2010 John Wiley & Sons A/S

Community Dent Oral Epidemiol 2010; 38: 310314

All rights reserved

A school-based fluoride mouth

rinsing programme in Sarawak: a
3-year field study

Catherine Jean-Ai Chen1, Kwok Sung

Ling1, Rashidah Esa2, Jit Chie Chia1,
Andrew Eddy1 and Siew Lian Yaw1
1
Oral Health Division, Sarawak State Health
Department, Sarawak, Malaysia,
2
Department of Community Dentistry,
Faculty of Dentistry, University of Malaya,
Kuala Lumpur, Malaysia

Chen CJ-A, Ling KS, Esa R, Chia JC, Eddy A, Yaw SL. A school-based fluoride
mouth rinsing programme in Sarawak: a 3-year field study. Community Dent
Oral Epidemiol 2010; 38: 310314.  2010 John Wiley & Sons A S
Abstract Background: This study was undertaken to assess the impact of
fluoride mouth rinsing on caries experience in a cohort of schoolchildren
3 years after implementation. Methods: 270 children aged 89 years from four
schools in Sarawak were selected at baseline. Baseline data was collected to
ensure that the selected schools did not differ significantly. Children from two
schools rinsed with 0.2% sodium fluoride under supervision, while those from
the other schools did not. Results: After 3 years, 242 schoolchildren remained
in the study. At the end of the study, the mean DMFT for the test group was 2.3
(95% CI, 1.932.67) while the mean DMFT for the control group was 4.01 (95%
CI, 3.394.63). The mean DMFS for the test group was 3.40 (95% CI, 2.684.12)
while the mean DMFS for the control group was 6.67 (95% CI, 5.477.87). After
3 years, 24.2% of those in the test group remained caries free compared to 11.5%
in the control group. The risk of developing caries decreased 0.52 times among
the children from the test group exposed to the fluoride mouth rinsing
programme as compared to the unexposed control group (RR = 0.48, 95% CI,
0.260.85). Discussion and conclusion: The findings show that a school-based
weekly 0.2% sodium fluoride mouth rinsing programme is an effective caries
preventive measure and should be implemented in fluoride-deficient areas as a
means of reducing the prevalence of dental caries in these communities.

Fluoride mouth rinsing is one of the most widely

used caries preventive public health methods. In
1965, Torrel and Ericsson (1) reported that daily use
of a 0.05% sodium fluoride mouth rinse reduced
the development of new caries by 50%, while
fortnightly rinsing reduced the caries level by
about one-third. This study became a classic model
in the field of fluoride mouth rinsing. The effect of
fluoride mouthrinses on the incidence of caries in
children has been extensively investigated during
the past four decades in a large number of clinical
trials. These have demonstrated the effectiveness of
fluoride mouth rinses in reducing dental caries by
1545% over a period of 26 years (25). A Cochrane review by Marinho et al. (6) concluded that
regular and supervised use of fluoride mouthrinse
by children is associated with a clear reduction in
caries increment. The review found that daily and

310

Key words: caries prevention; field study;

fluoride mouth rinsing
Catherine Chen, Oral Health Division,
Sarawak State Health Department, Jln Tun
Abg Hj Openg, 93590 Kuching, Sarawak,
Malaysia
Tel.: 6082 245308 (or) 6013 5673493
Fax: 6082 231720
e-mail: jeanai62@hotmail.com (or)
catherinecj@srwk.moh.gov.my
Submitted 22 January 2009;
accepted 18 December 2009

weekly or fortnightly rinse programmes resulted

on average in 26% fewer decayed, missing or filled
permanent tooth surfaces. It is thought that the
caries-preventive effect of fluoride mouth rinsing
relates to its influence on the demineralization remineralization process in enamel and
dentine (7).
Studies by Wei and Yiu (7) and Twetman et al.
(8) have shown that school-based fluoride mouth
rinsing programmes are a safe and effective means
of controlling dental decay in children and adolescents, especially in communities with limited
exposure to fluorides. In an evaluation of a supervised school-based fluoride mouth rinsing programme in Edinburgh, Levin et al. (9) concluded
that fluoride mouth rinsing can be effectively
targeted at children from deprived areas through
school-based initiatives. In another evaluation on
doi: 10.1111/j.1600-0528.2010.00529.x

