Water fluoridation between public health and public law: an assessment of regulations across countries and their preventive medicine implications.

Background: Among health professionals and health policymakers concern is growing as to the difficulty of balancing the prevention of dental caries through cost-effective interventions and the need to limit unnecessary exposure of the population, and especially children, to environmental chemicals. In this respect, the use of water fluoridation to prevent tooth decay epitomizes the dilemma by raising questions relevant to both public health and public law, ranging from the balance of public health and medical self-determination, the division of powers between local or national authorities over water fluoridation, and the need to avoid the adverse effects of socioeconomic inequalities as well as both under- and over-exposure. Study design: We carried out a narrative review by searching the relevant literature about the laws and rules related to drinking water fluoridation at the community level in the US, UK, and Europe, in order to discuss how the issue is handled from both a public health and public law perspective. Methods: Sources of data for this review were the biomedical and legal literature retrieved by searching online databases, and websites of public health and legal institutions. Results and Conclusions: We found that water fluoridation is still largely adopted throughout the US, while in the UK and particularly in the European Union only a minor part of the population is subject to it. In addition, the recommended and maximum allowed amounts of fluoride in drinking water are being adapted to the public health recommendations and the new regulations, within an evolving evaluation of the epidemiologic evidence and the risk assessment currently in progress by two major regulatory agencies, the US National Toxicology Program - NTP and the European Food Safety Authority - EFSA. Under a comparative public law perspective, the three investigated legislations are facing a reassessment of their policies and regulations, to allow for effective and safe public health measures in the field of water fluoridation and more generally for a preferred use of topical fluoride for caries prevention. A consistent trend across these legislations is the choice to centralize at the national level regulatory and management issues related to water fluoridation, and to carefully balance benefits for dental caries prevention in children and the potential risks of systemic overexposure associated with excess fluoride intake, by promptly responding to the evolving indications by the scientific community and the public health professionals.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review.

OBJECTIVES: To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis. METHODS: Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal. RESULTS: Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis. CONCLUSIONS: Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Cost-effectiveness analysis of a school-based dental caries prevention program using fluoridated milk in Bangkok, Thailand.

BACKGROUND: This study modelled the cost-effectiveness, from a societal perspective, of a program that used fluoridated milk to prevent dental caries in children who were 6 years old at the beginning of the program, versus non-intervention, after 6 years. METHODS: After 6 years, children in the milk-fluoridation program had a significant (34%) reduction in dental caries experience compared to those in the comparison community (i.e., received school milk without added fluoride) (DMFS: 1.06 vs. 1.60). RESULTS: This improvement was achieved with an investment of Thailand Baht (THB) 5,345,048 over 6 years (or THB 11.88 per child, per year) (1 US$ = THB(2011) 30.0). When comparing the costs of the operation of the program and dental treatment in the test community with those of the comparison community, the program resulted in a net societal savings of THB 8,177,179 (range 18,597,122 to THB 7,920,711) after 6 years. This investment would result in 40,500 DMFS avoided in a community with a childhood population of 75,000 [DMFS avoided: 75,000 x (- 0.54)]. CONCLUSIONS: While the analysis has inherent limitations due to its dependence on a range of assumptions, the results suggest that, from a societal perspective, when compared with the non-intervention group, the Bangkok Metropolitan Administration intervention appeared to be a more cost-efficient option than current standard oral health care.

Management of dental caries among children: a look at the cost-effectiveness.

INTRODUCTION: Dental caries is the most prevalent non-communicative disease worldwide. Although the etiological factors are well known for years, reducing the number of decayed and missing teeth in children still remains as a barrier. Preventive and curative options are numerous but little is known about their economical advantages. Selecting the intervention that offers the best balance of effectiveness and financial resources becomes crucial in the current situation of budget restrictions worldwide. AREAS COVERED: This expert review summarizes available evidence on cost-effectiveness analyses of preventive and curative measures to manage dental caries in children. EXPERT COMMENTARY: Preventive measures have been more extensively studied than dental caries treatment. Only water fluoridation and tooth brushing are well-established as cost-effective preventive approaches. Despite the increasing number of cost analysis treatment studies in the literature, most of them focus on the cost description, with no correlation to the intervention effectiveness. There is a current need of well-designed and well-reported cost-effectiveness regarding dental caries management.

Milk fluoridation for the prevention of dental caries.

