Water Fluoridation - Alternatives

Alternatives

Although water fluoridation is the most effective means of achieving fluoride exposure that is community-wide, other fluoride therapies are also effective in preventing tooth decay; they include fluoride toothpaste, mouthwash, gel, and varnish, and fluoridation of salt and milk. Dental sealants are effective as well, with estimates of prevented cavities ranging from 33% to 86%, depending on age of sealant and type of study.

Fluoride toothpaste is the most widely used and rigorously evaluated fluoride treatment. Its introduction in the early 1970s is considered the main reason for the decline in tooth decay in industrialized countries, and toothpaste appears to be the single common factor in countries where tooth decay has declined. Toothpaste is the only realistic fluoride strategy in many low-income countries, where lack of infrastructure renders water or salt fluoridation infeasible. However, it relies on individual and family behavior, and its use is less likely among lower economic classes; in low-income countries it is unaffordable for the poor. Fluoride toothpaste prevents about 25% of cavities in young permanent teeth, and its effectiveness is improved if higher concentrations of fluoride are used, or if the toothbrushing is supervised. Fluoride mouthwash and gel are about as effective as fluoride toothpaste; fluoride varnish prevents about 45% of cavities. By comparison, brushing with a nonfluoride toothpaste has little effect on cavities.

The effectiveness of salt fluoridation is about the same as that of water fluoridation, if most salt for human consumption is fluoridated. Fluoridated salt reaches the consumer in salt at home, in meals at school and at large kitchens, and in bread. For example, Jamaica has just one salt producer, but a complex public water supply; it started fluoridating all salt in 1987, achieving a notable decline in cavities. Universal salt fluoridation is also practiced in Colombia and the Swiss Canton of Vaud; in France and Germany fluoridated salt is widely used in households but unfluoridated salt is also available, giving consumers choice about fluoride. Concentrations of fluoride in salt range from 90 to 350 mg/kg, with studies suggesting an optimal concentration of around 250 mg/kg.

Milk fluoridation is practiced by the Borrow Foundation in some parts of Bulgaria, Chile, Peru, Russia, Macedonia, Thailand and the UK. Depending on location, the fluoride is added to milk, to powdered milk, or to yogurt. For example, milk-powder fluoridation is used in rural Chilean areas where water fluoridation is not technically feasible. These programs are aimed at children, and have neither targeted nor been evaluated for adults. A 2005 systematic review found insufficient evidence to support the practice, but also concluded that studies suggest that fluoridated milk benefits schoolchildren, especially their permanent teeth.

Other public-health strategies to control tooth decay, such as education to change behavior and diet, have lacked impressive results. Although fluoride is the only well-documented agent which controls the rate at which cavities develop, it has been suggested that adding calcium to the water would reduce cavities further. Other agents to prevent tooth decay include antibacterials such as chlorhexidine and sugar substitutes such as xylitol. Xylitol-sweetened chewing gum has been recommended as a supplement to fluoride and other conventional treatments if the gum is not too costly. Two proposed approaches, bacteria replacement therapy (probiotics) and caries vaccine, would share water fluoridation's advantage of requiring only minimal patient compliance, but have not been proven safe and effective. Other experimental approaches include fluoridated sugar, polyphenols, and casein phosphopeptide–amorphous calcium phosphate nanocomplexes.

A 2007 Australian review concluded that water fluoridation is the most effective and socially the most equitable way to expose entire communities to fluoride's cavity-prevention effects. A 2002 U.S. review estimated that sealants decreased cavities by about 60% overall, compared to about 18–50% for fluoride. A 2007 Italian review suggested that water fluoridation may not be needed, particularly in the industrialized countries where cavities have become rare, and concluded that toothpaste and other topical fluoride offers a best way to prevent cavities worldwide. A 2004 World Health Organization review stated that water fluoridation, when it is culturally acceptable and technically feasible, has substantial advantages in preventing tooth decay, especially for subgroups at high risk.