Community Water Fluoridation Flashcards
How does fluoride prevent caries?
- Fluoride present in fluid at the plaque/tooth interface promotes remineralisation
- The Fluoro-Apatite formed is less susceptible to demineralisation
- Topical effect greater than systemic effect
- Fluoride may also have an effect on bacteria and metabolic pathways resulting in less acid being produced
- Maintain elevated oral levels of fluoride for as long as possible (little and often)
What lesions is fluoride most effective on?
- Early lesions
What are the two broad types of Oral reservoirs?
Mineral deposits (CaF2; FAP)
- CaF2 in saliva and fluid phase of plaque
Biologically/bacterially bound calcium-fluoride
What is community water fluoridation?
- Adjustment of natural fluoride content of community water supply to achieve optimum caries prevention whilst minimising risk of dental fluorosis
What are the constituents added to community water fluoride?
- Hydrofluorosilicic acid or hexafluosilicic acid H2SiF6
- Sodium fluorosilicate or sodium silicofluoride, Na2SiF6
- Typically 0.5 – 1.2ppm, dependent on climate (related to ambient air temperature; latitude)
What act stipulates the community water fluoridation?
- Section 87C (2) of the Water Act 2003
- Code of practice from the Drinking water inspectorate
What is the fluoride Content of Scottish water?
- Water Supplier Scottish water
- Glasgow Dental School supplied by Milngavie M3 treatment works
- Mean = 0.10mgF/l (<0.04 - 0.12) natural water fluoride content
What is the UK legislation in regard to water fluoride?
- Water Fluoridation Act (1985)
- Water Industry Act (1991)
(Neither Act delivered change) - Water Act 2003, Section 58 (Fluoridation of Water supplies) Applies in England & Wales
‘may’ vs. ‘shall’
What is the Water Act 2003?
- Replaced flawed legislation - Water (Fluoridation) Act 1985 / Water Industry Act 1991)
- May replaced with shall
- Requirement for public consultation before new scheme implemented
- Statutory requirement for ‘authority’ o monitor heath effects of fluoridation (section 90A)
What is the current Legislation on water fluoridation in Scotland?
- level of fluoride in the water varies from 0.001 ppm to 1ppm. Water fluoridation is adjusting this natural fluoride concentration to 1ppm.
- Water (Fluoridation) Act 1985 (now consolidated into the 1991 Water Industry Act) still extant
What are some barriers to Water fluoridation?
- Objections/acceptability (Moral/ethical) (Safety & efficacy)
- Political barriers
- Geographical barriers
- Financial barriers
What are the ethical/ moral considerations of water fluoridation?
- Need to take into account Human civil rights
- Beneficial and has no harmful consequences
- Not infringe any basic human right (choice to drink it)
- Replicates a situation naturally
- Question of is it unethical to fluoridate where practical to do so?
What are some safety/ efficacy considerations to water fluoridation?
- The chemical used are industrial waste products
- Fertilizer production - hydrogen fluoride reacts with silica to produce hexafluorosilicic acid
- Concerns fluoride and fluoride components are toxic ( link to cancers/ bone disorders/ cognitive impairment?)
- Acute toxicity
- Cumulative posion
- Fluorosis
When is fluorosis a concern?
- Not a concern with community water fluoridation in addition to fluoride toothpaste
- There is a dose response with fluorosis
- Higher levels of fluoride worldwide with some areas 5.5-25ppmF is a concern
- Concern when effects aesthetic/severity and skeletal
What is the Clinical presentation of Fluorosis?
- Snow flaking appearance on teeth
- Lack clear border, opaque, white spots, narrow white lines on enamel surface of most of the teeth
What are some efficacy concerns around water fluoridation?
- Does it work in preventing caries?
- Is there a declining effect of fluoridation
- Can we get other sources of fluoride
- How do we control for confounding factors like social class and population migration
What are some political barriers of water fluoridation?
- Anti-fluoridation lobby very vocal
- Highly emotive topic
- Differing opinions across political parties
- How to tackle increasing level of disease, rising health inequalities, financial and workforce challenges
What was the return on investment of oral health improvement programmes for 0-5 year olds?
- Public health England
included; - Targeted supervision tooth brushing programme
- Targeted fluoride varnish programme
- Water fluoridation provides universal programme
- Targeted provision of toothbrushes and paste by post
- Targeted provision of toothbrushes and paste by post and health visitors
- Improvements generally but still not good enough with regional differences and inequality
What issues were addressed with the development of novel techniques?
Bias
Objectivity
Longitudinal assessment
(population selection/recruitment)
All Tested and proven in clinical environment
What is the conclusion from PHE Water fluoridation health monitoring report for England 2014?
- Water fluoridation is safe and effective in public health intervention but ongoing review required
What was the CATFISH study?
- Assess effects and costs of systemic and topical exposure in utero abd exposure to water fluoridation
- Following new WF scheme on cohort of children with falling disease levels compared to birth cohort of children in absence of WF
- Measure impact of water fluoridation on social class inequalities in child dental health
What were the outcomes of CATFISH study?
