Effects of fluoridated drinking water on dental caries in Australian adults

Effect of fluoridated water on invasive NHS dental treatments for adults: the LOTUS retrospective cohort study and economic evaluation

Background

Most water fluoridation studies were conducted on children before the widespread introduction of fluoride toothpastes. There is a lack of evidence that can be applied to contemporary populations, particularly adolescents and adults.

Objective

To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults, using a natural experiment design.

Design

Retrospective cohort study using routinely collected National Health Service dental claims (FP17) data.

Setting

National Health Service primary dental care: general dental practices, prisons, community dental services, domiciliary settings, urgent/out-of-hours and specialised referral-only services.

Participants

Dental patients aged 12 years and over living in England (n = 6,370,280).

Intervention and comparison

Individuals exposed to drinking water with a fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were matched to non-exposed individuals on key characteristics using propensity scores.

Outcome measures

Primary: number of National Health Service invasive dental treatments (restorations/'fillings' and extractions) received per person between 2010 and 2020. Secondary: decayed, missing and filled teeth, missing teeth, inequalities, cost effectiveness and return on investment.

Data sources

National Health Service Business Services Authority dental claims data. Water quality monitoring data.

Primary outcome

Predicted mean number of invasive dental treatments was 3% lower in the optimally fluoridated group than in the sub/non-optimally fluoridated group (incidence rate ratio 0.969, 95% CI 0.967 to 0.971), a difference of -0.173 invasive dental treatments (95% CI -0.185 to -0.161). This magnitude of effect is smaller than what most stakeholders we engaged with (n = 50/54) considered meaningful.

Secondary outcomes

Mean decayed, missing and filled teeth were 2% lower in the optimally fluoridated group, with a difference of -0.212 decayed, missing and filled teeth (95% CI -0.229 to -0.194). There was no statistically significant difference in the mean number of missing teeth per person (0.006, 95% CI -0.008 to 0.021). There was no compelling evidence that water fluoridation reduced social inequalities in treatments received or missing teeth; however, decayed, missing and filled teeth data did not demonstrate a typical inequalities gradient. Optimal water fluoridation in England in 2010-20 was estimated to cost £10.30 per person (excluding original setup costs). Mean National Health Service treatment costs for fluoridated patients 2010-20 were 5.5% lower per person, by £22.26 (95% CI -£23.09 to -£21.43), and patients paid £7.64 less in National Health Service dental charges per person (2020 prices).

Limitations

Pragmatic, observational study with potential for non-differential errors of misclassification in fluoridation assignment and outcome measurement and residual and/or unmeasured confounding. Decayed, missing and filled teeth data have not been validated. Water fluoridation cost estimates are based on existing programmes between 2010 and 2020, and therefore do not include the potentially significant capital investment required for new programmes.

Conclusions

Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects, which may not be meaningful for individuals, and we could find no evidence of a reduction in social inequalities. Existing water fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower National Health Service treatment costs. These relatively small savings should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes.

Future work

National Health Service dental data are a valuable resource for research. Further validation and measures to improve quality and completeness are warranted.

Trial registrations

This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Water fluoridation in Australia: A systematic review

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

Genes and single nucleotide polymorphisms in the pathway of saliva and dental caries: a systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to investigate the influence of single nucleotide polymorphisms (SNPs), related to genes in salivary composition and flow, on dental caries experience. Sixteen studies were included in the systematic review and ten in the meta-analysis. Forty-four SNPS, covering four genes (CA6, AQP2, AQP5, and MUC5B) were identified. Most of the SNPs were not associated with caries in meta-analysis. Homozygous TT genotype of the SNP CA6 rs17032907(C/T) was associated with caries [OR = 3.23(1.39-7.49)]. The pool effect of the SNPs assessed in AQP5 was associated with a reduction in the likelihood of caries [OR = 0.75(0.59-0.95)]. Considering all SNPs of salivary composition and flow, the effect allele was associated with a 75% increase in the likelihood of caries [OR = 1.75(1.06-2.89)] in the homozygous genotype. The present findings showed that the genes in salivary composition and flow can play an important role in dental caries experience.

FOK l Vitamin D Receptor Gene Polymorphism and Risk of Dental Caries: A Case-Control Study

The prevalence of dental caries in individuals who practice good oral hygiene increasingly indicates that other etiological factors, such as genetic factors, may be responsible for occurrence of caries, and its prevalence in younger individuals, such as adolescents, is an early manifestation of their genetic makeup. Therefore, there is a need to investigate the correlation of various genetic factors with the occurrence of dental caries in populations. Thus, this study assessed the relationship between single nucleotide polymorphism (rs2228570) in the vitamin D receptor gene and dental caries susceptibility. After obtaining ethical approval (NU/CEC/2020/0339), 377 adults, aged 18–40 years, were included in this study. Among the participants consenting to participate, salivary samples were collected, and an oral examination was conducted using the World Health Care Oral Health Survey Format 2013. The DMFT and PUFA index scores were recorded along with basic demographic details. The subjects were categorized as caries-free (controls, DMFT = 0) and caries-active (cases). The case group was further divided into the high-risk group (DMFT ≤ 10), moderate-risk group (DMFT = 4–9), and low-risk group (DMFT = 1–3). Saliva samples were used for vitamin D level analysis and DNA isolation. Polymerase chain reaction-based restriction fragment length polymorphism analysis using Fok1 digestion was performed on the isolated DNA. Salivary vitamin D levels were markedly higher in the caries-free group than in the caries-active group (p < 0.001). The T allele of rs2228570 was significantly associated with having active caries, while the C allele was associated with being caries-free. Individuals with the rs2228570 TC genotype had 2.814-fold increased likelihood, and individuals with the TT genotype had 3.116- fold increased likelihood of being caries-active. This finding is important in terms of patient counselling, as well as possibly in terms of prevention and treatment of caries.

A study of the association between psychiatric symptoms and oral health outcomes in a population-based birth cohort at 30-year-old follow-up

OBJECTIVE

Most studies of the association between psychiatric disorders and poor oral health have been conducted in clinical settings. Where available, data from community surveys have generally been cross-sectional or considered anxiety and depression as a consequence of poor oral health, not the other way round. This study therefore used a birth cohort to assess the association of mental health, measured both cross-sectionally and longitudinally, and oral health at 30-year follow-up.

METHODS

There were 2456 adults with data on dental outcomes and oral health care at 30-year follow-up. Psychiatric morbidity was measured at both 21- and 30-year follow-up using standardised instruments including the Centre for Epidemiological Studies-Depression (CES-D) scale and Composite International Diagnostic Interview (CIDI).

