Referendum opposition to fluoridation and health literacy: a cross-sectional analysis conducted in three large US cities.

OBJECTIVE: To explore health literacy as a marker of voter confusion in order to understand the basis for public opposition to community water fluoridation. DESIGN: A cross-sectional study. SETTING: Conducted in three large US cities of San Antonio, Texas (602 voting precincts); Wichita, Kansas (171 voting precincts); and Portland, Oregon (132 voting precincts). Precinct-level voting data were compiled from community water fluoridation referendums conducted in San Antonio in 2002, Wichita in 2012 and Portland in 2013. PARTICIPANTS: Voter turnout expressed as a percentage of registered voters was 38% in San Antonio (n=2 92 811), 47% in Wichita (n=129 199) and 38% in Portland (n=164 301). MAIN OUTCOME MEASURES: The dependent variable was the percentage of votes in favour of fluoridating drinking water. Precinct-level voting data were mapped to precinct scores of health literacy, and to US Census and American Community Survey characteristics of race/ethnicity, age, income and educational attainment. Multilevel regression with post-stratification predicted the precinct mean health literacy scores, with weights generated from the National Association of Adult Literacy health literacy survey, with item response theory computed scoring for health literacy. Predictive models on voter support of community water fluoridation were compared using robust linear regression to determine how precinct-level characteristics influenced voter support in order to determine whether health literacy explained more variance in voting preference than sociodemographic characteristics. RESULTS: Precinct-level health literacy was positively associated with voter turnout, although sociodemographic characteristics were better predictors of turnout. Approximately 60% of voters opposed community water fluoridation in Wichita and Portland, whereas in San Antonio, a small majority (53%) voted in favour of it. Models suggest that a one SD increase in health literacy scores predicted a 12 percentage point increase support for community water fluoridation. CONCLUSION: Educational attainment and health literacy are modifiable characteristics associated with voting precincts' support for community water fluoridation.

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

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

Knowledge of primary care professionals about fluoride topics.

BACKGROUND: Scientific evidence on the benefits of fluoride was responsible for an important change in dental practice. Individual and collective actions have been planned to impact the epidemiology of oral health. However, questions around this topic persist, making discussions and researches still necessary. In this regard, the aim of this study was to verify the fluoride-related knowledge of pediatricians (PP) and dentists (DS) working in primary care, comparing related aspects such as its multiple sources of intake and dental fluorosis. METHODS: A group of PP and DS answered as self-administered questionnaire related to fluoride knowledge. PP group presented a lower level of adherence (34%) in comparison to the DS group (70%). RESULTS: Fluoride-related topics were learnt at undergraduate courses by 95,95% of dentists and 38.46% of pediatricians. Ninety-two per cent of DS and 78.57% of PP claimed to know the clinical aspects of dental fluorosis. Pediatricians tend to indicate the use of fluoridated dentifrices at any age but advise less about the right amount to be placed on the toothbrush in comparison to DS. CONCLUSIONS: Dentists and pediatricians presented limited fluoride-related knowledge. Continued education/training is encouraged and necessary at this level in order to deliver the benefits of fluoride use to populations.

Survey of Oral Health Awareness in Neuchâtel 9th Graders.

The oral health habits of pupils had not yet been analyzed for the canton of Neuchâtel. A questionnaire was provided to 9th grade high school pupils (final year) of the three schools located in the Neuchâtel area to asses both oral health knowledge and habits in this connection. The average age was 15.5±0.8 years, and 78.1% of the questionnaires were returned. The prophylaxis program was conducted for a total of 4.5 h during pupils’ entire time at school. The results showed that both knowledge and oral health habits could be improved. As a positive outcome, 99% of the pupils brush their teeth before going to bed. Comparisons with similar 10-year-old studies from other cantons (Bern, Vaud) showed major differences in knowledge, for example on the importance of fluoridation. Only 54% of the pupils in Neuchâtel knew that fluoride offers some protection against caries, in spite of the fact that 89% thought that brushing with fluoridated toothpaste protects against caries. Most of the pupils used a fluoridated toothpaste. Furthermore, we found that self-reported sugar consumption was correlated with caries experience, but brushing frequency was not. We recommend introducing a review course for pupils in their last school year, in order to practice interdental cleaning, redefine appropriate, tooth-friendly snacks, and emphasize the importance of regular dental check-ups.

