Dental Caries (Cavities): Community Water Fluoridation

The CPSTF finding is based on evidence from a systematic review published in 2000 (McDonagh et al., search period 1966-1999; 26 studies on caries; 13 on oral health disparities; 88 on fluorosis), combined with more recent evidence (search period 1999-2012; 29 studies of which 2 reported effects on caries, 3 reported on oral health disparities, and all measured fluorosis). All included studies evaluated intervention effectiveness of community water fluoridation among children.

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to oral health. The finding updates and replaces the 2000 CPSTF finding on Dental Caries: Community Water Fluoridation.

Information about data variability is available in the Task Force Finding and Rationale Statement.

Results from both the McDonough et al. review and the updated search for evidence showed a decrease in new dental caries after community water fluoridation began and an increase in new dental caries when it stopped.

• Combined evidence showed a median decrease of 15.2 percentage points in caries after community water fluoridation began (12 studies).
• Included studies showed that community water fluoridation reduced the prevalence of dental caries across socioeconomic groups.

2000 Review — McDonagh et al. (search period 1966-1999)

• After community water fluoridation was started:
  • The number of individuals free of dental caries increased by a median of 14.6 percentage points (11 studies).
  • The median number of decayed, missing, or filled teeth decreased by 2.25 (10 studies).
• When community water fluoridation was stopped:
  • Studies reported an increase in the number of decayed, missing, or filled teeth (6 studies) or surfaces (2 studies).

Updated Evidence (search period 1999-2012)

• After community water fluoridation was started:
  • The number of individuals free of dental caries increased by a median of 25.1 percentage points (1 study).
• When community water fluoridation was stopped:
  • The total number of decayed, missing, or filled tooth surfaces decreased by 0.59 among children 8 years of age, and 1.39 among children 14 years of age (1 study) when compared to communities that continued community water fluoridation.
  • The number of new decayed, missing, or filled surfaces increased by 0.13 among children 8 years of age, and by 0.47 among children 14 years of age (1 study) when compared to communities that continued community water fluoridation.

Information about data variability is available in the Task Force Finding and Rationale Statement.

Ten studies were included in the economic review. Monetary values are presented in 2013 U.S. dollars.

Intervention cost:

• For urban communities, per capita annual cost ranged from $0.11 to $4.92 (6 studies).
• Population size was the main cause of variation; as the size of a community’s population went up, the cost per person went down.
• Cost estimates were based on two main components:
  • One-time fixed cost (for equipment, pipework, fluoridation pump, and tank area)
  • Annual recurring cost (for fluoride compounds, monitoring, maintenance, and operations)

Intervention benefit:

• Benefit-only studies that used regression models concluded that the presence of water fluoridation was related to a reduction in dental treatment cost or claims (4 studies).
• Studies that provided benefit and cost information reported a per capita annual benefit of community water fluoridation that ranged from $5.49 to $93.19 (6 studies).
• The main causes of variation were the number of benefit components considered in each study (e.g., averted healthcare cost, averted productivity loss, other losses averted) and the assumptions made. Geographic differences in dental treatment and labor costs also played a role.

Benefit cost ratio:

• Benefit cost ratios ranged from 1.1:1 to 135.0:1 (6 studies).
• Lower benefit cost ratios generally were associated with small community population sizes, with ratios increasing as community population size increased. This is mainly related to economies of scale on the cost side.

Based on results, the Task Force finding should be applicable to the following:

• Communities across the United States
• Groups from all socioeconomic status (SES) groups

There is limited information about the unique effects of community water fluoridation among populations that are exposed to fluoride through other sources (e.g., dental products, infant formula).