RESULTS

At follow-up, 850 participants (34.6%) had undergone a dental extraction for infection or decay, and 810 had experienced significant dental pain over their lifetime. One third had not visited a dental clinic in the previous two years and 40% failed to brush their teeth at least twice daily. On adjusted analyses, dental extraction and pain were significantly associated with psychiatric morbidity cross-sectionally at 30-year follow-up and also longitudinally when psychiatric symptoms were present at both 21 and 30 years old. Several cross-sectional measures of psychiatric morbidity were also associated with frequency of tooth brushing. There were no associations with dental clinic visits.

CONCLUSIONS

The study demonstrates there are associations between oral and mental health, which are not limited to clinical settings, but were observed at a population level.

Maintaining Good Oral Health With Fluoridated Water

Community water fluoridation (CWF) has been a public health measure against tooth decay since 1945. Strong evidence supports the use of CWF in reduction in caries risk in the pediatric population, and numerous studies also show benefit in adults. CWF remains an important contributor to oral health despite the availability and widespread use of other fluoride-containing dental products. The efficacy, safety, and optimal use of CWF will be discussed.

Dental caries in wild primates: Interproximal cavities on anterior teeth

Dental caries has been reported in a variety of primates, although it is still considered rare in wild populations. In this study, 11 catarrhine primate taxa (n = 339 individuals; 7946 teeth) were studied for the presence of caries. A differential diagnosis of lesions in interproximal regions of anterior teeth was undertaken, since they had been previously described as both carious and non-carious in origin. Each permanent tooth was examined macroscopically, with severity and position of lesions recorded. Two specimens were examined further, using micro-CT scans to assess demineralization. Differential diagnosis confirmed the cariogenic nature of interproximal cavities on anterior teeth (ICATs). Overall results show 3.3% of all teeth (i.e., anterior and posterior teeth combined) were carious (n = 262), with prevalence varying among species from 0% to >7% of teeth affected. Those with the highest prevalence of ICATs include Pan troglodytes verus (9.8% of anterior teeth), Gorilla gorilla gorilla (2.6%), Cercopithecus denti (22.4%), Presbytis femoralis (19.5%), and Cercopithecus mitis (18.3%). ICATs make up 87.9% of carious lesions on anterior teeth. These results likely reflect dietary and food processing differences among species, but also between the sexes (e.g., 9.3% of all female P. troglodytes verus teeth were carious vs. 1.8% in males). Processing cariogenic fruits and seeds with the anterior dentition (e.g., wadging) likely contributes to ICAT formation. Further research is needed in living primate populations to ascertain behavioral/dietary influences on caries occurrence. Given the presence of ICATs in frugivorous primates, their diagnosis in archaeological and paleontological specimens may shed light on diet and food processing behaviors in fossil primates.

Age period cohort analysis of chewing ability in Korea from 2007 to 2018

There have been marked improvements in oral health in Korea during the past 10 years, including chewing ability. We sought to disentangle age, period, and cohort effects in chewing ability between 2007 and 2018. We analyzed data from the Korea National Health and Nutrition Examination Survey. The main variable was chewing difficulty, which was assessed among participants aged 20 years and older. APC analysis revealed three trends in chewing difficulty: (1) there was an increase in chewing difficulty starting at around 60 years of age (age effect), (2) there was a steady decrease in chewing difficulty during the observation period (period effect), and (3) chewing ability improved with each successive generation born after 1951 (cohort effect). Regarding recent improvements in chewing ability, cohort effects were somewhat more important than period effects.

Fluoride in the drinking water and dental caries experience by tooth surface susceptibility among adults

Background

Dental caries is the most prevalent non-communicable health condition globally. The surface-based susceptibility hierarchy indicates that surfaces in the same group have similar susceptibility to caries, where the most susceptible group consists of occlusal surfaces of first molars and buccal surfaces of lower first molars, and the least susceptible surfaces are smooth and proximal surfaces of first premolars, canines and incisors. Therefore, fluoride in the drinking water could impact one group more than the other group. The present study examined the association between fluoride levels in the drinking water and dental caries experience in adults in the context of varying tooth surface susceptibility.

Methods

Data from the cross-sectional National Lithuanian Oral Health Survey conducted in 2017–2019 included a stratified random sample of 1398 35–74-year-olds (52% response rate). Dental caries experience in dentine was measured at a surface level. The surfaces were grouped according to their caries susceptibility (group 1 being the most and group 4 the least susceptible), and dental caries experience was calculated separately for each susceptibility group, creating four outcomes. Information about explanatory variable, fluoride levels in the drinking water, was provided by the water suppliers. The questionnaire inquired about potential determinants: sociodemographic characteristics and oral health-related behaviors. Chi-square, Mann–Whitney U and Kruskal Wallis tests were used for descriptive statistics, and linear regression analyses to examine the association between fluoride levels and four outcomes.

Results

The proportions of median decayed, missing, filled surfaces decreased following the surface-based susceptibility hierarchy (group 1–33%, group 2–28%, group 3–24%, group 4–15%). When adjusted for potential determinants, higher-level fluoride (≥ 0.7 ppm vs < 0.7 ppm) in the drinking water associated with lower dental caries experience in all surface-based susceptibility hierarchy groups; Group 1: β = − 0.23 (95 %CI − 0.44; − 0.001), Group 2: β = − 0.44 (95 %CI − 0.82; − 0.07), Group 3: β = − 1.14 (95 %CI − 1.88; − 0.41) and Group 4: β = − 6.28 (95 %CI − 9.29; − 3.30).

Conclusions

The higher-level fluoride in the drinking water associated with lower dental caries experience in adults and this was observed in all surface-based susceptibility groups. However, there is a need to validate the surface-based susceptibility hierarchy in longitudinal adult studies.

Dental caries in South African fossil hominins

Once considered rare in fossil hominins, caries has recently been reported in several hominin species, requiring a new assessment of this condition during human evolution. Caries prevalence and location on the teeth of South African fossil hominins were observed and compared with published data from other hominin samples. Teeth were viewed macroscopically, with lesion position and severity noted and described. For all South African fossil hominin specimens studied to date, a total of 10 carious teeth (14 lesions), including 4 described for the first time here, have been observed. These carious teeth were found in a minimum of seven individuals, including five Paranthropus robustus, one early Homo, and one Homo naledi. All 14 lesions affected posterior teeth. The results suggest cariogenic biofilms and foods may have been present in the oral environment of a wide variety of hominins. Caries prevalence in studied fossil hominins is similar to those in pre-agricultural human groups, in which 1–5% of teeth are typically affected.

