No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
A systematic review on fluoridated food in caries prevention
Abstract
Objective:
This paper aims to provide a systematic review of the caries-prevention effect of fluoridated food, excluding water. The main aim of this review was to evaluate the presence of scientific evidence relating to the effects of fluoride intake via food on the occurrence of carious lesions. The outcome was defined as a clinical outcome, so only papers evaluating a decrease in caries indices were included.
Materials and methods:
Relevant databases (Medline®, Embase®, The Cochrane Library) were searched. The date range was set from 01.01.1966 to 03.31.2011. One hundred and thirty-nine reports were identified and assessed. Only three papers fulfilled the inclusion criteria and were discussed in detail.
Results:
No paper related to the use of fluoridated salt in caries prevention fulfilled the inclusion criteria. The use of milk as a vehicle for providing additional fluoride in a dental public health programme was evaluated in two papers. The consumption of fluoridated milk was an effective measure to prevent caries in the primary teeth. The use of fluoridated sugar demonstrated a reduction in caries increment in the permanent dentition in one paper.
Conclusions:
Literature on the effectiveness of fluoridation in foods in caries prevention is scant and almost all the studies have been conducted in children. There is low evidence that the use of milk fluoridation is effective in reducing the caries increment.
Supplementary resource (1)
... We identified one systematic review that aimed to evaluate the effectiveness of fluoridated salt for caries prevention in primary dentition. The review, conducted by Cagetti et al. [119], is described in Section 4.5.5.3.1. However, none of the included primary trials evaluated the use of this intervention. ...
... We identified one systematic review on the effectiveness of fluoridated sugar for caries prevention in primary dentition. Cagetti et al. [119] identified one trial on the effectiveness of sugar fluoridation for caries prevention. However, this trial reported on permanent dentition only (see Section 4.6.5.3.3 on the effect of fluoridated sugar on permanent dentition). ...
... We identified two systematic reviews on the topic of fluoridated milk for caries prevention in permanent dentition. Yeung Cagetti et al. [119] examined the effectiveness of fluoridated food (e.g. milk, salt, and sugar) in the prevention of caries. ...
The purpose of this overview of reviews was to provide evidence to assist with the development of clinical guidelines on the primary prevention of dental caries in primary, permanent, and mixed dentition.
Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance in this process over time, where there is net demineralisation of tooth structure by organic acids formed from the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars).
The HRB found that, relative to all other types of interventions, and taking the volume of evidence for each intervention category into account, the evidence for caries prevention in primary dentition was strongest for fluoride supplements. The evidence for caries prevention in permanent dentition was strongest for fluoride mouth rinse, fluoride gels, and fluoride solutions. The evidence for caries prevention in mixed dentition was strongest for vitamin D and xylitol (although it is important to note that the volume of evidence in the mixed dentition category was generally very low). However, the overview also revealed a fragmented body of research, with a substantial proportion of single-trial outcomes and a low and very low degree of certainty in the evidence for the majority of the interventions. Following a systematic quality assessment, the methodological quality of the included systematic reviews was generally low. Further high-quality, adequately powered RCT research is required; in the meantime, conclusions may only be drawn narrowly, if at all, with respect to the most effective approaches by which to prevent dental caries using individual-based primary prevention interventions prior to the development of any dental decay/dental caries.
... The criteria aimed to select the highest quality research designs capable of determining effectiveness and safety for policy and practice application. Unfortunately, though the topic has been studied globally, 13,16,17 the specific type of robust evidence needed from LACCs contexts is currently lacking. Dental caries is a multi-factorial disease influenced by characteristics like access to dental care, oral hygiene practices, diet, and socioeconomic factors 18,19 that may differ across LACC societies today and compared to other regions. ...
... While fluoride-based programs have been widely adapted globally based on evidence predominantly from mostly on high-income countries in North America and Western Europe rather than LACCs. Furthermore, evidence from other regions has primarily consisted of retrospective survey data, ecological studies, and database analyses 13,16,17 that cannot prove causality due to a lack of randomisation and control groups. 20 Only a limited number of randomised controlled trials or prospective cohort studies under the condition that follow-up assessments were conducted on the same participants have evaluated community water, salt fluoridation and milk fluoridation specifically. ...
... 20 Only a limited number of randomised controlled trials or prospective cohort studies under the condition that follow-up assessments were conducted on the same participants have evaluated community water, salt fluoridation and milk fluoridation specifically. 13,16,17 Given the methodological limitations of observational designs for determining intervention effectiveness and safety, this paucity of high-quality experimental evidence from the target context represents a notable gap. For decision-makers considering large-scale community programs, the risks versus benefits need to be directly assessed through research adhering to the highest scientific standards possible within real-world settings. ...
Dental caries is a significant global public health challenge, particularly among children and adolescents. It affects individuals' quality of life and can lead to various adverse outcomes, including pain, infection, and impaired school performance. Fluoride has been widely recognized as a key component in oral health improvement programs due to its ability to prevent tooth demineralization and promote remineralization. This systematic review aimed to evaluate the existing literature on the effectiveness of fluoridated food interventions in preventing dental caries in Latin American and Caribbean children and adolescents. The study focuses on this specific region, which faces unique challenges such as limited access to dental care services, socioeconomic inequalities, and cultural practices that may influence oral hygiene and dietary habits. The review follows the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. A comprehensive search was conducted in multiple databases, including EMBASE, MEDLINE, Scielo, and Web of Science. The search strategy utilized relevant MeSH terms and Boolean phrases related to fluoridated food interventions and dental caries in children aged 12 years and younger. After screening the articles based on predetermined inclusion criteria, no study met the eligibility criteria for inclusion in the systematic review. Overall, the systematic review highlights the absence of high-quality available evidence specifically focused on the effectiveness of fluoridated food interventions on children and adolescents of the Latin American and the Caribbean, underscoring the importance of conducting further studies to inform evidence-based decisions regarding public health policies, resource allocation, and oral health promotion strategies in this population.
... As no effort is required from the individual for ingesting fluoridated water, salt or milk, these methods have been designated as automatic systems for dental caries prevention. The use of milk as a vehicle for providing additional fluoride in dental public health programmes was evaluated in two recent systematic reviews (Cagetti et al. 2013;Yeung et al. 2015). Cagetti et al. (2013) searched literature from 01.01.1966 to 03.31.2011 and found nine papers of which only two papers fulfilled their inclusion criteria (Bian et al. 2003;Stecksén-Blicks et al. 2009). ...
... The use of milk as a vehicle for providing additional fluoride in dental public health programmes was evaluated in two recent systematic reviews (Cagetti et al. 2013;Yeung et al. 2015). Cagetti et al. (2013) searched literature from 01.01.1966 to 03.31.2011 and found nine papers of which only two papers fulfilled their inclusion criteria (Bian et al. 2003;Stecksén-Blicks et al. 2009). Both these studies investigated the caries-prevention effect of milk fluoridation on primary teeth. ...
... Four studies suggested that fluoridated milk had a beneficial effect, reducing caries incidence in both the primary and permanent dentitions. Cagetti et al. (2013) concluded that the consumption of fluoridated milk was an effective measure to prevent caries in primary teeth but that there was low evidence that the use of milk fluoridation was effective in reducing the caries increment. Yeung et al. (2015) included in a Cochrane review only one unpublished RCT and concluded that there was lowquality evidence to suggest that fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. ...
Aim
To update the exisitng European Academy of Paediatric Dentistry (EAPD) 2009 fluoride guidelines.
Methods
Experts met in Athens, Greece duirng November 2018 for the following groups: I Fluoride toothpastes, II Fluoride gels, rinses and varnishes, III Fluoridated milk, fluoridated salt, tablets/lozenges and drops, IV Water fluoridation. Systematic reviews and meta-analyses were reviewed and discussed for each of the groups. The GRADE system was used to assess the quality of evidence which was judged as HIGH, MODERATE, LOW or VERY LOW based on the assessment of eight criteria which can influence the confidence of the results. Following the quality assessment, GRADE was then used to indicate the strength of recommendation for each fluoride agent as STRONG or WEAK/CONDITIONAL.
Results
Parents must be strongly advised to apply an age-related amount of toothpaste and assist/supervise tooth brushing until at least 7 years of age. The EAPD strongly endorses the daily use of fluoride as a major part of any comprehensive programme for the prevention and control of dental caries in children. Regardless of the type of programme, community or individually based, the use of fluoride must be balanced between the estimation of caries-risk and the possible risks of adverse effects of the fluorides. Fluoride use is considered safe when the manufacturer's instructions are followed. Preventive programmes should be re-evaluated at regular intervals and adapted to a patient's or population's needs and risks.
Conclusions
For the majority of European Countries, the EAPD recommends the appropriate use of fluoride toothpaste in conjunction with good oral hygiene to be the basic fluoride regimen.
... From an economic viewpoint, salt fl uoridation appears to be a costeffective measure, with one report indicating the per capita costs average between 0.015 and 0.030 (USD) per year (Gillespie and Marthaler 2005 ). However, recent reviews point to the lack of available, randomized clinical trials comparing salt fl uoridation to other methods of caries prevention (Espelid 2009 ;Cagetti et al. 2013 ). ...
... While individual trials have suggested significant benefi ts associated with milk fl uoridation programs (Rusoff et al. 1962 ;Stephen et al. 1984 ), systematic reviews of fl uoridated milk have concluded that there is a lack of wellcontrolled randomized clinical trials to confi rm the effectiveness of this approach (Espelid 2009 ;Cagetti et al. 2013 ;Yeung et al. 2005Yeung et al. , 2015. Though some effectiveness has been shown for primary teeth (Cagetti et al. 2013 ), as noted in a recent Cochrane review: "There is low quality evidence to suggest fl uoridated milk may be benefi cial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. ...
... While individual trials have suggested significant benefi ts associated with milk fl uoridation programs (Rusoff et al. 1962 ;Stephen et al. 1984 ), systematic reviews of fl uoridated milk have concluded that there is a lack of wellcontrolled randomized clinical trials to confi rm the effectiveness of this approach (Espelid 2009 ;Cagetti et al. 2013 ;Yeung et al. 2005Yeung et al. , 2015. Though some effectiveness has been shown for primary teeth (Cagetti et al. 2013 ), as noted in a recent Cochrane review: "There is low quality evidence to suggest fl uoridated milk may be benefi cial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. Additional randomized clinical trials of high quality are needed before we can draw defi nitive conclusions about the benefi ts of milk fl uoridation" (Yeung et al. 2015 ). ...
It is known that fluoride helps to prevent tooth decay, however an excess of fluoride can cause enamel fluorosis. In this chapter, we will discuss current knowledge about fluoride and its effect on teeth, including dental fluorosis, fluoride and caries prevention, and enamel remineralizing agents.
... Finally, Cagetti et al. and Yeung et al. conducted systematic reviews on the caries-preventive effect of fluoridated foods and showed that fluoridated milk has a beneficial effect on reducing the incidence and progression of caries in schoolchildren, but the scientific evidence remains weak [61,62]. There is low-quality evidence to suggest fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. ...
... Our results showed that there is low-quality scientific evidence on the effectiveness of F supplementation in milk and DPs, but some studies showed a beneficial effect in school children in reducing caries incidence and progression. [61,62]. The lack of scientific interest in this topic may be due to the current availability of other F ingestion systems, such as water, toothpastes, or the use of topical products to prevent dental caries. ...
Diet plays an important role in the etiopathology of dental caries. Milk and dairy products (DPs), especially in children and adolescents, are important sources of protein, calcium and phosphorus and could have an effect on dental and oral health. The aim of this scoping review was to analyze the scientific literature on the non-cariogenic effect of milk and DPs, with a focus on their potential to prevent dental caries in children and adolescents. PubMed, EMBASE, and Web of Science were searched for publications relevant to our topic from January 2013 to 30 September 2023. Thirty-eight studies were included in the qualitative analysis. The included studies highlight the properties of milk and DPs that contribute to enamel remineralization, exhibit antibacterial action, inhibit the growth of cariogenic bacteria, and promote a balanced oral microbiome. With regard to the addition of probiotics (PBs) and fluoride (F) to DPs, the mixed results of the studies analyzed did not allow a clear statement to be made about their non-cariogenic effects. However, several studies show that the addition of PBs can reduce cariogenic bacteria, create a protective barrier against pathogens and support the host’s natural defense mechanisms. Further long-term and high-quality studies are needed to understand the impact of milk and its constituents on oral health in order to promote effective caries prevention strategies in children and adolescents.
... Fluoride enters to the human body either in food or through the respiration process (Cagetti, 2013) [18] . About 90% of fluoride is absorbed in the gastrointestinal tract after consumption (around 25% is consumed in the stomach and up to 77% in some part of the small intestine). ...
... Fluoride enters to the human body either in food or through the respiration process (Cagetti, 2013) [18] . About 90% of fluoride is absorbed in the gastrointestinal tract after consumption (around 25% is consumed in the stomach and up to 77% in some part of the small intestine). ...
Fluoride is a monotonic ion and an essential mineral for body. The use of Fluoride include cavity prevention, prevent from tooth decay, biochemical reagent. The consumption limit is set to be maximum 1.5 mg/l by WHO. The long term exposure to excess fluoride has several negative impact on human health, water bodies, environment and agricultural fields. The source of fluoridation may include the natural occurring minerals, coal mines or the anthropogenic action. Several materials (Biomass, rice husk ash, bone char, shale, and low grade coal) and methods (Adsorption, membrane separation, and column studies) have been in use for defluoridation of water. Among the above mentioned methods adsorption is proved to be economical, easy and efficient for fluoride removal for domestic and industrial help.
... Fluoride is one of the mineral ions present in water, which is essential for human body to strength bone and prevent tooth decay [5]. Some natural mineral that contains fluorine is granite, basalt, and fluorite. ...
... A total of four kinds of process were taken in to consideration for the criteria analysis i.e. adsorption, coagulation, membrane processes and ion exchange. The process was classified based on the result obtained from the normalised matrix and considering the weightage parameter for Medium (5) Low (1) Low (1) Low (1) Medium (5) Medium (5) Medium (5) The normalised value obtained in Table 3. were then proceed with multiplication with weightage given to each criteria. Assuming that all the criteria plays the same important role in defluoridation process, they were given the same weightage value each. ...
The increase in hazardous substances in drinking water is an eye-catching problem of modern world. Where the urban life style is setting new goals, the environment safety of living beings is in poor hands. Almost each and every living thing depends on water for basic survival, but the pollution makes it difficult for health and growth. Fluoride is an ion present in nature and also essential for our body. It helps to strengthen the bone and teeth. But the rapid industrialisation increases the amount of fluoride in natural sources, this increased level tends to decline the health of human, water animals, and plants. So our focus should be to remove the excess fluoride, make water drinkable as per the quality standards for a better future. Various techniques are discussed like coagulation, ion-exchange, membrane separation, adsorption, and electrocoagulation for fluoride removal with advantages and disadvantages. An analysis was performed keeping various criteria for the removal of fluoride ion from water. Adsorption was found to be most suitable compared to others.
... Fluoride is one of the mineral ions present in water, which is essential for human body to strength bone and prevent tooth decay [5]. Some natural mineral that contains fluorine is granite, basalt, and fluorite. ...
