The effect of cessation of drinking water fluoridation on dental restorations and crowns in children aged 3-5 years in Israel - a retrospective study.

BACKGROUND: Community water fluoridation began in the 1945 as a public health measure to prevent and control caries and was implemented in Israel in 1981. Community water fluoridation reduced caries significantly, but in 2014, the Ministry of Health decided to stop Community water fluoridation in Israel. The aim of our study was to examine the effect of fluoridation cessation on the dental health of children aged 3-5, treated in "Assuta Tel Aviv" dental clinics, under general anesthesia or deep sedation. METHODS: The computerized Maccabi-Dent database provided data for this retrospective study. Records from the years 2014-2019 including treatment codes for procedures relevant to the study, the number of stainless-steel crowns and restorations of all types were examined. Kruskal-Wallis test was performed to compare the results from before and after fluoridation cessation. RESULTS: A statistically significant increase in the mean number of treatments in the years after fluoridation cessation (P < 0.05) was found. There was approximately a two-fold increase in the number of all treatments for all ages. CONCLUSION: The results of the study emphasize the advantages of water fluoridation and are further proof of the need to restore community water fluoridation in Israel.

Socioeconomic vulnerability and access to community water fluoridation in Washington.

BACKGROUND: The aim of the authors was to determine whether socioeconomic vulnerability is associated with community water fluoridation (CWF). METHODS: The authors used US Census Bureau data to create 4 county-level vulnerability markers (percentages non-White, Hispanic or Latino, below the federal poverty threshold, education below high school), obtained county-level CWF data from the Washington State Department of Health, and evaluated associations using Spearman rank correlation coefficient and the Kruskal-Wallis rank sum test. The authors then interviewed 122 community members in Washington (December 2022-March 2023) and analyzed the interview data inductively. RESULTS: A higher percentage of non-White people at the county level was associated with a significantly higher level of CWF (Spearman rank correlation coefficient, 0.55; 95% CI, 0.29 to 0.82; P < .001), whereas county-level poverty was associated with significantly lower CWF (Spearman rank correlation coefficient, -0.36; 95% CI, -0.70 to -0.03; P = .02). High school completion was not associated with county-level CWF. Significantly larger proportions of Hispanics and Latinos lived in counties with higher CWF (P < .05). From the interviews, more participants thought tap water was healthy than unhealthy, but 41% had mixed feelings. Similarly, more participants thought CWF was acceptable than unacceptable, with 35% reporting mixed feelings. Negative views about tap water and CWF were more common among non-White participants. CONCLUSIONS: People in racially and ethnically diverse communities in Washington appear to have greater access to CWF, whereas those in lower-income communities have poorer access. PRACTICAL IMPLICATIONS: CWF is an important population-level strategy to prevent caries. Additional work is needed to improve access to CWF, especially for people from low-income communities.

Consistency of information on the provision of water fluoridation in Brazil.

OBJECTIVE: This study aimed to assess the consistency of data regarding the provision of fluoridation in Brazilian municipalities with water supply systems. METHODS: Official data from the National Basic Sanitation Survey and the National Information System on Sanitation for 2017 were compared. RESULTS: Out of 5,570 municipalities in Brazil, 4,546 (81.6%) had water supply systems. The agreement between data sources was 84%, with a Kappa of 0.668, indicating substantial agreement. However, the estimates of fluoridation provision exhibited an average discrepancy of 8.1 percentage points, ranging from 1.2 points in the Central-West region to 21.4 points in the Northeast region. CONCLUSION: To address these inconsistencies, it is essential to enhance information sources, ensuring more reliable data for health, sanitation authorities, and society at large.

Cross-sectional study of association between caries and fluoridated water among third-grade students in Pennsylvania.

