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Meta-Analysis
. 2024 Oct 4;10(10):CD010856.
doi: 10.1002/14651858.CD010856.pub3.

Water fluoridation for the prevention of dental caries

Zipporah Iheozor-Ejiofor  1 , Tanya Walsh  2 , Sharon R Lewis  2 , Philip Riley  2 , Dwayne Boyers  3 , Janet E Clarkson  2   4 , Helen V Worthington  2 , Anne-Marie Glenny  2 , Lucy O'Malley  2
Affiliations
Meta-Analysis

Water fluoridation for the prevention of dental caries

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

Abstract

Background: Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation (CWF) is currently practised in about 25 countries; health authorities consider it to be a key strategy for preventing dental caries. CWF is of interest to health professionals, policymakers and the public. This is an update of a Cochrane review first published in 2015, focusing on contemporary evidence about the effects of CWF on dental caries.

Objectives: To evaluate the effects of initiation or cessation of CWF programmes for the prevention of dental caries. To evaluate the association of water fluoridation (artificial or natural) with dental fluorosis.

Search methods: We searched CENTRAL, MEDLINE, Embase and four other databases up to 16 August 2023. We also searched two clinical trials registers and conducted backward citation searches.

Selection criteria: We included populations of all ages. For our first objective (effects of initiation or cessation of CWF programmes on dental caries), we included prospective controlled studies comparing populations receiving fluoridated water with those receiving non-fluoridated or naturally low-fluoridated water. To evaluate change in caries status, studies measured caries both within three years of a change in fluoridation status and at the end of study follow-up. For our second objective (association of water fluoridation with dental fluorosis), we included any study design, with concurrent control, comparing populations exposed to different water fluoride concentrations. In this update, we did not search for or include new evidence for this objective.

Data collection and analysis: We used standard methodological procedures expected by Cochrane. For our first objective, we included the following outcomes as change from baseline: decayed, missing or filled teeth ('dmft' for primary and 'DMFT' for permanent teeth); decayed, missing or filled tooth surfaces ('dmfs' for primary and 'DMFS' for permanent teeth); proportion of caries-free participants for both primary and permanent dentition; adverse events. We stratified the results of the meta-analyses according to whether data were collected before or after the widespread use of fluoride toothpaste in 1975. For our second objective, we included dental fluorosis (of aesthetic concern, or any level of fluorosis), and any other adverse events reported by the included studies.

Main results: We included 157 studies. All used non-randomised designs. Given the inherent risks of bias in these designs, particularly related to management of confounding factors and blinding of outcome assessors, we downgraded the certainty of all evidence for these risks. We downgraded some evidence for imprecision, inconsistency or both. Evidence from older studies may not be applicable to contemporary societies, and we downgraded older evidence for indirectness. Water fluoridation initiation (21 studies) Based on contemporary evidence (after 1975), the initiation of CWF may lead to a slightly greater change in dmft over time (mean difference (MD) 0.24, 95% confidence interval (CI) -0.03 to 0.52; P = 0.09; 2 studies, 2908 children; low-certainty evidence). This equates to a difference in dmft of approximately one-quarter of a tooth in favour of CWF; this effect estimate includes the possibility of benefit and no benefit. Contemporary evidence (after 1975) was also available for change in DMFT (4 studies, 2856 children) and change in DMFS (1 study, 343 children); we were very uncertain of these findings. CWF may lead to a slightly greater change over time in the proportion of caries-free children with primary dentition (MD -0.04, 95% CI -0.09 to 0.01; P = 0.12; 2 studies, 2908 children), and permanent dentition (MD -0.03, 95% CI -0.07 to 0.01; P = 0.14; 2 studies, 2348 children). These low-certainty findings (a 4 percentage point difference and 3 percentage point difference for primary and permanent dentition, respectively) favoured CWF. These effect estimates include the possibility of benefit and no benefit. No contemporary data were available for adverse effects. Because of very low-certainty evidence, we were unsure of the size of effects of CWF when using older evidence (from 1975 or earlier) on all outcomes: change in dmft (5 studies, 5709 children), change in DMFT (3 studies, 5623 children), change in proportion of caries-free children with primary dentition (5 studies, 6278 children) or permanent dentition (4 studies, 6219 children), or adverse effects (2 studies, 7800 children). Only one study, conducted after 1975, reported disparities according to socioeconomic status, with no evidence that deprivation influenced the relationship between water exposure and caries status. Water fluoridation cessation (1 study) Because of very low-certainty evidence, we could not determine if the cessation of CWF affected DMFS (1 study conducted after 1975; 2994 children). Data were not available for other review outcomes for this comparison. Association of water fluoridation with dental fluorosis (135 studies) The previous version of this review found low-certainty evidence that fluoridated water may be associated with dental fluorosis. With a fluoride level of 0.7 parts per million (ppm), approximately 12% of participants had fluorosis of aesthetic concern (95% CI 8% to 17%; 40 studies, 59,630 participants), and approximately 40% had fluorosis of any level (95% CI 35% to 44%; 90 studies, 180,530 participants). Because of very low-certainty evidence, we were unsure of other adverse effects (including skeletal fluorosis, bone fractures and skeletal maturity; 5 studies, incomplete participant numbers).

