial and income subgroups of Brazilian adolescents

OBJECTIVES

The aim of this study was to assess the impact of community water fluoridation (CWF) on differences in dental caries decline across racial and socioeconomic subgroups of Brazilian adolescents.

METHODS

Two nationwide Brazilian population-based oral health surveys were used (Brazilian Oral Health Survey 2003 and 2010). In total, 7,198 adolescents from 15 years to 19 years old living in 50 cities investigated in both surveys were included. The mean numbers of untreated decayed teeth (DT) according to racial (Whites vs. Browns/Blacks) and socioeconomic subgroups (at or above the minimum wage per capita vs. under) were analysed. Difference-in-differences negative binomial regressions were adjusted by schooling, age, and sex. Decayed, missing, and filled teeth and DT prevalence, calculated as a categorical variable, were used in sensitivity analyses.

RESULTS

The adjusted difference of reduction in DT was similar across socioeconomic subgroups (β=-0.05; 95% confidence interval [CI], -0.45 to 0.35) and favoured, but not to a significant degree, Whites (β=-0.34; 95% CI, -0.74 to 0.04) compared to Brown/Blacks in fluoridated areas. In non-fluoridated areas, significant differences were observed in the mean number of DT, favouring the higher socioeconomic subgroup (β=-0.26; 95% CI, -0.53 to -0.01) and Whites (β=-0.40; 95% CI, -0.69 to -0.11) in relation to their counterparts. The sensitivity analyses confirmed the findings.

CONCLUSIONS

The similar reduction in DT across income subgroups suggests that CWF has had a beneficial effect on tackling income inequalities in dental caries within a 7-year timeframe.

Disparities in dental health issues and oral health care visits in US children with tobacco smoke exposure

BACKGROUND

The objective of the authors was to assess the relationships between tobacco smoke exposure (TSE) and dental health and dental care visits among US children.

METHODS

The authors examined 2018-2019 National Survey of Children's Health data on TSE, dental health, and oral health care visits. Children aged 1 through 11 years (N = 32,214) were categorized into TSE groups: no home TSE (did not live with a smoker), thirdhand smoke (THS) exposure (lived with a smoker who did not smoke inside the home), or secondhand smoke (SHS) and THS exposure (lived with a smoker who smoked inside the home). The authors conducted multivariable logistic regression analyses, adjusting for child age, sex, race or ethnicity, prematurity, caregiver education level, family structure, and federal poverty threshold.

RESULTS

Children with home SHS and THS exposure were at increased odds of having frequent or chronic difficulty with 1 or more oral health problem (adjusted odds ratio [AOR], 1.59; 95% CI, 1.07 to 2.35; P = .022) and carious teeth or caries (AOR, 1.74; 95% CI 1.14 to 2.65; P = .010) than those with no TSE. Compared with children aged 1 through 11 years with no TSE, children with SHS and THS exposure were 2.22 times (95% CI, 1.01 to 4.87; P = .048) more likely to have not received needed oral health care but at decreased odds of having had any kind of oral health care visit (AOR, 0.55; 95% CI, 0.32 to 0.95; P = .032), including a preventive oral health care visit (AOR, 0.60; 95% CI, 0.36 to 0.99; P = .047).

CONCLUSIONS

TSE in children is associated with caries and inadequate oral health care visits.

PRACTICAL IMPLICATIONS

The pediatric dental visit is an opportune time to educate caregivers who smoke about dental health to improve their children's teeth condition and increase oral health care visits.

Intersectoral collaboration and coordination mechanisms for implementing water fluoridation: Challenges from a case study in Brazil

OBJECTIVES

Community water fluoridation has been associated with better oral health conditions globally and reduced dental caries. While oral health policies are governed by the health sector agenda, water fluoridation is undertaken by public, private, and mixed public/private companies of the sanitation sector. The first aim of this study was to investigate the degree of intersectoral collaboration, and the second was to investigate how the coordination mechanisms are perceived by the sanitation agents of the sectors involved in water quality management, for the potential establishment of water fluoridation in a central-west state in Brazil.

METHODS

Semi-structured interviews were conducted with chief sanitation agents from nonprofit, profit, and mixed public/private companies responsible for water quality and fluoridation in a purposive sample. Theoretical frameworks of intersectoral collaboration and coordination mechanisms were used for analysis.

RESULTS

Twelve interviews were conducted. Informal collaboration was identified in the sanitation sector within companies involved in water provision. The main coordination mechanisms were network-type mechanisms, which involve consultations and knowledge sharing, and market-type mechanisms, which explore new job opportunities and cost-effectiveness, especially in water quality measures. Enabling themes (enablers) were identified, such as positive attitude toward including water quality and fluoridation in a collaborative health and sanitation common agenda. Moreover, fluoridation did not meet the regulatory and surveillance agenda at the state level, and until that moment, there was no proposal of the health sector for water fluoridation.