School-based fluoride mouth rinsing programme

preventive oral health activities for children in

Woudenberg, The Netherlands, Pieterse et al. (10)
concluded that children who had never rinsed with
fluoride were almost four times more likely to have
caries lesions than children who rinsed for at least
3 years. This strongly indicates that long-term
rinsing with fluoride has a positive effect on caries
status.
The findings of the National Oral Health Survey
of School Children in Malaysia (11) showed that
the oral health status of 12-year-olds in Sarawak
was about 10 years behind that in Peninsula
Malaysia. The mean DMFT (decayed, missing,
filled teeth) of 12-year-olds in Peninsula Malaysia
was 1.6 whereas in Sarawak it was 2.5. Following
this, the Oral Health Division formulated a 10-year
Master Plan, named Pinnacle 2010. The main
objective of Pinnacle 2010 is to fast track the
improvement in the oral health status of the people
in Sarawak particularly schoolchildren. Key strategies towards the achievement of this objective
include oral health promotion efforts such as oral
health education, tooth brushing drills in primary
schools as well as the expansion of community
water fluoridation to more areas.
In Sarawak, only 69.5% of the population
receives fluoridated water supplies (12). A fairly
large population of schoolchildren, particularly
those in the rural schools, do not receive the
benefits of water fluoridation. Although the
effectiveness of fluoride mouth rinses has been
demonstrated in other localities, there have not
been any similar studies in Sarawak. Thus, this
study was undertaken to evaluate the effectiveness
of a school-based weekly fluoride mouth rinsing
programme among rural schoolchildren residing in
a nonfluoridated area. This paper reports the
impact of fluoride mouth rinsing on the caries
experience of a cohort of schoolchildren from
participating schools 3 years after implementation.

Methodology
Selection of the test and control schools
Four schools in Selangau District, Sibu Division,
were selected based on the following criteria: the
schools were located in nonfluoridated areas with
no public water supply. Their only source of
drinking water was rain and river water with less
than 0.1 ppm fluoride. The children were of similar
socioeconomic and ethnic background (95.5% of
the children were Ibans) and had high caries
experience with a mean DMFT of 2.5 or higher at
12 years of age.
Prior to the start of the fluoride mouth rinsing
programme, baseline data for all four participating
schools was obtained to ensure that they were
similar with regard to caries status, daily tooth
brushing practices, use of fluoridated toothpaste
and consumption of sweetened foods and drinks
(Table 1). In order to verify whether students were
using fluoridated toothpaste, students were interviewed and shown samples of popular toothpaste
brands. These were classified into fluoridated and
nonfluoride toothpaste based on available data
(1315).
The four selected primary schools were then
assigned to test and control groups based on the
school enrolment, accessibility and distance from
the dental facility that would assist in supervising
the fluoride mouth rinsing programme. As
cooperation from school authorities and accessibility of participating schools were considered as
critical to the sustainability of the field study, the
selection of the test schools was not randomized.

Selection of the cohort

Primary Two and Three (8 and 9-year old) schoolchildren formed the cohort for this intervention
study. Parental consent for all participating schoolchildren, and approval from state and local

Table 1. Mean and mean difference in DMFT and DMFS scores at baseline and 3 years after implementation of fluoride
mouth rinsing for the test and control groups (N = 242)
Study
group
Mean DMFT
Test
Control
Mean DMFS
Test
Control

At baseline
(95% CI)

After 3 years
(95% CI)

Mean difference
(95% CI)

SE
mean

t (d.f.)

P-valuea

120
122

1.06 (0.831.29)
1.01 (0.79 1.23)

2.30 (1.932.67)
4.01 (3.394.63)

1.24 (0.961.52)
3.00 (2.473.53)

0.14
0.27

8.84 (119)
11.27 (121)

0.00
0.00

120
122

1.55 (1.042.06)
1.49 (1.031.95)

3.40 (2.684.12)
6.67 (5.477.87)

1.85 (1.332.37)
5.18 (4.266.11)

0.26
0.47

7.06 (119)
11.08 (121)

0.00
0.00

Paired t-test was performed.

311

Chen et al.

education departments were obtained prior to the

implementation of this study. Trial runs using
plain water were conducted on two separate
occasions prior to the actual rinsing with sodium
fluoride solution. This was to ensure that all
participating children were able to rinse correctly,
and to avoid any possible ingestion of sodium
fluoride solution. In this study, all participating
children were able to rinse successfully after the
trial runs.