Authors' conclusions: Contemporary studies indicate that initiation of CWF may lead to a slightly greater reduction in dmft and may lead to a slightly greater increase in the proportion of caries-free children, but with smaller effect sizes than pre-1975 studies. There is insufficient evidence to determine the effect of cessation of CWF on caries and whether water fluoridation results in a change in disparities in caries according to socioeconomic status. We found no eligible studies that report caries outcomes in adults. The implementation or cessation of CWF requires careful consideration of this current evidence, in the broader context of a population's oral health, diet and consumption of tap water, movement or migration, and the availability and uptake of other caries-prevention strategies. Acceptability, cost-effectiveness and feasibility of the implementation and monitoring of a CWF programme should also be taken into account.

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Conflict of interest statement

ZIE has declared that they have no conflict of interest.

TW is a co‐author on Goodwin 2022 and Co‐Director (since July 2023) of the Colgate‐Palmolive Dental Health Unit based at The University of Manchester. She has been Statistical Editor for Cochrane Oral Health. TW did not participate in the assessment of Goodwin 2022.

SL is a former Deputy Co‐ordinating Editor for the Bone, Joint and Muscle Trauma group; she has had no role in the editorial process for the review.

PR is Deputy Co‐ordinating Editor for Cochrane Oral Health; he has had no role in the editorial process for this review.

DB has declared that they have no conflict of interest.

JC is Joint Co‐ordinating Editor for Cochrane Oral Health; she has had no role in the editorial process for this review.

HW was previously Joint Co‐ordinating Editor for Cochrane Oral Health/Statistical Editor; she has had no role in the editorial process for this review.

AMG is Joint Co‐ordinating Editor for Cochrane Oral Health; she has had no role in the editorial process for this review.

LO'M has declared that they have no conflict of interest.

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Kim 2019 {published data only}
    1. Kim H-N, Kong W-S, Lee J-H, Kim J-B. Reduction of dental caries among children and adolescents from a 15-year community water fluoridation program in a township area, Korea. International Journal of Environmental Research and Public Health 2019;16(1306):1-13. [DOI: 10.3390/ijerph16071306] - DOI - PMC - PubMed
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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McGrady 2012 {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}
    1. Pontigo-Loyola A, Islas-Marquez A, Loyola-Rodriguez J, Maupome G, Marquez-Corona M, Medina-Solis C. Dental fluorosis in 12- and 15-year-olds at high altitudes in above-optimal fluoridated communities in Mexico. Journal of Public Health Dentistry 2008;68(3):163-6. - PubMed
Pot 1974 {published data only}
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Ray 1982 {published data only}
    1. Ray S, Ghosh S, Tiwari I, Nagchaudhuri J, Kaur P, Reddy D. Prevalence of dental fluorosis in relation to fluoride in drinking water in two villages of Varanasi (U.P.). Indian Journal of Public Health 1982;26(3):173-8. - PubMed
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}
    1. Rwenyoyi C, Bjorvatn K, Birkeland J, Haugejorden O. Altitude as a risk Indicator of dental fluorosis in children residing in areas with 0.5 and 2.5 mg fluoride per litre in drinking water. Caries Research 1999;33:267-74. - PubMed
Saravanan 2008 {published data only}
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Scheinin 1964 {published data only}
    1. Scheinin A, Kalijaervi E, Harjola O, Heikkinen K. Prevalence of dental caries and dental health in relation to variable concentration of fluorides in drinking water; a clinical study on Finnish school-children. Acta Odontologica Scandinavica 1964;22:229-54. - PubMed
Segreto 1984 {published data only}
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Sellman 1957 {published data only}
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Selwitz 1995 {published data only}
    1. Selwitz R, Nowjack Raymer R, Kingman A, Driscoll W. Prevalence of dental caries and dental fluorosis in areas with optimal and above-optimal water fluoride concentrations: a 10-year follow-up survey. Journal of Public Health Dentistry 1995;55(2):85-93. - PubMed
Selwitz 1998 {published data only}
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Shanthi 2014 {published data only}
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Shekar 2012 {published data only}
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Skinner 2013 {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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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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Vuhahula 2009 {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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Wang 2012 {published data only}
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Warnakulasuriya 1992 {published data only}
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Whelton 2006 {published data only}
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Wondwossen 2004 {published data only}
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Zheng 1986 {published data only}
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Zimmermann 1954 {published data only}
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References to studies excluded from this review

