Association between low fluoride exposure and children's intelligence: a meta-analysis relevant to community water fluoridation.

OBJECTIVES: Previous meta-analyses have mainly focused on studies conducted in endemic fluorosis areas with relatively high fluoride concentrations. These are impoverished rural communities in China, India, and Iran, and the findings cannot be generalised to developed countries. Therefore, we investigated the association between fluoride concentrations relevant to community water fluoridation and children's cognition measured with IQ scores by synthesising effect sizes reported in observational studies. METHODS: A previous meta-analysis and the National Toxicology Program database that included a search of multiple databases and the authors' search of PubMed, Google Scholar, and Mendeley provided the data. Cross-sectional and cohort studies examining the association between fluoride and children's cognition and intelligence scores were selected. Two reviewers abstracted data using standard procedures. We performed three meta-analyses to synthesise the effects using the random effects models. RESULTS: Eight studies of standardized mean difference in IQ scores from non-endemic fluorosis areas found no statistically significant difference between recommended and lower levels of fluoride (standardized mean difference = 0.07; 95% confidence interval: -0.02, 0.17; I2 = 0%), and no significant fluctuation in IQ scores across the differences in fluoride concentrations by non-linear modeling with restricted cubic spline (P = 0.21). Meta-analyses of children's and maternal spot urinary fluoride associated pooled regression coefficients (Betachildren = 0.16; 95% confidence interval: -0.40, 0.73; P = 0.57; I2 = 0%, Betamaternal = -0.92; 95% CI: -3.29, 1.46; P = 0.45; I2 = 72%) were not statistically significant. Further regression analysis by standardizing absolute mean IQ scores from lower fluoride areas did not show a relationship between F concentration and IQ scores (Model Likelihood-ratio test: P-value = 0.34.) CONCLUSIONS: These meta-analyses show that fluoride exposure relevant to community water fluoridation is not associated with lower IQ scores in children. However, the reported association observed at higher fluoride levels in endemic areas requires further investigation.

Does water fluoridation affect the prevalence of enamel fluorosis differently among racial and ethnic groups?

OBJECTIVES: There are reports showing higher prevalence of enamel fluorosis among African-American children. This study was conducted to assess whether the effect of water fluoride level on enamel fluorosis is different among different race/ethnicity groups among US school children. METHODS: Data from the National Survey of Oral Health of US School Children 1986-1987 were analyzed to determine the prevalence of enamel fluorosis among 7-17 year-old children. The association between race/ethnicity and enamel fluorosis was examined using logistic regression modeling after controlling for potential confounders age, gender, water fluoridation, other sources of fluoride, and region of residence. RESULTS: The prevalence of very mild to severe enamel fluorosis was 20.8 (95% CI, 15.4, 26.3) and 25.7 (95% CI, 15.0, 36.5) percent among non-Hispanic White and non-Hispanic Black children, respectively. Neither the adjusted odds ratio of 1.3 (0.8, 2.0) for the non-Hispanic Black group nor the interaction effect between non-Hispanic Black and water fluoridation were statistically significant. CONCLUSIONS: Enamel fluorosis was not associated with race/ethnicity. Our analysis suggests that exposure to similar levels of fluoride in the water does not appear to place certain race/ethnic groups at a higher risk for developing enamel fluorosis, and lowering the optimal range of drinking water fluoride to a single value of 0.7 ppm will provide a level of protection against enamel fluorosis that will benefit all race/ethnicity groups.

Changes in Caries Experience, Untreated Caries, Sealant Prevalence, and Preventive Behavior Among Third-Graders in New York State, 2002-2004 and 2009-2012.

OBJECTIVE: This study assessed changes in caries experience, untreated caries, sealant prevalence, and preventive behavior among third-grade children in New York State to monitor progress toward state health objectives. METHODS: We analyzed children's data from the 2002-2004 (n=10,865) and 2009-2012 (n=6,758) New York State Oral Health Survey. We calculated differences in weighted percentages and 95% confidence intervals for caries experience, untreated caries, sealant prevalence, and preventive behavior. We used logistic regression procedures to assess the independent effects and interaction terms on dental caries experience. RESULTS: The percentage of children with dental caries and untreated caries decreased from 54.1% and 33.0% in 2002-2004 to 45.2% and 23.6% in 2009-2012, respectively. While this decrease was not uniform across income subgroups, the prevalence of sealants, a key measure of the use of preventive services, increased significantly from 16.7% to 36.0% among lower-income children. CONCLUSIONS: Measurable improvement in reducing dental caries prevalence among third-grade children has been made in New York State, but this improvement was not uniform across subgroups. Specifically, disease prevalence among lower-income children remained high, underscoring the need to strengthen existing programs and identify additional policy and programmatic interventions.