Procedure for fluoride mouth rinsing

Following World Health Organization (WHO)
recommendations (16), it was decided to adopt
the once-a-week rinse regime, using a freshly
prepared 0.2% sodium fluoride solution. Furthermore, there were less classroom interruptions with
this method. School teachers were trained by the
researchers to prepare and dispense the sodium
fluoride solution. This was prepared by mixing a
pack of 10 g of sodium fluoride in 5 l of distilled
water. The mixture was shaken until all the sodium
fluoride powder had dissolved. Ten millilitres of
the freshly prepared sodium fluoride solution was
dispensed to each child who then rinsed for 1 min
under the teachers supervision once a week. The
children were instructed not to eat, drink or rinse
with water for the next 30 min. After two training
sessions, the school teachers were able to prepare
and dispense the sodium fluoride solution on their
own. However, the researchers visited the schools
weekly for a month, and then at 3-month intervals
throughout the duration of the study.

Examination for dental caries

The participating schoolchildren were examined
annually for dental caries by two dental public
health officers. Caries was assessed using DMFT
and DMFS indices, as described in WHO Basic
Methods 4th edition, 1997 (17). Calibration for
inter-examiner agreement was done at the
beginning of the study on 20 subjects. The percentage agreement was 0.99 with a Kappa of 0.905.

Data management and analysis

Data was entered and analysed using SPSS Ver
12.0. The paired t-tests for mean and mean difference in DMFT and DMFS for the test and control
groups were performed (18, 19). The assumptions
made were that the test and control samples were
independent, and variances were not equal. The
McNemar tests for percentage caries free and the
relative risk measure for the test group and

312

control groups were also performed (19, 20). The

significance level was set at P < 0.05.

Results
At baseline, 270 schoolchildren aged 89 years
participated in the study. After 3 years, 242 schoolchildren were still in the programme. There were
122 children in the control group and 120 from the
test group. The attrition rate was 10.3%, mainly
due to transfers to other schools.
Prior to the start of the fluoride mouth rinsing
programme, baseline data for all four participating
schools was obtained to ensure that they were
similar with regards to daily tooth brushing
practices, use of fluoridated toothpaste and consumption of sweetened foods and drinks. No
statistically significant differences between the test
and control schools were found with regards to
gender and daily tooth brushing practices. However, there was a slight difference in the amount of
toothpaste used with 46.8% of children in the test
group reporting that they used more than the
recommended amount of toothpaste (pea-size
amount) when brushing their teeth compared to
35.0% in the control group. There was also a slight
difference in the amount of sweetened food and
drinks consumed (with 29.4% of children in the test
group reporting that they consumed sweetened
food and drinks more than twice a day compared
to 12.8% in the control group.
At baseline, there was no significant difference in
caries status of the test and control groups. However, at the end of the study, there were significant
differences in the mean DMFT and DMFS between
the test and control groups. The mean DMFT for
the test group was 2.30 [95% confidence interval
(CI), 1.932.67, P < 0.00] while the mean DMFT for
the control group was 4.01 (95% CI, 3.394.63,
P < 0.00). The mean DMFS for the test group was
3.40 (95% CI, 2.684.12, P < 0.00), while the mean
DMFS for the control group was 6.67 (95% CI,
5.477.87, P < 0.00) (Table 1). A higher proportion
(24.2%) of the children in the test group remained
caries free at the end of the study compared to the
control group (11.5%). The McNemar test was
significant (P < 0.00). In addition, the risk of
developing caries decreased 0.52 times among the
children from the test group exposed to the
fluoride mouth rinsing programme as compared
to the unexposed control group (RR = 0.48, 95%
CI, 0.260.85) (Table 2).

School-based fluoride mouth rinsing programme

Table 2. Percentage caries free at baseline and 3 years
after implementation of fluoride mouth rinsing for the
test and control groups (N = 242)
Baseline

% caries
free
n
Test
Control

3 years
later
n

Relative
P-valuea risk (RR)

91 75.8 29 24.2 0.00

0.48 (95%
CI, 0.260.85)

108 88.5 14 11.5 0.00

McNemars test was performed.

