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.

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.

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.

La concentración de fluoruro en las aguas consumidas en la Región de Murcia no es suficiente para prevenir la caries dental / Fluoride concentrations in water consumed in the Region of Murcia are not sufficient to prevent dental caries

INTRODUCCIÓN: La caries sigue siendo la enfermedad crónica más frecuente en el niño y es considerada un problema de salud pública. El flúor es la principal medida protectora contra la caries dental y el agua de consumo es la principal fuente de ingesta de flúor. Objetivo El objetivo de nuestro trabajo fue calcular la concentración de ión fluoruro en el agua de abastecimiento de 10 zonas y en 10 aguas embotelladas comercializadas en la Región de Murcia. MATERIAL Y MÉTODOS: La concentración de fluoruro en las aguas se determinó con un electrodo ion-selectivo para flúor previamente calibrado con patrones de fluoruro preparados con TISAB II. RESULTADOS: En el agua de abastecimiento, se detectaron concentraciones de fluoruro entre 0.09 y 0.18 mgF/L (ppm) en las aguas embotelladas la concentración de fluoruro varió desde 0.04 a 0.50 ppm. CONCLUSIONES: El fluoruro está presente en aguas consumidas en la Región de Murcia pero en concentraciones que no alcanzan niveles preventivos para la caries dental. Es necesario prescribir suplementos de flúor en niños con alto riesgo de caries y para ello se deben contabilizar todas las fuentes externas de flúor, incluido el agua

INTRODUCTION: Dental caries remains the most frequent chronic disease in childhood and is considered a public health problem. Fluoride has proven effectiveness in the prevention of caries and drinking water is the main source of fluoride intake. The objective of this study was to determine fluoride concentrations in tap water from 10 areas and in 10 bottled waters sold in the Region of Murcia. MATERIALS AND METHODS: The concentration of fluoride in water was determined using a fluoride ion-selective electrode with a direct technique previously calibrated with standard fluoride concentrations prepared with TISAB II. RESULTS: In tap water, fluoride concentrations from 0.09 to 0.18 mgF/L (ppm) were detected; in bottled waters the concentration of fluoride varied from 0.04 to 0.50 ppm. CONCLUSION: Fluoride is present in the water consumed in the Region of Murcia but in concentrations that do not prevent dental caries. Fluoride supplements should be prescribed in children at high risk of caries, and for this, all external sources of fluoride intake, including water, must be accounted for

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.

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.

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.

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.

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.

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.

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.

Dental caries experience and associated factors in 12-year-old-children: a population based-study.

Relevant public policies in oral health have been implemented in Brazil since 2004. Changes in the epidemiological status of dental caries are expected, mainly in the child population. This study aimed to assess the dental caries experience and associated factors among 12-year-old children in the state of São Paulo, Brazil. A cross-sectional population-based study was conducted with data obtained from 415 cities, including a total of 26,325 schoolchildren who were included by the double-stage cluster technique, by lot and by systematic sampling. The statistical model included data from the São Paulo Oral Health Survey (SBSP 2015), the Human Development Index (HDI) and the Social Vulnerability Index (SVI). A theoretical-conceptual model categorized the variables into three blocks, namely, contextual (HDI, SVI, region of residence and fluoridation of water), individual (sex and ethnicity) and periodontal conditions (gingival bleeding, dental calculus and the presence of periodontal pockets), for association with the experience of caries (DMFT). Statistically significant associations were verified by hierarchical multivariate logistic (L) and Poisson (P) regression analyses (p < 0.05). The results showed that 57.7% of 12-year-old children had caries experience. Factors that determined a greater prevalence of dental caries in both models were nonwhite ethnicity (ORL = 1.113, ORP = 1.154) and the presence of gingival bleeding (ORL = 1.204, ORP = 1.255). Male children (ORL = 0.920 ORP = 0.859) and higher HDI (ORL = 0.022), ORP = 0.040) were associated with a lower prevalence of dental caries experience. Water fluoridation was associated with a lower DMFT index (ORP = 0.766). Dental caries experience is still associated with social inequalities at different levels. Policymakers should direct interventions towards reducing inequalities and the prevalence of dental caries among 12-year-old children.

A retrospective nationwide study of the dental caries experience of New Zealand children with orofacial cleft.

