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Datin Dr Norain binti Abu Talib Pengarah Kanan Kesihatan Pergigian

Water Fluoridation – A Public Health Approach in Caries Prevention in Malaysia. Norain AT , Norlida A. Symposium Pengurusan dan Peroditan Industri Air 2009 2 - 3 November 2009 SACC, Shah Alam, Selangor. Datin Dr Norain binti Abu Talib Pengarah Kanan Kesihatan Pergigian

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Datin Dr Norain binti Abu Talib Pengarah Kanan Kesihatan Pergigian

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  1. Water Fluoridation – A Public Health Approach in Caries Prevention in Malaysia Norain AT , Norlida A Symposium Pengurusan dan Peroditan Industri Air 2009 2 - 3 November 2009 SACC, Shah Alam, Selangor Datin Dr Norainbinti Abu Talib PengarahKananKesihatanPergigian KementerianKesihatan Malaysia ORAL HEALTH DIVISION, MOH, MALAYSIA

  2. Penyakit karies gigi • Penyakitkronik paling meluasdiduniaterutamadikalangankanak-kanak • Negara-negaraperindustrian, 60-90% kanak-kanaksekolahmengidappenyakitkaries – miskindanminoriti • (Selwitz et al. (2007), Petersen & Lennon, 2004) • Apabilaberlakukariesgigiprosesrawatanakanberulang . • ContohJangkahayattampalan amalgam 9-14 tahun(Griffin et al. (2001) ORAL HEALTH DIVISION, MOH, MALAYSIA

  3. Etiologikariesgigi Permukaan gigi Plak bacteria karies makanan masa ORAL HEALTH DIVISION, MOH, MALAYSIA

  4. Primary intervention of dental caries ORAL HEALTH DIVISION, MOH, MALAYSIA

  5. Cara penyampaian Fluorida • Air minum (1945) • garam(1950) • susu(1959 ) • pil/titisan(1960) • larutan (1943) • Ubatgigi(1945) • Kumurmulut (1946) • Gels(1967) • Varnishes(1968) Topikal Systemik ORAL HEALTH DIVISION, MOH, MALAYSIA

  6. World Health Assembly,2007 (WHA 60.17) The sixtieth World Health Assembly urges member states:…(4) for those countries without access to optimal levels of fluoride, and which have not yet established systematic fluoridation programmes, to consider the development and implementation of fluoridation programmes, giving priority to equitable strategies such as the automatic administration of fluoride, for example, in drinking water, salt or milk and the provision of affordable toothpaste. ORAL HEALTH DIVISION, MOH, MALAYSIA

  7. Pengunaan fluorida diMalaysia ORAL HEALTH DIVISION, MOH, MALAYSIA

  8. Pemfluoridaanbekalan air minum • satukaedahperawatanbekalan air awamdimanafluoridaditambahsupayamencapaiparas optimum kedalambekalan air terawatdilojiperawatanbekalan air • Tujuannyaadalahuntukmengawalpenyakitkariesdikalanganmasyarakat yang menerimabekalan air tersebut ORAL HEALTH DIVISION, MOH, MALAYSIA

  9. Benefits of Fluoride • Epidemiological studies in 1930s in the USA established the relation between concentration of fluoride in water and caries experience • Water fluoridation began in the USA in 1945. Now reaching 355 million people in 31 countries in addition to at least 50 million receiving optimal fluoride levels in water naturally • 1940’s onwards – development of other ways of delivering fluoride • Water fluoridation recognized as one of the ten great public health achievements of the 20th century in the U.S (MMWR, October 22, 1999 /48(41);933-940) ORAL HEALTH DIVISION, MOH, MALAYSIA

  10. Geographical areas with high natural fluoride levels (> 1.5 mg/l) ORAL HEALTH DIVISION, MOH, MALAYSIA

  11. Percentage of population receiving fluoridated water, including both artificial and natural fluoridation     80–100%   60–80%       40–60%       20–40%      1–20%  <1%   unknown ORAL HEALTH DIVISION, MOH, MALAYSIA