... A total of four kinds of process were taken in to consideration for the criteria analysis i.e. adsorption, coagulation, membrane processes and ion exchange. The process was classified based on the result obtained from the normalised matrix and considering the weightage parameter for Medium (5) Low (1) Low (1) Low (1) Medium (5) Medium (5) Medium (5) The normalised value obtained in Table 3. were then proceed with multiplication with weightage given to each criteria. Assuming that all the criteria plays the same important role in defluoridation process, they were given the same weightage value each. ...
The increase in hazardous substances in drinking water is an eye-catching problem of modern world. Where the urban life style is setting new goals, the environment safety of living beings is in poor hands. Almost each and every living thing depends on water for basic survival, but the pollution makes it difficult for health and growth. Fluoride is an ion present in nature and also essential for our body. It helps to strengthen the bone and teeth. But the rapid industrialisation increases the amount of fluoride in natural sources, this increased level tends to decline the health of human, water animals, and plants. So our focus should be to remove the excess fluoride, make water drinkable as per the quality standards for a better future. Various techniques are discussed like coagulation, ion-exchange, membrane separation, adsorption, and electrocoagulation for fluoride removal with advantages and disadvantages. An analysis was performed keeping various criteria for the removal of fluoride ion from water. Adsorption was found to be most suitable compared to others.
... Fluoride is one of the mineral ions present in water, which is essential for human body to strength bone and prevent tooth decay [5]. Some natural mineral that contains fluorine is granite, basalt, and fluorite. ...
... A total of four kinds of process were taken in to consideration for the criteria analysis i.e. adsorption, coagulation, membrane processes and ion exchange. The process was classified based on the result obtained from the normalised matrix and considering the weightage parameter for Medium (5) Low (1) Low (1) Low (1) Medium (5) Medium (5) Medium (5) The normalised value obtained in Table 3. were then proceed with multiplication with weightage given to each criteria. Assuming that all the criteria plays the same important role in defluoridation process, they were given the same weightage value each. ...
The increase in hazardous substances in drinking water is an eyecatching
problem of modern world. Where the urban life style is
setting new goals, the environment safety of living beings is in poor
hands. Almost each and every living thing depends on water for
basic survival, but the pollution makes it difficult for health and
growth. Fluoride is an ion present in nature and also essential for
our body. It helps to strengthen the bone and teeth. But the rapid
industrialisation increases the amount of fluoride in natural sources,
this increased level tends to decline the health of human, water
animals, and plants. So our focus should be to remove the excess
fluoride, make water drinkable as per the quality standards for
a better future. Various techniques are discussed like coagulation,
ion-exchange, membrane separation, adsorption, and electrocoagulation
for fluoride removal with advantages and disadvantages.
An analysis was performed keeping various criteria for the removal
of fluoride ion from water. Adsorption was found to be most
suitable compared to others.
... In addition to fluorine, the capacity of which has been widely recognized as an anti-carious agent [5][6][7], a broad range of chemical agents have been used to reduce the cariogenicity of S. mutans in the biofilm [8]. Nevertheless, the increasing phenomenon of antibiotic resistance [9] necessitates the study of alternative therapeutic strategies to chemicals, and new substances, including natural extracts, have been widely investigated [10,11]. ...
... Despite developments in the understanding of biological and physico-chemical mechanisms, dental caries remains one of the most common diseases of our era, affecting 60% to 90% of children and 100% of adults worldwide [37]. The main methods of prevention have been based on the daily use of fluoride toothpaste, a reduction in both the amount and regularity of sugar intake, and drinking fluoridated water [6,38,39]. However, the effect of fluorine is mainly to increase resistance to demineralization and promote remineralization in teeth, while its antimicrobial activity has not generally been considered significant [40,41]. ...
In view of the increasing interest in natural antimicrobial molecules, this study screened the ability of Thymus capitatus (TC) essential oil and Citrus limon var. pompia (CLP) extract as raw extracts or incorporated in vesicular nanocarriers against Streptococcus mutans and Candida albicans. After fingerprint, TC or CLP were mixed with lecithin and water to produce liposomes, or different ratios of water/glycerol or water/propylene glycol (PG) to produce glycerosomes and penetration enhancer vesicles (PEVs), respectively. Neither the raw extracts nor the nanovesicles showed cytotoxicity against human gingival fibroblasts at all the concentrations tested (1, 10, 100 μg/mL). The disc diffusion method, MIC-MBC/MFC, time-kill assay, and transmission electron microscopy (TEM) demonstrated the highest antimicrobial potential of TC against S. mutans and C. albicans. The very high presence of the phenol, carvacrol, in TC (90.1%) could explain the lethal effect against the yeast, killing up to 70% of Candida and not just arresting its growth. CLP, rich in polyphenols, acted in a similar way to TC in reducing S. mutans, while the data showed a fungistatic rather than a fungicidal activity. The phospholipid vesicles behaved similarly, suggesting that the transported extract was not the only factor to be considered in the outcomes, but also their components had an important role. Even if other investigations are necessary, TC and CLP incorporated in nanocarriers could be a promising and safe antimicrobial in caries prevention.
... Porém, apenas o flúor verdadeiramente absorvido tem potencial de causar fluorose, todavia nem todo flúor que é ingerido é absorvido 2 . Destaca-se assim a prevenção da fluorose dentária em pacientes menores de 6 anos, que corresponde ao período de mineralização do esmalte, e isto, se o flúor for usado em excesso, ressaltando a importância da orientação quanto a sua utilização 4 . ...
... Desta forma, o uso de dentifrício com concentração de 1100 ppm, mas em mínima quantidade na escova parece ser o método mais adequado para usufruir os benefícios e minimizar os riscos dos dentifrícios fluoretados 5 , 19,20 . Deste modo o conhecimento dos profissionais de saúde bucal e o repasse da informação aos pais sobre a correta administração dos cremes dentais a fim de realizarem a melhor escolha para combater o risco de manifestação ou atividade da doença cárie, bem como em relação à fluorose, para assim, poderem tomar decisões mais apropriadas 4 . ...
Introdução: A escovação com dentifrício fluoretado é o melhor meio paraprevenir a cárie dentária, independente da idade. Objetivo: Avaliar o perfil de prescrição de dentifrício fluoretado por cirurgiões dentistas em crianças menores de 06 anos. Métodos: Foram entrevistados 62 odontólogos da rede pública do município de Cascavel – PR, e entregue um questionário com seis questões específicas. Resultados: Os cirurgiões dentistas relataram prescrever dentifrício fluoretado (64,5%), e orientam a quantidade a ser colocada na escova (93,5%), também conhecem sobre toxicidade do flúor e as causas da fluorose. Quanto a idade indicada para início da escovação com dentifrício fluoretado as prescrições foram a partir dos 6 anos de idade (24,2%) ou quando a criança soubesse cuspir (17,7%). Conclusão: Os entrevistados prescrevem dentifrício fluoretado para crianças menores de 6 anos de idade. Porém grande parte diferiu sobre a concentração ideal de flúor que deve ser utilizada, além da idade inicial que deve ser prescrito o creme dental fluoretado.
... Thus there is not sufficient evidence to determine whether the use water fluoridation has a significant impact in the reduction of caries (35). In 2013, Cagetti et al. (26) conducted a systematic review regarding the effectiveness of fluoridated food in caries prevention, excluding water. The assessments recorded studies of the effect of fluoridated milk in children primary teeth and the results underlined the improvement in preventing decays. ...
... In Jamaica a work was conducted about the impact of salt fluoridation among children and the authors concluded that a reduction in caries prevalence can be obtained, but without any scientific evidences. According to this review, the efficacy of food fluoridation in preventing dental decays was low and the majority of the trials have been conducted in children (26). Also the fluoridate milk, despite the poor quality of the studies retrieved in the systematic review of Yeung (13), would seem to provide benefits to children in school age, especially for the permanent dentition. ...
Background
The objective of this study is to review medical and non medical treatments for prevention of caries.
Material and Methods
A comprehensive literature search of the most relevant and updated published studies from 01/01/2002 through December 2015 in PubMed/MEDLINE, Embase and Scopus databases regarding the efficacy of strategies and treatments aiming to prevent the development of caries was performed selecting papers on the basis of the Evidence-based Medicine Criteria.
Results
We identified thirty systematic reviews on prevention of caries. Analyzing the data the retrieved literature, performance of prevention treatments seems to be high.
Conclusions
Prevention treatments may have a relevant impact on the avoiding the development of caries planning.
Key words:Dental caries, prevention, fluoride.
... However, while the evidence of water fluoridation in caries control has been firmly established over the last decades (McDonagh et al., 2000), systematic reviews have concluded that the number of studies with good quality that evaluated the effects of fluoridated milk in preventing caries is insufficient. Overall, the included studies suggested that fluoridated milk was beneficial to school children, to prevent caries in the permanent (Yeung et al., 2005) or primary (Cagetti, Campus, Milia, & Lingstrom, 2013) dentitions. High-quality studies, nonetheless, are still necessary in order that unequivocal evidence can be established. ...
... Despite fluoridated milk has been recommended as an alternative vehicle to deliver fluoride since 1953 and some clinical studies have attested the preventive effect of this measure to prevent caries, evidence on this regard has not been firmly established so far (Cagetti et al., 2013;Yeung et al., 2005). Recently, various mechanistic studies have attempted to contribute to a better understanding of the effect of fluoridated milk against caries, using in vitro and in situ models. ...
... ➢ Diet: the use of fluoridated water, milk, and salt represented a traditional way to prevent dental caries. However, there is weak evidence to support their use due to their low efficiency in reduction of dental caries (34) . ...
Background: Orthodontic treatment with fixed appliances is frequently associated with difficulties in maintaining good oral hygiene and creation of plaque-retentive areas on tooth surfaces that are typically more prone to the development of caries; such drawbacks may result in white spot lesion (WSL) development that affects the esthetic outcome following bracket debonding. This review article focuses on orthodontic WSLs development, prevention, and remineralization potential via incorporating various remineralizing / antibacterial additives into orthodontic adhesives. Results: Unbalanced enamel demineralization and remineralization processes, along with rapid alterations in the dental plaque bacterial ecology, particularly acidogenic bacteria, are the causes of the start and progression of a carious lesion. Without significantly compromising an adhesive mechanical performance, several antibacterial and remineralizing substances have been added to orthodontic adhesives in an effort to reduce bacterial colonization and promote remineralization. Conclusions: Antibacterial and/or remineralizing substances were utilized as additives in the creation of innovative orthodontic adhesive systems to address white spot lesions (WSLs) and improve the ability of enamel remineralization. Compared to adding only one agent, including multiple agents in an orthodontic adhesive system may have a greater impact on lowering enamel demineralization and improving enamel remineralization during orthodontic therapy.
... mg per child. 47 This dosage is carefully regulated based on factors such as age and existing fluoride exposure, minimizing the risk of adverse effects. However, milk fluoridation is regarded as less effective than water fluoridation because fluoride tends to form insoluble compounds in milk, which can diminish its absorption in the body. ...
Fluoride is a natural element recognized for its dental benefits. Fluoride prevents caries due to its antimicrobial activity, enhancing enamel resistance and promoting remineralization After decades of fluoridation of municipal water supplies to reduce dental caries, an intense debate has resurfaced regarding water fluoridation as a public health strategy to combat caries. This renewed discourse occurs against the backdrop of extensive data that clearly demonstrate the vital role of fluoride in caries prevention. Indeed, the Centres for Disease Control and Prevention has stated water fluoridation as 1 of the top ten public health interventions in the twentieth century. The FDI World Dental Federation also advocates systemic fluoride use as a cost-effective caries prevention strategy, and supports its inclusion in public health policies through a number of policy directives. This debate in the US has intensified as a Court concluded that water fluoridation poses unreasonable risks such as reduction of the intelligence quotient (IQ) in children. Additionally, recent statements from the leadership of the US Health and Human Services agency suggest that water fluoridation may cause more harm than good leading some states, like Utah, to revoke fluoridation mandates This article aims to provide a contemporary perspective on fluoride by revisiting its benefits, controversies, and potential risks. It highlights the dual role of fluoride in both individual oral care and public health and underscores the necessity for safe, equitable, and effective delivery strategies tailored to the needs of diverse populations, balancing its preventive advantages with potential health concerns. The review culminates with a summary of policy statements from the FDI World Dental Federation regarding the promotion of oral health through both systemic and topical fluoridation.
... Calcium fluoride is considered a calcium and fluoride reservoir in the oral cavity; this material will be dissolved when pH drops, releasing fluoride and calcium in the oral cavity (6) . Fluoride and calcium are the main components to form fluorapatite crystals after the remineralization process following elevation in pH in the oral cavity (7) . ...
Background: Demineralization and white spot lesions are the most common complications in fixed orthodontic treatment. It is useful to enhance the remineralization properties of the orthodontic primer by the addition of remineralizing agents. Fluoride and calcium are regarded as the main component of enamel fluorohydroxyapatite crystals. This pilot study compared three mixing methods of calcium fluoride nanoparticles (nCaF2) with conventional orthodontic primer (Transbond XTTM) to develop a primer with enamel remineralization properties. Materials and methods: The nanoparticles were added to Transbond XTTM primer to form 20% (w/w) of the final solution. Three dark plastic bottles were prepared and stored until mixing. The first sample was mixed by a Vortex machine, the second was mixed with an electric agitator, and the third one was mixed with a customized plastic spatula adapted to a dental engine and a straight handpiece. Cured blocks of the developed primer were prepared and were examined for homogeneity, cracks, and agglomeration of the nanoparticles within the primer using Field Emission Scanning Electron Microscopy (FESM). Results: The third Sample showed a continuous distribution of nanoparticles with no apparent cracks or agglomeration of nanoparticles. In contrast, a higher agglomeration was seen in the first sample than in the other two. Conclusion: Mixing of nCaF2 with Transbond XTTM orthodontic primer was best achieved by the customized plastic spatula adapted to a dental engine compared to Vortex and electric agitator machines.
... Both fluoridated milk and salt are available in some countries and are typically applied in school settings, implemented in health and nutrition programs (56). They have been regarded as successful communitybased strategies in dental caries prevention, particularly among children, but the low quality of evidence prevents from drawing definitive conclusions (57)(58)(59). Additionally, some concerns emerged related to the risk of hypertension associated with the promotion of salt consumption. ...
Background:
Dental caries is the most common infectious disease, affecting approximately 60 to 90% of the world population, especially young children, and disadvantaged communities. Due to the extremely high prevalence and the significant negative impact on general health, well-being, and quality of life it is considered a global public health problem. Despite the improvement of policies to promote oral health care in the past decades, dental caries is still a healthcare challenge, characterized by increasing disparities among different social groups between and within countries. Fluoride-based prevention of dental caries is a cost-effective approach, that has been implemented since 1940's. It includes systemic and topical administrations, through community-based or individual programs. Preventive interventions should be tailored to individual and community caries risk assessment and estimate of cumulative fluoride intake, in order to maximize the preventive effect and avoid the risk of potential adverse effects associated with excessive fluoride exposure. Regulation of public health policies plays a major role in this context.
Study design:
Scoping review.
Methods:
The aim of this scoping review was to report an overview of current guidelines regarding fluoride-based preventive strategies for dental caries and relevant policies on the matter, as well as to address current issues related to public health aspects of dental caries prevention. We searched for the relevant literature on the matter, focusing on policy documents, such as recommendations, position papers and guidelines, issued from the major scientific and regulatory institutions involved in oral health promotion and on publications concerning relevant aspects of public health law.