How effective and cost-effective is water fluoridation for adults? Protocol for a 10-year retrospective cohort study

BACKGROUND

Tooth decay can cause pain, sleepless nights and loss of productive workdays. Fluoridation of drinking water was identified in the 1940s as a cost-effective method of prevention. In the mid-1970s, fluoride toothpastes became widely available. Since then, in high-income countries the prevalence of tooth decay in children has reduced whilst natural tooth retention in older age groups has increased. Most water fluoridation research was carried out before these dramatic changes in fluoride availability and oral health. Furthermore, there is a paucity of evidence in adults. The aim of this study is to assess the clinical and cost-effectiveness of water fluoridation in preventing invasive dental treatment in adults and adolescents aged over 12.

METHODS/DESIGN

Retrospective cohort study using 10 years of routinely available dental treatment data. Individuals exposed to water fluoridation will be identified by sampled water fluoride concentration linked to place of residence. Outcomes will be based on the number of invasive dental treatments received per participant (fillings, extractions, root canal treatments). A generalised linear model with clustering by local authority area will be used for analysis. The model will include area level propensity scores and individual-level covariates. The economic evaluation will focus on (1) cost-effectiveness as assessed by the water fluoridation mean cost per invasive treatment avoided and (2) a return on investment from the public sector perspective, capturing the change in cost of dental service utilisation resulting from investment in water fluoridation.

DISCUSSIONS

There is a well-recognised need for contemporary evidence regarding the effectiveness and cost-effectiveness of water fluoridation, particularly for adults. The absence of such evidence for all age groups may lead to an underestimation of the potential benefits of a population-wide, rather than targeted, fluoride delivery programme. This study will utilise a pragmatic design to address the information needs of policy makers in a timely manner.

The Concept of Sustainable Development of Modern Dentistry

This paper concerns the assessment of the current state of dentistry in the world and the prospects of its sustainable development. A traditional Chinese censer was adopted as the pattern, with a strong and stable support on three legs. The dominant diseases of the oral cavity are caries and periodontal diseases, with the inevitable consequence of toothlessness. From the caries 3.5–5 billion people suffer. Moreover, each of these diseases has a wide influence on the development of systemic complications. The territorial range of these diseases and their significant differentiation in severity in different countries and their impact on disability-adjusted life years index are presented (DALY). Edentulousness has a significant impact on the oral health-related quality of life (OHRQoL). The etiology of these diseases is presented, as well as the preventive and therapeutic strategies undertaken as a result of modifying the Deming circle through the fives’ rules idea. The state of development of Dentistry 4.0 is an element of the current stage of the industrial revolution Industry 4.0 and the great achievements of modern dental engineering. Dental treatment examples from the authors’ own clinical practice are given. The systemic safety of a huge number of dentists in the world is discussed, in place of the passive strategy of using more and more advanced personal protective equipment (PPE), introducing our own strategy for the active prevention of the spread of pathogenic microorganisms, including SARS-CoV-2. The ethical aspects of dentists’ activity towards their own patients and the ethical obligations of the dentist community towards society are discussed in detail. This paper is a polemic arguing against the view presented by a group of eminent specialists in the middle of last year in The Lancet. It is impossible to disagree with these views when it comes to waiting for egalitarianism in dental care, increasing the scope of prevention and eliminating discrimination in this area on the basis of scarcity and poverty. The views on the discrimination of dentistry in relation to other branches of medicine are far more debatable. Therefore, relevant world statistics for other branches of medicine are presented. The authors of this paper do not agree with the thesis that interventional dental treatment can be replaced with properly implemented prophylaxis. The final remarks, therefore, present a discussion of the prospects for the development of dentistry based on three pillars, analogous to the traditional Chinese censer obtaining a stable balance thanks to its three legs. The Dentistry Sustainable Development (DSD) > 2020 model, consisting of Global Dental Prevention (GDP), Advanced Interventionist Dentistry 4.0 (AID 4.0), and Dentistry Safety System (DSS), is presented.

Genes in the pathway of tooth mineral tissues and dental caries risk: a systematic review and meta-analysis

OBJECTIVES

To perform a systematic review of the literature, investigating the influence of tooth mineral tissues genes on dental caries.

MATERIALS AND METHODS

Five databases were searched. Only human studies with cross-sectional, longitudinal, and case-control design were included. Meta-analysis was performed for each polymorphism, providing allele and genotype estimates. A meta-analysis was performed, pooling several polymorphisms for each gene. A Funnel Plot and Egger's test were also performed.

RESULTS

A total of 1124 records were found. Of these, 25 papers were included in the systematic review and 18 in the meta-analysis. Most of the studies (52%) were of medium quality. With regard to the allele analysis, the T allele of rs134136 (TFIP11) (OR 1.51; 95%CI 1.02-2.22) showed an association with high experience of caries and the summarization of polymorphisms investigated in the TFIP11 gene, after exclusion of SNP linkage disequilibrium, showed an association with caries experience (OR 1.64; 95%CI 1.08-2.50). An analysis of the homozygous genotype did not show any significant association. The pooled SNPs of AMBN showed associations with caries (OR 0.45; 95%CI 0.29-0.72). The pooled polymorphisms of AMELX were associated with caries experience (OR 1.78; 95%CI 1.23-2.56). In the analysis of the homozygous genotype, no SNP showed a significant association. Egger's test showed no significant publication bias for all models (p > 0.05).

CONCLUSION

The present findings showed that the genes TFIP11, AMBN, and AMELX play an important role in dental caries.

CLINICAL RELEVANCE

Several single nucleotide polymorphisms related to the genes in the formation of tooth mineral are linked to the occurrence of dental caries, and these genes have proved to be important for an explanation of differences in the risk of dental caries.