BACKGROUND: Caries is the most common chronic disease among children. In Pennsylvania, a comprehensive oral health Basic Screening Survey and assessment of the association between caries and community water fluoridation (CWF) among children have not been conducted. METHODS: From 2021 through 2022, the first Basic Screening Survey was conducted among third-grade students in Pennsylvania. Oral health and demographic data were collected. CWF data were provided by the Pennsylvania Department of Environmental Protection. The relative risk of developing caries in association with CWF was assessed using the GENMOD procedure in SAS, Version 9.4 (SAS Institute) in this cross-sectional study. RESULTS: Caries prevalence was 59.7% among 4,120 screened students. Participation in the free or reduced lunch program and CWF were each significantly associated with risk of developing caries after adjustment for age, sex, and race and ethnicity. The risk of developing caries was 33% higher among students who participated in the free or reduced lunch program than those who did not participate (relative risk, 1.33; 95% CI, 1.24 to 1.42). Students with the highest CWF coverage had a nearly 16% lower risk of developing caries than those without CWF coverage (relative risk, 0.84; 95% CI, 0.75 to 0.94). CONCLUSIONS: CWF was significantly associated with a reduced risk of developing caries. Efforts are needed to increase CWF coverage, along with promotion of oral health education and healthy dietary habits among Pennsylvania children. PRACTICAL IMPLICATIONS: Increasing CWF coverage will reduce caries burden among Pennsylvania children. Although Pennsylvania has no state laws to regulate CWF, these findings are persuasive for local municipalities to consider expanding CWF coverage.

Water Fluoridation and Birth Outcomes in California.

BACKGROUND: There is a lack of research on the relationship between water fluoridation and pregnancy outcomes. OBJECTIVES: We assessed whether hypothetical interventions to reduce fluoride levels would improve birth outcomes in California. METHODS: We linked California birth records from 2000 to 2018 to annual average fluoride levels by community water system. Fluoride levels were collected from consumer confidence reports using publicly available data and public record requests. We estimated the effects of a hypothetical intervention reducing water fluoride levels to 0.7 ppm (the current level recommended by the US Department of Health and Human Services) and 0.5 ppm (below the current recommendation) on birth weight, birth-weight-for-gestational age z-scores, gestational age, preterm birth, small-for-gestational age, large-for-gestational age, and macrosomia using linear regression with natural cubic splines and G-computation. Inference was calculated using a clustered bootstrap with Wald-type confidence intervals. We evaluated race/ethnicity, health insurance type, fetal sex, and arsenic levels as potential effect modifiers. RESULTS: Fluoride levels ranged from 0 to 2.5 ppm, with a median of 0.51 ppm. There was a small negative association on birth weight with the hypothetical intervention to reduce fluoride levels to 0.7 ppm [-2.2g; 95% confidence interval (CI): -4.4, 0.0] and to 0.5 ppm (-5.8g; 95% CI: -10.0, -1.6). There were small negative associations with birth-weight-for-gestational-age z-scores for both hypothetical interventions (0.7 ppm: -0.004; 95% CI: -0.007, 0.000 and 0.5 ppm: -0.006; 95% CI: -0.013, 0.000). We also observed small negative associations for risk of large-for-gestational age for both the hypothetical interventions to 0.7 ppm [risk difference (RD)=-0.001; 95% CI: -0.002, 0.000 and 0.5 ppm (-0.001; 95% CI: -0.003, 0.000)]. We did not observe any associations with preterm birth or with being small for gestational age for either hypothetical intervention. We did not observe any associations with risk of preterm birth or small-for-gestational age for either hypothetical intervention. CONCLUSION: We estimated that a reduction in water fluoride levels would modestly decrease birth weight and birth-weight-for-gestational-age z-scores in California. https://doi.org/10.1289/EHP13732.

The CATFISH study: An evaluation of a water fluoridation program in Cumbria, UK.

OBJECTIVES: The objective was to assess the effectiveness of a Water Fluoridation program on a contemporary population of children. METHODS: The study used a longitudinal prospective cohort design. In Cumbria, England, two groups of children were recruited and observed over a period of 5-6 years. The Birth Cohort consisted of families recruited from two hospitals in Cumbria where children were conceived after water fluoridation was reintroduced. The systemic and topical effects of community water fluoridation were evaluated in the Birth Cohort. The Older Cohort were approximately 5 years old and recruited from primary schools in Cumbria, shortly after water fluoridation was reintroduced. The predominantly topical effects of fluoridated water were evaluated in the Older Cohort. The primary outcome was the proportion of children with clinical evidence of caries experience in their primary (Birth Cohort) or permanent teeth (Older Cohort). Unadjusted and adjusted regression models were used for analysis. RESULTS: The final clinical examinations for the Birth Cohort involved 1444 participants (mean age 4.8 years), where 17.4% of children in the intervention group were found to have caries experience, compared to 21.4% in the control group. A beneficial effect of water fluoridation was observed adjusting for deprivation (a socioeconomic measure), sex, and age, (adjusted odds ratio 0.74 95% CI 0.55 to 0.98). The final Older Cohort clinical examinations involved 1192 participants (mean age 10.8 years) where 19.1% of children in the intervention group were found to have caries experience compared to 21.9% in the control group (adjusted odds ratio 0.80, 95% CI 0.58 to 1.09). For both the Birth Cohort and Older Cohort there was evidence of a beneficial effect on dmft/DMFT count (IRR 0.61, 95% CI 0.44, 0.86) and (IRR 0.69, 95% CI 0.52, 0.93) respectively. No conclusive proof was found to indicate that the effectiveness of water fluoridation differed across area deprivation quintiles. CONCLUSIONS: In the contemporary context of lower caries levels and widespread use of fluoride toothpaste, the impact of water fluoridation on the prevalence of caries was smaller than previous studies have reported. It is important to consider the clinical importance of the absolute reduction in caries prevalence against the use of other dental caries preventive measures.