Community water fluoridation reduced dental caries in Australian adults born before its widespread implementation at least as much as after its widespread adoption.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Effects of fluoridated drinking water on dental caries in Australian adults. Slade GD, Sanders AE, Do L, Roberts-Thomson K, Spencer AJ. J Dent Res 2013;92:376. REVIEWERS: Vinicius N. Tavares, DDS, MPH, Jayanth V. Kumar, DDS, MPH PURPOSE/QUESTION: This study investigated the long term caries-prevention benefits of community water fluoridation for individuals born before its widespread implementation SOURCE OF FUNDING: Government: National Health and Medical Research Council grants Industry: Colgate-Palmolive, New York, USA provided gifts for study participants Other: Australian Dental Association and state and territory health departments and dental services TYPE OF STUDY/DESIGN: Retrospective cohort study LEVEL OF EVIDENCE: Level 2 STRENGTH OF RECOMMENDATION GRADE: Not applicable.

Diabetes and tooth loss: an analysis of data from the National Health and Nutrition Examination Survey, 2003-2004.

BACKGROUND: The authors conducted an analysis of data from the National Health and Nutrition Examination Survey (NHANES) to understand the association between diabetes and tooth loss in the United States. METHODS: The authors analyzed the oral examination and self-reported diabetes data obtained from the NHANES 2003-2004 cycle and included 2,508 participants representing a civilian, noninstitutionalized U.S. population 50 years and older. The authors calculated the prevalence of edentulism and the number of missing teeth among dentate people, and they used multiple regression analyses to assess the association between diabetes and tooth loss. RESULTS: The prevalence of edentulism was 28 percent and 14 percent among people with and without diabetes, respectively. The multiple logistic regression analysis revealed that people with diabetes were more likely to be edentulous than were those without diabetes (adjusted odds ratio = 2.25; 95 percent confidence interval, 1.19-4.21). Among dentate adults, those with diabetes had a higher number of missing teeth than did adults without diabetes (mean [standard error {SE}] = 9.8 [0.67]), mean [SE] = 6.7 [0.29]); P < .01). CONCLUSIONS: These study results revealed that adults with diabetes are at higher risk of experiencing tooth loss and edentulism than are adults without diabetes. One of every five cases of edentulism in the United States is linked to diabetes. Practical Implications. Although the association between diabetes and periodontal disease is well established, health care professionals also need to recognize the risk of tooth loss and its effect on quality of life among people with diabetes.

Early childhood caries-related visits to emergency departments and ambulatory surgery facilities and associated charges in New York state.

BACKGROUND: The authors assessed the extent of early childhood caries- (ECC-) related visits to emergency departments (EDs) and ambulatory surgery facilities (ASFs) in children younger than 6 years and associated treatment charges in New York state from 2004 through 2008. METHODS: The authors obtained data from the New York state's Statewide Planning and Research Cooperative System (Albany) and calculated descriptive statistics and rates according to selected indicators, as well as total and average per-visit treatment charges. RESULTS: From 2004 through 2008, the number of ECC-related visits to EDs and ASFs increased by 349 and 1,039, respectively. Most ECC-related visits were to ASFs. The total annual treatment charges increased from $18.5 million to $31.3 million from 2004 to 2008, and average per-visit charges increased from $4,237 to $5,501 during the same period. CONCLUSIONS: ECC-related visits to EDs and ASFs by children younger than 6 years and the associated treatment charges increased substantially from 2004 through 2008 in New York state. Practice Implications. Dental professionals need to determine the reasons parents seek dental care for their children in EDs and ASFs and effective strategies for preventing ECC to avoid the subsequent need for seeking dental care in EDs and ASFs.

Geographic variation in medicaid claims for dental procedures in New York State: role of fluoridation under contemporary conditions.

