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The British Fluoridation Society and the National Community Water Fluoridation Network recently worked together on the ‘talking fluoridation’ webinar for dental teams, which described the evidence base for fluoridation. This webinar (https://vimeo.com/755521540/a730570ef8) started us thinking about a series of articles for dental teams around the science and the arguments for new schemes. We think that it is likely that areas in north east England would go out to public consultation on fluoridation later this year. This will be the first public consultation since 2008, and the first undertaken under the new 2022 legislation and carries with it the possibility of the first wholly new scheme since 1985. This is therefore a good time to be raising awareness of the benefits of fluoridation so dental teams, particularly those in the north east are familiar with the science and evidence base, and are confident in discussing the benefits fluoridation can bring.
Community water fluoridation (CWF) is not a new intervention.1 Described by the US Centers for Disease Control and Prevention as one of the top 10 public health achievements of the 20th century, it arguably remains more relevant today as an essential tool to improve health and reduce health inequality.2 The questions coming into sharp focus based on unacceptable health inequality are not if, but what, why, why CWF and where. And most importantly, when.
Why?
The why question points to pockets of poor oral health, oral health inequality and the realization that across the NHS, we need to focus more on prevention.
Over time there has been increasing awareness of the critical importance of oral health as part of overall general health and wellbeing and the role good oral health has in improving conditions, such as diabetes and cardiovascular disease.3 We know poor child oral health causes pain, sleepless nights, poor school readiness and significant time off work for parents/guardians.4
Oral health inequality, like most other non-communicable diseases, is closely related to socio-economic factors.5 Child oral health has a similar social gradient to child obesity, where children living in the most deprived areas are likely to have at least three times the decay experience of children living in the least deprived areas. While generally, dental decay among children has been reducing over time, it remains an issue, and the relative inequalities in the prevalence of dental caries in 5-year-old children in England increased between 2008 and 2019, which is unacceptable for what is an almost entirely preventable disease.6
Tooth decay remains the most common reason for admission to hospital. In 2020–2021, 26,741 children had GA extractions costing an alarming £50.9 million for the episodes recorded. Shockingly, the caries-related tooth extraction episode rate for children and young people living in the most deprived communities is nearly 3.5 times that of those living in the most affluent communities.7
Pre-pandemic, there was increased awareness of embedded health inequalities. Post-pandemic, we have seen inequalities widen, impacting disproportionately on certain ethnic population groups and those living in deprivation.8 It is becoming ever clearer that across health in general, we need to adopt a greater focus on investing in prevention. The consultation ‘Advancing our health: prevention in the 2020s’9 talked about driving a reinvigorated prevention agenda based on strong foundations of early years health programmes. These included a targeted supervised toothbrushing scheme aimed at reaching 30% of the most deprived 3–5 year olds by 2022, and exploring ways of removing funding barriers to fluoridating water to encourage more areas that are interested to come forward.
Recently NHSE have developed the Integrated Care Board (ICB) Core20PLUS5 strategy10 to drive reductions in health inequality. This new approach focuses on the most deprived 20% of the population, key clinical areas for accelerated improvement and specific population groups who have poor access to, and/or outcomes from heath services. The Children and Young People (CYP) Core20PLUS5 approach critically includes oral health as a key clinical area with a focus on reducing child GA extractions.
Why CWF?
The why CWF is a simple argument. Community water fluoridation reduces both the prevalence and severity of dental caries. The 2017 Australian review found that water fluoridation reduces tooth decay in children and adolescents by 26–44%, and by 27% in adults.11 This is consistent with several international reviews.12,13
CWF also has a significant effect on health inequalities. The odds of experiencing caries are reduced by 23% for 5 year olds living in the least deprived areas, and 52% for 5 year olds living in the most deprived areas at concentrations of ≥0.7 mg/l, compared to the lowest fluoride concentration of <0.1 mg/l. As the greatest reductions in the odds of having caries experience were observed in children living in the most deprived areas, fluoridation can be said to narrow differences in dental health between more and less deprived children.14
Fluoridation has a significant impact on preventable child GA extraction and the shocking levels of hospital admissions for children. Hospital admissions are 59% lower in fluoridated areas.15
Community water fluoridation is also the most cost-effective oral health improvement intervention, returning £21.98 for every £1 invested over 10 years,16 and the most sustainable.17
Fluoridation is also the only intervention that does not require compliance or behaviour change by individuals.18 We also need to consider that interventions that do rely on behaviour change and compliance are more likely to increase health inequalities, not decrease them.
It is clear then that CWF improves health and reduces inequality, especially among children, and aligns with the ICB Core20PLUS5 aims and strategy.
Where?
The where question is one for all integrated care boards (ICBs) whose strategic needs assessments describe poor levels of oral health. The 42 ICBs19 are newly formed partnerships of organizations with responsibilities to plan and deliver integrated health care services to improve the lives of people who live and work in their area through:
ICB areas where there is poor oral health and wide oral health inequalities should be considering CWF where it is technically feasible. In particular, where child GA waiting lists are long, ICBs should look at ways of preventing dental decay and increasing access to care for children as part of the CYP Core20PLUS5 strategy. Water fluoridation uniquely satisfies all the responsibilities listed above. It is very important then, that if we are serious about improving health and reducing health inequality, fluoridation is considered as a crucial part of oral health improvement and the Core20PLUS5 strategy. Certainly, the recently published consensus statement from the Association of Directors of Public Health supports this point of view, stating that poor oral health and wide inequality is:
‘a result of a wider system failure to take forward proven, cost-effective public health measures that prevent tooth decay and improve everyone's health and wellbeing’.20
This statement reflects the fact that public health policy must be based around the totality of the established evidence base, and must not waiver when confronted by single studies of poor quality.21 As the statement by the four UK Chief Medical Officers says:
‘On balance, there is strong scientific evidence that water fluoridation is an effective public health intervention for reducing the prevalence of tooth decay and improving dental health equality across the UK. It should be seen as a complementary strategy, not a substitute for other effective methods of increasing fluoride use’.22
When?
As discussed earlier, there is the possibility of a consultation on CWF in north east England in 2023, and the prospect of moving forward with new schemes in due course. It has been a practising lifetime since the last new scheme was implemented. Understanding the benefits of fluoridation leading to science-based conversations with the public are critical in terms of negating misunderstanding and misinformation. It is our hope that you enjoy our community water fluoridation series, and like the COVID vaccination campaign, do not underestimate the role you can play in combating misunderstanding, improving health and narrowing inequality.