Jayanth V. Kumar

Fluorides in Dental Public Health Programs

The use of fluorides in dental public health programs has a long history. With the availability of fluoridation and other forms of fluorides, dental caries have declined dramatically in the United States. This article reviews some of the ways fluorides are used in public health programs and discusses issues related to their effectiveness, cost, and policy.

Effect of Tobacco Smoke on the Oral Health of US Women of Childbearing Age

OBJECTIVES To determine the oral health status of US women of childbearing age and to analyze the effect of tobacco smoke on their oral health. METHODS Data from the 1999-2004 National Health and Nutrition Examination Survey were evaluated for women 15-44 years of age. The association of exposure to tobacco smoke with untreated caries, mean DMFS, gingivitis, and periodontitis were examined in bivariate and regression analyses controlling for potential confounders. RESULTS The prevalence of untreated caries was 25%, for gingivitis 49%, and for periodontitis 6%. After adjusting for potential confounders, self-reported current smoking was a strong independent risk indicator for untreated caries, periodontitis, and to a lesser extent for greater DMFS count. Women with detectable cotinine levels below 15 ng/mL presented with an increased risk for gingivitis. Independent factors associated with increased risk for untreated caries were being Black, having less than a high school education, Medicaid or no health insurance, previous live births, and infrequent and episodic dental visits. Characteristics associated with gingivitis were being Mexican-American, obese, pregnant, and having infrequent dental visits. Older age, no insurance, and the last dental visit for treatment were independently associated with periodontitis. CONCLUSIONS Dental caries and periodontitis were prevalent among certain subgroups of women of reproductive age. Smoking was found to be a significant risk indicator for various negative oral health outcomes. Barriers to accessing to dental care that were manifested by untreated caries among Black women, mothers, and Medicaid beneficiaries must be better understood.

Intra-oral Distribution of Dental Fluorosis in Newburgh and Kingston, New York

Previous studies of intra-oral distribution of dental fluorosis in low-fluoride areas reported that teeth that formed later in life were more frequently affected compared with the early-forming teeth. The steady increase of plasma fluoride with age, even under constant fluoride exposure, has been suggested as a possible mechanism for this clinical manifestation. To determine the intra-oral distribution of Deans Index scores and the effect of fluoride exposure on early- and late-forming teeth, we analyzed data collected on 2193 seven-to 14-year-old lifelong residents of fluoridated or non-fluoridated areas. Logistic regression procedures were used to determine the effects of fluoridation, early brushing, daily supplements, and other socio-demographic variables on early-and late-forming teeth. The results show that the occurrence of very mild or greater levels of fluorosis in the upper anterior teeth was 7 to 10% in the fluoridated area and 5 to 9% in the nonfluoridated area. In the fluoridated area, the occurrence of fluorosis increased from anterior to posterior teeth. Both early- and late-forming teeth were affected by exposure to fluoridation, daily fluoride supplement use, or brushing before the age of two years. This analysis showed that the esthetic consequence of exposure to multiple sources of fluoride was less dramatic, as evidenced by the lower frequency in upper anterior teeth compared with posterior teeth. The longer maturation process of the posterior teeth and the thicker enamel appear to be the likely explanation for the higher occurrence of dental fluorosis in posterior teeth.

Evaluation of a school-based sealant program in New York State.

This study evaluated the outcome of a targeted dental sealant program by comparing the survival probabilities of sealed high-risk first molar tooth sites to unsealed low-risk tooth sites in 1,122 children enrolled in a school-based sealant program. A comparison of the survival probabilities between low-risk first molar teeth that did not receive sealants and the sealed high-risk first molar teeth did not show significant differences. The results suggest that the protocol used by the program provides a satisfactory method for identification of children who could best benefit from sealants in a school-based situation.

Dental Caries and Tetracycline-stained Dentition in an American Indian Population

Complaints of enamel defects in American Indian children residing on the St. Regis reservation in New York State prompted an epidemiological study. The results of that study, reported earlier (Rebich et al., 1983), indicated that over one-fifth of the American Indian children had discoloration of the dentition due to ingestion of tetracycline during the years of tooth formation. These data also provided an ideal opportunity to examine the link between tetracycline staining and caries which has been postulated by previous authors. American Indian children, ages 7-18, were found to have a higher caries experience than other children and a lower rate of dental service utilization, as evidenced by the filled component of the DMFS index (FS/DMFS). Within the American Indian population, however, no indication was found of any association between tetracycline staining and dental caries.

Reducing early childhood caries in a Medicaid population: A systems model analysis

BACKGROUND Despite early childhood caries (ECC) being largely preventable, its repair accounts for a disproportionate share of Medicaid expenditures. In this study, the authors model disease reductions and cost savings from ECC management alternatives. METHODS The authors apply system dynamics modeling to the New York State Medicaid population of young children to compare potential outcomes of 9 preventive interventions (water fluoridation, fluoride varnish, fluoride toothpaste, medical screening and fluoride varnish application, bacterial transmission reduction, motivational interviewing, dental prevention visits, secondary prevention, and combinations) and the effect of defluoridating New York City. RESULTS Model simulations help project 10-year disease reductions and net savings from water fluoridation, motivational interviewing, and fluoride toothpaste. Interventions requiring health professionals cost more than they save. Interventions that target children at high risk, begin early, and combine multiple strategies hold greatest potential. Defluoridating New York City would increase disease and costs dramatically. CONCLUSIONS The variety of population-level and individual-level interventions available to control ECC differ substantially in their capacity to improve childrens oral health and reduce state Medicaid expenditures. PRACTICAL IMPLICATIONS Using Medicaid and health department dollars to deliver ECC preventive and management interventions holds strong promise to improve childrens oral health while reducing state dental expenditures in Medicaid.