The Psychological Models of Health-related Behavior in Understanding Sugars Intake in Adults: A Review

Free sugars intake plays a major role in dental caries formation and other general health issues such as obesity. Therefore, interventions, which assist individuals or populations in the control of their free sugars intake, are of central importance in caries prevention strategies. There is good evidence that behavioral interventions benefit from a foundation in conceptual theories of behavior change founded on empirical data. In this review, we discuss the future application of seven theories, including six common psychological theories in predicting and developing interventions to reduce free sugars intake related to dental caries among adults. For each model, we summarize its key features and the data derived from its application in general and oral health settings and make recommendations for future research. We searched Medline, PsycINFO, Global Health, PubMed, and Embase databases to identify items dealing with dental caries, adults, sugars intake, and six psychological theories. These included the Transtheoretical Model of Change, Theory of Planned Behavior, Social Cognitive Theory, Information-Motivation-Behavioral Skills model, PRIME Theory, and Behavior Change Wheel theories. We searched literature published in the last 10 years, and priority was given to systematic reviews and randomized control trials. Although there is extensive literature on the application of the six psychological theories, there is a gap in knowledge about their effectiveness in reducing free sugars intake related to dental caries among adults. There is a need for better-designed trials of interventions based on the clear operationalization of psychological constructs to reduce sugars intake among the adult population.

Risk Factors Associated with Carious Lesions in Permanent First Molars in Children: A Seven-Year Retrospective Cohort Study

The aim of this study was to evaluate the risk factors associated with the occurrence of caries in permanent teeth (PT) and in the permanent first molar (PFM) seven years after their eruption. Children born in 2005 who were enrolled in a Community Dental Program were included. A total of 278 children were enrolled. Evaluated risk factors were parental caries experience, educational level of the mother, routine medications, systemic diseases, dietary habits, toothbrushing frequency, existence of molar incisor hypomineralization (MIH) in the PT, and caries in the temporary teeth (TT). Associations between independent variables and the DMF-T (decayed, missing, and filled teeth in PT) and DMF-M (DMF in PFM) indices, only considering cavitated and non-cavitated carious lesions or cavitated carious lesions as outcomes, were evaluated by Poisson regression with robust variance analysis. A cariogenic diet (sweets and soft drinks), toothbrushing frequency of <1 a day, a presence of df-t (decayed and filled temporary teeth) score of >0, low educational level of the mother, and existence of MIH were associated with high DMF-T or DMF-M values (p < 0.05). We can conclude that the intake of sweets and soft drinks, toothbrushing frequency, the presence of caries in TT, and MIH in PT were the best predictors of the occurrence of caries in PT and PFM.

Long-term variability in artificially and naturally fluoridated water supplies in England

OBJECTIVES

To understand the potential impact of exposure misclassification on water fluoridation studies in England, this paper aims to describe the long-term variation in water fluoride concentrations in both artificially and naturally fluoridated water supplies.

METHODS

Water fluoridation dose monitoring data were requested from all five English public water suppliers who artificially fluoridate their water, as well as from one water company that supplies naturally fluoridated water. Descriptive statistics were calculated, including annual means, standard deviations, minimum-maximum and absolute and relative frequencies.

RESULTS

Data were made available by two of the five English water companies who supply artificially fluoridated water and one water company that supplies naturally fluoridated water (40 398 individual samples). The data for fluoridated water spanned 18-35 years, whilst the data on naturally fluoridated water spanned 14 years. The artificially fluoridated samples showed wide variation in fluoride dose control, both between different water treatment works and over time. Mean fluoride concentrations in the artificially fluoridated supplies ranged from 0.53 (SD 0.47) to 0.93 (SD 0.22) mg F/L and were within the optimal range of 0.7-1.0 mg F/L in 27.7%-77.8% of samples. The naturally fluoridated supplies had a higher mean fluoride concentration of 1.06 (SD 0.18) and 1.15 (SD 0.16) mg F/L than the artificially fluoridated supplies, with lower variation over time. The naturally fluoridated supplies were above the optimal range in 75.5% and 53% of samples.

CONCLUSIONS

Assumptions that populations living in areas with a water fluoridation scheme have received optimally fluoridated water (0.7-1.0 mg F/L) are invalid. To support future research endeavours, as well as to provide 'external control' and facilitation of optimal dosing, it is recommended that a quarterly record of water fluoride concentrations (mean, standard deviation and minimum and maximum) are made available for every water supply in England, in a format that can be mapped against residential postcodes.

"Setting the scene in early childhood" - an MID approach for life

This article presents a discussion paper for both consideration and implementation of Minimal Intervention Dentistry (MID) principles by the general dental practitioner. It argues that if these concepts can be adopted in early childhood by both the community and the profession, "Teeth for Life" can become a reality for all. Oral Health promoting behaviours can be nurtured and supported from infancy and developed into everyday living practice for a lifetime thereby maintaining an optimal quality of life. MID techniques have become more refined and supported by scientific research in the recent times and should be considered an essential clinical guideline for the future disease management.

Reduction of Dental Caries Among Children and Adolescents From a 15-Year Community Water Fluoridation Program in a Township Area, Korea

Since 2000, a community water fluoridation program (CWFP) has been implemented in Hapcheon for over 15 years. We aimed to evaluate the caries-reducing effect on permanent teeth after this implementation. In 2015, evaluation surveys were conducted by our study group, 498 subjects aged 8, 10, 12, and 15 years. As the control, 952 similarly aged subjects were selected from the Sixth Korean National Health and Nutrition Examination Survey (2013-2015 KNHANES). Data of a prospective cohort of 671 8-,10- and 12-year-olds, collected when CWFP started, were used for the evaluation. Caries-reducing effects were estimated by decayed, missing and filled teeth (DMFT) scores between CWFP and control groups, pre- and post-program. Confounders including the mean number of sealant teeth and gender were adjusted for. The mean adjusted DMFT scores of 10-, 12- and 15-year-olds in Hapcheon were significantly lower compared to KNHANES DMFT scores; in addition, those of 8-, 10- and 12-year-olds after the 15-year CWFP were significantly lower than in 2000. The caries-reducing effect among 12-year-olds was 37.6% compared to those recorded in KNHANES, and 67.4% compared to those in 2000. In conclusion, the caries-reducing effect was so high that health policy makers should consider CWFP as a priority policy for caries-reducing in Korean children and adolescents.

Oral Development and Pathology

Background

The mouth is integral in the development of feeding, the initiation of digestion, and for speech and socialization. Signs of systemic disease and nutritional deficiencies often manifest in the mouth, and poor oral health can exacerbate many systemic conditions.

Methods

This review addresses the fetal development of the mouth, major anomalies, common minor physical findings, and pathologic conditions and their management.

Results

Pediatric practitioners have historically been poorly trained in diagnosis and management of oral conditions, so this article provides an overview of oral embryology and pathology, with a focus on hard and soft tissue disease identification, triage, and management. For primary prevention to be effective, pediatric providers must be knowledgeable about the process of dental caries, prevention of the disease, and available interventions, including fluoride.