OBJECTIVE: We conducted an evaluation to determine if the number of claims reimbursed for caries-related procedures for children in the New York State Medicaid program varied by county fluoridation coverage. METHODS: We calculated the mean number of claims per recipient for children in each county separately for the treatment of caries and all other procedures not related to caries using the 2006 Medicaid claims data. RESULTS: Compared with the predominantly fluoridated counties, the mean number of restorative, endodontic, and extraction procedures per recipient was 33.4% higher in less fluoridated counties. The mean number of claims per child for caries-related services was inversely correlated with the extent of fluoridation in a county (Spearman's correlation coefficient = -0.54, p < 0.0001), but claims for non-caries related services were not. CONCLUSIONS: These findings, when added to the already existing weight of evidence, have implications for promoting policies at the federal and state levels to strengthen the fluoridation program.

The association between enamel fluorosis and dental caries in U.S. schoolchildren.

BACKGROUND: The authors assessed the association between enamel fluorosis and dental caries to determine if there is any beneficial effect of enamel fluorosis in U.S. schoolchildren. METHODS: The authors used data from a National Institute of Dental Research survey of the oral health of U.S. children conducted in 1986 and 1987 to determine the prevalence of caries and mean decayed, missing or filled surfaces on permanent maxillary right first molars in children 7 to 17 years of age who had a history of a single residence. (To date, this is the only national oral health data set in the United States with detailed information on fluoride exposures.) They examined the association between enamel fluorosis and caries using logistic regression analysis, controlling for potential confounders in communities with water at or above optimal fluoridation levels and in communities with nonfluoridated or suboptimally fluoridated water. RESULTS: Permanent maxillary right first molars with fluorosis consistently had lower levels of caries experience than did normal molars. Adjusted odds ratios for caries prevalence in molars with fluorosis were 0.71 (95 percent confidence interval [CI], 0.56-0.89) in communities with nonfluoridated or suboptimally fluoridated water and 0.89 (95 percent CI, 0.74-1.06) in communities with water at or above optimal fluoridation levels. CONCLUSION: This study's findings suggest that molars with fluorosis are more resistant to caries than are molars without fluorosis. CLINICAL IMPLICATIONS: The results highlight the need for those considering policies regarding reduction in fluoride exposure to take into consideration the caries-preventive benefits associated with milder forms of enamel fluorosis.

Effect of tobacco smoke on the oral health of U.S. women of childbearing age.

OBJECTIVES: To determine the oral health status of US women of childbearing age and to analyze the effect of tobacco smoke on their oral health. METHODS: Data from the 1999-2004 National Health and Nutrition Examination Survey were evaluated for women 15-44 years of age. The association of exposure to tobacco smoke with untreated caries, mean DMFS, gingivitis, and periodontitis were examined in bivariate and regression analyses controlling for potential confounders. RESULTS: The prevalence of untreated caries was 25%, for gingivitis 49%, and for periodontitis 6%. After adjusting for potential confounders, self-reported current smoking was a strong independent risk indicator for untreated caries, periodontitis, and to a lesser extent for greater DMFS count. Women with detectable cotinine levels below 15 ng/mL presented with an increased risk for gingivitis. Independent factors associated with increased risk for untreated caries were being Black, having less than a high school education, Medicaid or no health insurance, previous live births, and infrequent and episodic dental visits. Characteristics associated with gingivitis were being Mexican-American, obese, pregnant, and having infrequent dental visits. Older age, no insurance, and the last dental visit for treatment were independently associated with periodontitis. CONCLUSIONS: Dental caries and periodontitis were prevalent among certain subgroups of women of reproductive age. Smoking was found to be a significant risk indicator for various negative oral health outcomes. Barriers to accessing to dental care that were manifested by untreated caries among Black women, mothers, and Medicaid beneficiaries must be better understood.

Oral health during perinatal period in New York State. Evaluation of 2005 Pregnancy Risk Assessment Monitoring System data.

Perinatal health and oral health behaviors and experiences were evaluated using the 2005 New York State Pregnancy Risk Assessment Monitoring System data. Pregnancy is an opportune time for oral health promotion; however, the data indicated that a substantial proportion of women reportedly did not make a dental visit and/or receive any oral health advice during pregnancy. We discuss the challenges, opportunities and next steps for promoting perinatal oral health programs in New York State.