CONCLUSIONS

Partnership creation, consolidation, and shared mission, especially between health and sanitation sectors, were identified as main challenges for implementing water fluoridation policy.

Associations of low level of fluoride exposure with dental fluorosis among U.S. children and adolescents, NHANES 2015-2016

Drinking water fluoridation was a mid-twentieth century innovation based on the medical hypothesis that consuming low doses of fluoride at the teeth forming years provided protection against dental decays. Numerous studies showed that high level exposure to fluoride could cause dental and skeleton fluorosis. However, there was limited study focusing on the fluorosis effect of low levels of exposure to fluoride. Therefore, our study aimed to examine whether the low level of fluoride exposure (measured in blood plasma and household tap water) was associated with the risk of dental fluorosis based on data of the National Health and Nutrition Examination Survey (NHANES) 2015-2016. We analyzed data in 2098 children and adolescents who had Dean's Index scores, and water and plasma fluoride measures. The Dean's Index score was measured by calibrated dental examiners using the modified Dean's fluorosis classification system. Fluoride was measured in plasma and household tap water. In this study, we found that the rate of fluoride concentration in water above the recommended level of 0.7 mg/L was 25%, but the prevalence of dental fluorosis was 70%. Binary logistic regression adjusted for covariates showed that higher water fluoride concentrations (0.31-0.50, 0.51-0.70, > 0.70 compared 0.00-0.30) were associated with higher odds of dental fluorosis (OR = 1.48, 95% CI: 1.13-1.96, p = 0.005; OR = 1.92, 95% CI: 1.44-2.58, p < 0.001, and OR = 2.30, 95% CI: 1.75-3.07, p < 0.001, respectively). The pattern of regression between plasma fluoride and dental fluorosis was similar. Inclusion, our study showed that even low level of water or plasma fluoride exposure was associated with increased the risk of dental fluorosis. The safety of public health approach of drinking water fluoridation for global dental caries reduction are urgently needed further research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICAL IMPLICATIONS

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

Does water fluoridation influence ethnic inequalities in caries in Brazilian children and adolescents?

OBJECTIVES

This study aimed to investigate the influence of community water fluoridation on ethnic inequalities in untreated dental caries among children and adolescents in Brazil while taking the human development context into account.

METHODS

Data from a nationwide Brazilian epidemiological population oral health survey were used (SB Brazil 2010). Outcomes were caries prevalence measured by the proportion of individuals with one or more untreated decayed teeth and caries severity defined by the mean number of untreated decayed teeth (DT). Three different contexts were considered: 1-cities with no water fluoridation; 2-cities with water fluoridation and low Human Development Index (HDI); and 3-cities with water fluoridation and high HDI. The exposure was ethnic/racial group (White, Pardo, Black) and covariates were age, sex and household income. Multilevel logistic and negative binomial regressions were performed with 6696 children (aged 5 years) and 11 585 adolescents (aged 12 and 15-19 years).

RESULTS

For both children and adolescents, ethnic differences in caries prevalence and mean DT were found in the nonfluoridated cities with low HDI and also in cities with high HDI, most of which were fluoridated. For example in nonfluoridated cities with low HDI, 5-year-old Pardo children were more likely to have untreated decay (OR = 1.22; 95% CI: 1.02, 1.46) and had more decayed teeth (RR = 1.18; 95% CI: 1.04, 1.34) than their White counterparts after adjusting for sex and household income. No statistically significant differences were observed in fluoridated cities with low HDI.

CONCLUSION

Water fluoridation appears to be associated with reduced ethnic inequalities in dental caries prevalence and mean DT among children and adolescents in more disadvantaged settings.

Fluoride contamination of selected food crops, domestic water, and milk consumed by communities around mount Meru in Northern Tanzania

This study assessed fluoride levels in domestic water, commonly consumed food crops, cow's, and human milk. Samples of vegetables were collected from farmer's home gardens, green banana from local markets, maize flour, and domestic water from households, while cow's and human (breast) milk were obtained from cows and lactating mothers. Fluoride levels were determined by using a fluoride ion-selective electrode. Fluoride levels were 0.03 ± 0.02 mg/kg in maize, In leafy vegetables the highest levels were found in nightshade 0.081 ± 0.008 mg/kg, while for banana varieties the highest levels were found in in East African highland 0.025 ± 0.004 mg/kg. Levels in cows and human breast milk were 0.34 ± 0.2 mg/L and 0.077 ± 0.06 mg/L, respectively. Levels in domestic and public tap water were 4.57 ± 0.4 mg/L and 4.74 ± 0.8 mg/L, respectively. Study provided useful knowledge of fluoride levels in several crops, milk, and domestic water.