  12. Optimum level varies for different countries according to climate, temperatures and consumption • WHO (1984) - maximum concentration of 1.5 ppm fluoride in drinking water to avoid dental fluorosis • The US Environmental Protection Agency (EPA) 1986 - maximum primary contaminant level (MCL) of 4 ppm fluoride for drinking water, based on the avoidance of skeletal, but not dental fluorosis - An MCL of 2 ppm fluoride was set to protect against moderate to severe dental fluorosis. ppm = mg/l USA – 0.7 – 1.2 ppm Australia – 0.6 – 1.1 ppm Hong Kong – 0.6 ppm Singapore – 0.6 ppm Malaysia – 0.5 ppm ORAL HEALTH DIVISION, MOH, MALAYSIA

  13. Dmf TeethPer Child Nine Years After Fluoridation,Grand Rapids, Michigan 16 GRAND RAPIDS (before fluoridation) 12 GRAND RAPIDS (9 years after fluoridation) DMF TEETH PER CHILD 8 4 AURORA (Natural fluoridation) 5 6 7 8 9 10 11 12 13 14 15 16 AGE ORAL HEALTH DIVISION, MOH, MALAYSIA

  14. dmfTEETH PER CHILDSARNIA, BRANTFORD AND STRATFORD1948 - 1959 9 AGE : 9 - 11 YEARS AGE : 12 - 14 YEARS 8 1948 7 1959 6 5 DMF TEETH PER CHILD 4 3 2 1 0 BRANT- FORD STRATFORD SARNIA BRANT- FORD STRAT- FORD SARNIA SARNIA - NO FLUORIDE BRANTFORD - FLUORIDATED SINCE 1945 STRATFORD - NATURALLY FLUORIDATED ORAL HEALTH DIVISION, MOH, MALAYSIA

  15. Current Development • USA 2010 Healthy People – 75% received fluoridated water(2006-69.2%) Oct 2007: Southern California begins water fluoridation • Australia 80% population coverage in all states except Queensland (5%). 2009 Major change – Queensland starts Fluoridation • UK South Central Strategic Health Authority agreed to implement fluoridation in Southampton in 2010 • Malaysia Reinstitution of fluoridation programme in Kelantan (2006) Reinstitution of Fluoridation programme in Terengganu (2008) ORAL HEALTH DIVISION, MOH, MALAYSIA

  16. Evidence Basis Water fluoridation…. • reduce caries prevalence • Still effective with use other fluoride sources • reduces caries for all social classes • may reduce the oral health gap between social classes • withdrawal of water fluoridation indicates that caries prevalence increases • no association between adverse effects and water fluoridation has been established except dental fluorosis • remains a relevant and valid choice as a population measure for the prevention of dental caries technically feasible and culturally acceptable, • A Systematic Review of Public Water Fluoridation. NHS Centre for Reviews and Dissemination, University of York, 2000 • Australian Government. National Health and Medical Research Council. A Systematic Review of the Efficacy and Safety of Fluoridation, June 2007 • Parnell C, Whelton H, O'Mullane D. Eur Arch Paediatr Dent. 2009 Sep;10(3):141-8. • NHMRC 1985 review of the safety and effectiveness of water fluoridation (NHMRC 1985) • The 1991 report The effectiveness of water fluoridation (NHMRC 1991) • Review of Water Fluoridation and Fluoride Intake from Discretionary Fluoride Supplements (National Health and Medical Research Council, 1999) • World Health Organization (WHO, 2006) • American National Academies of Science (NAS, 2006) reports on fluoride in drinking-water • International Programme of Chemical Safety (IPCS, 2002) report on fluoride. ORAL HEALTH DIVISION, MOH, MALAYSIA

  17. Other benefits of water fluoridationKumar JV. Is water fluoridation still necessary? Adv Dent Res 20:8-12, July, 2008 ‘Halo effect ‘ - persons in non-fluoridated areas also receive fluoride through beverages and foods processed in fluoridated areas –diminished difference in caries observed between fluoridated and non-fluoridated communities in recent years However, there is still a noticeable difference in dental caries between fluoridated and non-fluoridated communities despite the ubiquitous presence of fluoride in food, water, and dental products Fluoridated ORAL HEALTH DIVISION, MOH, MALAYSIA