Results:
Prevention of dental caries through fluoride can rely on topical fluorides for home-use (toothpastes and mouthrinses), professionally applied topical fluorides (gels, varnishes, silver diamine fluoride, fluoride-releasing restorative materials and sealants), fluoride supplements (tablets and drops), and community-based strategies (community water fluoridation, fluoridated salt and milk). Current relevant guidelines for all these preventive aids are outlined in the paper. A significantly greater preventive effect of topical fluorides has been widely established in the recent past, as compared to systemic effects. Furthermore, increasing concerns have emerged on potential adverse effects on general health associated with early and excessive systemic exposure to fluoride, especially for children, supported by recent meta-analyses. Also, community water fluoridation has raised significant aspects of relevance for health law and policies. In a public health perspective, healthcare policymakers should tackle social iniquities by promoting information and oral health literacy, through community and school-based programs, ensuring access to early dental visits and basic dental care and improving availability and affordability of fluoride topical products.
Conclusions:
Fluoride-based prevention can provide a simple and cost-effective approach to reduce the incidence of dental caries and the associated social burden. Among fluoride-based preventive strategies, systemic community-based administration of fluoride should be considered with great caution, due to the unfavorable risk-benefit ratio currently established. Topical fluoridated products are generally preferred, given the optimal risk-benefit ratio. Further efforts must be made to identify and tackle the barriers to dental caries prevention and related social iniquities from a public health perspective. Policies and laws on oral health should promote access to caries prevention with targeted comprehensive strategies.
... Bengi" menjadi hal yang penting dalam peningkatan kebiasaan menyikat gigi sebelum tidur malam pada anak. Kebiasaan menyikat gigi sebelum tidur malam dapat membersihkan sisa makanan yang menempel pada gigi sehingga pembentukan plak selama tidur dapat dihambat dan akumulasi plak menjadi berkurang (Linasari and Meilendra, 2019 (Cagetti et al., 2013). ...
Karies dan kebersihan gigi yang buruk dapat menyerang setiap orang, karena belum dibiasakan menggosok gigi dengan baik dan teratur minimal dua kali sehari, pagi setelah sarapan dan malam sebelum tidur. Selain itu, faktor makanan yang sering dikonsumsi juga dapat memicu percepatan pembentukan plak dan kalkulus pada gigi. Oleh karena itu, perlu dilakukan tindakan pencegahan agar tidak terjadi kerusakan lebih lanjut. Tujuan dari kegiatan pengabdian masyarakat ini adalah agar kelompok masyarakat binaan dapat dan teratur melakukan gosok gigi yang benar pada malam hari, dengan kegiatan pendampingan oleh pekerja sosial masyarakat. Masyarakat sasaran yang perilaku menggosok giginya salah adalah masyarakat yang berdomisili di wilayah pinggiran kota Semarang yaitu Kecamatan Tembalang khususnya di Desa Meteseh dan Rowosari yang berada di wilayah kerja Puskesmas Rowosari. Di Puskesmas Rowosari sudah ada Gasurkes (Petugas Surveilans Kesehatan) yang bertugas memantau pencegahan Demam Berdarah dan Ibu Hamil. Kader lain di masyarakat adalah mereka yang dibantu oleh Dinas Sosial yang disebut Pekerja Sosial yang bertugas membantu pemerintah memantau segala sesuatu yang ada di masyarakat, termasuk kebutuhan kesehatan. Bersama Gasurkes yang sudah mengenal masyarakat di wilayah binaan Puskesmas Rowosari, para Pekerja Sosial ini diberdayakan dengan memberikan pelatihan agar dapat berperan dalam memantau perilaku menggosok gigi pada malam hari, dan memantau pola makan dengan kesehatan gigi. Hasil pemberdayaan pekerja sosial untuk pemantauan perilaku menggosok gigi pada malam hari, terlihat dari indikator kebersihan gigi dan mulut ibu yang sebelum pendampingan paling banyak ditemukan pada kategori kurang (64%), dan setelah pendampingan, yang mendominasi kategori baik (69%). Pada kelompok anak, sebelum dilakukan intervensi terdapat 68% anak yang memiliki kebersihan gigi dan mulut dalam kategori buruk, dan setelah dilakukan pendampingan, hasilnya berada pada kategori baik sebanyak 64%. Pendampingan Sigi Bengi oleh Pekerja Sosial meningkatkan kebersihan gigi dan mulut anak. Kata kunci: Gosok gigi, kebersihan gigi, pekerja sosial.
... Water with higher fluoride concentrations can be found near volcanic hot springs. 2 Fluoride enters the body through diet, breathing, and fluoride-containing products. 3 Using fluoride dental products is the most effective strategy to prevent caries. 4,5 ...
the creative commons attribution noncommercial License. This allows others to remix, tweak, and build upon the work non commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Abstract Fluoride is a natural component of the environment; hence it is always present in people's life.Fluoride's maximum anti-caries advantages are primarily obtained by topical usage and direct contact on the tooth surface, according to studies conducted over the previous 30 years. The use of topical fluoride supplements on a daily basis is advantageous. Fluorosis is worldwide in distribution and endemic at least in 25 countries. According to studies conducted in various parts of India, the prevalence among school children 72.3% (West Bengal) 26 , 71.5% (Andhra Pradesh) 27 , 69.8% (Rajasthan) 28 , and 96.6 % (Haryana) 21. Kerala
... The arms and legs become deformed, the teeth begin to turn yellow and the gums begin to thaw. Many daughters who have been married to any other village also cannot remain untouched by the ill effects of this disease in the fluorosis-affected village (Cagetti et al., 2013). The ill-effects of disability start appearing more on women after becoming mothers. ...
According to data from the Environmental Protection Agency, fluoride is an agent that favors contamination in public drinking water and may has an adversely effect on human health. The Water Conservation Agency and World Health Organization have set a limit (1.5 mg fluoride per liter) on the maximum pollution level of fluoride that has some adverse effect. Fluoride is known to be used for stimulating the formation of bone cells, for preventing tooth decay. Fluoride shows its presence naturally and artificially but drinking water, food, dental products, and pesticides are major sources of fluoride that affect the human body in many ways, such as metabolic and nutritional disorders. Dental effect, musculoskeletal effects such as skeletal fluorosis, bone fractures, reproductive and developmental effects, neurotoxicity, and neurobehavioral effects, endocrine effects, genotoxicity and carcinogenicity, and some other effects like gastrointestinal system, kidneys, liver, and immune system are the effects on human health due to fluoride.
... Four systematic reviews have been published on the clinical effectiveness of milk fluoridation in preventing dental caries. The first three reviews found that all studies reported a reduction in dental decay among those consuming/receiving fluoridated milk (19)(20)(21). However, the fourth wider-ranging review, including 18 studies conducted in 12 countries, found that only nine studies demonstrated caries prevention in primary teeth and 12 in the permanent dentition (22). ...
Fluoride is one of the most abundant elements found in nature. Water is the major dietary source of fluoride. The only known association with low fluoride intake is the risk of dental caries. Initially, fluoride was considered beneficial when given systemically during tooth development, but later research has shown the importance and the advantages of its topical effects in the prevention or treatment of dental caries and tooth decay. Water fluoridation was once heralded as one of the best public health achievements in the twentieth century. Since this practice is not feasible or cost effective in many regions, especially rural areas, researchers and policy makers have explored other methods of introducing fluoride to the general population such as adding fluoride to milk and table salt. Lately, major concerns about excessive fluoride intake and related toxicity were raised worldwide, leading several countries to ban fluoridation. Health-care professionals and the public need guidance regarding the debate around fluoridation. This paper reviews the different aspects of fluoridation, their effectiveness in dental caries prevention and their risks. It was performed in the PubMed and the Google Scholar databases in January 2018 without limitation as to the publication period.
... 12 A tea bush accumulates F mainly in the leaves, absorbing it from the air and soil. 11,[13][14][15] Significant amounts of F are released during the preparation of an infusion because soluble F is easily absorbed in the digestive system and its bioavailability in relation to tea is about 95%. 11,16 Similar to tea, the most popular, the easiest to prepare, and the most frequently consumed form of herbal products are infusions, commonly referred to as "herbal teas." 17 A herbal tea can be prepared from fresh or dried flowers, leaves, seeds, or roots, usually by submerging the material in boiling water and keeping the solution under a lid for a few minutes. ...
The ground elder (Aegopodium podagraria L.) is a perennial plant that has been known and used in folk medicine for centuries. The interest in herbs has increased in recent years. The most popular, the easiest, and the most frequently consumed forms of herbal products are infusions. They are a source of numerous biologically active substances, including fluorine compounds. The aim of the study was to determine the extent to which the content of fluoride (F) in infusions of the ground elder was dependent on which morphological part of the plant and what water temperature were used during brewing. The plant material of Aegopodium podagraria L. (rhizome, leaves, flowers, and seeds) was taken from areas located in the West Pomeranian Voivodeship (Poland), from spring to autumn 2014. The lyophilised plant material was submerged in water (25, 70, 80, and 90ºC). F concentrations in infusions were measured by means of the potentiometric method. The statistical analysis was performed using Stat Soft Statistica 12.5. The concentration of F in the infusions was diversified depending on the morphological part of the plant and the temperature of water used to prepare the infusions. The lowest F content was observed in rhizome infusions (0.057±0.004 mg/L), and the highest in seed infusions (0.333±0.045 mg/L). In both cases the infusions were prepared with water at 80°C. The statistical analysis of the results showed that both the morphological part and water temperature had an influence on the content of F in the infusions.
... A similar correlation is observed in areas of seismic activity (FranCisCa, Perez 2009). Along with atmospheric precipitation, fluoride finds its way into the soil and groundwater and is later assimilated by plants consumed by humans and animals (including farm animals which serve as food for humans) (CaGetti et al. 2013). ...
Fluoride (F-) is the most reactive ion present in the human environment. It is commonly known to occur in bones and teeth, and it is used in the prevention of caries. If supplied in excess, fluoride has a toxic effect. In extreme cases, fluoride intoxication may lead to serious illnesses such as the fluorosis of teeth and bones. The aim of the study was to analyse correlations between the content of Fin hair and environmental factors, nutritional habits and anthropometric data of men and women from various regions of Poland. The level of fluoride was measured in the hair samples from n = 565 people (n = 273 women and n = 292 men, 16.9 to 73.2 years old) using the potentiometric method and an ion-selective electrode. The researchers carried out surveys regarding the personal characteristics of the participants and their nutritional habits. In our study, we demonstrated that despite the use of filters and devices that limit the entry of pollutants into the environment, 15% of the volunteers taking part in our study manifested fluoride values at the same level as employees of an aluminium factory who were exposed to this element due to their place of work. 68% of the examined persons belonged to the category classified as having a moderately increased level of fluoride accumulated in hair. Factors such as 902 the gender, size of the village/town and anthropometric conditions did not significantly influence the level of fluoride in hair, unlike the location of one's residence.
... Fluoride is a natural mineral that can enter the body by the ingestion of food, water and health products containing fluoride and, through respiration (Cagetti et al., 2013). In small doses, this element is the most efficient way to prevent dental caries (i.e., tooth decay) (Clark and Slayton, 2014). ...
Fluoride is often found in elevated concentrations in volcanic areas due to the release of magmatic fluorine as hydrogen fluorine through volcanic degassing. The exposure to high levels of fluoride can affect the processes of bone formation and resorption causing skeletal fluorosis, a pathology that can easily be mistaken for other skeletal diseases. In this study, we aimed to determine if fluoride concentration in the femoral bone of wild populations of the house mouse (Mus musculus) is a good biomarker of exposure to active volcanic environments naturally enriched in fluoride, allowing their use in biomonitoring programs.
The fluoride concentration of the whole femoral bone of 9 mice from Furnas (5 males and 4 females) and 33 mice from Rabo de Peixe (16 males and 17 females) was measured by the potentiometric method with a fluoride ion selective electrode.
Fluoride in bones was significantly higher in the mice from Furnas when compared with the mice from Rabo de Peixe (616.5 ± 129.3 μg F/g vs. 253.8 ± 10.5 μg F/g). Accumulation rates were also significantly higher in the mice collected in Furnas when compared with Rabo de Peixe individuals (3.84 ± 0.52 μg F/day vs. 1.22 ± 0.06 μg F/day).
The results demonstrate a significant association between exposure to fluoride in the active volcanic environment and fluoride content in bone, revealing that bone fluoride concentration is a suitable biomarker of chronic environmental exposure to fluoride.
... Approximately 25% of children and teenagers between the ages of 5 and 17 years old account for 80% of the dental caries in permanent teeth. 1 Currently, research has focused on designing products that prevent this disease, most of them aiming to eliminate S. mutans, whether using preventive or therapeutic resources once the carious lesion has settled; these resources have included mouth rinses, fluoride varnish, fluoride foods, toothpaste, gels, laser application and use of pit and fissure sealants. 6,[21][22][23][24][25] The use of fissure sealant is a common preventive measure used in many countries. Fissure sealants have made a significant contribution to decreased rates of dental caries. ...
Objective:
The objective of this study was to evaluate the effects of pit and fissure sealant mixed with silver nanoparticles on dental caries, by means of monthly measurement of fluorescence with DIAGNOdent over six months.
Study design:
This study was divided in two phases: experimental and clinical. In the experimental phase, the adhesion and microleakage of the pit and fissure sealant experiment were evaluated. Two groups of 10 teeth, without serious carious lesions, were included. Conventional (group A) and silver nanoparticles (group B) were added to the pit and fissure sealant. For the clinical phase, a split-mouth study was performed on 40 children aged 6-10 years old with healthy, erupted permanent first molars. A conventional pit and fissure sealant or a silver nanoparticle-mixed sealant was randomly placed. Repeated measures analysis was performed.
Results:
Conventional sealant presented an average microleakage of 30.6%, and the silver nanoparticle-mixed sealant showed 33.6% (P=NS). A three times greater reduction in fluorescence was found in the silver nanoparticles group compared to the conventional group (P<0.05). No sex- or age-based associations were found.
Conclusions:
The silver nanoparticle-mixed sealant reduced tooth demineralization significantly and likely increased remineralization, compared to the conventional sealant.
... Several metaanalyses of various databases point to few if any RCT investigations or high quality research protocols being used to document well defined clinical outcomes. Nevertheless, a consensus exists that exposure to salt fluoridation prevents more cavities than no such exposure at all [46][47][48][49][50][51]. ...
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.
... Since milk production is a non-centralized industry and traders can be non-cooperative, standardized fluoridation becomes quite difficult [30]. Moreover, there is little evidence that the use of milk fluoridation is effective in reducing the caries prevalence [37]. ...
... The most efficient way to prevent caries is by using fluoridated dental products (1,2). Fluoride enters the body with food, through respiration and products containing fluoride (3). Fluoride is a part of the natural environment and is therefore constantly present in people's lives. ...
Introduction:
Appropriate oral health care is fundamental for any individual's health. Dental caries is still one of the major public health problems. The most effective way of caries prevention is the use of fluoride.
Aim:
The aim of our research was to review the literature about fluoride toxicity and to inform physicians, dentists and public health specialists whether fluoride use is expedient and safe.
Methods:
Data we used in our review were systematically searched and collected from web pages and documents published from different international institutions.