Excess Risk of Dental Caries from Higher Free Sugars Intake Combined with Low Exposure to Water Fluoridation

The study aimed to quantify the excess risk of interaction between high free sugars (sugars) intake and lack of exposure to water fluoridation on child dental caries. Data from the Australian National Child Oral Health Study, a population-based survey of 24,664 children aged 5 to 14 y, were collected using parental questionnaires and oral epidemiological examinations by trained examiners. Information on socioeconomic status, dental health behaviors, and dental service use was used as covariates. The number of servings of sugars-containing foods and drinks consumed in a usual day was assessed as the main exposure, categorized into 5 groups. Residential history was used to calculate lifetime exposure to fluoridated water (LEFW), categorized as low (<25%), medium (25% to <75%), or high (75%-100%). Caries prevalence (dmfs/DMFS >0) and experience (dmfs/DMFS) in the primary (ages 5-10 y) and permanent (ages 8-14 y) dentitions were the main dependent variables. The association of sugars intake and LEFW with each outcome was estimated in multivariable log-Poisson regression models with robust standard error estimation, adjusted for covariates. The relative excess risk due to interaction (RERI) between sugars intake and LEFW was estimated. Strong positive gradients in all outcomes were observed across sugars intake groups. Relative to the lowest intake group, the 3 highest intake groups had significantly higher adjusted prevalence ratios for having caries and higher adjusted mean ratios of caries experience in both dentitions, after controlling for all covariates. LEFW strongly and consistently attenuated the effects of all levels of sugars intake on the outcomes. RERI estimates indicated that a combination of lack of exposure to fluoridated water and high sugars intake resulted in greater excess risk of primary and permanent caries than if there was no interaction. Evidently, children with high sugars intakes and low exposure to water fluoridation are at disproportionately higher risk of dental caries.

The additional benefit of professional fluoride application for children as an adjunct to regular fluoride toothpaste: a systematic review and meta-analysis

OBJECTIVE

To assess whether professional fluoride application (PFA) used in addition to regular fluoride toothpaste (RFT, ≥ 1,000 ppm) is more effective than RFT alone in children.

MATERIALS AND METHODS

A systematic search was conducted using the PubMed, Embase, Google Scholar and CENTRAL databases. Randomized controlled trials (RCTs) comparing the effectiveness of RFT + PFA and RFT alone were included. Meta-analyses with random-effects models were performed. The certainty of evidence was assessed using the GRADE approach.

RESULTS

A total of 2,729 records were identified from electronic and manual searches, which were screened by two reviewers independently and in duplicate. Six RCTs (5,034 participants) were included, of which four had high risk of bias and two had unclear risk of bias. The PFA used in all these trials was fluoride varnish (FV). In meta-analyses, no significant difference was observed between participants receiving FV + RFT and RFT alone of d(m/e)fs increment (mean difference (MD) - 0.17, 95% confidence interval (CI) - 0.60 to 0.26, P = 0.43, I² = 38%; 6 trials, 5,034 participants, moderate certainty evidence), incidence of caries (risk ratio (RR) 0.91, 95% CI 0.80 to 1.05, P = 0.21, I² = 41%; 4 trials, 4,487 participants, moderate certainty evidence) or changes in prevalence of caries (RR 0.89, 95% CI 0.78 to 1.01, P = 0.07, I² = 0%, 4 trials, 4,189 participants, low certainty evidence).

CONCLUSIONS

Low to moderate certainty evidence suggests that FV does not have significant additional caries-preventive benefit for children (under 8 years old) when provided as an adjunct to daily tooth brushing with RFT (≥ 1,000 ppm). There is insufficient evidence regarding the additional benefit of other PFA interventions.

CLINICAL RELEVANCE

The decision to apply FV to children needs to be made in light of their actual usage of RFT.

TRIAL REGISTRATION

PROSPERO (CRD42020165270).

Association of Oral Health Literacy and School Factors with Untreated Dental Caries among 12-Year-Olds: A Multilevel Approach

Dental caries are a global health problem that affects all age groups and must be considered a public health priority due to its significant financial costs and impact on the quality of life. This study evaluated the association between oral health literacy (OHL), school factors, and untreated dental caries in 12-year-old Brazilian adolescents using a multilevel approach. A population-based cross-sectional study was carried out with 740 adolescents randomly selected from private and public schools in Campina Grande, Brazil. Two dentists were trained and calibrated to diagnose dental caries using the Nyvad index and OHL using the Brazilian Rapid Estimate of Literacy in Dentistry (BREALD-30). The caregivers of the adolescents reported demographic data (sex, skin color, and socioeconomic status). Data of school factors such as the type of school and the school grade retention rate were classified through a 2-step hierarchical cluster analysis to obtain the school environment. A robust multilevel log-linear negative binomial regression for complex samples was performed (p < 0.05). In the analysis, adjusted by individual determinants, nonwhite skin color (RR = 2.20; 95% CI 1.56-3.12), a low socioeconomic status (RR = 1.60; 95% CI 1.09-2.34), a low OHL score (RR = 0.94; 95% CI 0.91-0.98), and low satisfaction with the last dental appointment (RR = 2.25; 95% CI 1.67-3.04) were associated with untreated dental caries. The following factors remained associated with untreated dental caries in the final model: students from an unfavorable learning environment (RR = 2.20; 95% CI 1.27-3.80), nonwhite skin color (RR = 1.92; 95% CI 1.27-2.91), a low socioeconomic status (RR = 1.82; 95% CI 1.12-2.94), a low OHL score (RR = 0.95; 95% CI 0.91-0.98), and low satisfaction with the last dental appointment (RR = 2.07; 95% CI 1.47-2.91). Untreated dental caries in early adolescence were impacted by the school environment, the socioeconomic status, OHL, and the adolescent's satisfaction with the last dental appointment.