- Modest benefit seen in caries reduction – much lower than seen in previous studies
- Still noted to be cost-effective
- No significant effect in reducing social gradient
What is given as fluoride therapy in community settings?
Water
School based brushing
Varnish
Salt
Milk
Tablets
Rinsing
What is given as fluoride therapy in office settings?
Varnish
Gels & Foams
Slow release
What is given as fluoride therapy in home settings?
Toothpaste
Mouthrinse
Tablets
What are the potential factors influencing results of fluoridated milk schemes?
Age at commencement
Population
F- concentration
Frequency of use
Distribution system
Consent/Compliance / drop out rate
What are the advantages of fluoridated milk?
- Natural healthy drink for children
- Important part of child’s diet - rich in nutrients
- Enables fluoride to be targeted to those who would benefit most
What are the disadvantages of Fluoridated milk?
- Distribution delayed until nursery/school age
- Not all children drink milk
- Distribution system/Shelf life/ Cost issues (higher than water F-)
- ? Lack of long-term benefit
What are fluoride supplements ?
- Tablets or drops
- used since 1940’s
- Originally used birth to 6years
- Later proven benefits children >5.5yrs old
- Systemic effect less imp than topical effect
- Advise continuation beyond 6years for at risk children like additional needs/ special care
What are the advantages of fluoride mouthwash?
-Commonly available for home use as:
Daily (0.05% 227ppmF)
Weekly (0.2% 909ppmF)
- Reductions in caries of around 30%
- Daily rinsing slightly more effective than weekly rinsing, but more expensive
- Generally good compliance
- Weekly more cost effective than daily
- Cost benefit ratio is low
What are the advantages of Acidulated mouthrinses?
- Low pH
- Stimulates mild demin on tooth surfaces
- Presence of fluoride stimulates remin
- Effective means of getting fluoride into teeth
- More so than non acidulated rinses
What are the advantages and disadvantages of Fluoride boosters?
- CPP-ACP – not suitable for those with milk allergies
- Used to be adjunct to F but now supplied with F
- Can be used at home or in office in trays
- Useful in markets with no access to high fluorides
- Systematic reviews indicate more research needed
What are APF (acidulated phosphate fluoride) gels?
- Professionally applied
- F conc 12,300 ppm
- Time consuming to apply (approx. 30 mins) – up to x2 / year
- Acute toxicity risk if ingested
- High cost per tooth surface saved
What is Duraphat Fluoride varnish?
- Sodium Fluoride 50 mg/ml = 22 600 ppm F-
- Gives sustained contact with Precipitation of calcium fluoride and Progressive release of fluoride
- Professional applied at reg intervals 2-4times a year
What factors determine anticaries activity of fluoride toothpaste?
- Fluoride concentration
- Frequency of application
- Rinsing behaviours
- When brushing takes place
How does the rinsing behaviour effect the effectiveness of fluoride toothpaste?
- Brushing with fluoride toothpaste elevates fluoride in mouth
- Rinsing with small vol of water removes excess F- and maintains fluoride in mouth
- Rinsing with large vol of water removes excess fluoride in mouth and reduces fluoride in mouth
What is the current advise for parents/children after toothbrushing?
- Spit out excess toothpaste
- Refrain from rinsing with water post-brushing
- Don’t eat or drink anything except water after brushing at night
What is the optimal brushing habits?
twice daily
not using beaker
1500 ppm F paste
What are some issues with using fluoride?
- Despite being topical – inevitable ingestion, particularly in young
- Increased risk of enamel fluorosis
- Risk – Benefit assessment between caries prevention and fluorosis risk
What are the risks from ingesting fluoride?
Acute toxicity
- Very rare
- Generally potential problem in very young
Chronic toxicity (fluorosis)
How Much Fluoride do Young Children Need to Swallow to Risk Fluorosis?
General consensus ~ 0.1 mg f/kg body weight
- 1 mg per day for 1 year-old
- 2 mg per day for 5-6 year-old
What are some considerations regarding topical fluoride?
- Quantity of toothpaste applied not strongly associated with efficacy.
- Efficacy is primarily concentration, not dose dependent as oral fluoride reservoir is small.
- Brush before bedtime - salivary flow rate reduced/increased oral retention.
- Anti caries benefit is topical.
- Increased risk of developing fluorosis is systemic.
- Methods favouring topical delivery whilst minimising ingestion will have the best risk/benefit profile.
How to maximise caries benefit but reduce fluorosis risk in young children?
- Keep toothpaste out of reach of young children.
- Brush frequently (twice daily: evening and one other time).
- Supervise brushing by young children.
- Use a small amount (pea/smear) of paste.
- Discourage swallowing
- Encourage spitting out, remove slurry: avoid excessive rinsing.
- Use a lower fluoride formulation if low caries risk, maximize fluoride concentration in relation to risk .