Armfield 2013 {published data only}
    1. Armfield JM, Spencer AJ, Roberts-Thomson KF, Plastow K. Water fluoridation and the association of sugar-sweetened beverage consumption and dental caries in Australian children. American Journal of Public Health 2013;103(3):494-500. [PMID: ] - PMC - PubMed
Do 2014 {published data only}
    1. Do LG, Miller J, Phelan C, Sivaneswaran S, Spencer AJ, Wright C. Dental caries and fluorosis experience of 8-12-year-old children by early-life exposure to fluoride. Community Dentistry and Oral Epidemiology 2014;42(6):553-62. [PMID: ] - PubMed
Hawew 1996 {published data only}
    1. Hawew RM, Ellwood RP, Hawley GM, Worthington HV, Blinkhorn AS. Dental caries in children from two Libyan cities with different levels of fluoride in their drinking water. Community Dental Health 1996;13(3):175-7. [PMID: ] - PubMed
Kämppi 2013 {published data only}
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Koh 2015 {published data only}
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Lee 2015 {published data only}
    1. Lee H-J, Han D-H. Exploring the determinants of secular decreases in dental caries among Korean children. Community Dentistry and Oral Epidemiology 2015;42(4):357-65. [PMID: ] - PubMed
McLaren 2022 {published data only}
    1. McLaren L, McNeil DA, Potestio M, Patterson S, Thawer S, Faris P, et al. Equity in children's dental caries before and after cessation of community water fluoridation: differential impact by dental insurance status and geographic material deprivation. International Journal for Equity in Health 2016;15:24. [PMID: ] - PMC - PubMed
    1. McLaren L, Patterson S, Thawer S, Faris P, McNeil D, Potestio M, et al. Measuring the short-term impact of fluoridation cessation on dental caries in Grade 2 children using tooth surface indices. Community Dentistry and Oral Epidemiology 2016;44(3):274-82. [PMID: ] - PMC - PubMed
    1. McLaren L, Patterson S, Thawer S, Faris P, McNeil D, Potestio ML, et al. Exploring the short-term impact of community water fluoridation cessation on children's dental caries: a natural experiment in Alberta, Canada. Public Health 2017;146:56-64. [PMID: ] - PubMed
    1. McLaren L, Patterson SK, Faris P, Chen G, Thawer S, Figueiredo R, et al. Fluoridation cessation and children's dental caries: a 7-year follow-up evaluation of Grade 2 schoolchildren in Calgary and Edmonton, Canada. Community Dentistry and Oral Epidemiology 2022;50(5):391-403. [PMID: ] - PMC - PubMed
    1. McLaren L, Patterson SK, Faris P, Chen G, Thawer S, Figueiredo R, et al. Fluoridation cessation and oral health equity: a 7-year post-cessation study of Grade 2 schoolchildren in Alberta, Canada. Canadian Journal of Public Health 2022;113(6):955-68. [PMID: ] - PMC - PubMed
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.
Zander 2013 {published data only}
    1. Zander A, Sivaneswaran S, Skinner J, Byun R, Jalaludin B. Risk factors for dental caries in small rural and regional Australian communities. Rural Remote Health 2013;13(3):2492. [PMID: ] - PubMed

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