Original ContributionsCover StoryReducing early childhood caries in a Medicaid population: A systems model analysis

BACKGROUND Despite early childhood caries (ECC) being largely preventable, its repair accounts for a disproportionate share of Medicaid expenditures. In this study, the authors model disease reductions and cost savings from ECC management alternatives. METHODS The authors apply system dynamics modeling to the New York State Medicaid population of young children to compare potential outcomes of 9 preventive interventions (water fluoridation, fluoride varnish, fluoride toothpaste, medical screening and fluoride varnish application, bacterial transmission reduction, motivational interviewing, dental prevention visits, secondary prevention, and combinations) and the effect of defluoridating New York City. RESULTS Model simulations help project 10-year disease reductions and net savings from water fluoridation, motivational interviewing, and fluoride toothpaste. Interventions requiring health professionals cost more than they save. Interventions that target children at high risk, begin early, and combine multiple strategies hold greatest potential. Defluoridating New York City would increase disease and costs dramatically. CONCLUSIONS The variety of population-level and individual-level interventions available to control ECC differ substantially in their capacity to improve childrens oral health and reduce state Medicaid expenditures. PRACTICAL IMPLICATIONS Using Medicaid and health department dollars to deliver ECC preventive and management interventions holds strong promise to improve childrens oral health while reducing state dental expenditures in Medicaid.

Does water fluoridation affect the prevalence of enamel fluorosis differently among racial and ethnic groups?: Race and enamel fluorosis

OBJECTIVES There are reports showing higher prevalence of enamel fluorosis among African-American children. This study was conducted to assess whether the effect of water fluoride level on enamel fluorosis is different among different race/ethnicity groups among US school children. METHODS Data from the National Survey of Oral Health of US School Children 1986-1987 were analyzed to determine the prevalence of enamel fluorosis among 7-17 year-old children. The association between race/ethnicity and enamel fluorosis was examined using logistic regression modeling after controlling for potential confounders age, gender, water fluoridation, other sources of fluoride, and region of residence. RESULTS The prevalence of very mild to severe enamel fluorosis was 20.8 (95% CI, 15.4, 26.3) and 25.7 (95% CI, 15.0, 36.5) percent among non-Hispanic White and non-Hispanic Black children, respectively. Neither the adjusted odds ratio of 1.3 (0.8, 2.0) for the non-Hispanic Black group nor the interaction effect between non-Hispanic Black and water fluoridation were statistically significant. CONCLUSIONS Enamel fluorosis was not associated with race/ethnicity. Our analysis suggests that exposure to similar levels of fluoride in the water does not appear to place certain race/ethnic groups at a higher risk for developing enamel fluorosis, and lowering the optimal range of drinking water fluoride to a single value of 0.7 ppm will provide a level of protection against enamel fluorosis that will benefit all race/ethnicity groups.

Does fluoride in drinking water delay tooth eruption

OBJECTIVES The objectives of this study are to determine the effect of fluoride exposure on permanent tooth eruption patterns as well as to understand its effect on caries attack rate by accounting for the number of erupted tooth surfaces. METHODS We analyzed data from the 1986-1987 National Survey of Oral Health of US Schoolchildren to determine the mean number of erupted permanent teeth and permanent first molars according to fluoride level in drinking water. The analysis included 13,348 children aged 5-17 years with a history of single residence. We also estimated the attack rate (decayed, missing, and filled surfaces/surfaces at risk) for fluoride deficient, suboptimal, and optimally fluoridated areas adjusting for covariates. Multivariable statistical analyses were performed to control for potential confounders. RESULTS By age 7, almost all permanent first molars had erupted. The adjusted mean number of erupted permanent first molars per child were 3.81, 3.67, and 3.92 in areas with <0.3, 0.3-<0.7, and 0.7-1.2 ppm of fluoride, respectively. The adjusted caries attack rate in the first permanent molars among 5- to 17-year-old children was 93, 81, and 78 per 1,000 surfaces in fluoride deficient, suboptimal, and optimally fluoridated areas, respectively (P < 0.0001). This pattern of higher first molar attack rate among children in the fluoride-deficient communities was also observed in all erupted teeth. CONCLUSION Exposure to fluoride in drinking water did not delay the eruption of permanent teeth. The observed difference in dental caries experience among children exposed to different fluoride levels could not be explained by the timing of eruption of permanent teeth.

Community water fluoridation reduced dental caries in Australian adults born before its widespread implementation at least as much as after its widespread adoption.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Effects of fluoridated drinking water on dental caries in Australian adults. Slade GD, Sanders AE, Do L, Roberts-Thomson K, Spencer AJ. J Dent Res 2013;92:376. REVIEWERS Vinicius N. Tavares, DDS, MPH, Jayanth V. Kumar, DDS, MPH PURPOSE/QUESTION: This study investigated the long term caries-prevention benefits of community water fluoridation for individuals born before its widespread implementation SOURCE OF FUNDING Government: National Health and Medical Research Council grants Industry: Colgate-Palmolive, New York, USA provided gifts for study participants Other: Australian Dental Association and state and territory health departments and dental services TYPE OF STUDY/DESIGN Retrospective cohort study LEVEL OF EVIDENCE Level 2 STRENGTH OF RECOMMENDATION GRADE: Not applicable.