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• The contribution of alternative fluoride sources (e.g., toothpaste, mouth rinses), especially with growing concerns about the overall effect of multiple fluoride exposures
• The effects of drinking bottled water on the benefits of community water fluoridation
• The role of water hardness and dietary calcium in the bioavailability of fluoride in individuals and communities with varying milk consumption patterns and degrees of water hardness. The presence of calcium circulating in the body is believed to be associated with reduced fluoride absorption from the gastrointestinal tract.
• Standardized measurement and reporting of dental fluorosis and caries to reduce measurement errors
• Non-dental harms of community water fluoridation
• The benefit of community water fluoridation to adults

• Included studies were conducted in the United States, Europe, Canada, Asia, South America, Africa, Australia, the Middle East, and New Zealand.
• Fluoride concentrations in most of the intervention sites ranged from 0.7 to 1.2 mg/L.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

Summary Evidence Table – Economic Review

The Community Preventive Services Task Force recommendation on community water fluoridation is based on evidence from the following:

• 28 studies about the effect of CWF on caries; 16 about oral health disparities, and 117 about dental fluorosis — most of which were included in an existing systematic review (McDonagh 2000, search period 1966-1999; 26 studies on caries; 13 on oral health disparities; 88 on fluorosis)
• 2 studies on caries; 3 on oral health disparities and 29 on fluorosis (search period 1999-2012)

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained n several publications).

Effectiveness Review

Systematic Review of Public Water Fluoridation

• McDonagh M, Whiting P, Bradley M, Cooper J, Sutton A, Chestnutt I, Misso K, Wilson P, Treasure E, Kleinjen J. A Systematic Review of Public Water Fluoridation. National Health Service Centre for Reviews and Dissemination. York(UK): University of York; 2000. Available at URL: http://www.nhs.uk/Conditions/Fluoride/Documents/crdreport18.pdf.

Studies from the Updated Search

Acharya S. Dental caries, its surface susceptibility and dental fluorosis in South India. International Dental Journal 2005;55(6):359 64.

Alarcon-Herrera M, Martin-Dominguez I, Trejo-vazquez R, Rodriguez-Doza S. Well water fluoride, dental fluorosis, bone fractures in the Guadiana Valley of Mexico. Fluoride 2001;34(2):134 49.

AlDosari AM, Akpata ES, Khan N. Associations among dental caries experience, fluorosis, and fluoride exposure from drinking water sources in Saudi Arabia. Journal of Public Health Dentistry 2010;70(3): 220 6.

Awadia A, Birkeland J, Haugejorden O, Bjorvatn K. Caries experience and caries predictors – a study of Tanzanian children consuming drinking water with different fluoride concentrations. Clinical Oral Investigations 2002;6(2):98 103.

Beltr n-Aguilar ED, Griffin SO, Lockwood SA. Prevalence and trends in enamel fluorosis in the United States from the 1930s to the 1980s. Journal of the American Dental Association 2002;133;157 65.

Chandrashekar J, Anuradha KP. Prevalence of dental fluorosis in rural areas of Davangere, India. International Dental Journal 2004;54:235 9.

Ekanayake L, Van Der Hoek W. Dental caries and developmental defects of enamel in relation to fluoride levels in drinking water in an arid area of Sri Lanka. Caries Research 2002;36(6):398 404.

Ermi RB, Koray F, Akdeniz BG. Dental caries and fluorosis in low- and high-fluoride areas in Turkey. Quintessence International 2003;34(5):354 60.

Franzolin SdeO, Gon alves A, Padovani CR, Francischone LA, Marta SN. Epidemiology of fluorosis and dental caries according to different types of water supplies. Ciencia Saude Coletiva 2010;15 Suppl 1: 1841 7.

Gray MM, Davies-Slowik J. Changes in the percentage of 5-year-old children with no experience of decay in Dudley towns since the implementation of fluoridation schemes in 1987. British Dental Journal 2001;190:30 2.

Grobleri SR, Louw AJ, van Kotze TJ. Dental fluorosis and caries experience in relation to three different drinking water fluoride levels in South Africa. International Journal of Paediatric Dentistry / the British Paedodontic Society [and] the International Association of Dentistry for Children 2001;11(5): 372 9.

Harding MA, Whelton H, O’Mullane DM, Cronin M, Warren JJ. Primary tooth fluorosis in 5-year-old schoolchildren in Ireland. European Journal of Paediatric Dentistry Official Journal of European Academy of Paediatric Dentistry 2005;6:155 61.