Fluorides in dental public health programs.

The use of fluorides in dental public health programs has a long history. With the availability of fluoridation and other forms of fluorides, dental caries have declined dramatically in the United States. This article reviews some of the ways fluorides are used in public health programs and discusses issues related to their effectiveness, cost, and policy.

The cultural and social context of oral and pharyngeal cancer risk and control among Hispanics in New York.

New York City (NYC) has one of the highest incidence and mortality rates of oral and pharyngeal cancer (OPC) for Hispanics of any major U.S. city. This qualitative assessment explores OPC awareness, attitudes, and screening practices among at-risk Hispanics, health care providers, and community leaders in a Hispanic neighborhood of NYC. Four focus groups (N=39) were conducted with at-risk Hispanics. Structured interviews were conducted with ten health care providers (four physicians, four dentists, two dental hygienists) and three key community leaders. Results showed major gaps in OPC awareness across all key stakeholders. Focus group participants expressed difficulty in accessing appropriate health care. Health care providers were not familiar with OPC prevention and early detection practices. Community leaders lacked the knowledge and resources necessary for advocating prevention and early detection for their constituencies. All participants reported cultural, social, and structural barriers to prevention. There is a need for developing a comprehensive, culturally competent health communication program that targets all key stakeholders in the at-risk Hispanic community of NYC.

Oral cancer prevention and early detection: knowledge, practices, and opinions of oral health care providers in New York State.

BACKGROUND: The purpose of this study was to assess the knowledge, practices, and opinions of dentists and dental hygienists in New York State regarding oral cancer prevention and early detection. METHOD: We sent questionnaires to a stratified random sample of dentists and dental hygienists selected from a list of licensed oral health care providers in New York State. We analyzed responses to the questionnaires, and we derived descriptive statistics. RESULTS: The effective response rate was 55% and 65% among dentists and dental hygienists, respectively. About 85% of dentists and 78% of dental hygienists reported providing annual oral cancer examination to their patients aged 40 and above. Although a majority assessed tobacco use, fewer practitioners assessed alcohol use. Both dentists and dental hygienists lacked knowledge in some aspects of risk factors, signs, and symptoms of oral cancer. However, dentists had significantly higher knowledge scores than dental hygienists. CONCLUSION: Dentists and dental hygienists in New York State are knowledgeable about oral cancer, but there are gaps in the knowledge of certain risk factors and in the oral cancer examination technique.

Preventing and detecting oral cancer. Oral health care providers' readiness to provide health behavior counseling and oral cancer examinations.

BACKGROUND: The authors conducted a study to examine oral cancer prevention and early detection practice patterns in a population-based random sample of practicing oral health care professionals in New York state. METHODS: The authors surveyed a population-based, self-weighting, stratified random sample of dentists (n = 1,025) and dental hygienists (n = 1,025) in New York state. They assessed the subjects' readiness to offer tobacco-use cessation and alcohol-abuse counseling and oral cancer examinations. RESULTS: The effective response rates were 55 and 66 percent for dentists and dental hygienists, respectively. In terms of readiness to perform oral cancer examinations for patients aged 40 years and older, the large majority (82 percent of dentists and 72 percent of dental hygienists) were in the maintenance stage of behavior, indicating that oral cancer examinations were a routine part of their practice. In terms of readiness to offer tobacco-use cessation counseling, only 12 percent of dentists and 21 percent of dental hygienists were in the maintenance stage, and only 2 percent of dentists and 4 percent of dental hygienists were in the maintenance stage of offering alcohol-abuse counseling. CONCLUSIONS: Oral cancer examinations seem to have been adopted as a standard of practice by most oral health care providers in New York state, but cancer prevention services, such as counseling regarding cessation of tobacco use and alcohol abuse, are lacking. CLINICAL IMPLICATIONS: Oral health care providers should be trained in oral cancer prevention services such as tobacco-use cessation and alcohol-abuse counseling and encouraged to include these services, along with continued provision of oral cancer examinations, as a standard aspect of care.

Oral health disparities in New York State.