UNLABELLED: The aim of this review is to give an overview of 55 years experience of milk fluoridation and draw conclusions about the applicability of the method. Fluoridated milk was first investigated in the early 1950s, almost simultaneously in Switzerland, the USA and Japan. Stimulated by the favourable results obtained from these early studies, the establishment of The Borrow Dental Milk Foundation (subsequently The Borrow Foundation) in England gave an excellent opportunity for further research, both clinical and non-clinical, and a productive collaboration with the World Health Organization which began in the early 1980s. Numerous peer-reviewed publications in international journals showed clearly the bioavailability of fluoride in various types of milk. Clinical trials were initiated in the 1980s - some of these can be classed as randomised controlled trials, while most of the clinical studies were community preventive programmes. CONCLUSION: These evaluations showed clearly that the optimal daily intake of fluoride in milk is effective in preventing dental caries. The amount of fluoride added to milk depends on background fluoride exposure and age of the children: commonly in the range 0.5 to 1.0 mg per day. An advantage of the method is that a precise amount of fluoride can be delivered under controlled conditions. The cost of milk fluoridation programmes is low, about € 2 to 3 per child per year. Fluoridation of milk can be recommended as a caries preventive measure where the fluoride concentration in drinking water is suboptimal, caries experience in children is significant, and there is an existing school milk programme.

Heterocontrole da fluoretação das águas de abastecimento público do Município de Canoas/RS / External control of fluoridation in public water supply of Canoas/RS

O objetivo do estudo foi avaliar a concentração de flúor presente na água de abastecimento público do município de Canoas/RS. Amostras da água de abastecimento foram coletadas em duplicatas por 8 meses em 22 diferentes pontos agrupados em três Estações de Tratamento (ETAs) da cidade. A medição da concentração de fluoreto foi realizada através do método eletrométrico. A análise das amostras coletadas no período avaliado demonstrou haver oscilação na concentração de flúor de acordo com os meses de coleta (de 0,185 a 1,605 ppm/L). Das amostras avaliadas, 96 (54,5%) estiveram inadequadas (< 0,6 ppm; > 0,9 ppm ) quanto à concentração de flúor presente. Das amostras inadequadas, a maioria apresentou concentração superior ao limite máximo de concentração aceitável para o padrão de potabilidade. Houve diferença estatisticamente significante entre as 3 ETAs em relação à adequação da concentração de flúor (p < 0,001). A grande variação em relação à concentração de flúor presente em diferentes pontos de coleta, bem como a alta porcentagem de amostras com padrão inadequado de fluoretação revelam a necessidade de se implantar medidas de heterocontrole permanente para garantir efetividade da fluoretação das águas.

The aim of this study was to evaluate the concentration of fluoride in public water supplies in Canoas/RS. Samples of drinking water were collected in duplicates for eight months on22 different points grouped into three water treatment plants of the city. The measurement of fluoride concentration was performed using the electrometric method. The analysis of samplescollected in the study period showed that there was oscillation in fluoride concentrations in accordance with the sampling months (from 0.185 to 1.605 ppm /L). Of the samples, 96 (54.5%)were inadequate (<0.6 ppm> 0.9 ppm) as the fluoride concentration. Of inadequate samples, the majority showed concentrations above the maximum acceptable concentration for drinking water standard. There was statistically significant difference among the three water treatment plantsregarding the suitability of the fluoride concentration (p <0.001). The large variation in relation to fluoride concentration as well as the high percentage of inadequate samples revealed the need to implement measures of external control to ensure continuous effectiveness of water fluoridation.

[Optimal fluoride level in drinking water and public health].

Water fluoridation is a safe, efficient, and well-proven way of preventing dental decay in the community. In countries such as Israel, where dental care is not covered by the national insurance law, this has an important role in reducing social inequalities in health care. For toddlers and children, water fluoridation is the only way of promoting dental health without a need for regular visits to dental clinics, and without regard to parent awareness and motivation. The other methods of fluoride supplementation do not succeed in reaching the level of safety and cost-efficiency of water fluoridation, and their use is successful only among upper socio-economic classes. Water fluoridation has been defined by the US CDC as one of the main achievements in health care during the 20th century. In spite of the legal difficulties raised by various activist groups, the use of water fluoridation is growing steadily among developed as well as third world countries. The Israeli bylaw of national water fluoridation that is in effect will enable the safe improvement of the overall dental health status of the population at an extremely low cost.

Recommendations for fluoride use in children. A review.

Fluoride has played a significant role in the improvement of the oral health of all Americans. Because of its effectiveness, cost and frequency of exposure, water fluoridation is the preferred method of delivery. Today, many products containing fluoride are available over the counter and as prescription items. The potential for exposure to multiple sources of fluoride has increased. Therefore, practitioners should prescribe fluoride therapy based on an understanding of patients' total exposure to fluoride and the need for additional amounts.