Results:
Fluoride occurs naturally in our environment but we consume it in small amounts. Exposure can occur through dietary intake, respiration and fluoride supplements. The most important factor for fluoride presence in alimentation is fluoridated water. Methods, which led to greater fluoride exposure and lowered caries prevalence, are considered to be one of the greatest accomplishments in the 20th century`s public dental health. During pregnancy, the placenta acts as a barrier. The fluoride, therefore, crosses the placenta in low concentrations. Fluoride can be transmitted through the plasma into the mother's milk; however, the concentration is low. The most important action of fluoride is topical, when it is present in the saliva in the appropriate concentration. The most important effect of fluoride on caries incidence is through its role in the process of remineralization and demineralization of tooth enamel. Acute toxicity can occur after ingesting one or more doses of fluoride over a short time period which then leads to poisoning. Today, poisoning is mainly due to unsupervised ingestion of products for dental and oral hygiene and over-fluoridated water.
Conclusion:
Even though fluoride can be toxic in extremely high concentrations, it`s topical use is safe. The European Academy of Paediatric Dentistry (EAPD) recommends a preventive topical use of fluoride supplements because of their cariostatic effect.
The demineralisation and remineralisation cycle needs to be controlled in order to prevent the decomposition of dental tissues. The use of fluoridated products, especially the consumption of fluoridated water and use of fluoridated toothpaste, provides significant reduction in caries risk in a cost-effective manner. Fluoride has also been used as a caries-preventive agent in varnishes and gels, and for decades anti-fluoride propaganda has questioned the public and the dental sector about its safety. Therefore, it is important to discuss the pros and cons of fluoride therapy using scientific evidence. More recently, a number of products containing calcium and phosphate have been released onto the market—these products use a variety of technologies and have varying levels of evidenced-based justification. The mechanisms of action of fluoride- and calcium-based technologies will be discussed in detail.
Background
The World Health Organisation has set out a clear priority for the implementation of interventions to reduce the burden of Early Childhood Caries (ECC), a global public health problem affecting over 500 million children around the world and having a substantial impact on child well-being and health system expenditure.
The aim of this study was to assess and develop international expert consensus on the evidence for fluoride-based interventions in early-year education settings (kindergartens/nursery and primary schools) for reducing ECC and to synthesise clear programme-level recommendations with regard to ECC prevention in this setting.
Methods
A systematic overview of systematic reviews, trials, and observational studies was performed to identify and critically appraise the available evidence on the effectiveness and cost-effectiveness of fluoride-based interventions in early-years education settings to prevent ECC.
This was followed by a three-stage modified Delphi panel study (n= 21) consisting of: round 1, an online survey to gather opinions on safety, effectiveness and feasibility of interventions; round 2, an iterative survey to consider collated group opinion and gather feedback on review findings; and finally, an online workshop with presentations and facilitated in-depth, recorded group discussions.
Results
There was high-quality evidence and consensus on delivering supervised toothbrushing in kindergartens (nurseries) and primary/elementary schools; this is safe and cost-effective, shows greater benefit to more disadvantaged children, helps child social development, and is feasible in high and low/middle-income countries. There was more moderate support for the effectiveness and cost-effectiveness of fluoride varnish application in this setting (especially where supervised toothbrushing with fluoride is in place). It was agreed that policy makers should prioritise at-risk groups where resources are limited, and that systemic fluoride interventions (Fluoride tablets, drops, milk, and salt) in this setting are no longer a priority.
Conclusion
Supervised toothbrushing with fluoridated toothpaste is the most effective, cost-effective, feasible and safest mechanism for children in early education settings. Universal coverage is preferred but where resources are limited targeting based on need is indicated. Panel consensus is that it remains appropriate in water fluoridated areas and is largely feasible in low/middle-income countries.
English summary
Fluoride in caries prevention, harmful effect?
764-771.
Dental personnel will meet claims that fluoride for caries prevention is harmful. Discussions concerning properties of fluoride are frequently encountered in media and on internet. The purpose of this study was firstly, to identify the arguments used against fluoride for caries prevention, and secondly, to evaluate the scientific documentation for association between fluoride and effects on humans. Data was collected by searches using Google and PubMed. Search to identify arguments for harmful effect of fluoride returned 7 246 300 hits. The most common arguments against fluoride included effect on teeth, skeleton, endocrine and nervous systems, kidneys, cardiovascular system and gastrointestinal tract. A total of 1 490 scientific publications were identified in PubMed search. After evaluation of titles and abstracts, 73 publications were evaluated. The results showed that fluoride had harmful effects on humans if dosages recommended in caries-preventive agents were exceeded. In dosages recommended in Norway, the caries-preventive effect of fluoride is well documented. When dental personnel encounter arguments against use of fluoride in dentistry it is important to take concerns seriously and provide solid, understandable information about the effects of fluoride on the human body.
Fluoridated-milk schemes have been developed and implemented in many countries to
prevent dental caries. This study aimed to evaluate the impact/influence of scientific publications, researchers, and institutions conducting research on milk fluoridation; to explore the international and inter-institutional collaboration and illustrate scientific output trends; and to pinpoint research hotspots in milk fluoridation research. This bibliometric analysis of original research articles on milk fluoridation includes all of the original articles published in peer-reviewed journals systematically extracted from the SCOPUS database. In total, 108 articles were included in this study, with a total
of 11,789 citations. A majority (67.6%) of these articles were in the subject area of ‘dentistry’, 22.2% externally funded, 14.8% published in the journal, Caries Research, 7.4% authored/co-authored by Twetman S, 6.5% by authors from Universidad de Chile, and the UK had the highest output (24.1%). The network visualizations showed that those countries with current/past histories of implemented milk fluoridation programs were interconnected on the network visualization map, and they were predominantly the hotspots for original research on milk fluoridation. This study also identified
inequalities in research outputs on the topic. With the current enormous global burden of dental caries in children, particularly in low- and middle-income countries, there is an urgent need for greater and more equitable funding of milk fluoridation research globally
A series of metallo-receptors containing ruthenium(II) bipyridine moiety as signaling unit and calix[4]arene coupled with azacrown as ionophore have been synthesized and characterized. These molecules exhibit metal to ligand charge transfer (MLCT) absorption band at 456 nm and ³MLCT luminescence band at 614 nm. Electrochemical study revealed that the Ru(II) of these complexes oxidize in the potential range +1.23 to +1.30 V and the ligands exhibit three redox waves in the potential -1.36 to -1.89 V. Ion-binding property of these molecules has been studied using a large number of metal ions and anions with the aid of luminescence spectral change, which revealed that all of the three receptors bind Hg²⁺ and Pb²⁺ strongly, as evident from the enhancement in emission intensity with red shift of λmax. Among anions, H2PO4⁻ and F⁻ exhibited substantial quenching in emission intensity, suggesting their strong interaction with the receptors. To evaluate the binding constants (Ks), luminescence titration of the receptor molecules with the strongly interacting ions have been performed and the Ks values have been calculated from the titration data. The Ks values are in the range 4.77 x 10⁴ to 1.20 x 10³ M⁻¹ with descending order of Hg²⁺ > Pb²⁺ > H2PO4⁻ > F⁻. For anions, ¹H NMR spectral change were recorded with incremental addition of anions, the results obtained are discussed in light of ion-binding property and mechanism of interaction.
Minerals are classified as macro-, micro-, or ultra-trace according to the amounts present in the body and the amounts required from the diet to maintain health. They have many roles in the body including the formation of bones and teeth, are essential components of body fluids and tissues, are a part of enzymes, and are involved in nerve function. People have different requirements according to age, sex, and physiological state (e.g., pregnancy, anemia). Mineral bioavailability is affected by many factors including body needs. Deficiencies of certain minerals are global health concerns. Ingestion of large doses leads to accumulation in the body and can be fatal.
Thirteen new fluorine-containing drugs, which have been granted approval by the US Food and Drug Administration (FDA) in 2020, are profiled in this review. Therapeutic areas of these new fluorinated pharmaceuticals include medicines and diagnostic agents for Cushing's disease, neurofibromatosis, migraine, Alzheimer's disease, myelodysplastic syndromes, hereditary angioedema attacks, and various cancers. Molecules of these approved drugs feature aromatic fluorine (Ar-F) (11 compounds), aromatic Ar-CF3 (1), aliphatic CHF (1), and CF2 (1) groups. For each compound, we provide a spectrum of biological activity, medicinal chemistry discovery, and synthetic approaches.
Objective
This study aimed to evaluate the anti-caries effect of a fluoridated milk-based drink on a root caries model by assessing mineral loss and both biofilm microbial viability and acidogenicity under increasing concentrations of fluoride supplementation.
Design
Streptococcus mutans UA159 biofilms were grown on root dentin slabs for five days. The slabs were randomly assigned to following groups: milk-based drink (G1) and milk-based drink supplemented with 5-ppm NaF (G2), 10 ppm NaF (G3), and 20 ppm NaF (G4). A 10% sucrose and 0.9% NaCl solution were used as positive and negative-caries controls, respectively. Slabs/biofilms were exposed to the different treatments 3 times/day for 5 min. To estimate biofilm acidogenicity, the pH of the spent media was serially measured to calculate the area above the curve. Viable bacteria and dentin demineralization were assessed after the experimental phase. Results were compared using ANOVA followed by the Tukey test.
Results
G1 exhibited slightly lower acidogenicity than the positive caries control group (p < 0.05). G2, G3, and G4 induced lower acidogenicity than 10% sucrose and the non-supplemented milk-based drink. The lowest acidogenicity was found in G4 (p < 0.05). Fluoride-supplemented milk-based drinks (G2, G3, and G4) resulted in lower bacterial counts (p < 0.05) and induced lower demineralization (p < 0.05) than the positive caries control and non-supplemented milk-beverage (G1). There was a dose-dependent inhibition of demineralization with fluoride-supplemented milk-based drinks.
Conclusions
Fluoride supplementation of a milk-based drink for older adults may reduce its cariogenicity in root dentin.
Karies merupakan demineralisasi jaringan keras gigi yang diinisiasi oleh aktivitas mikrobial pada lapisan gigi. Salah satu tindakan untuk mencegah terjadinya karies adalah dengan penggunaan fluor sehingga terbentuk ikatan fluoroapatit pada gigi. Salah satu bahan alami yang mengandung konsentrasi fluor dan kalsium tinggi adalah, ikan teri (Stolephorus insularis), yang mengandung fluor sebanyak 15,7-38,3 ppm terutama dalam bentuk senyawa CaF2. Ikan teri sangat mudah ditemukan di Indonesia dan merupakan sumber fluor dan kalsium alami yang sangat baik, namun pembahasan mengenai potensi ikan teri untuk mencegah gigi berlubang masih sangat minim. Artikel ini merupakan ulasan telaah pustaka yang membahas mengenai potensi ikan teri untuk pencegahan gigi berlubang dari berbagai sumber literatur imiah dan penelitan ilmiah. Kandungan fluor dan kalsium pada ikan teri sangat tinggi, konsumsi ikan teri sebanyak 50 gram setiap hari dapat dimanfaatkan untuk mengoptimalkan pertumbuhan tulang dan mencegah gigi berlubang. Ikan teri dapat dikonsumsi langsung dengan diolah menjadi berbagai jenis makanan, bahan aktif dalam pasta gigi dan obat kumur, atau diolah menjadi krim dan gel sebagai fluor yang diaplikasikan secara topikal. Ikan teri merupakan sumber daya alam Indonesia yang melimpah dengan kandungan fluor dan kalsium yang tinggi. Bahan ini relatif murah dan mudah didapat. Sosialisasi mengenai kebaikan ikan teri dan studi lebih lanjut mengenaik pengolahan ikan teri sebaiknya terus dilakukan. Melihat potensi yang baik dari ikan teri, diharapkan bahan ini dapat menjadi salah satu alternatif untuk meningkatkan pencegahan gigi berlubang di masyarakat.
Glycyrrhiza echinata L. is a perennial plant of considerable commercial importance in medicine, pharmaceuticals, cosmetics, and tobacco industries and the production of food additives as flavoring and sweetening agent. This study, variation on composition and yield of essential oil from the underground parts of five accessions of G. echinata growing wild in northern Iran was investigated. Results showed high variability for the main constituents of essential oil among accessions of G. echinata. The presence of α-pinene and myrcene in two accessions suggests that these volatiles could serve as chemotaxonomic markers and also might be considered as potentially relevant for taste. The presence of β-caryophyllene and α- caryophyllene in three accessions could be strong potential for being used in medical applications (anticancer and analgesic properties). Generally, the essential oils from G. echinata and other species could be very competitive targets for phytochemical and food studies.
Background
Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of schoolchildren and the vast majority of adults. Milk may provide a relatively cost‐effective vehicle for fluoride delivery in the prevention of dental caries. This is an update of a Cochrane Review first published in 2005.
Objectives
To assess the effects of milk fluoridation for preventing dental caries at a community level.
Search methods
We searched the Cochrane Oral Health Group Trials Register (inception to November 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 10), MEDLINE via OVID (1946 to November 2014) and EMBASE via OVID (1980 to November 2014). We also searched the U.S. National Institutes of Health Trials Register (https://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (http://apps.who.int/trialsearch) for ongoing trials. We did not place any restrictions on the language or date of publication when searching the electronic databases.
Selection criteria
Randomised controlled trials (RCTs), with an intervention and follow‐up period of at least two years, comparing fluoridated milk with non‐fluoridated milk.
Data collection and analysis
Two authors independently assessed trial risk of bias and extracted data. We used standard methodological procedures expected by Cochrane.
Main results
We included one unpublished RCT, randomising 180 children aged three years at study commencement. The setting was nursery schools in an area with high prevalence of dental caries and a low level of fluoride in drinking water. Data from 166 participants were available for analysis. The study carried a high risk of bias. After three years, there was a reduction of caries in permanent teeth (mean difference (MD) −0.13, 95% confidence interval (CI) −0.24 to −0.02) and in primary teeth (MD −1.14, 95% CI −1.86 to −0.42), as measured by the decayed, missing and filled teeth index (DMFT for permanent teeth and dmft for primary teeth). For primary teeth, this is a substantial reduction, equivalent to a prevented fraction of 31%. For permanent teeth, the disease level was very low in the study, resulting in a small absolute effect size. The included study did not report any other outcomes of interest for this review (adverse events, dental pain, antibiotic use or requirement for general anaesthesia due to dental procedures).
Authors' conclusions
There is low‐quality evidence to suggest fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. Due to the low quality of the evidence, further research is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. There was only one relatively small study, which had important methodological limitations on the data for the effectiveness in reducing caries. Furthermore, there was no information about the potential harms of the intervention. Additional RCTs of high quality are needed before we can draw definitive conclusions about the benefits of milk fluoridation.