Fluoride exposure and duration and quality of sleep in a Canadian population-based sample

BACKGROUND

Fluoride from dietary and environmental sources may concentrate in calcium-containing regions of the body such as the pineal gland. The pineal gland synthesizes melatonin, a hormone that regulates the sleep-wake cycle. We examined associations between fluoride exposure and sleep outcomes among older adolescents and adults in Canada.

METHODS

We used population-based data from Cycle 3 (2012-2013) of the Canadian Health Measures Survey. Participants were aged 16 to 79 years and 32% lived in communities supplied with fluoridated municipal water. Urinary fluoride concentrations were measured in spot samples and adjusted for specific gravity (UF_SG; n = 1303) and water fluoride concentrations were measured in tap water samples among those who reported drinking tap water (n = 1016). We used multinomial and ordered logistic regression analyses (using both unweighted and survey-weighted data) to examine associations of fluoride exposure with self-reported sleep outcomes, including sleep duration, frequency of sleep problems, and daytime sleepiness. Covariates included age, sex, ethnicity, body mass index, chronic health conditions, and household income.

RESULTS

Median (IQR) UF_SG concentration was 0.67 (0.63) mg/L. Median (IQR) water fluoride concentration was 0.58 (0.27) mg/L among participants living in communities supplied with fluoridated municipal water and 0.01 (0.06) mg/L among those living in non-fluoridated communities. A 0.5 mg/L higher water fluoride level was associated with 34% higher relative risk of reporting sleeping less than the recommended duration for age [unweighted: RRR = 1.34, 95% CI: 1.03, 1.73; p = .026]; the relative risk was higher, though less precise, using survey-weighted data [RRR = 1.96, 95% CI: 0.99, 3.87; p = .05]. UF_SG was not significantly associated with sleep duration. Water fluoride and UF_SG concentration were not significantly associated with frequency of sleep problems or daytime sleepiness.

CONCLUSIONS

Fluoride exposure may contribute to sleeping less than the recommended duration among older adolescents and adults in Canada.

Food processing and its association with dental caries: Data from NHANES 2011-2014

OBJECTIVE

To assess whether proportional contribution of unprocessed or minimally processed, processed or ultra-processed foods to daily energy intake is associated with dental caries in US adults.

METHODS

This secondary cross-sectional analysis included adults aged 20 to 59 years old with complete oral examinations, using data gathered from cycles 2011-2012 and 2013-2014 of the continuous National Health and Nutrition Examination Survey (NHANES). Dietary recall data were categorized according to the NOVA classification into four groups: unprocessed or minimally processed foods (Group 1), processed culinary ingredients (Group 2), processed foods (Group 3) and ultra-processed foods (Group 4). The proportional contribution of each of these groups to mean daily energy intake was calculated and then cut into quartiles (Group 1, Group 3 and Group 4) or tertiles (Group 2). Two separate measures were used to assess dental caries: the decayed, missing, filled teeth (DMFT) index and, after exclusion of edentulous participants, prevalence of untreated caries. Poisson regression was used to model DMFT, while logistic regression was used to model the prevalence of untreated dental caries. Models were calculated for each NOVA group. All models were controlled for age, gender, race/ethnicity, level of education, income, access to oral health services, body mass index, smoking status and total energy intake. Analyses took into account NHANES sampling weights.

RESULTS

We analysed data from 5720 individuals, of whom 123 (2.2%) were edentulous. Mean DMFT was 9.7 (± 0.2), while the prevalence of untreated dental caries was 26.0%. Mean daily energy intake was 2170 kcal (± 17). Mean contribution to overall daily energy intake was 28.6% (± 0.5) for G1 foods, 4.3% (± 0.1) for G2 foods, 10.1% (± 0.2) for G3 foods and 56.9% (± 0.5) for G4 foods. A higher intake of G3 was associated with lower DMFT at the fourth quartile (0.89; 95%: CI 0.81-0.96), while a higher intake of G4 was associated with a higher DMFT at the fourth quartile (1.10; 95% CI: 1.04-1.16). In the adjusted models for untreated dental caries, no statistically significant associations were found with any of the NOVA groups.

CONCLUSION

Higher proportional intake of NOVA groups is only weakly associated with dental caries. Widespread exposure to a highly ultra-processed diet may explain these weak associations.

