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Meta-Analysis
. 2015 Jun 18;2015(6):CD010856.
doi: 10.1002/14651858.CD010856.pub2.

Water fluoridation for the prevention of dental caries

Zipporah Iheozor-Ejiofor  1 , Helen V Worthington, Tanya Walsh, Lucy O'Malley, Jan E Clarkson, Richard Macey, Rahul Alam, Peter Tugwell, Vivian Welch, Anne-Marie Glenny
Affiliations
Meta-Analysis

Water fluoridation for the prevention of dental caries

Zipporah Iheozor-Ejiofor et al. Cochrane Database Syst Rev. .

Update in

  • Water fluoridation for the prevention of dental caries.
    Iheozor-Ejiofor Z, Walsh T, Lewis SR, Riley P, Boyers D, Clarkson JE, Worthington HV, Glenny AM, O'Malley L. Iheozor-Ejiofor Z, et al. Cochrane Database Syst Rev. 2024 Oct 4;10(10):CD010856. doi: 10.1002/14651858.CD010856.pub3. Cochrane Database Syst Rev. 2024. PMID: 39362658 Free PMC article.

Abstract

Background: Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation was initiated in the USA in 1945 and is currently practised in about 25 countries around the world; health authorities consider it to be a key strategy for preventing dental caries. Given the continued interest in this topic from health professionals, policy makers and the public, it is important to update and maintain a systematic review that reflects contemporary evidence.

Objectives: To evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries.To evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis.

Search methods: We searched the following electronic databases: The Cochrane Oral Health Group's Trials Register (to 19 February 2015); The Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2015); MEDLINE via OVID (1946 to 19 February 2015); EMBASE via OVID (1980 to 19 February 2015); Proquest (to 19 February 2015); Web of Science Conference Proceedings (1990 to 19 February 2015); ZETOC Conference Proceedings (1993 to 19 February 2015). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization's WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on language of publication or publication status in the searches of the electronic databases.

Selection criteria: For caries data, we included only prospective studies with a concurrent control that compared at least two populations - one receiving fluoridated water and the other non-fluoridated water - with outcome(s) evaluated at at least two points in time. For the assessment of fluorosis, we included any type of study design, with concurrent control, that compared populations exposed to different water fluoride concentrations. We included populations of all ages that received fluoridated water (naturally or artificially fluoridated) or non-fluoridated water.

Data collection and analysis: We used an adaptation of the Cochrane 'Risk of bias' tool to assess risk of bias in the included studies.We included the following caries indices in the analyses: decayed, missing and filled teeth (dmft (deciduous dentition) and DMFT (permanent dentition)), and proportion caries free in both dentitions. For dmft and DMFT analyses we calculated the difference in mean change scores between the fluoridated and control groups. For the proportion caries free we calculated the difference in the proportion caries free between the fluoridated and control groups.For fluorosis data we calculated the log odds and presented them as probabilities for interpretation.

Main results: A total of 155 studies met the inclusion criteria; 107 studies provided sufficient data for quantitative synthesis.The results from the caries severity data indicate that the initiation of water fluoridation results in reductions in dmft of 1.81 (95% CI 1.31 to 2.31; 9 studies at high risk of bias, 44,268 participants) and in DMFT of 1.16 (95% CI 0.72 to 1.61; 10 studies at high risk of bias, 78,764 participants). This translates to a 35% reduction in dmft and a 26% reduction in DMFT compared to the median control group mean values. There were also increases in the percentage of caries free children of 15% (95% CI 11% to 19%; 10 studies, 39,966 participants) in deciduous dentition and 14% (95% CI 5% to 23%; 8 studies, 53,538 participants) in permanent dentition. The majority of studies (71%) were conducted prior to 1975 and the widespread introduction of the use of fluoride toothpaste.There is insufficient information to determine whether initiation of a water fluoridation programme results in a change in disparities in caries across socioeconomic status (SES) levels.There is insufficient information to determine the effect of stopping water fluoridation programmes on caries levels.No studies that aimed to determine the effectiveness of water fluoridation for preventing caries in adults met the review's inclusion criteria.With regard to dental fluorosis, we estimated that for a fluoride level of 0.7 ppm the percentage of participants with fluorosis of aesthetic concern was approximately 12% (95% CI 8% to 17%; 40 studies, 59,630 participants). This increases to 40% (95% CI 35% to 44%) when considering fluorosis of any level (detected under highly controlled, clinical conditions; 90 studies, 180,530 participants). Over 97% of the studies were at high risk of bias and there was substantial between-study variation.

Authors' conclusions: There is very little contemporary evidence, meeting the review's inclusion criteria, that has evaluated the effectiveness of water fluoridation for the prevention of caries.The available data come predominantly from studies conducted prior to 1975, and indicate that water fluoridation is effective at reducing caries levels in both deciduous and permanent dentition in children. Our confidence in the size of the effect estimates is limited by the observational nature of the study designs, the high risk of bias within the studies and, importantly, the applicability of the evidence to current lifestyles. The decision to implement a water fluoridation programme relies upon an understanding of the population's oral health behaviour (e.g. use of fluoride toothpaste), the availability and uptake of other caries prevention strategies, their diet and consumption of tap water and the movement/migration of the population. There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES. We did not identify any evidence, meeting the review's inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries in adults.There is insufficient information to determine the effect on caries levels of stopping water fluoridation programmes.There is a significant association between dental fluorosis (of aesthetic concern or all levels of dental fluorosis) and fluoride level. The evidence is limited due to high risk of bias within the studies and substantial between-study variation.