Vigilância da fluoretação da água no município de São Paulo, Brasil, no período 1990-2021: dos relatórios aos dados abertos / Health surveillance of community water fluoridation in the municipality of Sao Paulo, Brazil, in the period 1990-2021: from reports to open data

Introdução: A vigilância da qualidade da água para consumo humano requer verificação contínua dos padrões de potabilidade, entre os quais a concentração de fluoreto. Sistemas de vigilância lidam com informações de interesse público, nos marcos legais definidos pelo Estado. No mundo contemporâneo, implicam equilibrar o direito de acesso à informação e a garantia de privacidade. Objetivo: Caracterizar a evolução do sistema de vigilância da fluoretação da água no município de São Paulo e avaliar se a população esteve exposta a concentrações adequadas e seguras do parâmetro fluoreto nas águas de abastecimento público, no período 1990-2021. Método: O estudo é ecológico, com dados secundários de 49.515 registros, geocodificados e classificados conforme a Resolução SS-250 e o intervalo ótimo de concentração recomendada pelo Centro Colaborador do Ministério da Saúde em Vigilância da Saúde Bucal (0,545-0,944 mgF/L). Adicionalmente, realizou-se revisão do marco legal brasileiro que trata da Lei de Acesso à Informação e da Lei Geral de Proteção de Dados Pessoais, tendo em vista a publicação dos parâmetros de qualidade da água em portais de dados abertos governamentais. Resultados: A média das temperaturas máximas diárias foi estimada em 25,7ºC. Foi possível geocodificar 98,43% dos registros. Obteve-se a concentração média de 0,663 mgF/L, com desvio-padrão de 0,167. De acordo com a Resolução SS-250, 48.118 (97,18%) das amostras estiveram adequadas. Considerando o Documento de Consenso Técnico, 29.823 (60,23%) das amostras apresentaram máximo benefício na prevenção da cárie e 48.786 (98,53%) indicaram baixo risco para fluorose dentária. O período analisado apresenta ampliação do acesso a dados abertos governamentais de qualidade da água para consumo humano, com potencial para ampliar as possibilidades de controle social sobre as políticas públicas. Entretanto, impõe desafios à garantia da privacidade. Conclusão: A utilização de técnicas de geocodificação possibilitou a recuperação de uma série histórica sem precedentes na literatura científica. Os resultados indicam que a população paulistana esteve exposta a concentrações adequadas e seguras do parâmetro fluoreto nas águas de abastecimento público no período 1990-2021.

Introduction: The surveillance of water quality for human consumption requires continuous verification of potability standards, among which is fluoride concentration. Surveillance systems deal with public interest information within the legal frameworks defined by the State. In the contemporary world, this implies balancing the right to access information and the guarantee of privacy. Objective: To characterize the evolution of the water fluoridation surveillance system in the municipality of São Paulo and evaluate whether the population has been exposed to adequate and safe concentrations of the fluoride in public water supplies during the period 1990-2021. Method: The study is ecological, utilizing secondary data from 49,515 records, geocoded and classified according to Resolution SS-250 and the optimal concentration range recommended by the Collaborating Center of the Ministry of Health in Oral Health Surveillance (0.545-0.944 mgF/L). Additionally, a review of the Brazilian legal framework addressing the Access to Information Law and the General Data Protection Law was conducted, considering the publication of water quality parameters on open government data websites. Results: The average daily maximum temperatures was estimated at 25.7ºC. It was possible to geocode 98.43% of the records. The average fluoride concentration was 0.663 mgF/L, with a standard deviation of 0.167. According to Resolution SS-250, 48,118 (97.18%) of the samples were adequate. Considering the Technical Consensus Document, 29,823 (60.23%) of the samples showed maximum benefit in caries prevention, and 48,786 (98.53%) presented a low risk for dental fluorosis. The period analyzed shows an expansion of access to open government data on water quality for human consumption, with potential to broaden the possibilities for social control over public policies. However, it imposes challenges to the guarantee of privacy. Conclusion: The use of geocoding techniques enabled the recovery of an unprecedented historical series in the scientific literature. The results indicate that the São Paulo population was exposed to adequate and safe concentrations of the fluoride parameter in public water supplies during the period 1990-2021.