Conclusion

The embryology and anatomy of the oral cavity are complex, and the mouth is crucial to many physiologic processes. Pediatric primary care providers are uniquely positioned to prevent, identify, and triage dental caries, the most common chronic disease of childhood.

Dental conditions associated with preventable hospital admissions in Australia: a systematic literature review

Background

Over the past two decades, there has been a decrease in dental diseases in Australia; however, the number of preventable dental hospital admissions has not diminished. This review reports on the factors associated with preventable dental hospital admissions in Australia.

Methods

A search of five databases was conducted using Medical subject headings/Emtree terms and Index terms. All original studies, published between January1965 and March 2018 in English, based on the Australian population, and examining the prevalence of oral conditions as a cause for emergency department presentations and hospital admissions were included. The mixed method appraisal tool was used to evaluate the included studies.

Results

Eleven cross-sectional studies met inclusion and exclusion criteria. All the studies, except one from Tasmania, were from Western Australia. The most common reasons for preventable dental hospital admissions were dental caries, followed by embedded or impacted teeth. Malignant neoplasms were reported as main causes of preventable dental hospital admissions in the older population.

Conclusions

Most studies on preventable dental hospital admissions were from one Australian state (Western Australia). Further research is required to determine the national prevalence and incidence of preventable dental hospital admissions. A periodic audit of preventable dental hospital admission data is needed for delivery of a fair and effective dental services.

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

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

A survey of cariology teaching in Australia and New Zealand

BACKGROUND

The Australian and New Zealand chapter of the Alliance for a Cavity Free Future was launched in 2013 and one of its primary aims was to conduct a survey of the local learning and teaching of cariology in dentistry and oral health therapy programs.

METHODS

A questionnaire was developed using the framework of the European Organisation for Caries Research (ORCA)/Association of Dental Education in Europe (ADEE) cariology survey conducted in Europe in 2009. The questionnaire was comprised of multiple choice and open-ended questions exploring many aspects of the cariology teaching. The survey was distributed to the cariology curriculum coordinator of each of the 21 programs across Australia and New Zealand via Survey Monkey in January 2015. Simple analysis of results was carried out with frequencies and average numbers of hours collated and open-ended responses collected and compiled into tables.

RESULTS

Seventeen responses from a total of 21 programs had been received including 7 Dentistry and 10 Oral Health programs. Key findings from the survey were - one quarter of respondents indicated that cariology was identified as a specific discipline with their course and 41% had a cariology curriculum in written format. With regard to lesion detection and caries diagnosis, all of the program coordinators who responded indicated that visual/tactile methods and radiographic interpretation were recommended with ICDAS also being used by over half them. Despite all respondents teaching early caries lesion management centred on prevention and remineralisation, many taught operative intervention at an earlier stage of lesion depth than current evidence supports. Findings showed over 40% of respondents still teach operative intervention for lesions confined to enamel.

CONCLUSION

Despite modern theoretical concepts of cariology being taught in Australia and New Zealand, they do not appear to be fully translated into clinical teaching at the present time.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors related to reducing free sugar intake among white ethnic adults in the UK: a qualitative study

Objective/Aims:

To determine the barriers and enablers to behavioural change to reduce free sugar intake related to dental caries in a sample of UK adults who identify their ethnicity as White.

Materials and methods:

Qualitative study comprising semi-structured interviews of 27 participants. Interviews were recorded, transcribed and analysed using thematic analysis methods. The Capability-Opportunity-Motivation-Behaviour model (COM-B) and the Theoretical Domains Framework (TDF) were used to guide the derivation of themes.

Results:

Data saturation occurred at 27 interviews. The COM-B Model and TDF domains captured various factors that may influence the consumption of free sugar. TDF elements which are reflected in the study are: Knowledge; Psychological skills; Memory, attention, and decision processes; Behavioural regulation; Physical skills; Social influence; Environmental context and resources; Social and professional role and identity; Beliefs about capabilities; Beliefs about consequence; Intentions and goals reinforcement; and Emotions. COM-B Model elements which are reflected in the study are: psychological capabilities, physical capabilities, social opportunities, physical opportunities, reflective motivation, and automatic motivation.

Discussion and conclusion:

The COM-B model and TDF framework provided a comprehensive account of the barriers and facilitators of reducing sugar intake among white ethnic groups.

The costs and benefits of water fluoridation in NZ

BACKGROUND

Implementing community water fluoridation involves costs, but these need to be considered against the likely benefits. We aimed to assess the cost-benefit and cost-effectiveness of water fluoridation in New Zealand (NZ) in terms of expenditure and quality-adjusted life years.

METHODS

Based on published studies, we determined the risk reduction effects of fluoridation, we quantified its health benefits using standardised dental indexes, and we calculated financial savings from averted treatment. We analysed NZ water supplies to estimate the financial costs of fluoridation. We devised a method to represent dental caries experience in quality-adjusted life years.

RESULTS

Over 20 years, the net discounted saving from adding fluoride to reticulated water supplies supplying populations over 500 would be NZ$1401 million, a nine times pay-off. Between 8800 and 13,700 quality-adjusted life years would be gained. While fluoridating reticulated water supplies for large communities is cost-effective, it is unlikely to be so with populations smaller than 500.

CONCLUSIONS

Community water fluoridation remains highly cost-effective for all but very small communities. The health benefits-while (on average) small per person-add up to a substantial reduction in the national disease burden across all ethnic and socioeconomic groups.

Variation in Enamel Formation Genes Influences Enamel Demineralization In Vitro in a Streptococcus mutans Biofilm Model