Indermitte E, Saava A, Karro E. Exposure to high fluoride drinking water and risk of dental fluorosis in Estonia. International Journal of Environmental Research and Public Health 2009;6:710 21.

Kanagaratnam S, Schluter P, Durward C, Mahood R, Mackay T. Enamel defects and dental caries in 9-year-old children living in fluoridated and nonfluoridated areas of Auckland, New Zealand. Community Dentistry and Oral Epidemiology 2009;37(3):250 9.

Machiulskiene V, Baelum V, Fejerskov O, Nyvad B. Prevalence and extent of dental caries, dental fluorosis, and developmental enamel defects in Lithuanian teenage populations with different fluoride exposures. European Journal of Oral Sciences 2009;117(2):154 60.

Macpherson LMD, Conway DI, Gilmour WH, Petersson LG, Stephen KW. Photographic assessment of fluorosis in children from naturally fluoridated Kungsbacka and non-fluoridated Halmstad, Sweden. Acta Odontologica Scandinavica 2007;65:149 55.

Maupom G, Clark DC, Levy SM, Berkowitz J. Patterns of dental caries following the cessation of water fluoridation. Community Dentistry and Oral Epidemiology 2001;29(1):37 47.

McGrady MG, Ellwood RP, Srisilapanan P, Korwanich N, Worthington HV, Pretty IA. Dental fluorosis in populations from Chiang Mai, Thailand with different fluoride exposures – paper 1: assessing fluorosis risk, predictors of fluorosis and the potential role of food preparation. BMC Oral Health 2012;12(1):16.

Narbutait J, Vehkalahti MM, Milciuvien S. Dental fluorosis and dental caries among 12-yr-old children from high- and low-fluoride areas in Lithuania. European Journal of Oral Sciences 2007;115(2): 137 42.

Peres MA, Antunes JLF, Peres KG. Is water fluoridation effective in reducing inequalities in dental caries distribution in developing countries? Recent findings from Brazil. Sozial und Praventivmedizin 2006;51:302 10.

Pontigo-Loyola AP, Islas-M rquez A, Loyola-Rodr guez JP, Maupome G, Marquez-Corona ML, Medina-Solis CE. 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.

Riordan PJ. Dental fluorosis decline after changes to supplement and toothpaste regimens. Community Dentistry and Oral Epidemiology 2002;30(3):233 40.

Ruan JP, Yang ZQ, Wang ZL, Astr m AN, B rdsen A, Bjorvatn K. Dental fluorosis and dental caries in permanent teeth: rural schoolchildren in high-fluoride areas in the Shaanxi province, China. Acta Odontologica Scandinavica 2005;63:258 65.

Stephen KW, Macpherson LM, Harper Gilmour W, Stuart RA, Merrett MC. A blind caries and fluorosis prevalence study of school-children in naturally fluoridated and nonfluoridated townships of Morayshire, Scotland. Community Dentistry and Oral Epidemiology 2002;30(1):70 9.

Sudhir KM, Prashant GM, Subba Reddy VV, Mohandas U, Chandu GN. Prevalence and severity of dental fluorosis among 13- to 15-year-old school children of an area known for endemic fluorosis: Nalgonda district of Andhra Pradesh. Journal of the Indian Society of Pedodontics and Preventive Dentistry 2009; 27(4):190 6.

Tabari ED, Ellwood R, Rugg-Gunn AJ, Evans DJ, Davies RM. Dental fluorosis in permanent incisor teeth in relation to water fluoridation, social deprivation and toothpaste use in infancy. Br Dent J 2000; 189(4):216 20.

Warren JJ, Levy SM, Kanellis MJ. Prevalence of dental fluorosis in the primary dentition. Journal of Public Health Dentistry 2001;61(2):87 91.

Whelton H, Crowley E, O’Mullane D, Donaldson M, Kelleher V, Cronin M. Dental caries and enamel fluorosis among the fluoridated and non-fluoridated populations in the Republic of Ireland in 2002. Community Dental Health 2004;21(1):37 44.

Whelton H, Crowley E, O’Mullane D, Donaldson M, Cronin M, Kelleher V. Dental caries and enamel fluorosis among the fluoridated and non-fluoridated populations in the Republic of Ireland in 2002. Community Dental Health 2006;21(1),37 44.