Background
Socio-economic inequalities are associated with unequal exposure to social, economic and environmental risk factors, which in turn contribute to health inequalities. Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects on health inequalities. Methods
Systematic review methodology was used to identify systematic reviews from high-income countries that describe the health equity effects of upstream public health interventions. Twenty databases were searched from their start date until May 2017. The quality of the included articles was determined using the Assessment of Multiple Systematic Reviews tool (AMSTAR). ResultsTwenty-nine systematic reviews were identified reporting 150 unique relevant primary studies. The reviews summarised evidence of all types of primary and secondary prevention policies (fiscal, regulation, education, preventative treatment and screening) across seven public health domains (tobacco, alcohol, food and nutrition, reproductive health services, the control of infectious diseases, the environment and workplace regulations). There were no systematic reviews of interventions targeting mental health. Results were mixed across the public health domains; some policy interventions were shown to reduce health inequalities (e.g. food subsidy programmes, immunisations), others have no effect and some interventions appear to increase inequalities (e.g. 20 mph and low emission zones). The quality of the included reviews (and their primary studies) were generally poor and clear gaps in the evidence base have been highlighted. Conclusions
The review does tentatively suggest interventions that policy makers might use to reduce health inequalities, although whether the programmes are transferable between high-income countries remains unclear. Trial registrationPROSPERO registration number: CRD42016025283
The aim of the work was to extract, characterize, and formulate Thymus capitatus (Tymbra capitata) essential oil in phospholipid vesicles: liposomes, glycerosomes and Penetration Enhancer-containing Vesicles (PEVs). The steam-distilled essential oil was mainly composed of carvacrol. The oil was mixed with lecithin and water to produce liposomes, or different ratios of water/glycerol or water/propylene glycol (PG) to produce glycerosomes and PG-PEVs, respectively. Cryo-TEM showed the formation of unilamellar, spherical vesicles, and light scattering disclosed that their size increased in the presence of glycerol or PG, which improved long-term stability. The formulations were highly biocompatible, and capable of counteracting oxidative stress and favouring wound repair in keratinocytes, thanks to enhanced uptake. The antibacterial activity of the oil was demonstrated against cariogenic Streptococcus mutans, Lactobacillus acidophilus, and commensal Streptococcus sanguinis. The combination of antioxidant and antibacterial activities of Thymus essential oil formulations may be useful for the treatment of oral cavity diseases.
Fluormotstand. Er fluor som anbefales i kariesforebyggende arbeid skadelig? Forfattere Cecilie Osvik, tannlegestudent. Det odontologiske fakultet, Universitetet i Oslo Marte Rygg Årdal, tannlegestudent. Det odontologiske fakultet, Universitetet i Oslo Tove I. Wigen, førsteamanuensis, PhD. Institutt for klinisk odontologi, Avdeling for pedodonti og atferdsfag, Universitetet i Oslo Nina J. Wang, professor, dr.odont. Institutt for klinisk odontologi, Avdeling for pedodonti og atferdsfag, Universitetet i Oslo Tannhelsepersonell vil i løpet av sin yrkesaktive periode møte påstander om at fluor (fluorid) er skadelig. Med jevne mellomrom tas fluordiskusjonen opp i media og på internett. Hensikten med studien var å identifisere fluormotstandernes argumenter og vurdere den vitenskapelige dokumentasjon for skadelig effekt av fluor. Data ble innsamlet ved søk på Google og i PubMed. Søk for å identifisere argumenter mot bruk av fluor ga 7 246 300 treff. De mest brukte argumenter mot fluor var fare for skade i tenner, skjelett, endokrint system, nervesystem, nyre, hjerte-karsystem og gastrointestinaltraktus. Totalt 1490 vitenskapelige publika-sjoner ble identifisert ved søk i PubMed. Etter gjennomgang av tittel og sammendrag ble 73 publikasjoner inkludert, og doku-mentasjon for sammenheng mellom fluor og skadelig effekt vur-dert. Vurdering av vitenskapelig litteratur viste at i doser høyere enn de som anbefales i kariesforebyggende arbeid, kan fluor ha skadelig effekt på mennesker. I anbefalte doser er det solid doku-mentasjon for karieshemmende effekt av fluor. I møte med flu-orskeptikere er det viktig å ta deres bekymringer på alvor og gi god og forståelig informasjon om fluors effekter. annhelsepersonell vil i løpet av sin yrkesaktive periode møte påstander om at fluor er skadelig og pasienter som er engstelige for uheldige virkninger av fluor. Med jevne mellomrom tas fluordiskusjon opp i media og på inter-nett. Fluor brukes i stort omfang i kariesforebyggende arbeid, og i Norge anbefales alle å børste tennene med fluortannkrem (1). Den karieshemmende effekten av korrekt fluorbruk er vel-kjent og veldokumentert, men fluor kan ha uheldige bivirk-ninger som tannhelsepersonell må ha kunnskap om. Fluor er et grunnstoff som finnes naturlig i drikkevann i store deler av verden. I jordskorpen finnes fluor som fluo-ridforbindelser, de viktigste er fluoritt, kryolitt og fluorapatitt (2). Når det i dagligtale snakkes om fluor, er det fluorid man sikter til. Fluor har både lokal og systemisk effekt på helse. Ifølge forskrift er det i Norge ikke tillatt med fluorkonsentra-sjon høyere enn 1,5 ppm i drikkevann (3). I små mengder har fluor hemmende effekt på kariesutvik-ling (4). Sammenheng mellom fluor og karies er veldokumen-tert. Det er fluors lokale effekt i munnhulen som påvirker kariesutvikling. Fluor har flere virkningsmekanismer for å hindre kariesutvikling, den viktigste er dannelse av kalsi-umfluorid som former et beskyttende lag mot demineralise-ring av tannemalje (5). Tannhelsepersonell anbefaler fluor i form av tannkrem, tabletter, munnskyllevaeske, gel og lakk (4). I Norge anbefaler helsemyndighetene tannbørsting to ganger per dag med tannkrem med fluorinnhold fra 1000 til 1500 ppm. Bruk av andre fluorpreparater enn fluortannkrem anbefales etter individuell vurdering av kariesrisiko, utført av tannhelsepersonell (1). Ved bruk av fluorprodukter vil alltid noe fluor svelges og kan gi systemisk effekt (6). Andel som svelges avhenger av Hovedbudskap • Det er god dokumentasjon for at fluor har kariesforebyg-gende effekt • Dersom norske anbefalinger følges, er det ikke dokumen-tert skadelig effekt av fluor • Inntak av fluor i store mengder har skadelig effekt • I møte med personer som er skeptiske til bruk av fluor, er det viktig at tannhelsepersonell tar argumentene mot fluor alvorlig og gir oppdatert og dokumentert informasjon om fluors effekter T 764-771-Vit art Osvik Fluormotstand.fm
The demineralisation and remineralisation cycle needs to be controlled in order to prevent the decomposition of dental tissues. The use of fluoridated products, especially the consumption of fluoridated water and use of fluoridated toothpaste, provides significant reduction in caries risk in a cost-effective manner. Fluoride has also been used as a caries-preventive agent in varnishes and gels; for decades anti-fluoride propaganda questioned the public and the dental sector about its safety. Therefore, it is important to discuss the pros and cons of fluoride therapy using scientific evidence. More recently, a number of products containing calcium and phosphate have been released onto the market – these products use a variety of technologies and have varying levels of evidenced-based justification. The mechanisms of action of fluoride- and calcium-based technologies will be discussed in detail.
Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of schoolchildren and the vast majority of adults. Milk may provide a relatively cost-effective vehicle for fluoride delivery in the prevention of dental caries. This is an update of a Cochrane review first published in 2005.
To assess the effects of milk fluoridation for preventing dental caries at a community level.
We searched the Cochrane Oral Health Group Trials Register (inception to November 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 10), MEDLINE via OVID (1946 to November 2014) and EMBASE via OVID (1980 to November 2014). We also searched the U.S. National Institutes of Health Trials Register (https://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (http://apps.who.int/trialsearch) for ongoing trials. We did not place any restrictions on the language or date of publication when searching the electronic databases.
Randomised controlled trials (RCTs), with an intervention and follow-up period of at least two years, comparing fluoridated milk with non-fluoridated milk.
Two authors independently assessed trial risk of bias and extracted data. We used standard methodological procedures expected by The Cochrane Collaboration.
We included one unpublished RCT, randomising 180 children aged three years at study commencement. The setting was nursery schools in an area with high prevalence of dental caries and a low level of fluoride in drinking water. Data from 166 participants were available for analysis. The study carried a high risk of bias. After three years, there was a reduction of caries in permanent teeth (mean difference (MD) -0.13, 95% confidence interval (CI) -0.24 to -0.02) and in primary teeth (MD -1.14, 95% CI -1.86 to -0.42), as measured by the decayed, missing and filled teeth index (DMFT for permanent teeth and dmft for primary teeth). For primary teeth, this is a substantial reduction, equivalent to a prevented fraction of 31%. For permanent teeth, the disease level was very low in the study, resulting in a small absolute effect size. The included study did not report any other outcomes of interest for this review (adverse events, dental pain, antibiotic use or requirement for general anaesthesia due to dental procedures).
There is low quality evidence to suggest fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. Due to the low quality of the evidence, further research is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. There was only one relatively small study, which had important methodological limitations on the data for the effectiveness in reducing caries. Furthermore, there was no information about the potential harms of the intervention. Additional RCTs of high quality are needed before we can draw definitive conclusions about the benefits of milk fluoridation.
To evaluate the scientific evidence regarding laser technology for removal of carious tissue.
A search for literature on the effect of treatment and on economic aspects of laser technology identified 23 papers. No relevant studies on economic aspects were found. Regarding the effect of treatment, 16 papers were selected for assessment according to established criteria.
Cavity preparation and caries excavation by erbium laser were evaluated in three studies of medium quality. The time required to remove carious tissue was evaluated in five studies assessed as being of medium quality for this outcome. In four studies the effect of laser treatment on the dental pulp was included as an outcome but, due to the short follow-up time, the quality was assessed as low. Two studies that included the longevity of the restoration as an outcome were also assessed as being of low quality because the follow-up time was inadequate. Patient response was evaluated in three studies, which were assessed as being of medium quality with respect to this outcome.
There is limited scientific evidence that laser treatment is as effective as a rotary bur for removing carious tissue. Treatment time is prolonged. There is limited scientific evidence that adults prefer laser treatment. No conclusions can be drawn regarding biological or technical complications, children's perception of laser treatment or the cost-effectiveness of the method.
To review the safety and efficacy of fluoridation of drinking water.
Search of 25 electronic databases and world wide web. Relevant journals hand searched; further information requested from authors. Inclusion criteria were a predefined hierarchy of evidence and objectives. Study validity was assessed with checklists. Two reviewers independently screened sources, extracted data, and assessed validity.
Decayed, missing, and filled primary/permanent teeth. Proportion of children without caries. Measure of effect was the difference in change in prevalence of caries from baseline to final examination in fluoridated compared with control areas. For potential adverse effects, all outcomes reported were used.
214 studies were included. The quality of studies was low to moderate. Water fluoridation was associated with an increased proportion of children without caries and a reduction in the number of teeth affected by caries. The range (median) of mean differences in the proportion of children without caries was -5.0% to 64% (14.6%). The range (median) of mean change in decayed, missing, and filled primary/permanent teeth was 0.5 to 4.4 (2.25) teeth. A dose-dependent increase in dental fluorosis was found. At a fluoride level of 1 ppm an estimated 12.5% (95% confidence interval 7.0% to 21.5%) of exposed people would have fluorosis that they would find aesthetically concerning.
The evidence of a beneficial reduction in caries should be considered together with the increased prevalence of dental fluorosis. There was no clear evidence of other potential adverse effects.
The Cochrane Collaboration is an international organization that aims to help people make well-informed decisions about healthcare by preparing, maintaining and promoting the accessibility of systematic reviews on the effects of healthcare interventions. The Cochrane Oral Health Group aims to produce systematic reviews which primarily include all randomized control trials (RCTs) of oral health, including prevention, treatment and rehabilitation of oral, dental and craniofacial diseases and disorders. Full copies of the review papers can be accessed electronically at http:www.cochrane.orgreviewsindex.htm, clicking on ‘Login to the Cochrane Library’, followed by clicking on ‘Cochrane Reviews’, and selecting the appropriate review. This is a free service provided by the Australian Government.
The Australian Dental Journal publishes selected Abstracts in each issue for our readers' interest. A detailed description of the activities of the Cochrane Oral Health Group, written by the Review Group Co-ordinator, Dr Emma Tavender, was published in the June 2004 issue of the Journal (Aust Dent J 2004;49:58–59). Also, for explanations of abbreviations and terminology please see Appendix 1 on page 59 of the aforementioned article.
Editor
This paper outlines the burden of oral diseases worldwide and describes the influence of major sociobehavioural risk factors in oral health. Despite great improvements in the oral health of populations in several countries, global problems still persist. The burden of oral disease is particularly high for the disadvantaged and poor population groups in both developing and developed countries. Oral diseases such as dental caries, periodontal disease, tooth loss, oral mucosal lesions and oropharyngeal cancers, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)-related oral disease and orodental trauma are major public health problems worldwide and poor oral health has a profound effect on general health and quality of life. The diversity in oral disease patterns and development trends across countries and regions reflects distinct risk profiles and the establishment of preventive oral health care programmes. The important role of sociobehavioural and environmental factors in oral health and disease has been shown in a large number of socioepidemiological surveys. In addition to poor living conditions, the major risk factors relate to unhealthy lifestyles (i.e. poor diet, nutrition and oral hygiene and use of tobacco and alcohol), and limited availability and accessibility of oral health services. Several oral diseases are linked to noncommunicable chronic diseases primarily because of common risk factors. Moreover, general diseases often have oral manifestations (e.g. diabetes or HIV/AIDS). Worldwide strengthening of public health programmes through the implementation of effective measures for the prevention of oral disease and promotion of oral health is urgently needed. The challenges of improving oral health are particularly great in developing countries.
To assess the effectiveness of a dental caries prevention programme on the permanent dentition of Chilean rural schoolchildren using fluoridated powdered milk and milk derivatives.
The fluoridated products were delivered to 35,000 schoolchildren in the rural areas of the Ninth Region in Chile using the standard School Feeding Programme (PAE). The daily fluoride dose from milk fluoridated products was estimated at 0.65 mg/day, during approximately 200 schooldays/year. Cross-sectional samples of schoolchildren aged 6, 9 and 12 years from study communities and from positive control communities (ongoing APF-gel programme) were examined at the start of the study in November 1999 and after 36 months.
No significant differences were found for the DMFT and dmft indices among 6-year-olds in the study and positive control groups either at baseline or 36 months later. Significant reductions (range 24-27%) were observed in the DMFT index in 9 and 12-years-olds of the study communities when clinical data at baseline, in the absence of a fluoridated preventive programme, were compared to those obtained after 36 months of receiving fluoridated milk products. Upon the follow-up examination, the DMFT indices of schoolchildren aged 9 and 12 years old receiving fluoridated milk were not significantly different from those of the positive control comparison group of the APF-Gel programme.
Considering the relative costs and technical difficulties involved in both caries preventive programmes, it appears that in rural Chilean communities, fluoridation of powdered milk and milk derivatives is an effective alternative caries prevention programme in areas where either water fluoridation or other community delivered programmes are difficult to apply.
