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Canadian Institutes of Health Research

Fluoridation:

What’s the evidence?

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What’s the evidence? This webinar will focus on a number of sources of

information, including a systematic review featured on Health Evidence:

http://www.health-evidence.ca/articles/show/15981

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Q&A

Participant Side Panel in WebEx

Welcome!

This webinar has been made possible with support from the Canadian Institutes of Health Research

Fluoridation:

What’s the evidence?

Maureen Dobbins Scientific Director Tel: 905 525-9140 ext 22481 E-mail: dobbinsm@mcmaster.ca

Kara DeCorby Administrative Director

Lori Greco Knowledge Broker

Lyndsey McRae Research Assistant

Robyn Traynor Research Coordinator

The Health Evidence Team

Heather Husson Project Manager

Jennifer Yost Guest Presenter

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Discussion question:

What is the evidence on the effectiveness of water fluoridation for caries prevention?

Questions?

Searching for relevant evidence: The pyramid

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DiCenso, Bayley, & Haynes, 2009

What is the “Best

Available” Evidence?

Relevance Criteria: Addresses impact of water fluoridation in the context

of developed countries Produced within the last 15 years English-language

Search Strategy: Searched review-level evidence in public health related

to fluoridation on health-evidence.ca Reviewed reference lists of relevant reviews

Evidence Reviewed: PHAC: Drinking Water Fluoridation in Canada: Review and

Synthesis of Published Literature, 2011 Quebec PH: Water Fluoridation: An Analysis of the Health

Benefits and Risks, 2007 Australian Government, NHMRC: A Systematic Review

of the Efficacy and Safety of Fluoridation, 2007 NHS Centre for Reviews and Dissemination: A

Systematic Review of Water Fluoridation, 2000

Is it a Systematic Review? Is there a methods section? Does the methods section outline a search strategy? Are there inclusion criteria given? Did the reviewers assess relevance systematically? Did the reviewers conduct a quality assessment?

Literature Reviews: Quebec PH: Water Fluoridation: An Analysis of the Health

Benefits and Risks, 2007

No methodology reported PHAC: Drinking Water Fluoridation in Canada: Review and

Synthesis of Published Literature, 2011

Report some inclusion/exclusion criteria Report some searching methodology No quality assessment

Systematic Reviews: Australian Government, NHMRC: A Systematic Review

of the Efficacy and Safety of Fluoridation, 2007

Major Strength: Includes systematic reviews and primary studies Major Limitation: Quality assessment (lack of

information about # of reviewers and criteria) Minor Limitation: Search strategy (English-only,

limited number of databases)

Systematic Reviews: NHS Centre for Reviews and Dissemination: A

Systematic Review of Water Fluoridation, 2000

Health Evidence Quality Rating: 9 Major Strength: Meta-analyses, when appropriate Minor Limitation: Quality assessment (criteria

for case-control studies devised by reviewers)

Water Fluoridation is Effective

Significantly increases the percentage of caries-free children by 15.4% Range from as little of a 10.8% increase to as much

as 20.1% increase [95% Confidence Interval (CI)]

Six children need to receive fluoridated water for one additional child to be caries-free Range from five children to as many as nine children

[Number Needed To Treat (NNT)]

Water Fluoridation is Effective

Significantly decreases the number of decayed, missing, filled teeth (dmft/DMFT score) by 2.3 teeth Range from a decrease of1.8 teeth to as many as 2.8

teeth [95% Confidence Interval (CI)]

Based on moderate quality, moderate risk of bias evidence Across children of all ages

Water Fluoridation is Safe

Significant increase in the prevalence of fluorosis Flouride levels of 1.0ppm and 1.2ppm versus 0.4ppm

Prevalence of fluorosis causing “aesthetic concern” No significant difference between fluoride levels of

0.7ppm, 1.0ppm, and 1.2pmm versus 0.4ppm

Water Fluoridation is Safe

No significant increase in the prevalence of bone fractures

Unable to be determined for the prevalence of cancer (all causes, osteosarcoma, bone, thyroid)

Based on lowest quality evidence with high risk of bias Across children of all ages

Overall Considerations Drinking water fluoridation Clinically important increase in the prevalence of caries-free children of all ages Small number of children need access in order for one child to be caries-free No statistically significant increase in fluorosis of aesthetic concerns with increasing fluoride levels or bone fractures Evidence suggesting there is a relationship between water fluoridation and other health outcomes is low quality evidence Note: Consistent across “Evidence Reviewed”

General Implications Public health should support the fluoridation of drinking water Among all children of all ages At levels that are unlikely to cause to fluorosis and fluorosis of “aesthetic concern”

Practice & Policy Implications Support policies for the fluoridation of drinking water

at safe levels of fluoridation Be aware of community fluoridation status Be aware of the average daily intake of water by the

and the intake of fluoride from other sources Communicate evidence on the effectiveness and harms

associated with drinking water fluoridation to communities considering initiating drinking water fluoridation

continuing drinking water fluoridation

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