IN THE ABSTRACT
Community Fluoridation Status and Caries Experience in Children
STUDY AND RESULTS: This study compares the incidence of tooth decay among children (ages 5 to 11) in non-fluoridated communities with that in optimally fluoridated communities in 62 Tennessee communities. The fluoridated communities had been optimally fluoridated for at least 11 years. Communities with optimally fluoridated water had lower caries levels and higher percentages of caries-free children, even when the effects of age, race and socioeconomic status were controlled.
WHAT'S IMPORTANT: The survey did not obtain individual fluoride history or residence history. Because of widespread availability of fluoride products, including rinses and supplements, it is difficult to isolate the protective factor of fluoridated water. Although causality can not be implied, the findings do indicate that water fluoridation is an important public health measure.
FIND THIS STUDY: James Gillcrist, David Brumley, and Jennifer Blackford. Journal of Public Health Dentistry 61, no. 3 (Summer 2001): 168-171.
Water Fluoridation: Time to Reexamine the Issue
STUDY AND RESULTS: This study considers water fluoridation in the context of modern delivery systems. With the advent of fluoridated toothpaste, mouthwash and infant formulas, and the availability of commercially prepared beverages using fluoridated water, the incidence of dental fluorosis is increasing. A case study published in Contemporary Pediatrics in 1995 is included to demonstrate the dilemmas of fluoride supplementation. The case demonstrates that a child living in an area without fluoridated water possibly could receive as much as 0.98 milligrams (mg) of fluoride per day from toothpaste and beverages prepared with fluoridated water alone. Adding 0.5 mg of fluoride tablets or drops (as is now recommended by the ADA) would push the total daily intake to 1.48 mg, well above the .7-1.2 mg/liter considered as the recommended daily range. The study also documents other research on the adverse effects of excessive fluoride ingestion, citing dental fluorosis as the only condition that may result from excessive fluoride ingestion by children ages 18 months to 6 years whose permanent teeth are forming.
WHAT'S IMPORTANT: Pediatricians should be well-informed about the fluoride level of their patients' water supply so they do not recommend a fluoride supplement that could place the child at risk for developing dental fluorosis. Nurses and other providers of care can assist by advising parents about the importance of knowing the fluoride level of their local water supply and counseling them on the fluoride content of commercial products containing fluoride and the risks to young children who ingest too much.
FIND THIS STUDY: Simko, Lynn Coletta. Pediatric Nursing, (March-April 1997): 155 v. 5.
Investigation of the Possible Associations between Fluorosis, Fluoride Exposure, and Childhood Behavior Problems
STUDY AND RESULTS: This study investigated the potential association between fluoride exposure and behavior problems in children, as well as the prevalence of and risk factors for fluorosis. Researchers surveyed the parents of children between the ages of 7 and 11 from a private pediatric dental office in suburban Massachusetts. The surveys examined children's history of exposure to fluoride, social and medical backgrounds, and behavior using the Child Behavior Checklist. Of children studied, 69 percent had fluorosis, the majority of this was very mild. Most of the children had considerable fluoride histories: 86 percent lived in a fluoridated community; 54 percent used fluoride supplements; and 73 percent used fluoridated toothpaste early in life. No association between fluoride exposures in aggregate and fluorosis were found, but a significant association was found between supplemental fluoride exposure and fluorosis in children from birth to age 3. In addition, when comparing high and low fluorosis groups, no association was found between fluorosis and behavior problems in children. The study also found no association between fluoride exposure measured in aggregate and behavior problems in children.
WHAT'S IMPORTANT: The research results are based on a small population with similar fluoride exposure, socioeconomic status, and from the same geographic location. Therefore, an association between fluoride exposure and behavior problems cannot be definitively excluded based on this survey. More research is needed that examines groups with different levels of fluoride exposure.
FIND THIS STUDY: Morgan, Linda; Elizabeth Allred; Mary Tavares; David Bellinger; and Howard Needleman. Pediatric Dentistry 20, no. 4 (1998): 244-252.