Should we use milk fluoridation? A review.

This article presents the argument that because of several demonstrated advantages, milk fluoridation provides a valid alternative to water fluoridation when the latter is not possible. Extensive literature describing study of fluoride compounds administered with calcium-rich food, as well as clinical trials and laboratory experiments with fluoridated milk, have demonstrated its effectiveness in caries prevention. The main criticisms of milk fluoridation are decreased bioavailability of the fluoride, the cost and administrative burden involved, and (in some cases) lack of sound clinical conclusions regarding its preventive efficacy. These criticisms are reviewed in the light of evidence now available.

Evaluación del programa de fluoración del agua en 3 comunidades de Provincia La Habana / Assessment of a water fluoridation program in three communities from Havana Province

Se realizó un estudio comparativo en 3 comunidades de provincia La Habana (La Salud, Bauta y San José), con más de 5 años de incorporación al Programa Nacional de Fluoración, con el propósito de medir la reducción de la caries dental en relación con la fluoración del agua de consumo. Se evaluó la operación en sus acueductos mediante el análisis de la efectividad de las concentraciones del ion fluoruro, por lo que La Salud resultó la comunidad de mejor operación. La evaluación epidemiológica demostró, también en La Salud, un mayor tanto por ciento de reducción del índice de caries (75 por ciento )

The Venturi Fluoride Saturator project.

This study was conducted to determine whether Venturi Fluoride Saturator (VFS) systems could be used to fluoridate small community and school water supply systems with an acceptable level of maintenance. VFS systems were installed and operated at four school and six community well sites according to state and federal regulations and recommendations. School VFS systems were unable to maintain optimum fluoride residuals even with substantial maintenance. All six community well site VFS systems performed acceptably, with only a few short lapses. VFS system maintenance was labor intensive. Recurring problems were caused by lengthy equipment delivery delays, the unavailability of timely technical assistance to support the VFS system, and the inadequate quality of VFS equipment and design. Based upon these findings, further expansion of the use of VFS systems either for community or school fluoridation cannot be recommended. Additional study of and improvements in the VFS system are indicated. Three major recommendations appear appropriate: (1) extensive laboratory testing of the VFS system concept under controlled conditions should be performed to determine the functioning parameters of this equipment under different hydrodynamic conditions; (2) additional research and development of the VFS unit to improve the quality of operations and the quality control of manufacturing and assembly should be undertaken; and (3) a VFS equipment distribution network should be developed, with sufficient logistical and technical support to supply equipment parts and expertise for installation, monitoring, and maintenance in a timely and efficient manner.

[Caries prevention through a nutritional vehicle]. / La prevención de caries a través de un vehículo nutricional.

In order to evaluate the efficacy of fluoridated milk as a cariostatic nutritional product, the biological and technical possibilities of adding fluoride (F) as monofluorophosphate (MFP) to milk were studied, together with a preliminary cost estimation for this procedure. F ingestion by preschool children pertaining to the low and medium-low levels of population was estimated through polls and chemical analyses. The values of F ingestion obtained were in the range of 0.15-0.30 mg/day. The bioavailability of F in those dietary elements which have the highest F concentration was determined. Taking a value of 1.00 for F absorption from sodium fluoride (NaF) in water, relative values of 0.58 and 0.32 were obtained for tea ingestion on a fasting stomach, and together with solid food, respectively. The corresponding value for fish was 0.34. Through another bioavailability experiment it was shown that the absorption of F (from MFP) in milk, is as high as that of F (from NaF) in water. By means of a comparative cost estimation study, it was found that, for the Chilean situation, milk fluoridation is, at least, 1,000 times more economic than water fluoridation. It is concluded that milk fluoridation is an economical and viable alternative for some less developed countries.

Un sistema económico de fluoruración del agua en communidades rurales / An economic system of water fluoridation in rural communities

A gravity-operated mechanism for measuring fluoride dosage is described. It would be suitable for rural areas and communities which lack the funds to purchase an electric mechanism, or which have not electricity

The fluoridator described has functioned with proved accuracy for the four years of the test, in a community whose aqueduct has a constant flow of 12 liters per second and whose population is 4,500 inhabitants

The cost of the accessories and tanks which make up the fluoridator is only 2,420 Colombian pesos, or US$138.28

The fluoridator parts are simple, easy to obtain, economical and safe. These qualities make it feasible to build and use in any area. Moreover, because of its simplicity, and ordinary workman can operate it with easily understood instructions and with the assurance that there is no risk of any kind(AU)