Fluoride Concentration in Public Water Supply in a City in the Amazon Region

Abstract Objective: To analyze the fluoride concentration in the public water supply in Manaus, Brazil. Material and Methods: Water samples were collected in 50 mL polyethylene bottles, identified, and labeled. The collection was performed from September 2016 to August 2018. For the selection of collection points, all neighborhoods of the city of Manaus, divided into four health districts (North, South, East, and West), were mapped. From each district, 30 samples were collected, totaling 120 monthly samples. Water samples were analyzed using an ion analyzer, ORION 720-A, and a specific electrode, ORION 96-09. The ion analyzer and electrode were calibrated in standard solutions. The levels were classified in intervals based on technical consensus to guide the health surveillance agencies. Results: Of the 2,874 water samples, 50.3% were within the recommended range, and 49.7% were inadequate, with 31.6% considered above the parameters and 18.1% below. Among the districts, the North had the highest percentages of unsatisfactory samples, resulting in limited action to prevent tooth decay. During the 24 months of analysis, there were large oscillations in the values in all four districts of Manaus. Conclusion: Results reinforce the importance of heterocontrol for the city to guarantee the effectiveness of this public health measure.

Causal Effect of Tooth Loss on Functional Capacity in Older Adults in England: A Natural Experiment.

BACKGROUND/OBJECTIVES: Tooth loss is associated with reduced functional capacity, but so far, there is no relevant causal evidence reported. We investigated the causal effect of tooth loss on the instrumental activities of daily living (IADL) among older adults in England. DESIGN: Natural experiment study with instrumental variable analysis. SETTING: The English Longitudinal Study of Aging (ELSA) combined with the participants' childhood exposure to water fluoride due to the community water fluoridation. PARTICIPANTS: Five thousand six hundred and thirty one adults in England born in 1945-1965 participated in the ELSA wave seven survey (conducted in 2014-2015; average age: 61.0 years, 44.6% men). MEASUREMENTS: The number of natural teeth predicted by the exogenous geographical and historical variation in exposure to water fluoride from age 5 to 20 years old (instrumental variable) was used as an exposure variable. The outcome, having any limitations in IADL (preparing a hot meal, shopping for groceries, making telephone calls, taking medications, doing work around the house or garden, or managing money), was assessed by self-reported questionnaires. RESULTS: Linear probability model with Two-Stage Least Squares estimation was fitted. Being exposed to fluoridated water was associated with having more natural teeth in later life (coefficient: 0.726; 95% confidence interval (CI) = 0.311, 1.142; F = 11.749). Retaining one more natural tooth reduced the probability of having a limitation in IADL by 3.1 percentage points (coefficient: -0.031; 95% CI = -0.060, -0.002). CONCLUSION: Preventing tooth loss maintains functional capacity among older adults in England. Given the high prevalence of tooth loss, this effect is considerable. Further research on the mechanism of the observed causal relationship is needed.

Community water fluoridation exposure and dental caries experience in newly enrolled members of the Canadian Armed Forces 2006-2017.

OBJECTIVES: This cross-sectional study examines the dental caries experience of new Canadian Armed Forces (CAF) members in relation to enrollment from municipalities with and without water fluoridation. METHODS: The study population consisted of recruits who enrolled in the CAF between 2006 and 2017 with an enrollment address in municipalities with known fluoridation status (n = 24,552). Odontogram statistics from dental examinations were used to calculate the number of decayed, missing, and filled teeth (DMFT) and tooth surfaces (DMFS) for each recruit. The average difference between recruits from municipalities with and without fluoridation was determined using a linear regression model which adjusted for confounding by age and gender and allowed effect modification based on socio-economic status. RESULTS: The average recruit was male, 24 years of age, with 5.6 DMFT and 11.6 DMFS. After adjusting for age and gender, recruits residing in municipalities with water fluoridation had lower DMFT by 0.67 (CI - 0.55, - 0.79) points and lower DMFS by 1.77 (- 1.46, - 2.09) points. When allowing for effect modification by median income quintile of the recruits' home census tract, the average reduction in DMFT and DMFS was similar in all income quintiles, with average reductions in DMFT ranging from 0.47 to 1.02 and average reductions in DMFS ranging from 1.33 to 2.70. CONCLUSION: Residence in a municipality with water fluoridation was associated with reduced caries experience in a national sample of newly enrolled CAF members. The benefits of water fluoridation were uniform across neighbourhood income and military rank classes.