Community Water Fluoridation, Bone Mineral Density, and Fractures: Prospective Study of Effects in Older Women
STUDY AND RESULTS: This study documents older women's exposure to fluoridated water between the years 1971 and 1994 in four areas of the United States. Of the 7,238 white women ages 65 and older who were studied, those with continuous exposure to fluoridated water had fewer spine, hip, and humerus fractures than women with no exposure to fluoridated water, but had more wrist fractures. Women with exposure to fluoridated water for some-but not all-of the years studied showed the same fracture patterns as women with no exposure. The study controls for possible confounding factors, such as age, weight, education, calcium intake, estrogen use and smoking status and all fractures were confirmed by looking at the radiographic reports.
WHAT'S IMPORTANT: Unlike many studies that analyze communities as a whole, this analysis examines health outcomes at the individual level. If fluoride prevents or slows reductions in bone density, as suggested by this study, fluoridation could be a cost-effective means of reducing hip fracture due to osteoporosis.
FIND THIS STUDY: Phipps, Kathy R; Eric S. Orwoll; Jill D. Mason; and Jane A. Cauley. British Medical Journal 321, no. 7265 (Oct. 7, 2000): 860.
Aesthetically Objectionable Fluorosis Attributable to Water Fluoridation
STUDY AND RESULTS: This study, conducted by researchers in the CDC's Division of Oral Health, estimates the prevalence of perceived aesthetic problems attributable to current fluoridation through two different measures commonly used to assess fluorosis (discoloring of teeth). Children ages 12 to 14 years were selected from the National Survey of Oral Health in U.S. School Children (1986-87) if they had fluorosis, had lived only in one home, and had never received fluoride drops or tablets. The fluoride content of both residential and school water supplies was calculated through questionnaires, data from the 1985 CDC fluoridation census, and water samples. Fluorosis prevalence then was calculated from this sample using both an anterior fluorosis index, which applies only to front teeth, and Dean's fluorosis index, which applies to all teeth. The results indicated 18 percent and 28 percent respectively. (Dean's index produces higher estimates of fluorosis than anterior measures since front teeth are less likely to have fluorosis than back teeth.) Combining these and other findings, the study found that only 2 percent of U.S. schoolchildren had aesthetic problems in their teeth attributable to the recommended level of fluoride in drinking water between 1986 and 1987.
WHAT'S IMPORTANT: This study concludes that only 2 percent of children have aesthetically relevant fluorosis caused by water that is fluoridated at the recommended level. Using Dean's index may overestimate both aesthetically objectionable fluorosis prevalence and its association with fluoridation. The researchers suggest their findings be weighed against the fact that fluorosis results from fluoride exposure during a narrow age range and benefits of drinking fluoridated water accrue over the entire life span. The researchers also called for studies on the treatment costs and any potential productivity losses associated with enamel fluorosis, which at the time of publication were not available.
FIND THIS STUDY: Griffin, S.O., and Beltran, E.D. Community Dentistry and Oral Epidemiology, (June 2002), pp. 199-209.
U.S. Drinking Water: Fluoridation Knowledge Level of Water Plant Operators
STUDY AND RESULTS: The study, conducted over a two-year period, examines the knowledge level of small and large water plant operators who fluoridate drinking water in 12 states. Criteria for inclusion in the study were: 1) an active statewide fluoridation program; 2) a minimum of 50 percent of the population was drinking fluoridated water; 3) each area of the country was represented; and 4) both rural and urban states were represented. Researchers found that approximately 64 percent of plant operators knew the correct optimal fluoride concentration for their plant, and there was no difference in knowledge between small and large plant operators. Overall, 70 percent of operators cited "highly accurate" sources for determining the optimal fluoride concentration. Operators at large water plants were more likely than small plant operators to use highly accurate sources. Finally, the study found that just over one-fourth of operators were able to maintain the fluoride level in drinking water to within 0.1 mg/L of their target fluoride concentration. Again, large water plants were more successful in this effort.
WHAT'S IMPORTANT: When the fluoridation program was located in the state's environmental department, water plant operators were more likely to know the correct optimal fluoride concentration than when the programs were located in the health department. In addition, operators in states that require full-day fluoridation training were significantly more likely than operators in other states to know the most accurate reasons for choosing an optimal fluoridation level, and they were significantly more likely to be able to maintain the target water fluoridation concentration.
FIND THIS STUDY: Lalumandier, James; Leonor Hernandez; Ana Locci; and Tom Reeves. "U.S. Drinking Water: Fluoridation Knowledge Level of Water Plant Operators," Journal of Public Health Dentistry 61, no. 2 (Spring 2001): 92-98.
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