FluorideDental caries prevention in Asian nations

Background.—Dental caries is one of the most com-mon chronic diseases in humans. Socio-behavioral condi-tions and exposure to disease prevention programs cansignificantly influence the occurrence of dental caries ina population. Fluoride has proved effective in preventingdental caries, with population-wide automatic fluoridationmeasures providing the most equitable way to preventthis disease. Although community-based interventionshave been implemented in many countries, several devel-oping nations have not implemented these programs. Aworkshop on the use of fluoride in Asia was conducted inPhang-Nga, Thailand, in 2011. Representatives from variouscountries reported on interventions currently in place,program limitations, barriers to the use of fluoride, possiblesolutions, and ways to expand coverage. Recommendationswere made by the Working Group sessions.

Country Reports.—Malaysia has had water fluoridationsince the early 1950s, with 70% of the population benefit-ting. However, the consumption of bottled water or filteredwater is becoming more common, and both of these yieldfluoride-free water. Quality assurance and privatization ofthe water system are concerns.

Singaporehaswater fluoridationof essentially 100%of itspopulation. However, because the population obtains fluo-ride from several sources, there is a danger of fluorosis, sothe concentration of fluoride in the water has been lowered.

In Nepal, untreated dental caries prevalence is high. Aneffective community-based fluoride intervention is needed.

Fluoridehasnowbeenadded to iodized salt in Laos. Thereis a need to reinforce community education activities andpos-sibly increase the iodine and fluoride concentrations per kilo-gram of salt. An epidemiologic surveillance system is needed.

In Vietnam, fluoridation has been used since 1990 inHo Chi Minh City, producing a decrease in dental caries inchildren. However, 70% of the population of the countrydoes not benefit from a fluoridation program. Salt fluorida-tion is being evaluated as an option.

In Brunei, about 95% of the population drinks fluori-dated water. In addition, toothpaste containing fluoride isavailable, as are fluoride varnishes for children in school.

In Cambodia, salt has been fluoridated since 2008, butresponsible parties appear unmotivated to provide the

necessary oversight for the program. Effective technologyand education are needed to persuade the governmentand private sector of the importance of quality controland other issues.

Themilk fluoridation system in Thailand is the largest inthe world and is targeted at 4- to 12-year-old children inpublic schools. Taxes imposed on milk and Food andDrug Administration requirements have raised barriers tothe effectiveness of the milk program.

Hong Kong has experienced water fluoridation suc-cesses similar to those of Singapore. An oral health surveyconducted every 10 years confirms the success of dentalcaries prevention programs and monitors enamel fluorosisstatus.

Salt has been iodized to prevent goiter in India, soconsideration is being given to using salt fluoridation toprevent dental caries. Authorities have not been convincedof the effectiveness and safety of such a program. Before itcan be implemented, a distribution network should bedetermined and feasibility studies should be conducted.

Various fluoride prevention methods have been used inChina, depending on the province. School-based preven-tion programs, topical varnishes and gels, and water fluori-dation have been used to varying degrees. The focus hasbeen on children and older adults. Serious concerns havebeen raised concerning the manpower needed to imple-ment programs.

Recommendations.—The key Working Group conclu-sions are as follows:

1. The most effective and equitable caries preventionapproaches are population-wide automatic fluorida-tion measures using water, salt, or milk.

2. Before beginning any fluoridation program, feasibilitystudies should be done.

3. It is essential to educate the community about thebenefits of fluoride.

4. Countries will need technical assistance and guid-ance when planning, implementing, and assessingcommunity-based interventions.

5. An epidemiologic surveillance system is needed.6. Health systems research should be strengthened, and

efforts made to translate the information gained intocommunity-based practices.

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7. A simple handbook outlining the facts about fluorida-tion should be developed to use in countries that lacka caries prevention program.

8. Privatization may be a problem in some countries.9. It is important to share community experiences with

fluoride programs and recommendations with nationaland international public health authorities such as theWorld Health Organization (WHO).

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Clinical Significance.—Developing a dentalcaries prevention strategy is a process. Eventhough many developed nations have had onein place for many years, it is a struggle for

Dental Abstracts

developing nations to institute these measuressometimes. Using the resources of institutionssuch as the WHO may smooth the process.

Petersen PE, Baez RJ, LennonMA: Community-oriented administra-tion of fluoride for the prevention of dental caries: A summary ofthe current situation in Asia. Adv Dent Res 24:5-10, 2012

Reprints available from PE Petersen, World Health Organization,Global Oral Health Programme, Chronic Disease Prevention andHealth Promotion, 20 Avenue Appia, CH-1211, Geneva, Switzer-land; email: petersenpe@who.int