Oral health and related risk indicators in north-central Appalachia differ by rurality

OBJECTIVES

This cross-sectional study assessed differences in oral health and related behaviours and risk indicators by rurality in a north-central Appalachian population using the Andersen behavioural model as a conceptual framework.

METHODS

Participants were residents aged 18-59 years (n = 1311) from the Center for Oral Health Research in Appalachia, selected according to a household-based sampling strategy. Rural-Urban Continuum codes (RUC) corresponding to the participants' residences were used to classify participants as rural or urban. Mixed models were used to test rural-urban differences in measures of oral health, related behaviours, and need, enabling, and predisposing risk indicators. Models were adjusted for sociodemographic variables: age, sex, race, income, perceived socioeconomic status, educational attainment and dental insurance.

RESULTS

Rural residents had poorer oral health overall, with fewer sound teeth (β = -1.79), more dental caries (β = 0.27) and higher rates of edentulism (5.2% vs 2.8%). Differences also were observed for dental care utilization and perceived barriers to care. Rural residents were less likely to attend dental visits as often as needed (26.9% vs 42.8%) and were more prone to seek care only after experiencing a dental problem (64.3% vs 43.9%). Rural residents also were more likely to report high costs (89% vs 62.6%) as a major reason for not having dental visits. Rural-urban differences for some oral health characteristics and behaviours could be explained by sociodemographic characteristics, whereas others could not.

CONCLUSIONS

This study revealed rural-urban differences in risk indicators and oral health outcomes in north-central Appalachia. Many of these differences were explained, completely or partly, by sociodemographic factors.

Spatio-temporal trends in caries: A study on children in Berlin-Mitte

Background

Significant inequalities in caries distribution among children in Germany have been reported, but small‐scale areas remain understudied.

Aim

To examine spatio‐temporal trends in children's dental caries at the small‐area level in Berlin‐Mitte.

Design

Routinely collected data from Berlin's annual Health Examination Surveys were used, which also include information on age, sex, country of origin, and residential area. The study population consists of 14,866 children aged 5 to 7 between 2006 and 2014 in the district of Berlin‐Mitte. Outcome variables are the dmft (decayed, missing, and filled teeth), the presence of any caries experience, untreated caries, and caries risk. The outcomes are summarized descriptively and graphically presented for 10 quarters and 41 communities within Berlin‐Mitte.

Results

Relevant gaps in children's dental caries were discovered between the quarters of Mitte. Three quarters in the northeast part of Mitte have consistently indicated the lowest oral health status in all four outcomes, and children having high caries risk have been increasingly concentrating in this area over time. Despite the continuous improvements in the southern part, the averages in total of Mitte for all outcomes have risen.

Conclusion

Our findings confirm the spatiotemporally mounting disparities in children's oral health between the quarters in Berlin‐Mitte and that particular quarters need urgent attention. The small‐area approach made it easier and more effective to reveal the spatial distribution of children's dental caries at the local level. The small‐area analysis should be strongly encouraged in future caries research to narrow the inequalities in children's oral health.

Does Preventive Care Reduce Severe Pediatric Dental Caries?

INTRODUCTION

Tertiary oral health services (caries-related surgery, sedation, and emergency department visits) represent high-cost and ineffective ways to improve a child's oral health. We measured the impact of increased Texas Medicaid reimbursements for preventive dental care on use of tertiary oral health services.

METHODS

We used difference-in-differences models to compare the effect of a policy change among children (≤9 y) enrolled in Medicaid in Texas and Florida. Linear regression models estimated 4 outcomes: preventive care dental visit, dental sedation, emergency department use, and surgical event.

RESULTS

Increased preventive care visits led to increased sedation visits (1.7 percentage points, P < .001) and decreased emergency department visits (0.3 percentage points, P < .001) for children aged 9 years or younger. We saw no significant change in dental surgical rates associated with increased preventive dental care reimbursements.

CONCLUSION

Increased access to preventive dentistry was not associated with improved long-term oral health of Medicaid-enrolled children. Policies that aim to improve the oral health of children may increase the effectiveness of preventive dentistry by also targeting other social determinants of oral health.

A Case-Control Study of Fluoridation and Osteosarcoma

Public health policy decisions in the United States have resulted in 62.4% of the population having access to fluoridated water. The purpose of this study was to examine the association between community water fluoridation and osteosarcoma. A secondary data analysis was performed with data collected from 2 separate but linked studies. Patients for phase 1 and phase 2 were selected from US hospitals via a matched case-control study design. For both phases, cases included patients diagnosed with osteosarcoma, and controls were patients diagnosed with other bone tumors or nonneoplastic conditions. In phase 1, cases (n = 209) and controls (n = 440) were patients of record in the participating orthopedic departments from 1989 to 1993. In phase 2, cases (n = 108) and controls (n = 296) were incident patients who were identified and treated by orthopedic physicians from 1994 to 2000. This analysis included all patients who met eligibility criteria on whom we had complete data on covariates, exposures, and outcome. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% CIs for the association of community water fluoridation with osteosarcoma. A modestly significant interaction existed between fluoridation living status and bottled water use (P = 0.047). The adjusted OR for osteosarcoma and ever having lived in a fluoridated area for nonbottled water drinkers was 0.51 (95% CI, 0.31 to 0.84; P = 0.008). In the same comparison, the adjusted OR for bottled water drinkers was 1.86 (95% CI, 0.54 to 6.41; P = 0.326). Findings from this study demonstrated that community water fluoridation is not associated with an increased risk for osteosarcoma.