  18. Other benefits of water fluoridationKumar JV. Is water fluoridation still necessary? Adv Dent Res 20:8-12, July, 2008 There are other intangible benefit: • the progression of caries is delayed in the presence of fluoride, thereby providing more time for undertaking restorative treatment, when compared with 50 years ago • the disease in children is also now less complex to treat, since most of the lesions are in pits and fissures • the benefits continue into adulthood ORAL HEALTH DIVISION, MOH, MALAYSIA

  19. Dental Fluorosis • Hypomineralisation of tooth enamel or dentin produced by ingestion of above-optimum amounts of fluoride when teeth are developing • However, it has not been shown to pose any health risks beyond the possible esthetic concern ORAL HEALTH DIVISION, MOH, MALAYSIA

  20. Dental Fluorosis The severity is directly related to the age of the child at exposure, and the type, level and duration of the exposure. individual response, and nutritional and other factors ORAL HEALTH DIVISION, MOH, MALAYSIA

  21. Subject’s perception of fluorosis p<0.05 Source: Oral Health Division, MOH. Fluoride Enamel Opacities in 16-year-old Schoolchildren, 2000

  22. Water Fluoridation in Malaysia ORAL HEALTH DIVISION, MOH, MALAYSIA

  23. Policy statement “ Fluoridation of public water supplies be instituted in West Malaysia as soon as possible and further recommends that an optimum level of 0.7ppm fluoride be maintained in the reticulation system” (MOH,1971) ORAL HEALTH DIVISION, MOH, MALAYSIA

  24. History of fluoridation in Malaysia ORAL HEALTH DIVISION, MOH, MALAYSIA

  25. Why water fluoridation in Malaysia? • Caries is the most prevalence chronic disease and affect all ages • Good public water supply system where it reaches 95% of the population • fluoride level in natural water is less than the optimum level(0.5ppm) • Evident as safe and effective public health approach in reducing caries • Equitable benefits to the population • Recommended by World Health Organization • Recognized by large number of prominent national and international organizations ORAL HEALTH DIVISION, MOH, MALAYSIA

  26. Achievement after 35 years of Fluoridation ORAL HEALTH DIVISION, MOH, MALAYSIA

  27. Estimated population received fluoridated water, 2008 ORAL HEALTH DIVISION, MOH, MALAYSIA

  28. Number of Water treatment Plant with and without Fluoridation System, 2008 ORAL HEALTH DIVISION, MOH, MALAYSIA

  29. Per Capita Cost/Year 18 Sept 1972 – ‘recurrent expenditure at 16 cents per head of population served per year’ Loh KH (2004). Cost Estimation Study of Water Fluoridation Programme in Johor. ‘This study found that the estimated per capita cost of fluoride compound for fluoridating community water supply at the recommended level of 0.7 ppm in Johor is RM0.18 (S.D. 0.12) per year.’ ORAL HEALTH DIVISION, MOH, MALAYSIA

  30. 6 4.8 5 4.35 3.7 4 3.3 Mean DMFT 3 2.37 1.9 2 0.8 1 0.42 0 6-year-old 12-year-old 16-year-old Age group 1970 1988 1997 Incremental Improvement Attributed To Appropriate Use Of Fluorides And School Dental Programme However…… ORAL HEALTH DIVISION, MOH, MALAYSIA

  31. However, Caries Prevalence Remain High Among Children WHO goal 50% Oral Health Division, Ministry of Health Malaysia. National oral health survey of preschool children 2005 (NOHPS 2005), 2006 Oral Health Division, Ministry of Health Malaysia. Oral Health Status2008, Dec 2008 ORAL HEALTH DIVISION, MOH, MALAYSIA

  32. Caries Severity in Children < 18 Years from Several Surveys in Malaysia Oral Health Division, MOH, Various surveys ORAL HEALTH DIVISION, MOH, MALAYSIA

  33. ORAL HEALTHCARE UTILISATION15 years and above Oral Health Division, Ministry of Health Malaysia. The National Oral Health Survey of Adults 2000 (NOHSA 2000). November 2004 Institute for Public Health, Ministry of Health Malaysia. The Third National Health and Morbidity Survey 2006 (NHMS III). Oral Health. Jan 2008 ORAL HEALTH DIVISION, MOH, MALAYSIA