Acceptability of Salt Fluoridation in a Rural Latino Community in the United States: An Ethnographic Study.

Compared to other population groups in the United States, caries (tooth decay) is a disproportionately prevalent disease among Latino populations, especially among low-income and rural sub-groups and children under five years of age. Fluoride is a primary preventive for caries. While water fluoridation is a major and effective public health means for delivering fluoride on a mass scale, it does not reach many rural areas or population groups such as Latinos who eschew drinking water from municipal sources. This study examines the acceptability to such groups of salt fluoridation, an alternate means of delivering fluoride long used on a global scale. An ethnographic study in California's rural Central Valley was performed. Thirty individual interviews and 5 focus groups (N = 61) were conducted in Spanish to investigate low-income Latino migrant caregivers' experiences, views and understandings of domestic salt, oral health, caries prevention and fluoride. Audio data were transcribed, translated, coded and thematically analyzed. Table salt was readily available and frequently consumed. Both adult and child daily sodium consumption was high. Despite a general feeling that it was good, and present in dentifrices or dietary supplements, most participants had little knowledge about fluoride. Concerns were raised about cardio-vascular and other possibly deleterious effects if an increase in salt consumption occurred because fluoridated salt was viewed as having 'extra' benefits. Once informed about fluoride's safety and role in caries prevention, most participants expressed willingness to use fluoridated salt, especially if it benefitted children. Reassurance about its safety and benefits, and demonstration of its taste, were important aspects of acceptance. Taste was paramount. Participants would not consume more fluoridated salt than their current salt as that would result in unpleasant changes in food flavor and taste. While salt fluoridation is acceptable, the feasibility of producing and distributing fluoridated salt in the United States is, however, complex and challenging.

Public perceptions and scientific evidence for perceived harms/risks of community water fluoridation: An examination of online comments pertaining to fluoridation cessation in Calgary in 2011.

OBJECTIVES: To examine the perceived harms/risks of fluoridation as expressed in online forums relating to cessation and aftermath in Calgary, specifically, 1) which harms/risks are mentioned, 2) for those harms/risks, what kinds of evidence are cited, 3) to what extent is scientific literature cited, and what is its quality, and 4) for a subset of harms/risks, what is known from the broader scientific literature? METHODS: Relevant online comments were identified through free-text Internet searches, and those explicitly discussing the harms/risks of water fluoridation were extracted. Types of evidence mentioned were identified, and the scientific papers cited were reviewed. Finally, the broader scientific literature on two of the harms/risks was reviewed and synthesized. SYNTHESIS: We identified 17 distinct groups of harms/risks, which spanned human body systems, the environment and non-human organisms. Most often, no evidence was cited. When evidence was cited, types included individuals viewed as authorities and personal experiences. Reference to scientific articles was rare, and those papers (n = 9) had significant methodological concerns. Our review of scientific literature on fluoride and 1) thyroid functioning and 2) phytoplankton revealed some negative effects of fluoride at concentrations exceeding maximum recommended levels (>1.5 ppm). CONCLUSION: The findings have implications for communication with the public about fluoridation. First, to the extent that the public consults the scientific literature, it is essential that the methodological limitations of a study, as well as its relevance to community water fluoridation, be widely and promptly communicated. Second, scientific evidence is only one component of why some people support or do not support fluoridation, and communication strategies must accommodate that reality.

Risk perception, psychological heuristics and the water fluoridation controversy.

