Prevention
Content
A) Population level intervention
Water fluoridation represents a holistic but controversial approach to tackling caries
and involves raising the concentration of fluoride in water supplies to 1ppm optimum level to prevent caries whilst causing minimal aesthetic fluorosis.
Population level interventions such as this remove socioeconomic status as a factor
so are more likely to improve the oral health of everyone who drinks the water.
Under the Water Act 2003, fluoridation of water supplies is done by water
undertakers at the request of relevant authorities by adding either hexafluorosilicic
acid or disodium hexafluorosilicate into the water. According to Anglican Water, it is
paid for by the health authority and does not come out of one’s water bill. Several
groups such as Fluoride Action Network protest fluoridation by claiming amongst
other reasons that it’s a form of mass medication which has the potential to cause
illness/death but the safely tolerated dose is 1mg/kg so at 1ppm it is unlikely to be
toxic. In a systematic review (McDonagh M, et al 2000); the median difference at
1ppm in dmft/DMFT was observed at 2.25 teeth which suggests the effect on caries
is beneficial. However, at 1ppm an increased prevalence of fluorosis – estimated
12.5% (95% confidence level) - would experience aesthetically concerning fluorosis.
There was no clear evidence of other adverse effects such as increased bone
fracture or cancer incidence. The reviewer states that 214 studies of “low to
moderate” quality were used and a fair amount of heterogeneity was observed
between results of similar studies. In relation particularly to the negative impacts, it’s
stated how enamel opacities, observer bias and external fluoride sources may have
affected results. The review shows strong evidence for fluoride use in the prevention
of caries, but it isn’t of high enough quality to be completely conclusive. In terms of
its implementation, part of the 2012 NHS reforms called for better public consultation
to be obtained before the relevant authorities sanction fluoridation.
B. Community level prevention (15 marks)
Focusing on school-based prevention, the methods in this section would involve
health professionals and experts coming into deliver information to school that would
enforce schemes and improve the oral health across the school. Limitations of these
schemes are costs, consent and whether behaviours are retained at home. A good
scheme would be: cost-effective in improving oral health; not overly intrusive – in
terms of consent needed by parents –; and maintained at home – behavioural
retention.
(a)
Healthy eating:
In accordance with regular lunchtime meal provision, a change to a healthy menu
offers a method that: shouldn’t require written permission; is likely to improve the
overall health of a child; and there is also no significant cost difference between a
healthy and unhealthy diet. Diet follows the common risk-factor1 approach to oral
health with factors such as obesity possibly leading to caries. So providing healthy
meals in school time may help counter the effects of a poor diet and change the
eating behaviour of a child at home. However, further research needs to be done on
the long term benefits of diet on oral health to understand the efficacy. In addition,
behavioural changes are hard to enforce and changing the diet at school is not
guaranteed to change the diet at home.
(b) Fluoride milk
Heterogeneity between several studies across several factors including the
concentration of fluoride used meant there was insufficient evidence to provide
conclusive proof but the author concludes that for school children there is a benefit of
milk provision. With higher quality evidence there is a possibility that the scheme
may be more widely considered as early evidence is promising – significant
reduction in DMFT (78.4%) after 3 years between test and control groups in a
randomised controlled trial. However, currently the costs and need for consent
doesn’t make this scheme a priority.
1
Dictates how various diseases have multifactorial causations
Water fluoridation represents a holistic but controversial approach to tackling caries
and involves raising the concentration of fluoride in water supplies to 1ppm optimum level to prevent caries whilst causing minimal aesthetic fluorosis.
Population level interventions such as this remove socioeconomic status as a factor
so are more likely to improve the oral health of everyone who drinks the water.
Under the Water Act 2003, fluoridation of water supplies is done by water
undertakers at the request of relevant authorities by adding either hexafluorosilicic
acid or disodium hexafluorosilicate into the water. According to Anglican Water, it is
paid for by the health authority and does not come out of one’s water bill. Several
groups such as Fluoride Action Network protest fluoridation by claiming amongst
other reasons that it’s a form of mass medication which has the potential to cause
illness/death but the safely tolerated dose is 1mg/kg so at 1ppm it is unlikely to be
toxic. In a systematic review (McDonagh M, et al 2000); the median difference at
1ppm in dmft/DMFT was observed at 2.25 teeth which suggests the effect on caries
is beneficial. However, at 1ppm an increased prevalence of fluorosis – estimated
12.5% (95% confidence level) - would experience aesthetically concerning fluorosis.
There was no clear evidence of other adverse effects such as increased bone
fracture or cancer incidence. The reviewer states that 214 studies of “low to
moderate” quality were used and a fair amount of heterogeneity was observed
between results of similar studies. In relation particularly to the negative impacts, it’s
stated how enamel opacities, observer bias and external fluoride sources may have
affected results. The review shows strong evidence for fluoride use in the prevention
of caries, but it isn’t of high enough quality to be completely conclusive. In terms of
its implementation, part of the 2012 NHS reforms called for better public consultation
to be obtained before the relevant authorities sanction fluoridation.
B. Community level prevention (15 marks)
Focusing on school-based prevention, the methods in this section would involve
health professionals and experts coming into deliver information to school that would
enforce schemes and improve the oral health across the school. Limitations of these
schemes are costs, consent and whether behaviours are retained at home. A good
scheme would be: cost-effective in improving oral health; not overly intrusive – in
terms of consent needed by parents –; and maintained at home – behavioural
retention.
(a)
Healthy eating:
In accordance with regular lunchtime meal provision, a change to a healthy menu
offers a method that: shouldn’t require written permission; is likely to improve the
overall health of a child; and there is also no significant cost difference between a
healthy and unhealthy diet. Diet follows the common risk-factor1 approach to oral
health with factors such as obesity possibly leading to caries. So providing healthy
meals in school time may help counter the effects of a poor diet and change the
eating behaviour of a child at home. However, further research needs to be done on
the long term benefits of diet on oral health to understand the efficacy. In addition,
behavioural changes are hard to enforce and changing the diet at school is not
guaranteed to change the diet at home.
(b) Fluoride milk
Heterogeneity between several studies across several factors including the
concentration of fluoride used meant there was insufficient evidence to provide
conclusive proof but the author concludes that for school children there is a benefit of
milk provision. With higher quality evidence there is a possibility that the scheme
may be more widely considered as early evidence is promising – significant
reduction in DMFT (78.4%) after 3 years between test and control groups in a
randomised controlled trial. However, currently the costs and need for consent
doesn’t make this scheme a priority.
1
Dictates how various diseases have multifactorial causations