RéSUMé: OBJECTIFS: Cette étude transversale examine l'importance du niveau de la carie dentaire des nouveaux membres des Forces armées canadiennes (FAC) par rapport à l'enrôlement provenant des municipalités avec et sans fluoration de l'eau. MéTHODES: La population étudiée était constituée de recrues qui se sont enrôlés dans les FAC entre 2006 et 2017 avec une adresse d'inscription dans les municipalités dont le statut de fluoration est connu (n = 24 552). Les statistiques en provenance des odontogrammes des examens dentaires ont été utilisées pour calculer le nombre de dents et surfaces cariés, absents et obturés (CAOD & CAOF) pour chaque recrue. La différence moyenne entre les recrues des municipalités avec ou sans fluoration a été déterminée à l'aide d'un modèle de régression linéaire qui a été ajusté pour prendre en considération l'âge et le sexe et a permis une modification de l'effet en fonction du statut socioéconomique. RéSULTATS: La recrue moyenne était un homme de 24 ans avec 5,6 CAOD et 11,6 CAOF. Après ajustement en fonction de l'âge et du sexe, les recrues résidant dans les municipalités avec fluoration de l'eau avaient un CAOD inférieur de 0,67 points (IC -0,55, -0,79) et un CAOF inférieur de 1,77 points (-1,46, -2,09). En permettant la modification de l'effet par l'indice de revenu médian du secteur de recensement d'origine des recrues, la réduction moyenne du CAOD et du CAOF était similaire dans tous les niveaux de revenu, avec des réductions moyennes du CAOD d'entre 0,47 et 1,02 et des réductions moyennes du CAOF d'entre 1,33 et 2,70. CONCLUSION: La résidence dans une municipalité avec fluoration de l'eau a été associée avec une réduction des caries dans un échantillonnage national de nouveaux membres enrôlés dans les FAC. Les avantages de la fluoration de l'eau étaient uniformes dans l'ensemble des niveaux de revenu du quartier et des différentes classes de grade militaire.

The Association between Community Water Fluoridation and Bone Diseases: A Natural Experiment in Cheongju, Korea.

The present study aimed to investigate the association between bone diseases and community water fluoridation (CWF). An ecological study with a natural experiment design was conducted in Cheongju, South Korea, from 1 January 2004 to 31 December 2013. The community water fluoridation program was implemented in Cheongju and divided into CWF and non-CWF areas. To observe adverse health effects related to bone diseases, we conducted a spatio-temporal analysis of the prevalence of hip fracture, osteoporosis, and bone cancer in residents who have lived in CWF and non-CWF areas using National Health Insurance Service data. First, we used standardized incidence ratios to estimate the disease risk. Second, the hierarchical Bayesian Poisson spatio-temporal regression model was used to investigate the association between the selected bone diseases and CWF considering space and time interaction. The method for Bayesian estimation was based on the R-integrated nested Laplace approximation (INLA). Comparing the CWF area with the non-CWF area, there was no clear evidence that exposure to CWF increased health risks at the town level in Cheongju since CWF was terminated after 2004. The posterior relative risks (RR) of hip fracture was 0.95 (95% confidence intervals 0.87, 1.05) and osteoporosis was 0.94 (0.87, 1.02). The RR in bone cancer was a little high because the sample size very small compared to the other bone diseases (RR = 1.20 (0.89, 1.61)). The relative risk of selected bone diseases (hip fractures, osteoporosis, and bone cancer) increased over time but did not increase in the CWF area compared to non-CWF areas. CWF has been used to reduce dental caries in all population groups and is known for its cost-effectiveness. These findings suggest that CWF is not associated with adverse health risks related to bone diseases. This study provides scientific evidence based on a natural experiment design. It is necessary to continue research on the well-designed epidemiological studies and develop public health prevention programs to help in make suitable polices.