OBJECTIVES: To investigate the dental caries experience of New Zealand children born with orofacial cleft (OFC), to compare this to age-specific national population-based data and to investigate any differences by demographic characteristics, cleft type and exposure to community water fluoridation. METHODS: Nationwide retrospective study of 554 dental records from 478 children born after 1 January 2000 with OFC were assessed at aged 5 (n = 333) and 12 years (n = 221), with 76 children (15.9%) having records at both ages. Community Oral Health Service records were analysed to determine dental caries experience (dmft/DMFT). Logistic regression was used to assess the likelihood of having experienced dental caries (d3 mft/D3 MFT ≥ 1) and multivariable models for variables including demographic characteristics, cleft type and exposure to community water fluoridation. RESULTS: A higher (49.6%) caries prevalence (dmft ≥ 1) and mean dmft at 5 years old (2.3; SD 3.6) were found in children with OFC than 5-year-olds in the general population (prevalence 40.4% and mean dmft 1.8). The 12-year-old (37.6%) caries prevalence (DMFT ≥ 1) and mean DMFT 0.8 (SD 1.4) were similar to population-based data (caries prevalence 37.3% and mean DMFT 0.9). Children with caries (dmf/DMF ≥ 1) had means of 4.8 (SD 3.8) at age 5 and 2.1 (SD 1.4) at age 12 years. Greater caries experience was associated Pacific and Maori ethnicity, and not receiving community water fluoridation. No differences were detected by sex or cleft type. CONCLUSION: The dental caries experience for 5-year-old children with OFC was poor in relation to population-based data and similar for 12-year-olds. Preventive guidelines for children with OFC from an early age should be a priority, along with the extension of community water fluoridation coverage.

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.

Dental caries experience and associated factors in 12-year-old-children: a population based-study

Abstract Relevant public policies in oral health have been implemented in Brazil since 2004. Changes in the epidemiological status of dental caries are expected, mainly in the child population. This study aimed to assess the dental caries experience and associated factors among 12-year-old children in the state of São Paulo, Brazil. A cross-sectional population-based study was conducted with data obtained from 415 cities, including a total of 26,325 schoolchildren who were included by the double-stage cluster technique, by lot and by systematic sampling. The statistical model included data from the São Paulo Oral Health Survey (SBSP 2015), the Human Development Index (HDI) and the Social Vulnerability Index (SVI). A theoretical-conceptual model categorized the variables into three blocks, namely, contextual (HDI, SVI, region of residence and fluoridation of water), individual (sex and ethnicity) and periodontal conditions (gingival bleeding, dental calculus and the presence of periodontal pockets), for association with the experience of caries (DMFT). Statistically significant associations were verified by hierarchical multivariate logistic (L) and Poisson (P) regression analyses (p < 0.05). The results showed that 57.7% of 12-year-old children had caries experience. Factors that determined a greater prevalence of dental caries in both models were nonwhite ethnicity (ORL = 1.113, ORP = 1.154) and the presence of gingival bleeding (ORL = 1.204, ORP = 1.255). Male children (ORL = 0.920 ORP = 0.859) and higher HDI (ORL = 0.022), ORP = 0.040) were associated with a lower prevalence of dental caries experience. Water fluoridation was associated with a lower DMFT index (ORP = 0.766). Dental caries experience is still associated with social inequalities at different levels. Policymakers should direct interventions towards reducing inequalities and the prevalence of dental caries among 12-year-old children.

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

RESUMO: Introdução: Avaliou-se o efeito ajustado das características das empresas de saneamento na provisão da fluoretação da água de abastecimento público nos municípios brasileiros. Métodos: Estudo ecológico transversal com base no Censo Demográfico 2010, Pesquisa Nacional de Saneamento Básico 2008 e Atlas de Desenvolvimento Humano 2010. As variáveis independentes foram as características das empresas e dos municípios e o desfecho foi a falta de provisão da fluoretação. Estimou-se a razão de prevalência por meio de regressão de Poisson com variância robusta. Resultados: Incluíram-se 5.565 municípios brasileiros. Na análise ajustada, o desfecho foi independente e positivamente associado com municípios das macrorregiões Norte, Nordeste, Centro-Oeste e Sudeste, que tinham taxas de cobertura de serviços de água e esgoto abaixo do valor mediano, menos de 10 mil habitantes e índice médio e baixo/muito baixo de desenvolvimento humano. Quanto ao efeito independente das características das empresas, tiveram maior probabilidade de não ofertar fluoretação todas as empresas classificadas como de administração indireta do poder público, ou sociedade de economia mista, ou economia mista de caráter público; as municipais e intermunicipais (razão de prevalência - RP = 1,21; intervalo de confiança de 95% - IC95% 1,19 - 1,23); e a prefeitura, quando única executora (RP = 1,22; IC95% 1,20 - 1,25). Conclusão: A falta de provisão da fluoretação da água foi maior quando o serviço era prestado preponderantemente por administrações municipais e empresas privadas, associadas ou não a entidades públicas, independentemente das características dos municípios.

