LTP Priority: Better care for health conditions: Dental healthcare
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Introduction of community water fluoridation to reduce the number of emergency department visits by children and young people, currently accounting for 25% of all attendances.
Major driver of health inequalities in your area of work
Tooth decay is the most common reason for hospital admission for children aged 6-10 years-old. Whilst it is largely preventable it still remains a serious public health problem. PHE data shows that in 2017, almost a quarter of 5-year-olds started school with tooth decay. Whilst oral health has improved in this age group significant inequalities persist with almost half (47%) of 5 year olds in Rochdale having tooth decay in comparison with 13% in Cambridgeshire. In the most deprived decile in England, over a third of children have dental decay (36.3%), compared to just 12.5% in the least deprived decile. Tooth decay impacts on children and families, children who have toothache or who need treatment may have; pain, infections and difficulties with eating, sleeping, speaking and socialising. They may have to be absent from school and parents may also have to take time off work to take their children to a dentist or to hospital. Children’s poor oral health links to other key policy areas such as getting the best start in life, inequalities, child obesity, school readiness and development of speech and language.
Deprivation. Inclusion health groups: Migrants and Gypsy, Roma and Traveller communities.
Introduction of water fluoridation.
What the intervention is?
The intervention for NHS England commissioners is to work with and support local authorities who are considering implementing a water fluoridation scheme.
Either through STP/ICS plans or though NHS England dental commissioning plans, NHS England could resource planning phases such as feasibility studies (this has already been done in some areas) and support local consultations. Savings due to improved oral health because of water fluoridation fall to the NHS in terms of reduced GA extractions for children and reduced dental treatment costs for both children and adults.
Why support water fluoridation?
Fluoride in water can reduce the likelihood of experiencing dental decay and minimise its severity and is the only intervention to improve dental health that does not require behaviour change by individuals.
How this programme can be implemented at scale
Since April 2013 the power to make new proposals to establish, vary or terminate water fluoridation schemes sits with local authorities. There are a number of local authorities currently considering water fluoridation. Although decision making lies with the local authority, local partners such as the NHS have already been integral in supporting plans for proposals.
The intervention has been included in PHE’s return on investment tool for oral health. The PHE return on investment tool can be found on the gov.uk website. Based on the average dmft (decayed, missing or filled teeth) for 5-year-old children in England (national oral health survey of 5 year old children in 2013), the return on investment tool suggests for every £1 invested there is a £12.71 return on investment after 5 years and £21.98 after 10 years. This includes savings to primary and secondary NHS services.
The recently published Public Health England report, “Water Fluoridation Health Monitoring for England, PHE 2018”, compared a range of dental and non-dental health indicators in fluoridated and non-fluoridated areas. The PHE Water fluoridation health monitoring report (2018) concluded that water fluoridation is an effective and safe public health measure to reduce the frequency and severity of dental decay, and narrow differences in dental health between more and less deprived children and young people. If 5-year-olds with the most tooth decay drank fluoridated water they would have 28% less tooth decay and be 45-68% less likely to need teeth removed in hospital.
Water fluoridation schemes also impact on the oral health of the whole population including vulnerable older adults. Adults exposed to water fluoridation have shown a 27% reduction in caries experience (Ref: Griffin, S.O., Regnier, E., Griffin, P.M., & Huntley, V. (2007). Effectiveness of Fluoride in Preventing Caries in Adults. Journal of Dental Research, 86(5), pp. 410–415.)
Its conclusions concurred with those of other authoritative reviews in finding no convincing evidence of harm to health due to fluoridation schemes and lower levels of tooth decay in fluoridated areas. These findings were consistent with the previous report published in 2014.
There have been a number of authoritative reviews of water fluoridation undertaken since the first schemes were established in 1945. These contain scientific opinion on both effectiveness and safety. Recent reviews include:
- (European) Scientific Committee on Health and Environmental Risks – SCHER (2011)
- US Community Preventive Services Task Force (2013)
- Royal Society of New Zealand (2014)
- Cochrane Oral Health Group (2015)
- Health Research Board (Ireland) (2015)
- National Health and Medical Research Council (Australia)(2017)
- The Canadian Agency for Drugs and Technologies in Health (2019)
The common finding of the reviews looking at dental health is that levels of tooth decay are lower in fluoridated areas and, for reviews which looked at general health effects, that there is no credible scientific evidence that water fluoridation is harmful to health.
Guidance for Commissioners
Improving oral health: community water fluoridation toolkit – A toolkit to help local authorities make informed decisions on whether to implement, vary or terminate a water fluoridation scheme
There are Dental Public Health Consultants at all PHE Centres that LAs can contact for advice and support with water fluoridation.