No recent data on the experience of caries among Italian 12-year-olds are available. In 2004, an epidemiological survey called 'National Pathfinder among Children's Oral Health in Italy' was promoted and carried out. This study reports the actual oral health status of Italian 12-year-olds according to gender, residence area and geographical distribution. Clinical examinations were carried out from March 2004 to April 2005, according to WHO criteria, and included dental caries (decay at the dentinal lesion level) and Community Periodontal Index (CPI). 5,342 children (2,670 males, 2,672 females) were examined by 7 ad hoc calibrated raters. Dental caries experience was found in 43.1% (95% CI 41.8-44.4%) of the study population. The mean DMFT score was 1.09 (95% CI 0.98-1.21). Significant differences (p < 0.05) were observed among geographical sections for DT, FT and DMFT. An inverse relationship was observed between mean DMFT and gross national product per capita (p < 0.001). Gingival bleeding was observed in 23.8% of children, while 28.7% had calculus. Significant differences in CPI scores among sections were found throughout the sample in both males and females (p < 0.001). Over the past two decades, mean DMFT fell from over 5 to its present level, halving every decade; consequently, the recorded level of dental caries has become aligned with that in other Western European countries. Nevertheless, differences in DMFT values remain between children from different socioeconomic backgrounds.
Aim To determine the concentration of fluoride in saliva and supragingival dental plaque at designated time intervals after consumption of snacks prepared with a standardised amount of fluoridated salt. Study design The investigation had a single blind prospective crossover design. Methods A group of 11 healthy young adults volunteered to participate after verbal and written information and consent. After a 1-week fluoride depletion period, the subjects consumed popcorn prepared with either fluoridated (250 mg/kg) or non-fluoridated salt during 30 minutes. Unstimulated whole saliva and samples of supragingival plaque were collected before consumption (baseline) and at 30, 60 and 120 minutes after the intake. Fluoride concentration was determined with a fluoridespecific electrode and the post-ingestion levels were compared with baseline by ANOVA. Results In saliva, the mean fluoride concentrations at baseline ranged from 0.021 to 0.027 mg/L and after the 30 minutes consumption of fluoride prepared snacks a 15-fold increase (p < 0.001) was found. The same pattern was disclosed in the plaque samples. In both saliva and plaque, the fluoride levels remained significantly elevated after 2 hours (p < 0.001 and p < 0.05, respectively). Conclusion Consumption of snacks prepared with fluoridated table salt resulted in significantly increased fluoride levels in saliva and supragingival plaque for a period of at least two hours.
This paper comprizes a summarizing discussion for a set of 13 papers on the theme caries decline. The complexity of the issue is highlighted, and it is concluded that there is not one single factor explaining the changes observed. Actually, in one and the same population, different explanations may be relevant for different individuals, for different age groups, for different teeth and for different periods of time. A new model for understanding the interaction of various caries etiological factors is proposed. The model can illustrate how in one situation caries activity can increase (or decrease) due to one such factor, while in another situation different factors are more important. As it, in a graphic way, maps the interactions of relevant factors, the author has chosen to call it a cariogram, and the process of preparing such graphs, cariography.
An expert assessment of both the beneficial and toxic effects to human health posed by the use of fluorine and fluorides. Conclusions and recommendations are based on a critical analysis of well over 400 clinical and laboratory investigations. The introductory sections consider methods for the measurement of fluorides in inorganic and organic materials, sources and magnitude of exposure, and effects on health as determined through a large number of laboratory investigations. The most extensive section is devoted to a critical review of data on beneficial and toxic effects in humans. Beneficial effects of fluoride in drinking water, salt, milk, tablets, and topical applications are considered in terms of the preventive effects on dental caries and their use in the treatment of osteoporosis. Toxic effects reviewed include various forms of fluorosis, effects on renal function, hypersensitivity and dermatological reactions, and carcinogenic and teratogenic risks. On the basis of this review, the report confirms the beneficial effects of fluoride in the prevention of caries, while noting that long-term exposure to high quantities may damage enamel and bone; very high doses cause acute toxic effects and may be lethal.
Available on-line at: http://www.inchem.org/documents/ehc/ehc/ehc36.htm
Background
: Although the predominant beneficial effect of fluoride occurs locally in the mouth, the adverse effect, dental fluorosis, occurs by the systemic route. The caries attack rate in industrialized countries, including the United States and Canada, has decreased dramatically over the past 40 years. However, the prevalence of dental fluorosis in the United States has increased during the last 30 years both in communities with fluoridated water and in communities with nonfluoridated water. Dental fluorosis is closely associated with fluoride intake during the period of tooth development. Methods : We reviewed the major changes in infant feeding practices that have occurred since 1930 and the changes in fluoride intakes by infants and young children associated with changes in feeding practices. Results and Conclusions : Based on this review, we conclude that fluoride intakes of infants and children have shown a rather steady increase since 1930, are likely to continue to increase, and will be associated with further increase in the prevalence of enamel fluorosis unless intervention measures are instituted. Recommendations : We believe the most important measures that should be undertaken are (1) use, when feasible, of water low in fluoride for dilution of infant formulas; (2) adult supervision of toothbrushing by children younger than 5 years of age; and (3) changes in recommendations for administration of fluoride supplements so that such supplements are not given to infants and more stringent criteria are applied for administration to children.
Despite great improvements in terms of reduced prevalence and amount of dental caries in populations worldwide, problems still persist particularly among the underprivileged groups of both developed and developing countries. Research and practical experience gained in several countries have demonstrated however, that dental caries can be prevented effectively through establishment of fluoride programmes. Water fluoridation, salt fluoridation, milk fluoridation and use of affordable fluoridated toothpastes play the major roles in public health. The present paper outlines the relevance and some practical aspects in relation to implementation of salt fluoridation programmes. The World Health Organisation Oral Health Programme provides technical assistance to countries in the process of planning, implementing and evaluating salt fluoridation projects.
Unlabelled:
Fluoride has been used in dentistry for over 100 years for the purpose of preventing dental caries. During this time there has been great debate over the mode of action, the optimum method of delivery, and the potential risks associated with its use. This, the first of three papers, will provide a summary of the history of the use of fluoride, the mode of action, benefits and different methods of delivery. It will also discuss the potential risk of dental fluorosis.
Clinical relevance:
This article aims to provide a background for general practitioners for the appropriate use of fluorides in dentistry, enable them to understand the wider significance of fluoride in dentistry and to be able to answer non-clinical questions raised by patients.
Many children experience painful tooth decay which can lead to the tooth/teeth being extracted. Even if teeth are not extracted the tooth decay may be distressing, be expensive to treat and may involve children and their carers having time off school and work. Another Cochrane review showed that fluoride toothpastes do reduce dental decay, by about 24% on average, when compared with a non-fluoride toothpaste. This review compares toothpastes with different amounts of fluoride. This review includes 79 trials on 73,000 children. As expected the use of toothpaste containing more fluoride is generally associated with less decay. Toothpastes containing at least 1000 parts per million (ppm) fluoride are effective at preventing tooth decay in children, which supports the current international standard level recommended. Although none of the trials included in the review looked at fluorosis or mottling of the children's teeth, fluorosis may be an unwanted result of using fluoride toothpaste in young children and a Cochrane review on this topic has also been published. The possible risk of fluorosis should be discussed with your dentist who may recommend using a toothpaste containing less than 1000 ppm fluoride.
To present the evidence summarized in the Cochrane fluoride reviews.
An overview of the results of selected systematic reviews.
Relevant systematic reviews published in the Cochrane Database of Systematic Reviews (CDSR) were identified by searching 'The Cochrane Library issue 4, 2008', using the terms 'Fluoride' and 'Caries'. Complete Cochrane reviews assessing the effectiveness of any fluoride-based intervention for preventing caries were selected, and their main features and findings were reviewed.
14 papers were identified of which 11 were relevant full-text reviews. The results were assessed of 7 reviews published from 2002 to 2004 concerning the relative effectiveness of 4 topical fluoride treatments (toothpastes, gels, varnishes and mouthrinses) in preventing caries in children and adolescents. Comparisons in these reviews were made against non-fluoride controls, against each other, and against different combinations. Findings from 4 reviews published between 2004 and 2006, assessing other fluoride modalities (slow release devices, milk), specific comparison/site (fluoride varnishes versus sealants in occlusal surfaces), and particular population and caries outcome (fluorides for white spot lesions in orthodontic patients) were also assessed. The 7 reviews confirm a clear and similar effectiveness of topical fluoride toothpastes, mouthrinses, gels and varnishes for preventing caries, and show that additional caries reduction can be expected when another topical fluoride is combined with fluoride toothpaste. Evidence is insufficient to confirm the effectiveness of slow release fluoride devices and fluoridated milk. The comparative effectiveness of other modes of delivering fluoride, such as to orthodontic patients is also as yet unclear. Fissure sealants appear more effective than fluoride varnish for preventing occlusal caries but the size of the difference is unclear.
The benefits of topical fluorides are firmly established based on a sizeable body of evidence from randomized controlled trials. The size of the reductions in caries increment in both the permanent and the primary dentitions emphasizes the importance of including topical fluoride delivered through toothpastes, rinses, gels or varnishes in any caries preventive program. However, trials to discern potential adverse effects are required, and data on acceptability. Better quality research is needed to reach clearer conclusions on the effects of slow release fluoride devices, milk fluoridation, sealants in comparison with fluoride varnishes, and of different modes of delivering fluoride to orthodontic patients.
The aim was to examine recent literature and review the caries-preventive effect of fluoride toothpaste in children.
Based on three comprehensive systematic reviews published in 2003, a broad search of the PubMed and Cochrane library databases was conducted for papers published 2002-2008 using "fluoride toothpaste", "fluoride dentifrice" and "fluoride dental cream" as index terms. Relevant publications were identified after assessment of their abstracts. Papers were selected if they reported a prospective controlled design with caries data reported at baseline and at the end of the study. The targeted papers were critically assessed concerning design, methodology and performance according to a pre-determined checklist.
The initial search revealed 179 papers of which 15 met the inclusion criteria. There was strong evidence that daily use of fluoride toothpaste has a significant caries-preventive effect in children compared with placebo (prevented fraction 24%). The effect was boosted by supervised tooth brushing, increased brushing frequency to twice daily, and use of a toothpaste concentration of 1,500 ppm fluoride. There were few studies of high quality reporting findings from the primary dentition. There were no studies available, and therefore insufficient evidence, on when to commence brushing with fluoride toothpaste as well as on the post-brushing behaviour. The use of "adult" toothpaste in very young children seemed to increase the risk for mild dental fluorosis in low-caries communities but not in socially deprived high-caries populations.
The results reinforced the outstanding role of fluoride toothpaste as an effective caries preventive measure in children.
The aim of this study was to evaluate the effect of milk supplemented with probiotic bacteria and fluoride on caries development and general health in preschool children. Children 1-5 years of age (n = 248) attending 14 day care centres with 27 units in northern Sweden entered the study. The centres were randomly assigned to two parallel groups: children in the intervention group were served 150 ml milk supplemented with Lactobacillus rhamnosus LB21 (10(7) CFU/ml) and 2.5 mg fluoride per litre for lunch while the control group received standard milk. The double-blind intervention lasted for 21 months (weekdays) and data were collected through clinical examinations and questionnaires. The primary outcome was caries increment and secondary outcomes were measures of general health. The dropout rate was 25%. The mean baseline caries experience was 0.5 dmfs in the intervention units and 0.6 in the control units and after 21 months 0.9 and 2.2 (p < 0.05). The number of days with sick leave was similar in both groups but the children of the intervention units displayed 60% fewer days with antibiotic therapy (mean 1.9 vs. 4.7 days) and 50% less days with otitis media (0.5 vs. 1.0) (p > 0.05). In children who had participated during the whole 21-month intervention, fewer days with otitis media were reported (0.4 vs. 1.3 days, p < 0.05). No serious side effects were reported. It is concluded that daily consumption of milk containing probiotic bacteria and fluoride reduced caries in preschool children with a prevented fraction of 75%. Additional beneficial health effects were evident.
To measure the 5-year caries increment among high-risk children during their participation in the New England Children's Amalgam Trial (NECAT), and to evaluate sociodemographic factors that may account for any observed disparities.
NECAT recruited 534 children aged 6-10 with at least two decayed posterior occlusal surfaces from urban Boston and rural Maine. After restoration of baseline caries and application of sealants to sound surfaces, NECAT continued to provide free comprehensive semiannual dental care to participants. The net caries increment of children who completed the 5-year follow-up (n = 429) was calculated and predictors of caries increment were investigated using multivariate negative binomial models.
The majority of children (89%) experienced new caries by the end of the 5-year follow-up. Almost half (45%) had at least one newly decayed surface by the first annual visit. At year 5, the mean number of new decayed teeth was 4.5 +/- 3.6 (range 0-25) and surfaces was 6.9 +/- 6.5 (range 0-48). Time trends showed a noticeably higher increment rate among older children and young teenagers. Multivariate models showed that age (P < 0.001), number of baseline carious surfaces (P < 0.001), and toothbrushing frequency (<1/day versus >or=2/day, P = 0.04) were associated with caries increment. Only 48 children (11%) did not develop new caries.
Despite the receipt of comprehensive semiannual dental care, the vast majority of these high-risk children continued to develop new caries within 5 years. While disparities were observed by age, extent of prior decay, and toothbrushing frequency, no other sociodemographic factors were associated with caries increment, suggesting that the dental care provided during the trial reduced sociodemographic disparities in prior caries experience that were observed at baseline.
ater fluoridation has been promoted in many countries as an organized community effort to control dental caries. With the availability of fluorides targeted at individuals and the decline in dental caries, the need for fluoridation has been questioned. Recent reports show that water fluoridation, a community- level intervention, continues to be an efficient method for the delivery of fluoride in many countries. The advantages include its ability to deliver low levels of fluoride to saliva frequently, with high reach, at low cost, and with substantial cost savings. Water fluoridation has the potential to reduce oral health disparities by creating a healthy environment. Other forms of fluoride, such as fluoride toothpaste, and clinical interventions complement dental caries control strategies.
Much of the research regarding the efficacy of fluoridated milk was obtained prior to the routine use of fluoridated dentifrices. The aim was to investigate, in situ, the effect of fluoridated and non-fluoridated milk on mineral change in artificial caries lesions, with the additional use of fluoridated dentifrice. The roles of different milk fluoride concentrations, volumes and frequencies in mineral change were studied. In total, 29 edentulous subjects were recruited and tooth blocks, containing artificial caries lesions, were inserted into their full dentures at 4 areas (sites). Each subject followed 5 randomly ordered, 6-week beverage experiments: 0.5 mg of F in 200 ml of milk, 3 times per day; 1.5 mg of F in 200 ml of milk, once per day; 200 ml of milk, once per day; 200 ml of milk, 3 times per day, and no beverage (negative control). In addition, the subjects were allocated to 1 of 2 groups; experimental treatment only or treatment and dentifrice. Mineral change was measured with transverse microradiography. Statistical analysis was performed using 2-sample t tests and a general linear modelling procedure. For integrated mineral loss there was a statistically significant effect of group (p = 0.001), indicating fluoridated toothpaste significantly increased remineralisation. For lesion depth there was a statistically significant combined effect of 'group and site'. 'Experiment' had no statistically significant influence on change in integrated mineral loss or lesion depth. The study demonstrated that the use of fluoridated dentifrice twice per day had a positive effect on the remineralisation of caries lesions. However, no additional significant effect of fluoridated milk was observed.