Genetic studies have shown that variations in enamel formation genes are associated with caries susceptibility. The aim of this study was to test in vitro whether variants in these genes are associated with dental enamel demineralization in a Streptococcus mutans biofilm model. DNA and enamel samples were obtained from 213 individuals. DNA was extracted from saliva, and 16 single nucleotide polymorphisms were analyzed. The physical and chemical properties of sound enamel samples and the mineral loss and the lesion depth of the demineralized enamel samples under cariogenic challenge were analyzed. Microhardness, enamel chemicals, mineral loss and demineralization depth were compared between different genotypes at each single nucleotide polymorphism. The GG genotype of TUFT1 (rs17640579) and the GT genotype of MMP20 (rs1612069) exhibited increased microhardness (p = 0.044 and 0.016, respectively). The GG genotype of AMBN (rs7694409) had a higher magnesium level, while the CT genotype of TFIP11 (rs2097470) had a lower magnesium level (p = 0.044 and 0.046, respectively). The GT genotype of MMP20 (rs1612069) had a higher calcium level (p = 0.034). The GG genotype of AMBN (rs13115627), the AG genotype of ENAM (rs12640848) and the AA genotype of MMP20 (rs2292730) had a lower phosphorus level (p = 0.012, 0.006, and 0.023, respectively). The GG genotype of AMBN (rs13115627) was also associated with a higher calcium-phosphorus ratio (p = 0.034). Individuals with the CC genotype of TFIP11 (rs134143) exhibited significantly more mineral loss (p = 0.011) and a deeper lesions (p = 0.042). Individuals with the TT genotype of TFIP11 (rs2097470) had more mineral loss (p = 0.018). Individuals with the GG genotype of TUFT1 (rs17640579) exhibited a shallower demineralization depth (p = 0.047). Individuals with the GT genotype of MMP20 (rs1612069) exhibited a shallower demineralization depth (p = 0.042). Individuals with the GG genotype of ENAM (rs12640848) exhibited less mineral loss (p = 0.01) and a shallower demineralization depth (p = 0.03). Genetic variations in TFIP11, TUFT1, MMP20, and ENAM influenced enamel demineralization in a Streptococcus mutans biofilm model.

Critique of the review of 'Water fluoridation for the prevention of dental caries' published by the Cochrane Collaboration in 2015

The Cochrane Review on water fluoridation for the prevention of dental caries was published in 2015 and attracted considerable interest and comment, especially in countries with extensive water fluoridation programmes. The Review had two objectives: (i) to evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries, and (ii) to evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis. The authors concluded, inter alia, that there was very little contemporary evidence, meeting the Review's inclusion criteria, that evaluated the effectiveness of water fluoridation for the prevention of dental caries. The purpose of this critique is to examine the conduct of the above Review, and to put it into context in the wider body of evidence regarding the effectiveness of water fluoridation. While the overall conclusion that water fluoridation is effective in caries prevention agrees with previous reviews, many important public health questions could not be answered by the Review because of the restrictive criteria used to judge adequacy of study design and risk of bias. The potential benefits of using wider criteria in order to achieve a fuller understanding of the effectiveness of water fluoridation are discussed.

Clinical/Photographic/Scanning Electron Microscopy Analysis of Pit and Fissure Sealants After 22 Years: A Case Series

Pit and fissure sealant is a clinical technique adopted to prevent caries lesion development. Ionomeric and/or resin-based materials are commonly used for this purpose. This article presents a case series of sealed teeth with 22-year follow-up evaluated by clinical, photographic, and microscopic analysis. In 1992, sixteen patients (9-14 years of age) had at least three teeth sealed with one of the following materials: resin-modified glass ionomer cement (RMGIC, Vitrebond or Fuji II LC) or polyacid-modified resin composite (PMRC, VariGlass VLC), totaling 86 sealed permanent teeth. After 22 years, 10 patients were recalled, representing 41 teeth. The retention of sealants was assessed by three methods: clinical analysis by visual inspection; photography; and scanning electron microscope (SEM) images and classified as retained (pits and fissures filled by sealant material); partially retained (pits and fissures partially filled by sealant material); or totally lost (no material was found in pits and fissures). The SEM images provided a higher number of retained sealants when compared with the clinical and photographic evaluations. Also, no totally lost scores were found with SEM analysis, regardless of the sealing material. No caries lesions were found. A fully or partially retained sealant in pits and fissures was capable of preventing caries lesions after 22 years within the patient pool analyzed.

Fluoride induced endoplasmic reticulum stress and calcium overload in ameloblasts

OBJECTIVE

The aim of the study was to evaluate the involvement of endoplasmic reticulum stress and intracellular calcium overload on the development of dental fluorosis.

METHODS

We cultured and exposed rat ameloblast HAT-7 cells to various concentrations of fluoride and measured apoptosis with flow cytometry and intracellular Ca2+ changes using confocal microscopy, investigated the protein levels of GRP78, calreticulin, XBP1 and CHOP by western blotting, and their transcriptional levels with RT-PCR. We also created an in vivo model of dental fluorosis by exposing animals to various concentrations of fluoride. Subsequently, thin dental tissue slices were analyzed with H&E staining, immunohistochemical staining, and transmission electron microscopy, TUNEL assay was also performed on dental tissue slices for assessment of apoptosis.

RESULT

High fluoride concentration was associated with decreased ameloblast proliferation, elevated ameloblast apoptosis, and increased intracellular Ca2+ in vitro. The translation and transcription of the proteins associated with endoplasmic reticulum stress were significantly elevated with high concentrations of fluoride. Based on immunohistochemical staining, these proteins were also highly expressed in animals exposed to high fluoride concentrations. Histologically, we found significant fluorosis-like changes in tissues from animals exposed to high fluoride concentrations. Transmission electron microscopy cytology indicated significant apoptotic changes in tissues exposed to high concentrations of fluoride.

CONCLUSIONS

These results indicate that exposure to high levels of fluoride led to endoplasmic reticulum stress which induced apoptosis in cultured ameloblasts and in vivo rat model, suggesting an important role of calcium overload and endoplasmic reticulum stress triggered by high concentrations of fluoride in the development of dental fluorosis.

Access to Fluoridated Water and Adult Dental Caries

Systematic reviews have found no evidence to support a benefit of water fluoridation (WF) to prevent dental caries in adult populations. The aim of this natural experiment was to investigate whether lifetime access to fluoridated water is associated with dental caries experience among adults from Florianópolis, Brazil. The data originated from a population-based cohort study ( EpiFloripa Adult) initiated in 2009 ( n = 1,720) when participants were aged 20 to 59 years. The second wave was carried out in 2012 ( n = 1,140) and included a dental examination and a face-to-face questionnaire. Participants residing at the same address since the age of 7 y or before were included in the primary analyses. Sensitivity analyses were also performed. WF was implemented in the city in 2 different periods of time: 1982 (60% of the population) and 1996. Dental caries was assessed by the decayed, missing, and filled teeth (DMFT) index. A combination of residential status, participant’s age, and year of implementation of WF permitted the creation of participants’ lifetime access to fluoridated water: >75%, 50% to 75%, and <50% of a participant’s lifetime. Covariates included sex, age, socioeconomic mobility, educational attainment, income, pattern of dental attendance, and smoking. Participants who accessed fluoridate water <50% of their lifetime presented a higher mean rate ratio of DMFT (1.39; 95% CI, 1.05–1.84) compared with those living >75% of their lifetime with residential access to fluoridated water. Participants living between 50% and 75% and <50% of their lives in fluoridated areas presented a decayed and filled teeth mean ratio of 1.34 (95% CI, 1.02–1.75) and 1.47 (95% CI, 1.05–2.04) higher than those with residential access to fluoridated water >75% of their lifetime, respectively. Longer residential lifetime access to fluoridated water was associated with less dental caries even in a context of multiple exposures to fluoride.