OBJECTIVES: Increasingly, support for water fluoridation has come under attack. We seek an explanation, focusing on the case of Waterloo, Ontario, where a 2010 referendum overturned its water fluoridation program. In particular, we test whether individuals perceive the risks of water fluoridation based not on 'hard' scientific evidence but on heuristics and cultural norms. METHODS: A sample of 376 residents in Waterloo were surveyed in June 2012 using random digit dialing. We use factor analysis, OLS regression, as well as t-tests to evaluate a survey experiment to test the credibility hypothesis. RESULTS: Perceptions of fluoride as a risk are lower among those who perceive fluoride's benefits (B = .473, p < 0.001) and those whose cultural view is 'egalitarian' (B = .156, p < 0.05). The experiment shows a lower level of perception of fluoride's benefits among respondents who are told that water fluoridation is opposed by a national advocacy group (Group A) compared to those who are told that the government and the World Health Organization support fluoridation (Group B) (t = 1.6547, p < 0.05), as well as compared to the control group (t = 1.8913, p < 0.05). There is no difference between Group B and the control, possibly because people's already general support for fluoridation is less prone to change when told that other public organizations also support fluoridation. CONCLUSION: Public health officials should take into account cultural norms and perceptions when individuals in a community appear to rise up against water fluoridation, with implications for other public health controversies.

Knowledge and behaviour of parents in relation to the oral and dental health of children aged 4-6 years.

AIM: To evaluate baseline knowledge and behaviour of parents with regard to the oral and dental health of their young children. METHODS: Following ethical approval, six urban and rural schools were identified. Questionnaires were distributed to the parents of pupils (children aged 4-6 years). The questionnaire included several questions evaluating parental knowledge and behaviour of oral and dental health issues in their children. Each question was assigned a score of either 0 or 1 being inconsistent or consistent with current paediatric guidelines giving a maximum score of 6 for knowledge and 7 for behaviour. Chi-square analysis was used to analyse associations among variables. RESULTS: Parental knowledge varied widely among parents and across questions; however, 70.2 % of parents had scores greater than 3 (range 0-6). The majority of parents (65.8 %) also had scores greater than 3 (range 0-7) for behaviour. Deficiencies were noted in oral hygiene practices; very few parents brushed their child's teeth and were not aware of the recommended age of the first dental visit at 1 year (Age 1 visit). Parents without free medical care demonstrated high levels of knowledge (P < 0.05). Almost half of the parents thought that the information available to them on the oral health of their young children was insufficient. CONCLUSION: Parents appeared to have limited knowledge regarding the dental and oral health of their young children. This study indicates a need for improved education for parents, particularly in toothbrushing behaviour and use of toothpaste. Education strategies tailored to the Irish population should be explored.

Dental attendance, perceptions of cost and self-care of school year 12 and 13 students: A focus on Southland, New Zealand.

BACKGROUND AND OBJECTIVES: Adolescents and emerging adults can provide dentists with many challenges. Little information is available on their perceptions of dental costs once they turn 18 and dentistry is no longer State-funded. The aim of this study was to explore the use of dental care by Southland students in years 12 and 13, their perceptions of the cost of four common dental procedures, self-related oral health and dental self-care habits, time off school related to dental problems, and knowledge and views regarding fluoride. METHODS: After ethical approval, a 26-question survey was conducted of all Southland students in years 12 and 13. Data were statistically analysed in SPSS version 20 with the alpha value set at 0.05. RESULTS: The participation rate was 49.6%. Regular attendance for examinations was reported by 77.5% with non-attendance mainly related to attitudes around lack of importance or necessity. Reported dental attendance varied according to gender, ethnicity and decile rating of school attended. Although some were accurate in their estimations of dental costs, the standard deviation for all procedures was large. The majority thought that costs put people off going to the dentist. While 74.8% brushed their teeth at least twice daily, only 26.6% flossed regularly. Knowledge regarding fluoride was lacking. CONCLUSIONS: It may be advantageous to include education regarding costs of dental care with patients of this age. This may motivate them to improve their self-care and ensure that their oral health is of a high standard before their dental needs are no longer State-funded.

New Zealand dentists' views on community water fluoridation.