New York State population is diverse, with a large proportion of racial and ethnic minorities. The poverty rate is two- to three-times higher among minorities. Oral diseases are higher among low-income and/or less-educated groups and in racial and ethnic minorities. The use of dental services is also lower. Eliminating disparities in oral health will require enhanced efforts at preventing disease, promoting health and delivering appropriate care. It will also require a thorough understanding of the lower use of already available effective preventive and treatment services, and additional interventions to address the identified causes. Many initiatives have been undertaken in New York State to address these disparities.

Oral health and pregnancy: a review.

Pregnancy is a delicate condition involving complex physical and physiological changes. In recent times, there has been a greater focus on the oral health of pregnant women. Emerging evidence has shown that periodontal disease may be associated with preterm, low birthweight (LBW) babies. This has caught the attention of prenatal care providers, who often look to the dental community for information about the oral health aspects of pregnancy. Therefore, dental care providers should be well informed and better able to understand the management of different oral health conditions typically seen during pregnancy. In addition, prenatal care providers should forge a link with oral health care providers to prevent adverse outcomes. This article summarizes the oral health conditions associated with pregnancy.

The New York State Minority Health Survey: determinants of oral health care utilization.

OBJECTIVES: To determine the factors associated with visits to a dentist and more specifically the role of dental insurance coverage and to explore the reasons for not visiting a dentist among minorities in New York State. METHODS: The Minority Health Survey was a one-time, statewide, random digit-dialed telephone survey. We drew a directed acyclic graph (DAG) of the potential determinants of oral health care utilization for our population of interest and modeled the independent variables as determinants of oral health care utilization. The data for this study were analyzed in SUDAAN using appropriate weights and variance adjustments that accounted for the complex sampling design. Hence, this report is generalizable to the New York State adult "minority" population. RESULTS: About 63 percent respondents had visited a dentist in the past one year. Having dental insurance (adjusted odds ratio [adj OR]=2.5), having more than high school education (adj OR=1.9), being younger (adj OR=2.3 for 18-25 years vs age 40 years or older), being married (adj OR=1.7), being dentate (adj OR=0.3 for edentulousness), and having higher income (adj OR=0.5 for middle vs high income) were significantly associated with having visited a dentist in the past year. Cost and awareness-related factors were the most common reasons for not visiting a dentist. Most of the year 2000 oral health objectives measurable in this survey were not met. CONCLUSION: Increasing dental insurance coverage and increasing awareness about oral health care would be the two biggest factors in meeting the goals of year 2010.

Early childhood caries-related visits to hospitals for ambulatory surgery in New York State.

OBJECTIVES: The objective of this study was to assess the utilization of ambulatory surgery at hospitals for the treatment of early childhood caries in New York State. METHODS: Data for this study came from the Statewide Planning and Research Cooperative System in New York State. We analyzed 16,149 oral health-related ambulatory surgeries performed between 1996 and 1999 in children younger than 6 years of age. RESULTS: Between 1996 and 1999, the rate of hospitalization for dental caries in children younger than 6 years of age ranged from 180 to 193 cases per 100,000. Approximately two-thirds of the visits by children younger than 6 years old were due to dental caries. The highest rate was observed in 3-year-old children (346.5). The most frequent type of procedure performed was placement of stainless steel crowns. Medicaid was the primary source of reimbursement. CONCLUSIONS: These data illustrate that, although dental caries is preventable, it continues to be a significant problem in young children and results in a large number of ambulatory surgery visits.

Targeting dental sealants in school-based programs: evaluation of an approach.

Several guidelines have been published in the United States to promote the appropriate use of sealants in both individual care and public health programs. Targeting sealants to children and teeth at high risk for dental caries has been accepted as a desirable strategy in school-based programs. However, there is little evidence to show that programs are complying with these guidelines. This report examined the extent to which sealants were targeted to high-risk children at 11 different school-based programs in New York State. Data on 3357 children ages seven to nine were analyzed. The percent of children receiving sealants ranged from 41% to 88%. While in two sites (St. Lawrence & Onondaga) fewer than 52% of the children received sealants; more than 73% received sealants in the remaining nine sites (P < 0.05). The results suggest that there was a wide variation in the implementation of the guidelines for sealant use. Some reasons for not adhering to the guidelines were: difficulty in assuring parents and local dentists that some children were not at risk for caries; lack of confidence in the risk-assessment method; uncertainty regarding what constitutes deep pits and fissures; fear of misclassifying children and requests by school administrators, parents and local dentists that all children should benefit from preventive measures.