ABSTRACT: 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.

[Water fluoridation in Brazil: regional distribution and accuracy of information on surveillance in municipalities with more than 50,000 inhabitants]. / Fluoretação da água no Brasil: distribuição regional e acurácia das informações sobre vigilância em municípios com mais de 50 mil habitantes.

Sanitation data for 2008 indicated that 74.4% of Brazilian municipalities (counties) with more than 50,000 inhabitants were receiving fluoridated water, but no criteria were adopted to validate the information. The study aimed to verify the accuracy of information on water fluoridation, using as the reference water surveillance data from municipalities with more than 50,000 inhabitants in 2008 and during 2010-2015. Data from different sources were used, comparing the information pertaining to the period. Water samples were collected, and fluoride concentration was obtained by the electrometric method. Verification was performed by comparing the data obtained from different sources. Data were compared for 601 (97.9%) municipalities. The proportion of municipalities that performed surveillance based on external control increased from 39.4% to 48.5%. There was a high rate of false positives and false negatives (15.1%) in the data for 2008. Municipal coverage was 70.2%, or 4.2 percentage points below the published estimate (74.4%) for 2008. Surveillance records were observed in 54.3% of the fluoridated municipalities whose population coverage reached at least 50% of the population receiving treated water. There was an important improvement in fluoridation surveillance data, despite a high percentage of false positives and negatives. There are still wide interregional differences in the surveillance of water fluoridation in this sample of Brazilian municipalities, raising important public health challenges.

Dados de saneamento para 2008 indicavam que 74,4% dos municípios com mais de 50 mil habitantes recebiam água fluoretada, entretanto, critérios para a validação desta informação não foram adotados. O estudo objetivou verificar a acurácia da informação sobre a fluoretação da água, tomando-se por referência dados de vigilância da água em municípios com mais de 50 mil habitantes no ano de 2008 e no período de 2010-2015. Dados de diferentes fontes foram empregados comparando-se as informações relativas ao período. Amostras da água foram coletadas e a concentração de fluoreto foi obtida pelo método eletrométrico. O processo de verificação ocorreu pela confrontação dos dados obtidos por diferentes fontes. Seiscentos e um municípios (97,9%) tiveram os dados confrontados. A taxa de municípios que realizam vigilância com base no heterocontrole passou de 39,4% para 48,5%. Observou-se elevada taxa de falsos positivos ou negativos (15,1%) em relação aos dados de 2008. A cobertura municipal foi de 70,2%, 4,2 pontos abaixo da estimativa (74,4%) divulgada para 2008. Registros da prática da vigilância foram observados em 54,3% dos municípios fluoretados, cuja cobertura populacional alcança 50% ou mais da população que recebe água tratada. Houve sensível melhoria nos dados de vigilância em relação ao fluoreto, embora com porcentual importante de falsos positivos e negativos. Ainda são largas as diferenças inter-regionais relacionadas tanto à provisão da fluoretação da água quanto à implementação da vigilância nos municípios pesquisados, trazendo importantes desafios para a saúde pública.

Los datos de saneamiento en 2008 indicaban que un 74,4% de los municipios con más de 50 mil habitantes recibían agua fluorada, no obstante, no se adoptaron criterios para la validación de esta información. El estudio tuvo como objetivo verificar la exactitud de la información sobre la fluorización del agua, tomando como referencia datos de vigilancia del agua en municipios con más de 50 mil habitantes en el año 2008, y durante el período de 2010-2015. Se emplearon datos de diferentes fuentes comparando la información relativa a este período. Se recogieron muestras de agua y la concentración de fluoruro se obtuvo mediante un método electrométrico. El proceso de verificación se produjo por el contraste de datos obtenidos de diferentes fuentes. Se compararon los datos de 601 (97,9%) municipios. La tasa de municipios que realizan vigilancia en base al heterocontrol pasó de un 39,4% a un 48,5%. Se observó una elevada tasa de falsos positivos o negativos (15,1%), en relación con los datos de 2008. La cobertura municipal fue de un 70,2%, 4,2 puntos por debajo de la estimativa (74,4%) divulgada en 2008. Se observaron registros de la práctica de vigilancia en un 54,3% de los municipios fluorados, cuya cobertura poblacional alcanza a un 50% o más de la población que recibe agua tratada. Hubo una sensible mejoría en los datos de vigilancia respecto al fluoruro, a pesar de que había un porcentaje importante de falsos positivos y negativos. Todavía son grandes las diferencias interregionales relacionadas tanto respecto a la fluorización del agua, como a la implementación de vigilancia en los municipios investigados, implicando importantes desafíos para la salud pública.