Tea-drinking in very young children has been studied in a British city. The results suggested that the fluoride in tea would, in some cases, be sufficient to influence caries. Clinical findings to some extent supported this. The main purpose of the investigation reported here was to determine maximum possible fluoride intake in adults who were heavy tea drinkers in a fluoridated city and relate it to toxic thresholds. Heavy tea drinkers were traced through Health Visitors and voluntary organizations and the volumes and fluoride concentrations of their drinks were measured. Even the highest intake found (9 mg) is below the probable intake in Bartlett, Texas (8 ppm of fluoride), in relation to which no undesirable symptoms have been reported (Leone et al. 1954). This confirms the safety of fluoridation. The effects on fluoride concentration of evaporating soft and hard fluoride-containing waters to small bulk were compared. The results showed ceilings of 3 ppm of fluoride in hard water and about 14 ppm in soft water, much higher than the levels expected on the basis of the usually stated solubility of CaF2 (16 or 8 ppm of fluoride). However, under normal household conditions, it is most unlikely that dangerous levels of fluoride would be ingested from boiled water.
The fluoride contents of infusions prepared from 44 different brands and types of teas were measured. Fluoride concentrations ranged from 0.34 to 3.71 ppm (mean = 1.50 ppm) in caffeinated tea infusions, 0.02-0.14 ppm (mean = 0.05 ppm) in herbal tea infusions, and 1.01-5.20 ppm (mean = 3.19) in decaffeinated tea infusions. This is the first report of the fluoride content of decaffeinated teas. The mean fluoride content of decaffeinated tea infusions is significantly (p < 0.01) higher than the corresponding caffeinated tea. The use of mineral water containing a naturally high fluoride level during the process of decaffeination is the most likely explanation of the above observation.
This paper comprizes a summarizing discussion for a set of 13 papers on the theme caries decline. The complexity of the issue is highlighted, and it is concluded that there is not one single factor explaining the changes observed. Actually, in one and the same population, different explanations may be relevant for different individuals, for different age groups, for different teeth and for different periods of time. A new model for understanding the interaction of various caries etiological factors is proposed. The model can illustrate how in one situation caries activity can increase (or decrease) due to one such factor, while in another situation different factors are more important. As it, in a graphic way, maps the interactions of relevant factors, the author has chosen to call it a cariogram, and the process of preparing such graphs, cariography.
Dental caries appears to result from the action of multiple, interrelated factors. A companion study dealt with the plaque-flora/caries relationship (van Ruyven et al., 2000). The plaque-pH/caries relationship is the subject of this study. Since both studies involve the same subjects, plaques, and tooth surfaces, data on the examined factors have also been integrated. In vivo plaque pH determinations (microelectrode) were done on buccal sound (s) and "white-spot" (ws) caries surfaces in a selected dentition area in a low-caries (no ws) and higher-caries subject group. The pH response to sugar was evaluated before and after a sugar rinse, a local sugar application, or sucking on a sugary lozenge. pH profiles with sugar rinsing and normal or limited salivary flow conditions, showed progressively decreasing plaque pH values at various time points in the order of: low-caries subjects (s sites), higher-caries subjects (s sites), higher-caries subjects (s + ws sites), and higher-caries subjects (ws sites). The minimum pH values showed the same trend. Analyses of all data indicated only a statistical difference for minimum values for s sites in low-caries subjects vs. ws sites in higher-caries subjects, and for s and ws sites in the latter. Local sugar application and sucking on a sugary lozenge induced smaller pH drops than sugar rinsing; such suboptimal sugar exposure caused a disappearance of the difference between the minimum pH values for s and ws sites observed with sugar rinsing in the higher-caries subjects. Initial plaque pH values were similar regardless of subject or tooth caries status. The values were also not correlated with the plaque levels of strongly iodophilic polysaccharide-storing bacteria. Collectively, both studies indicate that increasing subject caries status is characterized by increasing plaque levels of highly-acid-tolerant, acidogenic bacteria and an increasing plaque-pH-lowering potential and support the dynamic relationship between these parameters.
The city of Kuopio in central Finland had fluoridated piped water for 33 years, beginning in 1959. Due to strong opposition by various civic groups, water fluoridation was stopped at the end of 1992. There is little information on the consequences of stopping fluoridation in a community with comprehensive dental care for all children and adolescents, who are frequently exposed to different fluoride measures both at home and in the dental office.
The aim of this repeated cross-sectional survey was to examine how discontinuation of water fluoridation in Kuopio affected caries in the primary dentition. Changes in the mean dmfs values between 1992 and 1995 in Kuopio were compared to those in Jyväskylä, a low-fluoride community that has repeatedly been used as the reference area for Kuopio.
In 1992 and 1995, independent random samples of all children aged 3, 6 and 9 years were drawn in Kuopio and Jyväskylä. The total number of subjects examined was 421 in 1992 and 894 in 1995. Calibrated dentists registered caries clinically and radiographically.
In all age groups both in 1992 and 1995, the point estimates for mean dmfs values were lower in the non-fluoridated town. In both towns, the observed mean dmfs values were smaller in 1995 than in 1992.
Despite discontinuation of water fluoridation, no increase of caries frequency in primary teeth was observed in Kuopio within a three-year period.
Water fluoridation in Kuopio, Finland, was stopped at the end of 1992. In our previous study, no increase in caries was found in Kuopio 3 years after the discontinuation of water fluoridation. The aim of the present study was to further observe the occurrence and distribution of caries in Kuopio and Jyväskylä, which was used as the reference town for Kuopio. In 1992, 1995 and 1998 independent random samples of all children aged 3, 6, 9, 12 and 15 years were drawn in Kuopio and Jyväskylä. The total numbers of subjects examined were 688, 1,484 and 1,530 in 1992, 1995 and 1998, respectively. Calibrated dentists registered caries clinically and radiographically. No indication of increasing caries could be found in the previously fluoridated town during 1992-1998. In both towns the mean dmfs and DMFS values either decreased or remained about the same during the observation period. When all study years and both towns were pooled, 25% of the 12- and 15-year-olds with the highest DMFS counts accounted for 79 and 67%, respectively, of all affected surfaces. The mean numbers of fluoride varnish and sealant applications had markedly decreased in 1993-1998 compared to 1990-1992. The fact that no increase in caries was found in Kuopio despite discontinuation of water fluoridation and decrease in preventive procedures suggests that not all of these measures were necessary for each child.
Although the predominant beneficial effect of fluoride occurs locally in the mouth, the adverse effect, dental fluorosis, occurs by the systemic route. The caries attack rate in industrialized countries, including the United States and Canada, has decreased dramatically over the past 40 years. However, the prevalence of dental fluorosis in the United States has increased during the last 30 years both in communities with fluoridated water and in communities with nonfluoridated water. Dental fluorosis is closely associated with fluoride intake during the period of tooth development.
We reviewed the major changes in infant feeding practices that have occurred since 1930 and the changes in fluoride intakes by infants and young children associated with changes in feeding practices.
Based on this review, we conclude that fluoride intakes of infants and children have shown a rather steady increase since 1930, are likely to continue to increase, and will be associated with further increase in the prevalence of enamel fluorosis unless intervention measures are instituted.
We believe the most important measures that should be undertaken are (1) use, when feasible, of water low in fluoride for dilution of infant formulas; (2) adult supervision of toothbrushing by children younger than 5 years of age; and (3) changes in recommendations for administration of fluoride supplements so that such supplements are not given to infants and more stringent criteria are applied for administration to children.
In 1987, Jamaica initiated a comprehensive island-wide salt fluoridation program. A survey was conducted in 1995 to monitor the impact of salt fluoridation among children in Jamaica.
Dental examinations of 1,120 children aged 6-8, 12, and 15 years were conducted according to World Health Organization criteria to assess dental caries, fluorosis, the presence of and need for dental sealants, and Community Periodontal Treatment Needs (CPI).
Age specific DMFT means observed in 1995 were 0.2 at age 7, 0.4 at age 8, 1.1 at age 12 and 3.0 at age 15. The mean DMFT scores in children 6, 12 and 15 years of age were dramatically lower than the corresponding scores of 1.7, 6.7 and 9.6 obtained at the baseline examination in 1984 for children of the same age groups, respectively (baseline data for 7- and 8-year-olds were not collected). The mean percentage of sound permanent teeth for all age groups was 90% in 1995. The percentage of children caries-free at baseline was 27.6% for 6 years, 2.8% for 12 years and 0.3% for 15 years of age. In 1995, the percentage of caries-free children (permanent teeth) was 61%. In 1984, 23 children were scored as having very mild or mild fluorosis. In 1995, five children were scored in the same categories of fluorosis, using Dean's criteria; thus, fluorosis remained at negligible levels in 1995.
The oral health survey conducted in Jamaica in 1995 indicated a significant decline in dental caries compared with findings in 1984. The major change in Jamaica during the interval was the introduction of salt fluoridation in 1987. Dental fluorosis was low in the 1995 survey.
To demonstrate the effectiveness of a dental caries prevention program on the primary dentition of Chilean rural children, using fluoridated powdered milk and milk derivatives.
Fluoridated milk and milk-cereal was given to about 1000 preschool children in Codegua, a rural community located in the 6th Region of Chile, using the standard National Complementary Feeding Program (PNAC). The daily fluoride dose from fluoridated powdered milk was estimated at 0.25 mg for infants (0-2 years old), 0.5 mg for children aged 2-3 years and 0.75 for children aged 3-6 years. Cross-sectional samples of children aged 3-6 years were taken from Codegua (study community) from 1994 to 1999 and from La Punta (control community) from 1997 and 1999.
Significant reductions (72%) were observed in the dmfs indices in the 3-6-year-old groups in Codegua, when comparing 1999 with 1994 data. In 1999, children in the study community showed significantly lower dmfs than children in the control community (41%). The proportion of caries-free children in the study community increased after 4 years of program implementation (from 22.0% to 48.4%).
Under Chilean rural conditions, fluoridation of powdered milk distributed through the PNAC is an effective caries prevention alternative for areas where water fluoridation might not be feasible.
This study determined fluoride (F) concentrations in whole saliva and dental plaque after intake of fluoridated milk using a randomised crossover experimental design. Eighteen healthy children (6-8 years) were subjected to each of four different 3-day drinking regimens: (a) 200 ml F-free tap water; (b) 200 ml tap water with 1.0 mg F; (c) 200 ml standard milk, and (d) 200 ml standard milk with 1.0 mg F. A washout period of 7 days was organised between the different drinking regimens. All children used F-free toothpaste prior to and during the trial and were instructed to avoid F-rich food and drinks. F concentration in unstimulated whole saliva was determined at baseline and after 15 and 120 min and in plaque samples at baseline and after 2 h. The mean baseline values ranged from 0.01 to 0.02 mg F/l in saliva and between 10.4 and 14.2 mg F/l in dental plaque. A statistically significant (p < 0.05) increase of F was disclosed in saliva 15 min after drinking F-containing milk and water (0.052 and 0.058 mg F/l, respectively). After 2 h, the salivary F(-) concentrations were back to baseline values. In the plaque, however, a statistically significant (p < 0.01) twofold increase was found at 2 h after the intake of fluoridated milk and water, respectively. The results indicate that consumption of fluoridated milk contributes to a F storing process with significantly elevated F concentrations in dental plaque up to 2 h after intake. Further studies are required to determine the 'therapeutic concentration' of F in dental plaque after intake of fluoridated milk.
In view of the conflicting reports of the extent and severity of dental caries in alcohol misusing subjects, a systematic survey of the fluoride content of alcoholic beverages was undertaken.
The fluoride content of beverages varied widely particularly if non-UK European products were considered.
Beers brewed in locations with high fluoride water levels may contribute significantly to the daily fluoride intake, particularly in alcohol misusing subjects and this may contribute to alcohol-associated bone disease.
The decline in the prevalence of caries has lead several authors to advocate the adoption of a 'high-risk' approach for caries preventive strategies. This paper analyses such an approach. It argues that the distribution of caries within a population follows certain laws: first, the mean caries score is a function of the prevalence; second, the variance is a function of the mean; and third, for a particular mean score, the distribution within the population is predetermined. Using data from the National Preventive Dentistry Demonstration Programme (NPDDP) in the US and the British Association for the Study of Community Dentistry (BASCD) epidemiological programmes in the UK the functions determining the distribution of caries within the population are examined. The findings indicate the changes in caries experience observed occurred throughout populations and are not confined to subgroups. Strategies limited to individuals 'at risk' would fail to deal with the majority of new lesions. The main emphasis should be centred on a population approach.
Children who brush their teeth at least once a day with a toothpaste that contains fluoride will have less tooth decay. Tooth decay (dental caries) is painful, expensive to treat and can sometimes lead to serious damage to teeth. Fluoride is a mineral that prevents tooth decay. The review of trials found that children aged 5 to 16 years who used a fluoridated toothpaste had fewer decayed, missing and filled permanent teeth after three years (regardless of whether their drinking water was fluoridated). Twice a day use increases the benefit. No conclusion could be reached about the risk that using fluoride toothpastes could mottle teeth (fluorosis), an effect of chronic ingestion of excessive amounts of fluoride when children are young.
In some regional areas of Indonesia, caries prevalence is increasing rapidly. As water, salt or milk fluoridation were not considered suitable for use throughout Indonesia, and fluoridated tooth paste is mostly too expensive, a fluoride co-crystallised sugar containing 10 ppm fluoride was prepared. Its efficacy in inhibiting caries development was tested in a field trial.
The field trial was established in Medan, Sumatera. All dietary background data necessary to ensure the safety of a trial were collected. Subjects chosen were 176 children who were residents of two orphanages and a boarding school for children of poor rural families. The trial used a double-blind format. Close monitoring of fluoride consumption was maintained, and fluoride excretion rates were assessed six monthly by urinary fluoride analysis.
Records of total tooth surface caries present initially and after 18 months of sugar supply showed that the children using fluoridated sugar had significantly fewer carious lesions than those who used normal sugar.
This result indicates that sugar might be considered as a further vehicle for supplementary dietary fluoride in communities where there is a high caries prevalence or high caries risk and little exposure to fluoride.
To compare caries in children initially aged 3 to 5 years who had participated for four years in a fluoridated school milk programme with a group of children in a similar community drinking non-fluoridated milk.
A four-year longitudinal study measuring caries experience and caries increment in primary molars and caries experience in permanent molars and incisors.
478 children in Knowsley (test group) and 396 in Skelmersdale (comparison group) were examined for caries (dmft/dfs) at baseline in 1997. Of these, 318 in Knowsley and 233 in Skelmersdale were re-examined at follow-up (dmft/dfs and DMFT/DFS) in 2001.
The mean ages at baseline of the children from the test and comparison groups were 4.7 and 4.8 years respectively. The baseline dmft/dfs was 1.73/2.51 in the test group and 1.29/2.15 in the comparison group. The 4-year dmft/dfs mean increments were 2.28/4.49 and 1.96/4.12 in test and comparison groups respectively. The DMFT/DFS at age 7-9 years in the test and comparison groups were 0.40/0.45 and 0.40/0.55 respectively.
The fluoridated school milk scheme, as configured in Knowsley. Merseyside, did not reduce caries within the primary dentition and, at best, had a small clinical impact on the permanent dentition up to 8 years of age.
To determine the concentration of fluoride in saliva and supragingival dental plaque at designated time intervals after consumption of snacks prepared with a standardised amount of fluoridated salt.
The investigation had a single blind prospective crossover design.