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Conflict of interest statement

Authors on this review have also been involved in the evaluation of the evidence using different methodology for the CDC Task Force Recommendation on Water Fluoridation

Figures

1
1
Figure 1. Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Initiation of water fluoridation compared with low/non‐fluoridated water: change in dmft
4
4
Initiation of water fluoridation compared with low/non‐fluoridated water: change in DMFT
5
5
Initiation of water fluoridation compared with low/non‐fluoridated water: change in proportion of caries‐free children (deciduous teeth)
6
6
Initiation of water fluoridation compared with low/non‐fluoridated water: change in proportion of caries‐free children (permanent teeth)
7
7
Proportion of the population with dental fluorosis of aesthetic concern by water fluoride level together with 95% confidence limits for the proportion (studies reporting up to and including 5ppm).
8
8
Proportion of the population with dental fluorosis of any level by water fluoride level together with 95% confidence limits for the proportion (studies reporting up to and including 5ppm F)
9
9
Source:CAPP database, 2015
1.1
1.1. Analysis
Comparison 1 Initiation of water fluoridation compared with low/non‐fluoridated water, Outcome 1 Change in decayed, missing or filled deciduous teeth (dmft).
1.2
1.2. Analysis
Comparison 1 Initiation of water fluoridation compared with low/non‐fluoridated water, Outcome 2 Change in decayed, missing or filled permanent teeth (DMFT).
1.3
1.3. Analysis
Comparison 1 Initiation of water fluoridation compared with low/non‐fluoridated water, Outcome 3 Change in proportion of caries free children (deciduous teeth).
1.4
1.4. Analysis
Comparison 1 Initiation of water fluoridation compared with low/non‐fluoridated water, Outcome 4 Change in proportion of caries free children (permanent teeth).
See this image and copyright information in PMC

References

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Kotecha 2012 {published data only}
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Kumar 1999 {published data only}
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Kumar 2007 {published data only}
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Kunzel 1976 {published data only}
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Kunzel 1997 {published data only}
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Leverett 1986 {published data only}
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Levine 1989 {published data only}
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Lin 1991 {published data only}
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Loh 1996 {published data only}
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Louw 2002 {published data only}
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Machiulskiene 2009 {published data only}
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Mackay 2005 {published data only}
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Macpherson 2007 {published data only}
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Mandinic 2009 {published data only}
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Mandinic 2010 {published data only}
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Masztalerz 1990 {published data only}
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Maupome 2001 {published data only}
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Mazzotti 1939 {published data only}
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McInnes 1982 {published data only}
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Mella 1992 {published data only}
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Mella 1994 {published data only}
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Meyer‐Lueckel 2006 {published data only}
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Milsom 1990 {published data only}
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Mondal 2012 {published data only}
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Montero 2007 {published data only}
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Nanda 1974 {published data only}
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Narbutaite 2007 {published data only}
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Narwaria 2013 {published data only}
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Nunn 1992 {published data only}
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Nunn 1994a {published data only}
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Nunn 1994b {published data only}
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Ockerse 1941 {published data only}
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Pontigo‐Loyola 2008 {published data only}
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Pot 1974 {published data only}
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Ray 1982 {published data only}
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Riordan 1991 {published data only}
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Riordan 2002 {published data only}
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Ruan 2005 {published data only}
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Rugg‐Gunn 1997 {published data only}
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Russell 1951 {published data only}
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Rwenyonyi 1998 {published data only}
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Rwenyonyi 1999 {published data only}
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Saravanan 2008 {published data only}
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Scheinin 1964 {published data only}
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Segreto 1984 {published data only}
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Sellman 1957 {published data only}
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Selwitz 1995 {published data only}
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Selwitz 1998 {published data only}
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Skotowski 1995 {published data only}
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Spadaro 1955 {published data only}
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Stephen 2002 {published data only}
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Sudhir 2009 {published data only}
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Szpunar 1988 {published data only}
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Tabari 2000 {published data only}
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Tessier 1987 {published data only}
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Tsutsui 2000 {published data only}
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Venkateswarlu 1952 {published data only}
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Vignarajah 1993 {published data only}
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Vilasrao 2014 {published data only}
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Villa 1998 {published data only}
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Wang 1993 {published data only}
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Wang 1999 {published data only}
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Warnakulasuriya 1992 {published data only}
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Zimmermann 1954 {published data only}
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References to studies excluded from this review

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Hoffmann 2004 {published data only}
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Hopcraft 2003 {published data only}
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Jones 1997 {published data only}
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Kalsbeek 1993 {published data only}
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Kirkeskov 2010 {published data only}
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Murray 1984 {published data only}
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Nirgude 2010 {published data only}
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Spencer 2008 {published data only}
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References to studies awaiting assessment

Wang 2014 {published data only}
    1. Wang Y, Wang C‐S, Xia Y‐T, Wang P‐H. Investigation on drinking water‐borne endemic fluorosis in Jiangsu, 2013. Journal of Environment and Health 2014;31(6):516‐8.

References to ongoing studies

Pretty (ongoing) {unpublished data only}
    1. An evaluation of a water fluoridation scheme in Cumbria. Ongoing study 2013.

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