Predictors of Plasma Fluoride Concentrations in Children and Adolescents.

Despite increasing concerns about neurotoxicity of fluoride in children, sources of fluoride exposure apart from municipal water fluoridation are poorly understood. We aimed to describe the associations of demographics, drinking water characteristics, diet, and oral health behaviors with plasma fluoride concentrations in U.S. children. We used data from 3928 6-19-year-olds from the 2013-2016 National Health and Nutrition Examination Survey. We used a 24-h dietary recall to estimate recent consumption of fluoridated tap water and select foods. We estimated the associations of fluoridated tap water, time of last dental visit, use of toothpaste, and frequency of daily tooth brushing with plasma fluoride concentrations. The participants who consumed fluoridated (≥0.7 mg/L) tap water (n = 560, 16%) versus those who did not had 36% (95% CI: 22, 51) higher plasma fluoride. Children who drank black or green tea (n = 503, 13%) had 42% higher plasma fluoride concentrations (95% CI: 27, 58) than non-tea drinkers. The intake of other foods and oral health behaviors were not associated with plasma fluoride concentrations. The consumption of fluoridated tap water and tea substantially increases plasma fluoride concentrations in children. Quantifying the contribution of diet and other sources of fluoride is critical to establishing safe target levels for municipal water fluoridation.

Caries prevalence among 18 years old, an epidemiological survey in Israel.

BACKGROUND: There is a lack of evidence on caries prevalence among 18 years old Israeli young adults with only a scarce evidence regarding this index age group. In the last few years dental care policy in Israel underwent substantial changes and a major reform in dental services was led by the Israeli Ministry of Health, including coverage of dental care for children by the state. In addition, a cessation of community water fluoridation was in a debate. The objective of the current study was to describe prevalence of caries among 18 years old Israeli young adults and to evaluate possible associations with personal and demographic variables. METHODS: The study was a cross sectional clustered survey. Participants were recruited to the study at their first day of military service. Participants completed a questionnaire for personal and demographic data, including: age, country of birth, education, and current smoking status. Then participants underwent clinical evaluation included DMFT and caries free rates. No radiographic evaluation was included in the current study. Univariate and multivariate statistical analysis were performed. RESULTS: A total of 702 participants were included in the study, 58.4% were males. Their mean age was 19.03 ± 0.65 years, 91.3% of the participants were born in Israel. Mean DMFT was 1.95 ± 2.67, and 46.7% (n = 328) were caries free. Higher DMFT score was significantly associated with participant's parents' education, country of birth, and smoking status. Lower caries free rates were significantly associated with participant's parents' education, and smoking status. After linear regression for total DMFT, all variables were significant predictors to higher DMFT, except father's education, while logistic regression for caries free, only mother's education was found to be a significant predictor. CONCLUSIONS: The current study presents encouraging low DMFT levels. Participants in this study were not included in the dental care services reform, and did enjoy the benefits of water fluoridation, enabling the results to play an important baseline data for future reference. Additionally, results should be considered when planning intervention programs for at risk groups. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (Identifier No. NCT02958891 , November 8th, 2016) and was approved by the IDF Institutional Review Board (#1524-2015).

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.

Characteristics of sanitation companies associated to water fluoridation of the supply systems of Brazilian municipalities, 2008. / Características das empresas de saneamento associadas à fluoretação da água dos sistemas de abastecimento de municípios do Brasil, 2008.

INTRODUCTION: The adjusted effect of the characteristics of sanitation companies on the provision of fluoridation into public water supply in Brazilian municipalities was evaluated. METHODS: Cross-sectional and ecological study based on the 2010 Demographic Census, 2008 National Survey on Basic Sanitation (PNSB), and 2010 Atlas of Human Development. The independent variables were the characteristics of utilities and municipalities, and the outcome was the lack of provision of fluoridation. Prevalence ratio was estimated with Poisson regression with robust variance. RESULTS: 5,565 Brazilian municipalities were included. In the adjusted analysis, the outcome was independently and positively associated to municipalities in the North, Northeast, Central-West and Southeast macro-regions, with coverage rates for water and sewage services below the median value, with less than 10,000 inhabitants, medium and low/very low in human development. Regarding the independent effect of the utilities' characteristics, they were more likely not to provide fluoridation, all the companies that were not classified as indirect administration of the government or mixed-capital company or mixed-capital company of public character; municipal and intermunicipal (PR=1.21; 95%CI 1.19-1.23); and when the municipal government is the only provider (PR=1.22; 95%CI 1.20-1.25). CONCLUSION: The lack of provision of water fluoridation was greater when the service was mainly provided by municipal administrations and private companies associated or not to public entities, regardless of the characteristics of the municipalities.