Caries Epidemiology and Community Dentistry: Chances for Future Improvements in Caries Risk Groups. Outcomes of the ORCA Saturday Afternoon Symposium, Greifswald, 2014. Part 1

This paper reviews the first part of the outcomes of the ORCA Saturday Afternoon Symposium 2014 dealing with ‘caries epidemiology and community dentistry: chances for future improvements in caries risk groups'. After the caries decline in many countries, there are remaining pockets of higher caries levels, mostly in the primary dentition and/or linked to a low socio-economic status (SES). The review into the evidence of caries-preventive measures clearly points to the use of fluorides, especially toothbrushing with fluoridated toothpaste and collective measures such as water fluoridation. In contrast to several unsuccessful high-risk approaches, community and public health programmes seem to be able to ensure a population-wide access and compliance in risk groups. Their simple and evidence-based measures mostly combine regular plaque removal and fluoride applications via toothbrushing, at least for children and adolescents. For the future, the common risk factor approach which addresses associations between oral health, social deprivation, diet, hygiene, smoking, alcohol use and stress should lead to combined efforts with other community health and education specialists. Further engagement with public policy, community leaders and administration is needed in order to strengthen healthy choices and behaviour, e.g. in ‘healthy' schools and kindergartens. It seems advisable that these population programmes also aim at improving upstream factors.

Diet and Dental Caries: The Pivotal Role of Free Sugars Reemphasized

The importance of sugars as a cause of caries is underemphasized and not prominent in preventive strategies. This is despite overwhelming evidence of its unique role in causing a worldwide caries epidemic. Why this neglect? One reason is that researchers mistakenly consider caries to be a multifactorial disease; they also concentrate mainly on mitigating factors, particularly fluoride. However, this is to misunderstand that the only cause of caries is dietary sugars. These provide a substrate for cariogenic oral bacteria to flourish and to generate enamel-demineralizing acids. Modifying factors such as fluoride and dental hygiene would not be needed if we tackled the single cause--sugars. In this article, we demonstrate the sensitivity of cariogenesis to even very low sugars intakes. Quantitative analyses show a log-linear dose-response relationship between the sucrose or its monosaccharide intakes and the progressive lifelong development of caries. This results in a substantial dental health burden throughout life. Processed starches have cariogenic potential when accompanying sucrose, but human studies do not provide unequivocal data of their cariogenicity. The long-standing failure to identify the need for drastic national reductions in sugars intakes reflects scientific confusion partly induced by pressure from major industrial sugar interests.

Water fluoridation for the prevention of dental caries

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The effect of lifetime fluoridation exposure on dental caries experience of younger rural adults

BACKGROUND

The aim of this study was to confirm whether the level of lifetime fluoridation exposure is associated with lower dental caries experience in younger adults (15-46 years).

METHODS

Data of the cohort born between 1960 and 1990 residing outside Australia's capital cities from the 2004-2006 Australian National Survey of Adult Oral Health were analysed. Residential history questionnaires were used to determine the percentage of each person's lifetime exposure to fluoridated water (<50%/50+%). Examiners recorded decayed, missing and filled permanent teeth (DMFT). Socio-demographic variables, periodontal risk factors, and access to dental care were included in multivariable least-squares regression models.

RESULTS

In bivariate analysis, the higher level of fluoridation category had significantly lower DMFT (mean 6.01 [SE=0.62]) than the lower level of fluoridation group (9.14 [SE=0.73] p<0.01) and lower numbers of filled teeth (4.08 [SE=0.43], 7.06 [SE=0.62], p<0.01). In multivariate analysis, the higher number of full-time equivalent dentists per 100,000 people was associated with a lower mean number of missing teeth (regression coefficient estimate=-1.75, p=0.03), and the higher level of water fluoridation with a lower mean DMFT (-2.45, p<0.01) and mean number of filled teeth (-2.52, p<0.01).

CONCLUSIONS

The higher level of lifetime fluoridation exposure was associated with substantially lower caries experience in younger rural adults, largely due to a lower number of filled teeth.

Contextual and individual indicators associated with the presence of teeth in adults

OBJECTIVE The objective of this study was to analyze whether socioeconomic conditions and the period of availability of fluoridated water are associated with the number of teeth present. METHODS This cross-sectional study analyzed data from 1,720 adults between 20 and 59 years of age who resided in Florianópolis, SC, Southern Brazil, in 2009. The outcome investigated was the self-reported number of teeth present. The individual independent variables included gender, age range, skin color, number of years of schooling, and per capita household income. The duration of residence was used as a control variable. The contextual exposures included the period of availability of fluoridated water to the households and the socioeconomic variable for the census tracts, which was created from factor analysis of the tract's mean income, education level, and percentage of households with treated water. Multilevel logistic regression was performed and inter-level interactions were tested. RESULTS Residents in intermediate and poorer areas and those with fluoridated water available for less time exhibited the presence of fewer teeth compared with those in better socioeconomic conditions and who had fluoridated water available for a longer period (OR = 1.02; 95%CI 1.01;1.02). There was an association between the period of availability of fluoridated water, per capita household income and number of years of education. The proportion of individuals in the poorer and less-educated stratum, which had fewer teeth present, was higher in regions where fluoridated water had been available for less time. CONCLUSIONS Poor socioeconomic conditions and a shorter period of availability of fluoridated water were associated with the probability of having fewer teeth in adulthood. Public policies aimed at reducing socioeconomic inequalities and increasing access to health services such as fluoridation of the water supply may help to reduce tooth loss in the future.

A 4-year assessment of a new water-fluoridation scheme in New South Wales, Australia

OBJECTIVE

To monitor the changes in dental caries prevalence of 5- to 7-year-old children living in a fluoridated area, a newly fluoridated area and in an area without water fluoridation, in NSW, Australia.