A Cross-Sectional Analysis of Community Water Fluoridation and Prevalence of Pediatric Dental Surgery Among Medicaid Enrollees

IMPORTANCE

Dental surgery under general anesthesia (DGA) is an ineffective, costly treatment for caries. Interventions to reduce the need for DGA are challenging because children's parents may not seek care until surgery is required. Community water fluoridation (CWF) effectively prevents early childhood caries, but its effectiveness in reducing severe early childhood caries is unknown.

OBJECTIVE

To determine whether access to CWF is associated with the prevalence of DGA.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional analysis of Medicaid claims data from 2011 to 2012. Deidentified data were derived from Medicaid claims and enrollee files for Massachusetts, Texas, Connecticut, Illinois, and Florida for children aged 9 years and younger enrolled in either a fee-for-service or managed care plan through their state's Medicaid program. Linear regression models tested for associations between CWF and covariates. Multivariable linear regression models tested for associations between CWF and outcomes. Regression models included clustered SEs at the county level. Data analysis was performed from December 2018 to March 2020.

EXPOSURES

Access to CWF was determined by estimating the proportion of a county's total population that had access to a fluoridated public water system.

MAIN OUTCOMES AND MEASURES

The main outcome was county-level DGA prevalence. Other outcomes were caries-related visit prevalence and patient quality indicators (asthma and diabetes). Covariates included county-level demographic, socioeconomic, and dental practitioner variables.

RESULTS

A total of 436 counties within 5 states per year (872 county-year observations), were included in the analysis. Adjusted analysis revealed that a 10% increase in the proportion of county's population access to CWF was associated with lower caries-related visit prevalence (-0.45 percentage points; 95% CI, -0.59 to -0.31 percentage points; P < .001). Increasing CWF access in 10% increments was associated with decreased DGA prevalence in unadjusted analysis (-0.39 percentage points; 95% CI, -0.67 to -0.12 percentage points; P = .006) but not in adjusted analysis (-0.23 percentage points; 95% CI, -0.49 to 0.02 percentage points; P = .07). Increasing the proportion of county's access to CWF by 10% was not associated with the prevalence of asthma-related exacerbations (-0.02 percentage points; 95% CI, -0.10 to 0.05 percentage points; P = .53) or diabetes-related exacerbations (-0.0003 percentage points; 95% CI, -0.0014 to 0.0009 percentage points; P = .66).

CONCLUSIONS AND RELEVANCE

This study extends our understanding of CWF's benefits for children's oral health. Specifically, these findings suggest that increasing a population's access to CWF's is associated with decreased caries-related visits and may also be associated with use of dental surgical services within high-risk populations.

Pediatric dental care use and parent- or caregiver-rated oral health among Alabama children enrolled in Medicaid

BACKGROUND

Reducing caries and improving access to dental care is a public health challenge. Understanding low use of dental care is of critical importance. This study estimated parent- or caregiver-reported prevalence and identified factors associated with children's dental care use, including the association with children's oral health.

METHODS

A cross-sectional analysis of children enrolled in Medicaid in Alabama, using data from the 2017 statewide Consumer Assessment of Healthcare Providers and Systems Health Plan Survey, was conducted. Associations were measured using adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) from logit regression and generalized linear model postestimation of least-squares means.

RESULTS

The 6-month prevalence of children receiving dental care was 70.4%. Children aged 0 through 3 years (aPR, 0.72; 95% CI, 0.53 to 0.91) had lower prevalence of care than other age groups. The prevalence of low-rated oral health was 9.2%. Low-rated oral health was associated with not receiving dental care (aPR, 1.50; 95% CI, 1.12 to 1.87) and parental education of 8th grade or less (aPR, 2.59; 95% CI, 1.20 to 3.98). Falsification tests determined that dental care use was not associated with ratings for overall health (aPR, 1.18; 95% CI, 0.83 to 1.52) or emotional health (aPR, 1.06; 95% CI, 0.79 to 1.33).

CONCLUSIONS

It was observed that children not receiving dental care had low-rated oral health; however, as a cross-sectional study, it was not possible to assess the temporality of this relationship.

PRACTICAL IMPLICATIONS

Oral health care providers should continue to recognize their role in educating parents and providing anticipatory guidance on children's oral health.