Association Between Community Water Fluoridation and Severe Dental Caries Experience in 4-Year-Old New Zealand Children.

Importance: Robust contemporary epidemiologic evidence for the population-wide efficacy of reticulated community water fluoridation is required. Objective: To evaluate whether community water fluoridation is associated with the national rates of severe caries among 4-year-old children in New Zealand after accounting for key sociodemographic characteristics. Design, Setting, and Participants: This was a near whole population-level, natural, geospatial cross-sectional study of 4-year-old children who had a health and development assessment as part of the nationwide B4 School Check screening program conducted in New Zealand between July 1, 2010, and June 30, 2016. The extracted database included 391 677 children. However, geospatial information was missing for 18 558 children, another 32 939 children were unable to be geospatially matched, 5551 children resided in areas with changing fluoridation status, and 58 786 children had no oral health screen recorded, leaving 275 843 (70.4%) eligible children. Data were released in August 2019; statistical analysis was performed from September 2019 to December 2019. Exposures: Community water fluoridation status from 2011 through 2016. Main Outcomes and Measures: Severe caries experience derived from the "lift the lip" oral health screening. Analyses were adjusted for age, sex, ethnicity, area-level deprivation, and residential location differences. Multilevel mixed-effects logistic regression models were used. Sensitivity analyses based on multiple imputed data were undertaken to measure any differential influence of missing data. Results: In the eligible sample of 275 843 children, the median age was 4.3 years (interquartile range, 4.1-4.6 years), 141 451 children (51.3%) were boys, and 153 670 children (55.7%) resided within fluoridated areas. Severe caries were identified for 24 226 children (15.8%) in fluoridated and 17 135 children (14.0%) in unfluoridated areas, yielding an unadjusted odds ratio of 0.93 (95% CI, 0.90-0.95). However, in the adjusted analyses, children residing in areas without fluoridation had higher odds of severe caries compared with those within fluoridated areas (odds ratio, 1.21; 95% CI, 1.17-1.24). The population attributional fraction associated with unfluoridated community water was 5.6% (95% CI, 4.7%-6.6%) in a complete case analysis. Conclusions and Relevance: This study finds that community water fluoridation continues to be associated with reduced prevalence of severe caries in the primary dentition of New Zealand's 4-year-old children.

The impact of stopping or reducing the level of fluoride in public water supplies on dental fluorosis: a systematic review.

OBJECTIVE: The increased availability of fluoride and concern over the impact of fluorosis, have led to guidance suggesting a decrease or cease in the optimal concentration of fluoride in water fluoridation schemes. To date there have been no systematic reviews looking at both impact of fluoride reduction and total cessation. This review aimed to examine the impact of stopping or reducing the level of fluoride in public water supplies on dental fluorosis. CONTENT: Multiple databases were searched (MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the Web of Science). Two reviewers independently screened sources, extracted data and assessed study quality. Results were synthesised qualitatively and quantitatively. The main outcome measure was the prevalence of dental fluorosis. SUMMARY: Six studies of cross-sectional design were included. Two studies were scored as evidence level B (moderate) and the remaining four publications were evidence level C (poor). Meta-analysis indicated fluorosis prevalence was significantly decreased following either a reduction in the concentration of fluoride or cessation of adding fluoride to the water supply (OR:6.68; 95% CI:2.48 to 18.00). OUTLOOK: The evidence suggests a significant decrease in the prevalence of fluorosis post cessation or reduction in the concentration of fluoride added to the water supply. However, this work demonstrates that when studies are subject to current expectations of methodological and experimental rigour, there is limited evidence with low methodological quality to determine the effect of stopping or reducing the concentration of fluoride in the water supply on dental fluorosis.

Water fluoridation in the ten largest municipalities of the state of Tocantins, Brazil. / Fluoretação da água dos dez maiores municípios do estado do Tocantins, Brasil.