A group of 11 healthy young adults volunteered to participate after verbal and written information and consent. After a 1-week fluoride depletion period, the subjects consumed popcorn prepared with either fluoridated (250 mg/kg) or non-fluoridated salt during 30 minutes. Unstimulated whole saliva and samples of supragingival plaque were collected before consumption (baseline) and at 30, 60 and 120 minutes after the intake. Fluoride concentration was determined with a fluoride-specific electrode and the post-ingestion levels were compared with baseline by ANOVA.
In saliva, the mean fluoride concentrations at baseline ranged from 0.021 to 0.027 mg/L and after the 30 minutes consumption of fluoride prepared snacks a 15-fold increase (p<0.001) was found. The same pattern was disclosed in the plaque samples. In both saliva and plaque, the fluoride levels remained significantly elevated after 2 hours (p<0.001 and p<0.05, respectively).
Consumption of snacks prepared with fluoridated table salt resulted in significantly increased fluoride levels in saliva and supragingival plaque for a period of at least two hours.
The milk fluoridation scheme established in Codegua, Chile, between 1994 and 1999 demonstrated the effectiveness of powdered milk as a community-based vehicle for fluoride to prevent dental caries. The present study aimed to compare caries prevalence in both the Codeguan control and test communities, three years after ending fluoride distribution through the powdered milk fluoridation scheme, to assess whether the benefits of such milk fluoridation were still present in the test community.
Children 3-6 years old living in Codegua (test community) and La Punta (control community) were examined for dental caries at their educational facilities by three trained and calibrated examiners using natural light, dental mirrors, and sickle probes. Differences in caries prevalence (dmfs) by year of the study were tested for statistically significant differences using the Mann-Whitney U test.
Findings from Codegua (1999-2002) indicate that the dental caries experience increased in all age groups following the termination of powdered milk fluoridation. These differences reached levels of statistical significance in the 3-, 4-, and 5- year old group (P < .03). Comparing results from Codegua and La Punta (2002), no statistically significant differences were found.
Termination of the powdered milk fluoridation scheme resulted in a deterioration of the dental health of children. After three years, dental caries prevalence was higher than that reached at the end of the scheme and equivalent to that of the control community without fluoride exposure. These results emphasize the need to establish and maintain an alternative mechanism of community-based fluoridation of proven effectiveness for the prevention of dental caries in communities where water fluoridation is not available.
Despite great improvements in the oral health of populations across the world, problems still persist particularly among poor and disadvantaged groups in both developed and developing countries. According to the World Oral Health Report 2003, dental caries remains a major public health problem in most industrialized countries, affecting 60-90% of schoolchildren and the vast majority of adults. Although it appears that dental caries is less common and less severe in developing countries of Africa, it is anticipated that the incidence of caries will increase in several countries of that continent, due to changing living conditions and dietary habits, and inadequate exposure to fluorides. Research on the oral health effects of fluoride started around 100 years ago; the focus has been on the link between water and fluorides and dental caries and fluorosis, topical fluoride applications, fluoride toothpastes, and salt and milk fluoridation. Most recently, efforts have been made to summarize the extensive database through systematic reviews. Such reviews concluded that water fluoridation and use of fluoride toothpastes and mouthrinses significantly reduce the prevalence of dental caries. WHO recommends for public health that every effort must be made to develop affordable fluoridated toothpastes for use in developing countries. Water fluoridation, where technically feasible and culturally acceptable, has substantial advantages in public health; alternatively, fluoridation of salt and milk fluoridation schemes may be considered for prevention of dental caries.
Dental caries is a common chronic disease that causes pain and disability across all age groups. If left untreated, dental caries can lead to pain and infection, tooth loss, and edentulism (total tooth loss). Dental sealants are effective in preventing dental caries in the occlusal (chewing) and other pitted and fissured surfaces of the teeth. Enamel fluorosis is a hypomineralization of enamel related to fluoride exposure during tooth formation (first 6 years for most permanent teeth). Exposure to fluoride throughout life is effective in preventing dental caries. This is the first CDC Surveillance Summary that addresses these conditions and practices.
1988-1994 and 1999-2002.
The National Health and Nutrition Examination Survey (NHANES) is an ongoing survey of representative samples of the civilian, noninstitutionalized U.S. population aged >/=2 months in NHANES 1988-1994 and all ages during 1999-2002. The dental component gathered information on persons aged >/=2 years.
During 1999-2002, among children aged 2-11 years, 41% had dental caries in their primary teeth. Forty-two percent of children and adolescents aged 6-19 years and approximately 90% of adults had dental caries in their permanent teeth. Among children aged 6-19 years, 32% had received dental sealants. Adults aged >/=20 years retained a mean of 24 of 28 natural teeth and 8% were edentulous. Among persons aged 6-39 years, 23% had very mild or greater enamel fluorosis. Disparities were noticed across all age groups, among racial/ethnic groups, persons with lower education and income, and by smoking status. From 1988-1994 to 1999-2002, four trends were observed: 1) no change in the prevalence of dental caries in primary teeth among children aged 2-11 years, 2) a reduction in prevalence of caries in permanent teeth of up to 10 percentage points among persons aged 6-19 years and up to six percentage points among dentate adults aged >/=20 years, 3) an increase of 13 percentage points in dental sealants among persons aged 6-19 years, and 4) a six percentage point reduction in total tooth loss (edentulism) among persons aged >/=60 years.
The findings of this report indicate that the dental caries status of permanent teeth has improved since the 1988-1994 survey. Despite the decrease in caries prevalence and severity in the permanent dentition and the increase in the proportion of children and adolescents who benefit from dental sealants, disparities remain.
These data provide information for public health professionals in designing interventions to improve oral health and to reduce disparities in oral health, for researchers in assessing factors associated with disparities and dental caries in primary teeth, and in designing timely surveillance tools to monitor total fluoride exposure.
To compare levels of caries experience in children attending schools in Wirral that have a fluoridated milk programme with children in a similar community which does not have a fluoridated milk programme.
A cross sectional study measuring caries experience in first permanent molars. Children were examined on an 'intention to treat' basis and the effect of clustering of children within schools was taken into account.
690 children in Wirral (test group) and 1,835 children in Sefton (comparison group) were examined for caries experience (DMFT/DT/DFS) in 2003. The mean ages of the children examined in the test and comparison groups were 10.79 and 10.83 years respectively.
Mean DMFT/DT/DFS values were 1.01/0.59/1.20 respectively in the test group and 1.46/1.02/1.89 respectively in the comparison group. Multiple linear regression analysis taking clustering of children within schools into account and with the Index of Multiple Deprivation 2000 as an explanatory variable gave the coefficients and p-values for DMFT/DT/DFS of 0.49 (p < 0.001)/0.43 (p < 0.001)/0.74 (p < 0.001) respectively.
A difference in children with caries experience of 13% and a difference in children with active decay of 16% was found when a district with a community fluoridated milk programme was compared with a district without a fluoridated milk programme.
Dental caries remain a public health problem for many developing countries and for underprivileged populations in developed countries. This paper outlines the historical development of public health approaches to the use of fluoride and comments on their effectiveness. Early research and development was concerned with waterborne fluorides, both naturally occurring and added, and their effects on the prevalence and incidence of dental caries and dental fluorosis. In the latter half of the 20th century, the focus of research was on fluoride toothpastes and mouth rinses. More recently, systematic reviews summarizing these extensive databases have indicated that water fluoridation and fluoride toothpastes both substantially reduce the prevalence and incidence of dental caries. We present four case studies that illustrate the use of fluoride in modern public health practice, focusing on: recent water fluoridation schemes in California, USA; salt fluoridation in Jamaica; milk fluoridation in Chile; and the development of "affordable" fluoride toothpastes in Indonesia. Common themes are the concern to reduce demands for compliance with fluoride regimes that rely upon action by individuals and their families, and the issue of cost. We recommend that a community should use no more than one systemic fluoride (i.e. water or salt or milk fluoridation) combined with the use of fluoride toothpastes, and that the prevalence of dental fluorosis should be monitored in order to detect increases in or higher-than-acceptable levels.
This paper aims at assessing the public health potential of salt fluoridation schemes. There is now solid evidence which shows that the cariostatic effectiveness of universal salt fluoridation is equivalent to that of water fluoridation in both the permanent and primary dentition. In countries of continental Europe, only domestic salt is fluoridated, and its consistent use may be expected to warrant a 30% reduction of caries prevalence. However, the effectiveness in the population at large is lower because only part of the population uses the fluoridated domestic salt. Under these conditions, it must be assumed that the effectiveness is further reduced because families in low S-E strata use fluoridated salt (FS) less frequently than those in the higher S-E strata who are known to use preventive methods like toothbrushing twice a day with a fluoride dentifrice more regularly. Model calculations tend to show that in Germany, where FS has reached a market share of 60%, the overall effectiveness is 14% instead of 30%. For France with a market share of 30% of the fluoridated domestic salt, model calculations lead to an overall effectiveness of 8%. In order to obtain a substantial decline of caries in the entire population, it is important to aim for a high market share of the FS of 80%, or preferably 90%. This goal can be reached with a relatively small budget. The task of health ministries would be to promote the switch from unfluoridated salt to FS; however, such promotion is often withheld by health ministries. It is possible, through modest price increases of salt, to finance effective campaigns inducing the majority of the population to use the fluoridated variety. On a world wide scale, fluoridation of salt has established itself as an efficient public health measure. It may be particularly beneficial for developing countries because it is by far the cheapest method and it is compatible with the use of fluoridated toothpastes.
Use of fluoridated milk has been shown to be a safe and effective method to prevent caries in permanent teeth in children. However, studies on its effectiveness on caries prevention in the primary teeth are scarce. The purpose of the present study was to evaluate the effect of milk fluoridation on caries development in young Chinese children.
This was a community-based demonstration study carried out in Beijing, China. All children in three selected kindergartens were invited to participate. Each participant consumed 200 ml of fluoridated milk (concentration 2.5 mg F- per litre) per day from Monday to Friday in the kindergarten, and was given two packs of fluoridated milk (250 ml) for consumption at home on Saturday and Sunday every week. Children from a similar background, but without access to fluoridated milk, attending two other kindergartens, were used as the control.
There were 534 children (mean age 54 +/- 4 months) and 305 children (mean age 53 +/- 4 months) in the test and control groups, respectively, at baseline. After 21 months, 417 and 247 children in the test and control groups, respectively, remained in the study. There was no statistically significant difference in the baseline mean dmft scores between the two groups (3.2 vs. 3.5, P = 0.312). After 21 months, the mean net caries increment was 0.4 dmft for the test group and 1.3 dmft for the control group (t-test, P < 0.001).
The consumption of fluoridated milk by the kindergarten children in Beijing was an effective measure in preventing caries in the primary teeth.
To measure and compare 24-h urinary fluoride excretion in children aged 1.5-3.5 years from European study sites and to use these data to estimate the 24-h fluoride intake.
Twenty-four-hour urine samples were collected from 3-year-old children (n = 86) who were already participating in a European multicentre study. Samples were collected from Cork, Ireland (n = 19) where the water is fluoridated to a concentration between 0.8 and 1.0 ppm and from five sites with a water fluoride concentration <0.15 ppm: Knowsley, England (n = 18); Oulu, Finland (n = 18); Reykjavik, Iceland (n = 4); Haarlem, the Netherlands (n = 6); Almada/Setubal, Portugal (n = 21). The volume of the samples was measured; they were analysed for fluoride concentration and the 24-h urinary fluoride excretion was calculated. From this an estimate of the daily fluoride intake was made.
It was found that the mean fluoride excretion in response to the usual conditions of fluoride intake in the children in the nonfluoridated areas ranged from 0.16 mg (+/-0.08) in Oulu to 0.33 mg (+/-0.27) in Almada/Setubal with an overall mean of 0.23 mg (+/-0.19). The mean 24-h fluoride excretion in fluoridated Cork was 0.37 mg (+/-0.11). There was a significant difference between the fluoride excretion in the nonfluoridated areas and that in the fluoridated areas, and the data were broadly in agreement with WHO standards.
The daily urinary fluoride excretion and estimated fluoride intake in these children appeared to be within acceptable limits.
Chronic diseases and injuries are the leading health problems in all but a few parts of the world. The rapidly changing disease patterns throughout the world are closely linked to changing lifestyles, which include diets rich in sugars, widespread use of tobacco, and increased consumption of alcohol. In addition to socio-environmental determinants, oral disease is highly related to these lifestyle factors, which are risks to most chronic diseases as well as protective factors such as appropriate exposure to fluoride and good oral hygiene. Oral diseases qualify as major public health problems owing to their high prevalence and incidence in all regions of the world, and as for all diseases, the greatest burden of oral diseases is on disadvantaged and socially marginalized populations. The severe impact in terms of pain and suffering, impairment of function and effect on quality of life must also be considered. Traditional treatment of oral diseases is extremely costly in several industrialized countries, and not feasible in most low-income and middle-income countries. The WHO Global Strategy for Prevention and Control of Noncommunicable Diseases, added to the common risk factor approach is a new strategy for managing prevention and control of oral diseases. The WHO Oral Health Programme has also strengthened its work for improved oral health globally through links with other technical programmes within the Department for Noncommunicable Disease Prevention and Health Promotion. The current oral health situation and development trends at global level are described and WHO strategies and approaches for better oral health in the 21st century are outlined.
AJMilk Fluoridation for the prevention of Dental Caries Available online at www.who.int/entity
- J Bánóczy
- Petersen Pe
Bánóczy J, Petersen PE, Rugg-Gunn AJMilk Fluoridation for the prevention of Dental Caries. Geneve. World Health Organization, 2009; Available online at www.who.int/entity/ oral_health/.../milk_fluoridation_2009_en.pdf, accessed may 12, 2012.
Acta Odontol Scand Downloaded from informahealthcare.com by University of Sydney on 08
- M G Cagetti
M. G. Cagetti et al. Acta Odontol Scand Downloaded from informahealthcare.com by University of Sydney on 08/27/14 For personal use only. References
Cochrane reviews of randomized trials of fluoride therapies for preventing dental caries
- V C Marinho
Marinho VC. Cochrane reviews of randomized trials of fluoride therapies for preventing dental caries. Eur Arch Paediatr
Dent 2009;10:183–91.
AJMilk Fluoridation for the prevention of Dental Caries Available online at www.who.int/entity Fluoridated milk for preventing dental caries
- J Bánóczy
- Pe Petersen
- Rugg-Gunn Yeung
- Ca Hitchings
- Jl Macfarlane
- Tv Threlfall
- Ag Tickle
- M Glenny
Bánóczy J, Petersen PE, Rugg-Gunn AJMilk Fluoridation
for the prevention of Dental Caries. Geneve. World Health
Organization, 2009; Available online at www.who.int/entity/
oral_health/.../milk_fluoridation_2009_en.pdf, accessed may
12, 2012.
[40] Yeung CA, Hitchings JL, Macfarlane TV, Threlfall AG,
Tickle M, Glenny AM. Fluoridated milk for preventing dental
caries. Cochrane Database Syst Rev 2005;20(3):CD003876.
Ten great public health achievements -United States, 1900–1999. MMWR Weekly Available online at www.cdc.gov/ mmwr/preview/mmwrhtml/00056796.htm
- Disease Centers
- Control
- Prevention
Centers for Disease Control and Prevention. Ten great public
health achievements -United States, 1900–1999. MMWR
Weekly. 1999. 48:241–3. Available online at www.cdc.gov/
mmwr/preview/mmwrhtml/00056796.htm.accessed may 12
2012.