One-pot synthesis of Cr(III)-incorporated Zr(IV) oxide for fluoride remediation: a lab to field performance evaluation study

A low-cost Cr(III)-incorporated Zr(IV) bimetallic oxide (CZ) was synthesized by simple chemical precipitation method for removal of fluoride from contaminated water. The physicochemical properties of CZ before and after fluoride removal were established with several instrumental techniques such as TEM with elemental mapping, SEM with EDX, XRD, IR, XPS, zeta potential measurement, etc. Batch adsorption technique were carried out to understand the factors affecting fluoride adsorption, such as effects of initial pH, adsorbent dose, co-occurring ions, contact time, and temperature. The maximum adsorption capacity observed at pH between 5 and 7. The fluoride adsorption processes on CZ obeyed the pseudo-second-order rate equations and both Freundlich and DR isotherm models. The maximum adsorption capacity of 90.67 mg g^-1 was obtained. The thermodynamic parameters ΔH⁰ (positive), ΔS⁰ (positive), and ΔG⁰ (negative) indicating the fluoride sorption system was endothermic, spontaneous, and feasible. The CZ also successfully used as fluoride adsorbent for real field contaminated water collected from the Machatora district, Bankura, West Bengal, India. Graphical abstract Schematic representation of CZ synthesis and its application for lab as well as field water purification purpose.

Area-level deprivation, childhood dental ambulatory sensitive hospitalizations and community water fluoridation: evidence from New Zealand

Background

We examined the association between area-level deprivation and dental ambulatory sensitive hospitalizations (ASH) and considered the moderating effect of community water fluoridation (CWF). The hypothesis was that higher levels of deprivation are associated with higher dental ASH rates and that CWF will moderate this association such that children living in the most deprived areas have greater health gain from CWF.

Methods

Dental ASH conditions (dental caries and diseases of pulp/periapical tissues), age, gender and home address identifier (meshblock) were extracted from pooled cross-sectional data (Q3, 2011 to Q2, 2017) on children aged 0–4 and 5–12 years from the National Minimum Dataset, New Zealand (NZ) Ministry of Health. CWF was obtained for 2011 and 2016 from the NZ Institute of Environmental Science and Research. Dental ASH rates for children aged 0–4 and 5–12 years (/1000) were calculated for census area units (CAUs). Multilevel negative binomial models investigated associations between area-level deprivation, dental ASH rate and moderation by CWF status.

Results

Relative to CWF (2011 and 2016), no CWF (2011 and 2016) was associated with increased dental ASH rates in children aged 0–4 [incidence rate ratio (IRR) = 1.171 (95% confidence interval 1.064, 1.288)] and aged 5–12 years [IRR = 1.181 (1.084, 1.286)]. An interaction between area-level deprivation and CWF showed that the association between CWF and dental ASH rates was greatest within the most deprived quintile of children aged 0–4 years [IRR = 1.316 (1.052, 1.645)].

Conclusions

CWF was associated with a reduced dental ASH rate for children aged 0–4 and 5–12 years. Children living in the most deprived areas showed the greatest effect of CWF on dental ASH rates, indicating that the greater health gain from CWF occurred for those with the highest socio-economic disadvantage. Variation in CWF contributes to structural inequities in oral-health outcomes for children.

Principles of fluoride toxicity and the cellular response: a review

Fluoride is ubiquitously present throughout the world. It is released from minerals, magmatic gas, and industrial processing, and travels in the atmosphere and water. Exposure to low concentrations of fluoride increases overall oral health. Consequently, many countries add fluoride to their public water supply at 0.7-1.5 ppm. Exposure to high concentrations of fluoride, such as in a laboratory setting often exceeding 100 ppm, results in a wide array of toxicity phenotypes. This includes oxidative stress, organelle damage, and apoptosis in single cells, and skeletal and soft tissue damage in multicellular organisms. The mechanism of fluoride toxicity can be broadly attributed to four mechanisms: inhibition of proteins, organelle disruption, altered pH, and electrolyte imbalance. Recently, there has been renewed concern in the public sector as to whether fluoride is safe at the current exposure levels. In this review, we will focus on the impact of fluoride at the chemical, cellular, and multisystem level, as well as how organisms defend against fluoride. We also address public concerns about fluoride toxicity, including whether fluoride has a significant effect on neurodegeneration, diabetes, and the endocrine system.

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

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

Emulation of Community Water Fluoridation Coverage Across US Counties

INTRODUCTION

Expansion of community water fluoridation has stalled in the United States, leaving 115 million Americans without fluoridated drinking water.

OBJECTIVE

This study used spatial regression methods to assess contributions of supply-side factors (neighboring counties' fluoridation coverage) and demand-side factors (health literacy, education, and population density of the local county) in predicting the extent of fluoridation in US counties.

METHODS

For this cross-sectional ecological analysis, data from the 2014 Water Fluoridation Reporting System for all 3,135 US counties were merged with sociodemographic data from the 2014 American Community Survey and county-level estimates of health literacy based on the National Association of Adult Literacy Survey. We employed multilevel geographically weighted autoregressive models to predict fluoridation coverage of each county as a function of fluoridation coverage of neighboring counties and local-county covariates: either health literacy or sociodemographic characteristics. Akaike's Information Criterion was used to distinguish the better model in terms of explanatory power and parsimony.