Economic Review

Centers for Disease Control and Prevention. Water fluoridation and costs of Medicaid treatment for dental decay–Louisiana, 1995-1996. MMWR 1999;48(34):753-7.

Ciketic S, Hayatbakhsh MR, Doran CM. Drinking water fluoridation in South East Queensland: a cost-effectiveness evaluation. Health Promotion Journal of Australia 2010;21(1):51-6.

Cobiac LJ, Vos T. Cost effectiveness of extending the coverage of water supply fluoridation for the prevention of dental caries in Australia. Community Dentistry and Oral Epidemiology 2012;40(4): 369-76.

Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. Journal of Public Health Dentistry 2001;61(2):78-86.

Kumar JV, Adekugbe O, Melnik TA. Geographic variation in Medicaid claims for dental procedures in New York State: role of fluoridation under contemporary conditions. Public Health Reports 2010;125(5):647-54.

Maupome G, Gullion CM, Peters D, Little SJ. A comparison of dental treatment utilization and costs by HMO members living in fluoridated and nonfluoridated areas. Journal of Public Health Dentistry 2007;67(4):224-33.

O’Connell JM, Brunson D, Anselmo T, Sullivan PW. Costs and savings associated with community water fluoridation programs in Colorado. Prev Chronic Dis 2005;2:A06.Available from URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459459/pdf/PCD2SIA06.pdf

Tchouaket E, Brousselle A, Fansi A, Dionne PA, Bertrand E, Fortin C. The economic value of Quebec’s water fluoridation program. Journal of Public Health 2013;21(6):523-33.

Texas Health Department. Water Fluoridation Costs in Texas: Texas Health Steps (EPSDT-Medicaid). Report to fulfill House Concurrent Resolution 145, Texas 75^th Legislature; May 2000. Available at URL: www.dshs.state.tx.us/dental/pdf/flstudy.pdf.

Wright JC, Bates MN, Cutress T, Lee M. The cost effectiveness of fluoridating water supplies in New Zealand. Australian and New Zealand Journal of Public Health 2001;25(2):170-8.

Implementation Resource

Rural Health Information Hub, Oral Health Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of oral health programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• Community Water Fluoridation Model

In 2012, electronic searches of the literature were conducted by a public health librarian in the databases listed below. Search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. The types of documents searched in the databases included journal articles, books, book chapters, reports, conference papers, and dissertations. In addition, the bibliographies of all reviewed articles were used to identify any further literature.

Search Strategy

OHG Trials Register via Cochrane Register of Studies (Searched 8/21/12)

1. ((fluorid* or flurid* or fluorin* or flurin*))
2. water*
3. (#1 and #2)

CENTRAL via The Cochrane Library (to issue 7, 2012)

1. MeSH descriptor Fluoridation this term only
2. MeSH descriptor Fluorides explode all trees
3. MeSH descriptor Fluorine this term only
4. (fluorid* in All Text or fluorin* in All Text or flurin* in All Text or flurid* in All Text)
5. (#1 or #2 or #3 or #4)
6. MeSH descriptor Dietary supplements this term only
7. MeSH descriptor Water supply this term only
8. water* in All Text
9. (#6 or #7 or #8)
10. MeSH descriptor Tooth demineralization explode all trees
11. (caries in All Text or carious in All Text)
12. (teeth in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
13. (tooth in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
14. (dental in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
15. (enamel in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
16. (dentin in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
17. (root* in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
18. MeSH descriptor Dental plaque this term only
19. ((teeth in All Text or tooth in All Text or dental in All Text or enamel in All Text or dentin in All Text) and plaque in All Text)
20. MeSH descriptor Dental health surveys explode all trees
21. (“DMF Index” in All Text or “Dental Plaque Index” in All Text)
22. (#10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #21)
23. (#5 and #9 and #22)

MEDLINE via OVID (March 5, 2012 to August 21, 2012)