Discussion
The limitations of this study include those common
to studies where assignment of subjects to test and
control groups was known to the examiners. In this
study, there was a difference in mean DMFT of
almost two teeth between the test and control
groups, and more children in the test group (24.2%)
remained caries free compared to the control group
(11.5%). This is similar to the findings of schoolbased weekly fluoride mouth rinsing programmes
undertaken in Japan and Nepal (21, 22).
In a recent review on clinical findings regarding
fluoride mouth rinses and implication for their use,
Wei and Yiu (7) have recommended that schoolbased fluoride mouth rinsing programmes should
be implemented in fluoride-deficient communities
while Levin et al. (9) concluded that school-based
fluoride rinsing was effective in lowering DMFT
levels in areas of deprivation.
Studies by Ripa et al. (3), Kobayashi et al. (21),
Holland et al. (23), Poulsen et al. (24) and others
concluded that in order for more children to
remain caries free throughout their school years,
fluoride mouth rinsing programmes should start at
a younger age, and be continued up to the age of
1214 years, while Pieterse et al. (10) found that
fluoride rinsing for at least 3 years has a positive
effect on caries status. In Sarawak, children aged
712 years participated in weekly fluoride mouth
rinsing, as these are the age groups that attend
primary schools. Children younger than 7 years
were not included in the programme, as there were
concerns about accidental swallowing of the
sodium fluoride solution among parents and
teachers of the children. However, studies among
Japanese preschool children have found that
children aged 45 years can perform fluoride
mouth rinsing safely and efficiently (25).
Although the cost of implementing a schoolbased weekly fluoride rinsing programme was not

calculated in this study, a similar study in Japan

(21) estimated the cost of implementation at US$
0.20 per child per year.
In the WHO Country Area Profile Programme, a
review on a school-based fluoride mouth rinse
programme for preschool children in Japan (26)
concluded that this programme has so far been the
only community oriented health measure that has
contributed to caries prevention of the permanent
teeth in areas where community water fluoridation
is not available. The findings of the present study
support this view.
In this study, no fissure sealant application was
done as an additional caries preventive measure.
However, in a 2-year study in Finland (27), the use
of a combined fluoride rinsing and sealant
programme in first permanent molars among 7- to
9-year-old children resulted in almost complete
elimination of caries in the study group. In Ireland
(28), a combined fortnightly 0.2% sodium fluoride
mouth rinse programme was combined with sealants on the first and second molars in the test group,
with impressive results. This suggests that a combination of fluoride mouth rinsing with fissure
sealant applications would further enhance the
impact of these caries prevention measures.

Conclusions and recommendations

The positive benefit of weekly sodium fluoride
mouth rinses on caries reduction would be a major
population-based strategy in our endeavour to
ensure that schoolchildren remain caries free
throughout their school years. Improvement in
the oral health status of schoolchildren in Sarawak
is one of the main objectives of the Pinnacle 2010
Master Plan. One of the impact goals in this Master
Plan is to reduce the mean DMFT of 12-year-old
schoolchildren to one or less by the year 2010. In
the rural areas of Sarawak, where there is no
fluoridated water supply and little access to oral
healthcare services, it is even more important that
schoolchildren remain caries free. Following the
findings of this field study, weekly fluoride mouth
rinsing was implemented in 18 rural primary
schools throughout Sarawak.
Based on the findings of this study and other
similar studies, we recommend that school-based
weekly fluoride mouth rinsing programmes should
be implemented in fluoride-deficient areas as a
means of reducing the prevalence of dental caries
in these areas. In addition, to get the maximum

313

Chen et al.

impact of caries prevention, fluoride mouth rinsing programmes could be combined with other
preventive activities such as fissure sealant application to further reduce caries levels.

Acknowledgements
The authors thank the Director General of Health,
Malaysia, for permission to publish this study; Oral
Health Division, Sabah Health Department, and the
Sandakan District Oral Health Department for their
cooperation and advice during the researchers visit to
observe the fluoride mouth rinsing programme in
Sandakan, Sabah; Divisional Dental Officer, Sibu,
Sarawak, and the staff who assisted in the implementation and monitoring of the fluoride mouth rinsing
programme; Sarawak Education Department and the
Sibu Divisional Education Officer for permission to
conduct this programme; and the principal, teachers
and students of the participating schools in Selangau
District, Sibu, Sarawak.

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