  34. Dental Caries Prevalence among Malaysian Adults from Various Surveys 35 30 29.5 25 20 Percentage caries free 18.1 15 13.9 10 11.8 9 8.2 5.5 6.9 3.7 3.9 3 5 5 3.3 4.6 6.6 2.9 1.5 2.9 2.8 0.9 3.5 3.6 1.5 1.2 0 15-19 20-24 25-29 30-34 35-44 45-54 55-64 65+ Age group 1974 1990 2000 ORAL HEALTH DIVISION, MOH, MALAYSIA

  35. 30 25.2 23.5 25 22.8 20.3 20.7 20.1 20 17.8 15.6 14.5 15.4 Mean DMFT 15 12.9 12.1 11.5 12.1 10.9 8.8 9.1 10 8.4 6.9 6.2 6 4.6 4.4 5 2.9 0 15-19 20-24 25-29 30-34 35-44 45-54 55-64 65+ Age Group 1974 1990 2000 Inequalities persist ORAL HEALTH DIVISION, MOH, MALAYSIA

  36. Caries Experience among Adults of Different Age Groups between Selected Countries Source: WHO Oral Health Country/Area Profile Programme ORAL HEALTH DIVISION, MOH, MALAYSIA

  37. ORAL HEALTH DIVISION, MOH, MALAYSIA

  38. Water Fluoridation Programme Population Coverage, 2008 98.0% 98.0% 4.7% 88.3% 17.7% 97.9% 68.1% 4.3% 96.3% 81.6% 99.9% 100% 95.0% 98.0% Source: Oral Health Division, MOH 96.7% ORAL HEALTH DIVISION, MOH, MALAYSIA

  39. Inequalities Persist By Location ORAL HEALTH DIVISION, MOH, MALAYSIA

  40. Differences in Dental Caries Experience (DMFT) among 16-year-old Schoolchildren between Fluoridated (F) and Non-Fluoridated (NF) Areas Oral Health Division, Ministry of Health Malaysia. National oral health survey of school children 1997 (NOHSS ’97), 1998 Oral Health Division, Ministry of Health Malaysia. Fluoride enamel opacities in 16-year-old school children, June 2001 ORAL HEALTH DIVISION, MOH, MALAYSIA

  41. Penutup Pemfluoridaanbekalan air minummasihrelevandanterbuktisebagaikaedah yang kosefektifdalammencegahkariesgigidiMalaysia. • Kariesgigi dental caries is very common • KetidaksamaanKesihatanpergigianberterusan • >95% of the population menerimabekalan air paip • Parasfluoridadalam air yang belumdirawatadalahrendah Walaubagaimanapunsemuaagensiperlumemainkanperanandanmemberisokonganpaduuntukmenjalankan program inisupayadapatmeningkatkankesihatanpergigiansertakualitihidupmasyarakat. • Menentukanparas optimum fluorida • Pastikanliputanmasyarakatpertingkatkan • Pastikanfluoridadapatdikekalkandiretikulasi ORAL HEALTH DIVISION, MOH, MALAYSIA

  42. Syor Jawatankuasa Khas 1971 “Strongly recommends that fluoridation of public water supplies be instituted in West malaysia as soon as possible and further recommends that an optimum level of 0.7 ppm fluoride be maintained in the reticulation system” ORAL HEALTH DIVISION, MOH, MALAYSIA

  43. 25 April 1972 “ Jema’ahMenteribersetujubahawaKementerianKesihatanbolehmelancarkanrancanganmembubohfloraidkepadabekalan air dengansegeradengantidakpayahmenerimapersetujuandaripadaKerajaan-KerajaanNegeri. Walaubagaimana pun, Kerajaan-KerajaanNegeripatutjugadiberitahudiatastindakan yang demikian”. ORAL HEALTH DIVISION, MOH, MALAYSIA

  44. Working together to improve the nation oral health and quality of life A lifetime of healthy smiles!

  45. Thank you for your attention ORAL HEALTH DIVISION, MOH, MALAYSIA

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