1. Fluoridation/
2. exp Fluorides/
3. Fluorine/
4. (fluorid$ or fluorin$ or flurin$ or flurid$).mp.
5. or/1-4
6. Dietary supplements/
7. Water supply/
8. water$.mp.
9. or/6-8
10. exp TOOTH DEMINERALIZATION/
11. (caries or carious).mp.
12. (teeth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
13. (tooth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
14. (dental adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
15. (enamel adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
16. (dentin$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
17. (root$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
18. Dental plaque/
19. ((teeth or tooth or dental or enamel or dentin) and plaque).mp.
20. exp DENTAL HEALTH SURVEYS/
21. (“DMF Index” or “Dental Plaque Index”).mp.
22. or/10-21
23. case reports.pt.
24. Comment/
25. Letter/
26. Editorial/
27. or/23-26
28. exp animals/ not humans.sh.
29. 5 and 9 and 22
30. 29 not (28 or 27)

EMBASE via OVID (March 5, 2012 to August 21, 2012)

1. Fluoridation/
2. exp Fluoride/
3. Fluorine/
4. (fluorid$ or fluorin$ or flurin$ or flurid$).ti,ab.
5. or/1-4
6. Diet supplementation/
7. Water supply/
8. water$.ti,ab.
9. or/6-8
10. exp Dental caries/
11. (caries or carious).ti,ab.
12. (teeth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.
13. (tooth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.
14. (dental adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.
15. (enamel adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.
16. (dentin$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.
17. (root$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.
18. Tooth plaque/
19. ((teeth or tooth or dental or enamel or dentin) and plaque).ti,ab.
20. (“DMF Index” or “Dental Plaque Index” or “dental health survey*”).ti,ab.
21. or/10-20
22. 9 and 21
23. exp animals/
24. exp human/
25. 24 not 23
26. 22 and 25

ZETOC Conference Proceedings (Whole Database)

fluoride AND water AND caries
fluoridation AND water AND caries
fluoride AND water AND carious
fluoridation AND water AND carious
fluoride AND water AND dental
fluoridation AND water AND dental
fluoride AND water AND tooth
fluoridation AND water AND tooth
fluoride AND water AND teeth
fluoridation AND water AND teeth

Web of Science Conference Proceedings (1990 to November 2, 2012)

1. TS=(fluorid* or fluorin* or flurin* or flurid*)
2. TS=water*
3. TS=(caries or carious)
4. TS=(teeth and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
5. TS=(tooth and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
6. TS=(dental and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
7. TS=(enamel and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
8. TS=(dentin* and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
9. TS=(root* and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
10. TS=((teeth or tooth or dental or enamel or dentin) and plaque)
11. TS=(“DMF Index” or “Dental Plaque Index”)
12. #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11
13. #1 and #2 and #12

Proquest (To November 5, 2012)

ab(water*) AND ab(caries OR carious OR dental OR tooth OR teeth OR plaque)

Economic Review

The search for economic evidence included the following bibliographic databases: PubMed, Centres for Reviews and Dissemination University of York (CRD-YORK),EconLit (EBSCOhost), Embase (OVID), ERIC (ProQuest), Social Sciences Citation Index SSCI (Web of Science), and WorldCat. In addition, reference lists of included studies were screened and subject matter experts were solicited for additional articles.

Search terms and strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software.

PubMed, Searched: 11/26/2013
Results: 360

#1 “fluoridation”[mesh] or “fluorides”[mesh] or “fluorine”[mesh] or fluorid*[all fields] or fluorin*[all fields] or flurin*[all fields] or flurid*[all fields]

#2 “dietary supplements”[mesh] or “water supply”[mesh] or water*[all fields]

#3 ((“teeth” OR “tooth” OR “dental” OR “enamel” OR “root” OR “roots” OR dentin*) AND ( “caries”[all fields] or “carious”[all fields] or decay* or lesion* or demineral* or remineral*))

#4 “dental plaque”[mesh] OR “tooth demineralization”[mesh] OR “caries” OR “carious”

#5 ((“teeth” OR “tooth” OR “enamel” OR “root” OR “roots” OR dentin*) AND “plaque”))

#6 “dental health surveys”[mesh] OR “dmf index” or “dental plaque index”