Water fluoridation is a strategy for caries control recommended by the WHO. In Brazil, it is regulated by law but this program has not been successfully implemented in the North region. This research aimed to collect data on the existence of external control (heterocontrol) in the ten largest municipalities in the state of Tocantins, Brazil, and to analyze fluoride concentration in the public water supply of these cities. The study was conducted from May-August/17, and its theoretical-methodological framework was a quantitative, descriptive and cross-sectional analysis. Water collections were carried out monthly, using sampling protocol of water collection of the network. Fluoride concentration in the waters was determined with ion specific electrode by the direct technique. It was verified that water fluoridation monitoring is only been done in Palmas, capital of the state, starting in 2016. Thirty-two percent of waters samples analyzed showed fluoride concentration to obtain the maximum benefit of reduction caries and 27.5% of them presented a high or very high risk of dental fluorosis. It is necessary to implement a program to control the concentration of fluoride in the water of the municipalities of Tocantins, in order to ensure that the population is not deprived of the anticaries' benefits of the adjustment of fluoride concentration of the treated water.

Fluoretação da água é uma estratégia de controle da cárie, recomendada pela OMS. No Brasil ela é regulamentada por lei, mas não tem sido implementada com sucesso na região Norte. Os objetivos desta pesquisa foram levantar dados sobre a existência do heterocontrole nos 10 maiores municípios tocantinenses e analisar a concentração de fluoreto presente na água de abastecimento público destas cidades. A pesquisa foi realizada de maio-agosto/17 e teve como marco teórico-metodológico a análise quantitativa, descritiva e transversal. Coletas de água foram realizadas mensalmente, utilizando protocolo de amostragem de coleta de água da rede. A concentração de fluoreto nas águas foi feita com eletrodo íon específico pela técnica direta. Constatou-se que a vigilância da fluoretação da água está em operação na capital do estado desde 2016. Com relação a concentração de fluoreto na água, foi encontrado que 31,6% das amostras analisadas estavam adequadas para o máximo benefício de redução de cárie e 27,5% delas apresentavam risco alto ou muito alto de fluorose dentária. É necessário implementar um programa de controle da concentração de flúor na água no Tocantins, a fim de garantir que a população não seja privada dos benefícios anticárie da agregação de flúor à agua tratada.

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.

Fluoretação da água dos dez maiores municípios do estado do Tocantins, Brasil / Water fluoridation in the ten largest municipalities of the state of Tocantins, Brazil

Resumo Fluoretação da água é uma estratégia de controle da cárie, recomendada pela OMS. No Brasil ela é regulamentada por lei, mas não tem sido implementada com sucesso na região Norte. Os objetivos desta pesquisa foram levantar dados sobre a existência do heterocontrole nos 10 maiores municípios tocantinenses e analisar a concentração de fluoreto presente na água de abastecimento público destas cidades. A pesquisa foi realizada de maio-agosto/17 e teve como marco teórico-metodológico a análise quantitativa, descritiva e transversal. Coletas de água foram realizadas mensalmente, utilizando protocolo de amostragem de coleta de água da rede. A concentração de fluoreto nas águas foi feita com eletrodo íon específico pela técnica direta. Constatou-se que a vigilância da fluoretação da água está em operação na capital do estado desde 2016. Com relação a concentração de fluoreto na água, foi encontrado que 31,6% das amostras analisadas estavam adequadas para o máximo benefício de redução de cárie e 27,5% delas apresentavam risco alto ou muito alto de fluorose dentária. É necessário implementar um programa de controle da concentração de flúor na água no Tocantins, a fim de garantir que a população não seja privada dos benefícios anticárie da agregação de flúor à agua tratada.

Abstract Water fluoridation is a strategy for caries control recommended by the WHO. In Brazil, it is regulated by law but this program has not been successfully implemented in the North region. This research aimed to collect data on the existence of external control (heterocontrol) in the ten largest municipalities in the state of Tocantins, Brazil, and to analyze fluoride concentration in the public water supply of these cities. The study was conducted from May-August/17, and its theoretical-methodological framework was a quantitative, descriptive and cross-sectional analysis. Water collections were carried out monthly, using sampling protocol of water collection of the network. Fluoride concentration in the waters was determined with ion specific electrode by the direct technique. It was verified that water fluoridation monitoring is only been done in Palmas, capital of the state, starting in 2016. Thirty-two percent of waters samples analyzed showed fluoride concentration to obtain the maximum benefit of reduction caries and 27.5% of them presented a high or very high risk of dental fluorosis. It is necessary to implement a program to control the concentration of fluoride in the water of the municipalities of Tocantins, in order to ensure that the population is not deprived of the anticaries' benefits of the adjustment of fluoride concentration of the treated water.