METHODS

Dental caries prevalence was recorded for 5- to 7-year-old children, living in the three study locations, by six trained and calibrated examiners in 2008, 2010 and 2012. A questionnaire recorded demographic data, toothbrushing behaviour and sugary drink consumption. Caries experience was measured using the decayed, missing, and filled teeth (dmft) index for primary teeth, the percentage of children who were caries free and the significant caries index. Univariate analysis was undertaken to determine independent predictors of caries.

RESULTS

The caries prevalence changed over time. In 2008, the mean dmft index was 1.40 for the fluoridated area, 2.02 for the area about to fluoridate and 2.09 for the unfluoridated control. By 2012, these mean dmft scores were 0.69, 0.72 and 1.21, respectively. In the two areas where children received fluoridated water, the significant caries index was 2.30 for the fluoridated area and 2.40 for the newly fluoridated area. The significant caries score for children in the unfluoridated location was 3.93. Multivariate analysis showed that over time the differences in dental caries prevalence between the established fluoride area and the newly fluoridated area diminished. However, children in the unfluoridated control area continued to demonstrate significant differences in the mean number of decayed teeth compared with children in the fluoridated comparator sites, and the proportions of children free from decay were significantly higher in the fluoridated areas than in the unfluoridated area.

CONCLUSION

Fluoridation of public water supplies in Gosford and Wyong offers young children better dental health than those children who do not have access to this public health measure.

Weaker dental enamel explains dental decay

Dental caries continues to be the most prevalent bacteria-mediated non-contagious disease of humankind. Dental professionals assert the disease can be explained by poor oral hygiene and a diet rich in sugars but this does not account for caries free individuals exposed to the same risk factors. In order to test the hypothesis that amount of amelogenin during enamel development can influence caries susceptibility, we generated multiple strains of mice with varying levels of available amelogenin during dental development. Mechanical tests showed that dental enamel developed with less amelogenin is "weaker" while the dental enamel of animals over-expressing amelogenin appears to be more resistant to acid dissolution.

Does lower lifetime fluoridation exposure explain why people outside capital cities have poor clinical oral health?

BACKGROUND

Australians outside state capital cities have greater caries experience than their counterparts in capital cities. We hypothesized that differing water fluoridation exposure was associated with this disparity.

METHODS

Data were the 2004-06 Australian National Survey of Adult Oral Health. Examiners measured participant decayed, missing and filled teeth and DMFT Index, and lifetime fluoridation exposure was quantified. Multivariable linear regression models estimated differences in caries experience between capital city residents and others, with and without adjustment for fluoridation exposure.

RESULTS

There was greater mean lifetime fluoridation exposure in state capital cities (59.1%, 95% confidence interval = 56.9, 61.4) than outside capital cities (42.3, confidence interval = 36.9, 47.6). People located outside capital city areas had differing sociodemographic characteristics and dental visiting patterns, and a higher mean DMFT (capital cities = 12.9, non-capital cities = 14.3, p = 0.02), than people from capital cities. After adjustment for sociodemographic characteristics and dental visits, DMFT of people living in capital cities was less than non-capital city residents (regression coefficient = 0.8, p = 0.01). The disparity was no longer statistically significant (regression coefficient = 0.6, p = 0.09) after additional adjustment for fluoridation exposure.

Effects of Water Fluoridation on Caries Experience in the Primary Dentition in a High Caries Risk Community in Queensland, Australia

Objectives: In December 2008, artificial water fluoridation was introduced for the first time to the Logan-Beaudesert district in the state of Queensland, Australia. The aim of this study was to evaluate the effects of water fluoridation in the primary dentition in this community after a period of 36 months. Methods: Children aged 4-9 years with clinical examinations and bitewing radiographs (BWs) taken before water fluoridation (pre-F) were randomly selected as comparison controls for age matched children who had been exposed to a mean period of 36 months of water fluoridation (post-F). A total of 201 sets of pre-F BWs from children (mean age 6.95 ± 1.05 years) and 256 sets of post-F BWs from children (mean age 7.19 ± 1.23 years) attending schools in the district were randomly selected. Caries experience in the primary dentition was determined as decayed, missing or filled teeth/surfaces (dmft/dmfs). Results: The caries prevalence for the pre-F group was 87% compared to 75% in the post-F group (Odds ratio (OR): 0.44, 95% CI: 0.27-0.72). Overall, there was a 19 percent reduction of mean dmft from 4.54 in the pre-F group to 3.66 in the post-F group (p = 0.005). After fluoridation, the dmfs was reduced from 6.68 to 5.17 (p = 0.0056). The distal surfaces of maxillary first primary molars experienced the greatest reduction (26%) in caries experience after water fluoridation (p < 0.001). Conclusions: After only 36 months of water fluoridation there was a significant drop in caries prevalence from 87 to 75% and a 19% reduction in caries experience in a community with one of the highest caries rates in Australia.

Analysis of public dental service waiting lists in Queensland

Information on public dental service waiting lists is available as part of the Queensland Government open data policy. Data were summarised across the care categories and health districts to present the total number and percentage of people waiting for care and who have waited beyond the desirable period. As of 31 December 2012 there were 130 546 people on the dental waiting list; of these 85.8%, 8.5% and 2.2% were waiting for general care desirable within 24, 12 and 3 months, respectively. Across all care categories, almost 56% of those on the waiting list were beyond the desirable waiting period. The average number of people on the waiting list and the average number waiting beyond the desirable time differ substantially per clinic by district. Ongoing analysis of the Queensland public dental service waiting list database will determine the impact on patient waiting times of Federal Government initiatives announced in 2012 to treat an estimated 400 000 patients on waiting lists nationwide over the next 3 years and to expand services to assist low-income adults to receive dental services.

A critique of recent economic evaluations of community water fluoridation

BACKGROUND

Although community water fluoridation (CWF) results in a range of potential contaminant exposures, little attention has been given to many of the possible impacts. A central argument for CWF is its cost-effectiveness. The U.S. Government states that $1 spent on CWF saves $38 in dental treatment costs.

OBJECTIVE

To examine the reported cost-effectiveness of CWF.

METHODS

Methods and underlying data from the primary U.S. economic evaluation of CWF are analyzed and corrected calculations are described. Other recent economic evaluations are also examined.

RESULTS

Recent economic evaluations of CWF contain defective estimations of both costs and benefits. Incorrect handling of dental treatment costs and flawed estimates of effectiveness lead to overestimated benefits. The real-world costs to water treatment plants and communities are not reflected.

CONCLUSIONS

Minimal correction reduced the savings to $3 per person per year (PPPY) for a best-case scenario, but this savings is eliminated by the estimated cost of treating dental fluorosis.