#7 “case reports”[Publication Type] OR “Comment” [Publication Type] OR “letter”[Publication Type] OR “editorial”[Publication Type]

#8 “economics” [Subheading] OR “Economics”[Mesh] OR “Cost-Benefit Analysis”[Mesh] OR “Health Expenditures”[Mesh] OR “Capital Expenditures”[Mesh] OR “Cost of Illness”[Mesh] OR “Cost Savings”[Mesh] OR “Health Care Costs”[Mesh] OR “Quality-Adjusted Life Years”[Mesh] OR “Fees, Dental”[Mesh] OR economic[Title/Abstract] OR economic*[title/abstract] OR “cost”[Title/Abstract] or “costs”[title/abstract] or “costly”[title/abstract] OR benefit*[title/abstract] OR “dollar”[Title/Abstract] or “dollars”[title/abstract] OR “expenditure”[Title/Abstract] or “expenditures”[title/abstract] OR “wtp”[Title/Abstract] OR “willingness to pay”[Title/Abstract] OR increment*[Title/Abstract] OR “sensitivity analysis”[Title/Abstract] OR “sensitivity analyses”[Title/Abstract] OR “breakeven”[Title/Abstract] OR “break even”[Title/Abstract] OR “discount rate”[Title/Abstract] OR “discount rates”[Title/Abstract] OR “lost productivity”[Title/Abstract] OR “value”[Title/Abstract] OR “qaly”[Title/Abstract] OR “daly”[Title/Abstract] OR “quality adjusted life years”[Title/Abstract] OR “quality adjusted life yr”[Title/Abstract] OR “quality adjusted lifeyears”[Title/Abstract] OR “disability adjusted life”[Title/Abstract] OR “disability adjusted life expectancy”[Title/Abstract] OR “disability adjusted life year”[Title/Abstract] OR “disability adjusted life year estimates”[Title/Abstract] OR “disability adjusted life year loss”[Title/Abstract] OR “disability adjusted life year loss rates”[Title/Abstract] OR “disability adjusted life years”[Title/Abstract] OR “disability adjusted life years daly”[Title/Abstract] OR treatment saving[Title/Abstract] OR “treatment savings”[Title/Abstract] OR “dental fee”[Title/Abstract] OR “dental fees”[Title/Abstract] OR “money”[Title/Abstract] Filters: Publication date from 1995/01/01 to 2013/12/31

#9 “humans”[mesh]

#10 “Animals”[Mesh] OR “Animal Experimentation”[Mesh]

#11 #1 AND #2

#12 #3 OR #4 OR #5 OR #6

#13 #10 NOT #9

#14 #11 AND #12 AND #8

#15 #14 NOT #13

#16 #15 NOT #7

CRD-YORK NHS EED, Searched: 12/2/2013
Results: 50

Results for: ((fluorid* or fluorin* or flurin* or flurid*)) and ((Economic evaluation:ZDT and Bibliographic:ZPS) OR (Economic evaluation:ZDT and Abstract:ZPS)) IN NHSEED FROM 1995 TO 2013

EconLit (EBSCOhost), Searched: 12/2/2013
Results: 25
Search modes – Boolean/Phrase, 1995-2013

S11
S5 OR S9

S10
S5 OR S9

S9
S1 AND S8

S8
S2 OR S3 OR S4 OR S6 OR S7

S6
fluorid* or fluorin* or flurin* or flurid*

S5
fluoridation of water

S4
teeth or plaque

S3
dental or tooth

S2
caries or carious

S1
Water

Embase (OVID), Searched: 12/3/2013
Results: 17

1
fluoridation/

2
exp “economic aspect”/

3
exp “cost benefit analysis”/

4
2 or 3

5
1 and 4

6
limit 5 to (exclude medline journals and yr=”1995 -Current”)

ERIC (ProQuest), Searched: 12/3/2013
Results: 259

Search modes – Boolean/Phrase, 1995-2013

S8
S4 AND S7

S7
(economic* or cost* or expenditure* or utility or dollar* or wtp or “willingness to pay” or increment ) OR ( “lost productivity” or “sensitivity analysis” or breakeven or “break even” or discount* or value or qaly or daly or fee or fees or saving or savings or money ) OR ( “quality adjusted life” or “disability adjusted life” )