RESULTS

In the best-fit model, an increase from the first to third quartile of neighboring counties' fluoridation coverage was associated with an increase of 27.76 percentage points (95% confidence limits [CI] = 27.71, 27.81) in a local county's fluoridation coverage, while an increase from the first to third quartile of local county's health literacy was associated with an increase of 2.8 percentage points (95% CL = 2.68, 2.89). The results are consistent with a process of emulation, in which counties implement fluoridation based upon their population's health literacy and the extent of fluoridation practiced in neighboring counties.

CONCLUSION

These results suggest that demand for community water fluoridation will increase as health literacy increases within a county. Furthermore, when considering expansion of fluoridation, non-fluoridated communities can benefit from precedents from nearby communities that are fluoridated.

KNOWLEDGE TRANSFER STATEMENT

Expanded coverage of community water fluoridation has stalled in the United States. The economic theory of diffusion describes how, over time and space, policy enacted in one community can influence public opinion in a neighboring community. This study applies geospatial analysis of county-level data and the theory of policy diffusion to demonstrate that fluoridated counties can promote the implementation of community water fluoridation in their neighboring, non-fluoridated communities.

EDX-analysis of fluoride precipitation on human enamel

One mechanism of action for the anticaries effect of topical fluoridation is through precipitation of CaF₂. In this in vitro study energy-dispersive x-ray spectroscopy (EDX) is used as a semiquantitative method to detect enamel fluoride-precipitation under the influence of acidic and neutral pH-value and absence or presence of a salivary pellicle. Crowns of 30 human caries-free third molars were quartered into four specimens and the enamel surface ground flat and polished. Two specimens each were stored in human saliva (120 minutes pellicle formation). Teeth were randomly allocated into 6 treatment groups: NaF_a (experimental acidic sodium fluoride; 12500 ppmF⁻, pH 4.75); NaF_n (experimental neutral sodium fluoride; 12500 ppmF⁻, pH 7.0); GB_a (acidic gel base; 0 ppmF⁻, pH 4.75); GB_n (neutral gel base; 0 ppmF⁻, pH 7.0); AmF-NaF_a (experimental acidic amine/sodium fluoride; 12500 ppmF⁻, pH 4.75); EG_a (acidic amine/sodium fluoride; Elmex Geleé, CP-GABA GmbH; 12500 ppmF⁻, pH 4.75). Each gel was applied for 60 seconds to one specimen with and one specimen without pellicle. Two specimens served as controls (no gel, without/with pellicle). Atomic percent (At%) of O, F, Na, Mg, P, Ca was measured by EDX. ∆At% and Ca/P-ratios were calculated. EDX could semi-quantify superficial enamel fluoride-precipitation. Only specimens treated with acidic fluoride gels showed fluoride-precipitation, a salivary pellicle tended to decrease At%F.

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.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Fluoride Dentifrice Overcomes the Lower Resistance of Fluorotic Enamel to Demineralization

We evaluated if the low resistance of fluorotic enamel to demineralization could be overcome by fluoride dentifrice (FD) treatment. Paired enamel slabs of sound and fluorotic enamel (n = 20/group) from human teeth presenting Thylstrup and Fejerskov index (TF) scores from 0 to 4 were obtained. Half of the anatomic surface of the enamel slabs was isolated and used as a control (baseline) regarding enamel mineralization and fluoride concentration. The slabs were submitted to a pH-cycling model simulating a high cariogenic challenge, and 2×/day they were treated with placebo dentifrice (PD) or FD (1,100 µg F/g, as NaF). After 10 days, the slabs were cut into two halves. Enamel demineralization was evaluated by cross-sectional microhardness in one half, and the fluoride formed (FF) concentration was determined in the other half. For statistical analysis, the data on net demineralization area (ΔΔS) and FF (µg F/g) were grouped into TF0, TF1-2, and TF3-4, and analyzed by two-way ANOVA followed by Tukey's test (α = 5%). The factors studied were TF (0, 1-2, and 3-4) and dentifrice treatment (PD or FD). The effect of the factors was statistically significant for ΔΔS and FF (p < 0.05). In the PD group, the following pattern for ΔΔS was observed: TF3-4 > TF1-2 > TF0 (p < 0.05); however, the groups did not differ (p > 0.05) when FD was used. Regarding FF, the groups treated with PD did not differ (p > 0.05), but the greatest (p < 0.05) FF concentration was found in group TF3-4 treated with FD. These findings suggest that the higher susceptibility of fluorotic enamel to demineralization lesions is decreased by the use of FD.

Association Between Water Fluoridation and Income-Related Dental Caries of US Children and Adolescents

This cohort study examines the incidence of dental caries in children and adolescents of varying income levels living in areas with vs without water fluoridation.