OBJECTIVE: To determine whether New Zealand general dental practitioners support community water fluoridation (CWF), and to gauge their opinions on its possible systemic side-effects. METHODS: An online survey was conducted in 2010, involving the 1174 general dental practitioners who had email addresses on the Dental Register and were contactable in New Zealand. A total of 465 dentists (39.6%) participated. RESULTS: Most practitioners (93.5%) reported supporting community water fluoridation; the other 6.5% either were unsure or did not support it. Higher proportions of more recent graduates supported CWF. Some 85.6% of practitioners thought that drinking fluoridated water was a harmless way to prevent dental caries, but 6.2% felt that fluoridated water may cause other health problems. There were no systematic differences by sociodemographic and practice characteristics, except that a higher proportion of males and more experienced practitioners reported being confident in discussing CWF-related issues. CONCLUSIONS: Most New Zealand dental practitioners support community water fluoridation, although a very small proportion believe that it is harmful and/or does not prevent caries.

Associations between oral health behavior and anxiety about water fluoridation and motivation to establish water fluoridation in Japanese residents.

Since 1972, community water fluoridation programs have not been practiced in Japan. Risk perception among the population plays an important role in the implementation of water fluoridation programs. The oral health behavior of Japanese children has changed, especially due to recent increases among children in the use of fluoridated products and fluoride applications by dentists. The purpose of this study was to examine the associations between oral health behavior, risk perception, and the desire to implement water fluoridation among Japanese residents. We distributed a questionnaire survey (response rate: 92.8%) to mothers with children aged two or three years (n = 573). There was a correlation between anxiety and level of motivation to implement water fluoridation (Spearman coefficient: 0.355, P < 0.001). Exposure to various fluoride experiences was higher in the "not anxious" group. The motivation level was significantly higher in subjects who had a better understanding of the effectiveness of fluoride, those who used fluoride tooth paste, and those whose children received fluoride applications from dentists. We conclude that increased knowledge of and experience with fluoride might help decrease the perception of risk and increase motivation for implementing water fluoridation among the general public.

Cities without cavities: democracy, risk, and public health.

This essay examines the history of fluoride debates in four Canadian cities. It argues that fluoride's opponents were primarily motivated by what they saw as the health and environmental risks of adding fluoride to the water supply. They also believed that fluoridating the public water supply was a fundamental violation of civil liberties. The fluoride debates have much to teach us about how people evaluate potential health risks and how they respond to state interventions in the field of public health.

Parental support for water fluoridation in Lithgow, New South Wales.

BACKGROUND: The objective of this paper was to report on the level of support for water fluoridation among parents of primary school children in Lithgow and on the socio-demographic and oral health factors that may have influenced this support. METHODS: As part of a survey in Lithgow of the oral health status of school children, their parents were asked to complete an oral health-related questionnaire. Questions on support for fluoridation and socio-demographics were included. Descriptive statistics and logistic regression analysis were used to examine associations between variables. RESULTS: Seventy per cent of the responding parents supported water fluoridation. However, this support was significantly higher among those from a higher socio-economic background. Nearly half the parents thought that health authorities or the government should take on the responsibility for matters related to water fluoridation. No statistically significant differences in caries experience were observed amongst children whether or not their parents supported fluoridation, except for 5-6 year olds (p < 0.01). CONCLUSIONS: Lithgow parents strongly supported the introduction of water fluoridation but suggested that governments and health authorities should adopt a more proactive role in relation to fluoridation implementation.

'Into every home, into every body': organicism and anti-statism in the British anti-fluoridation movement, 1952-1960.

This article argues that the anti-fluoridation campaigns in the 1950s stemmed from concerns about both the increasing 'chemicalization' of food and the growing authority of the state over the private home and individual body. The British Housewives League (BHL), an organization typically thought insignificant after the late 1940s, was in fact at the centre of these campaigns. Steeped in the beliefs of inter-war and wartime organicism, the housewives believed that government intervention in food production and distribution was producing a post-war diet laden with harmful chemicals. The Ministry of Health's proposals to test water fluoridation in select communities in the early 1950s only further convinced the housewives that the state was harming the nation both physically and politically. More and more citizens would have no choice but to drink impure, potentially harmful water, they argued, and the burgeoning state would continue encroaching on private homes and bodies. While scholars have already demonstrated that what we now think of as 'leftist' environmental ideas were popular among 'rightist' movements of the 1930s and 1940s, the anti-fluoridation campaigns show that the BHL continued in the post-war years to intertwine our present-day notions of 'left' and 'right' ideologies.