S4
S1 OR S2 OR S3

S3
caries or carious or dental or teeth or tooth or “oral health”

S2
fluoridation of water

S1
fluorid* OR flurid* OR fluorin* OR flurin*

Social Sciences Citation Index SSCI (Web of Science), Searched: 11/26/2013
Results: 34

# 10

# 8 AND #9
Databases=SSCI Timespan=1995-2013

# 9
TS=(cost*) or TS=(benefit*) or TS=(utility) or TS=(expenditure*) or TS=(dollar*) or TS=(wtp) or TS=(willingness near/2 pay) or TS=(increment*) or TS=(lost near/1 productivity) or TS=(sensitivity near/1 analysis) or TS=(breakeven) or TS=(break near/1 even) or TS=(discount*) or TS=(value) or TS=(qaly) or TS=(daly) or TS=(quality near/1 adjusted near/1 life) or TS=(disability near/1 adjusted) or TS=(treatment near/1 saving*) or TS=(dental near/1 fee*) or TS=(money)

#8
#6 AND #7

# 7
#3 OR #4 OR #5

# 6
#1 AND #2

# 5
TS=(DMF near/1 index)

# 4
TS=(caries) or TS=(cavit*) or TS=(carious) or TS=(decay*) or TS=(lesion*) or TS=(demineral*) or TS=(reminerali*)

# 3
TS=(tooth) or TS=(teeth) or TS=(dental) or TS=(enamel) or TS=(dentin*) or TS=(root*)

# 2
TS=(water*)

# 1
TS=(fluorid*) or TS=(fluorin*) or TS=(flurin*) or TS=(flurid*)

WorldCat (Worldcat.org), Searched: 12/3/2013
Results: 42

Kw: fluorid* kw:water kw:economic*

Kw: fluorid* kw:water kw:cost*

Embase (OVID), Searched: 12/3/2013
Results: 17

1
fluoridation/

2
exp “economic aspect”/

3
exp “cost benefit analysis”/

4
2 or 3

5
1 and 4

6
limit 5 to (exclude medline journals and yr=”1995 -Current”)

Centers for Disease Control and Prevention. 2010 Water Fluoridation Statistics. Retrieved from http://www.cdc.gov/fluoridation/statistics/2010stats.htm. Accessed August 2, 2013.

Centers for Disease Control and Prevention. Engineering and administrative recommendations for water fluoridation, 1995. MMWR 1995;44(RR-13):1-40.

McDonagh M, Whiting P, Bradley M, Cooper J, Sutton A, Chestnutt I, Misso K, Wilson P, Treasure E, Kleinjen J. A Systematic Review of Public Water Fluoridation. National Health Service Centre for Reviews and Dissemination. York(UK): University of York; 2000.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• More than 70% of U.S. residents who rely on community water systems receive fluoridated water (CDC, 2013).
• Potential barriers to implementation include start-up costs, social acceptability, media attention, and limited knowledge of the benefits and harms of community water fluoridation among the general public, healthcare providers, and policymakers.
• Messages that address these potential barriers and are tailored to the general public and healthcare professionals could lead to greater awareness and acceptance of community water fluoridation.
• Daily monitoring of fluoride levels in fluoridated community water supplies is recommended to maintain optimal fluoride concentrations (CDC, 1995).

There is no evidence that shows community water fluoridation results in severe dental fluorosis.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of children and adolescents with lifetime tooth decay — OH-01
• Reduce the proportion of children and adolescents with active and untreated tooth decay — OH-02
• Reduce the proportion of adults with active or untreated tooth decay — OH-03
• Increase the proportion of people whose water systems have the recommended amount of fluoride — OH-11

Health Impact in 5 Years (HI-5)

HI-5 highlights community-wide approaches that have demonstrated 1) positive health impacts, 2) results within five years, and 3) cost effectiveness and/or cost savings over the lifetime of the population or earlier.

• Water Fluoridation