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
Kementerian Kesihatan Malaysia

ORAL HEALTH DIVISION, MOH, 1

 Penyakit karies gigi
• Penyakit kronik paling meluas di dunia terutama
di kalangan kanak-kanak
• Negara-negara perindustrian, 60-90% kanak-
kanak sekolah mengidap penyakit karies –
miskin dan minoriti
• (Selwitz et al. (2007), Petersen & Lennon, 2004)
• Apabila berlaku karies gigi proses rawatan akan
berulang .
• Contoh Jangka hayat tampalan amalgam 9-14
tahun (Griffin et al. (2001)

ORAL HEALTH DIVISION, MOH, MALAYSIA 2

Etiologi karies gigi

Permukaan
Plak
gigi
bacteria

karies

makanan masa

ORAL HEALTH DIVISION, MOH, MALAYSIA 3

Primary intervention of dental caries

Type of
intervention
Challenges

Tooth structure Ensure strong enamel structure

Good oral Knowledge and practice
hygiene How many of us brush and floss our teeth at
(Dental Health least 2 times a day effectively everyday
education) through out our life?
Bacteria No available vaccine yet
Foods High consumption of sugar
(Malaysian consume about 40 kg/capita/year)
Fluoride Safe and effective vehicles for delivery

ORAL HEALTH DIVISION, MOH, MALAYSIA 4

 Cara penyampaian Fluorida

Systemik Topikal
 Air minum (1945)  larutan (1943)
 garam(1950)  Ubat gigi(1945)
 susu(1959 )  Kumur mulut (1946)
 pil/titisan(1960)  Gels(1967)
 Varnishes(1968)

ORAL HEALTH DIVISION, MOH, MALAYSIA 5

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.

World Health Assembly,2007 (WHA 60.17)

ORAL HEALTH DIVISION, MOH, MALAYSIA 6

Pengunaan fluorida diMalaysia
Pendekatan melalui
penduduk Pendekatan topikal
(systemik )

 pemfluoridaan bekalan air  Ubat gigi berfluorida (1000-

minum boleh dimenafai oleh rakyat 1500ppm) – memerlukan
yang menerima bekalan air pengawasan orang dewasa jika
berfluorida. digunakan oleh kanak-kanak
 Kumuran Berfluorida- memerlukan
pengawasan personel kesihatan
 sapuan gel, buih dan varnish
flluorida(Fluoride gel/foam/varnish)
– sapuan perlu dibuat oleh doktor
atau jururawat pergigian

ORAL HEALTH DIVISION, MOH, MALAYSIA 7

Pemfluoridaan bekalan air minum
• satu kaedah perawatan bekalan air
awam di mana fluorida di tambah
supaya mencapai paras optimum
ke dalam bekalan air terawat di loji
perawatan bekalan air
• Tujuannya adalah untuk
mengawal penyakit karies di
kalangan masyarakat yang
menerima bekalan air tersebut
ORAL HEALTH DIVISION, MOH, MALAYSIA 8
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 9

Geographical areas with high natural fluoride levels (>
1.5 mg/l)

ORAL HEALTH DIVISION, MOH, MALAYSIA 10

 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 11

Optimum level varies for different countries according
to climate, temperatures and consumption
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

 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.

ORAL HEALTH DIVISION, MOH, MALAYSIA 12

 Dmf Teeth Per Child Nine Years After Fluoridation,
Grand Rapids, Michigan

16 DMF TEETH PER CHILD

GRAND RAPIDS
12 (before fluoridation)
GRAND RAPIDS
(9 years after fluoridation)
8

4
AURORA
(Natural fluoridation)

5 6 7 8 9 10 11 12 13 14 15 16

AGE

ORAL HEALTH DIVISION, MOH, MALAYSIA 13

 dmf TEETH PER CHILD
SARNIA, BRANTFORD AND STRATFORD1948 - 1959

9 AGE : 9 - 11 YEARS AGE : 12 - 14 YEARS

8
DMF TEETH PER CHILD

1948
7
1959
6
5
4
3
2
1
0
SARNIA BRANT- STRATFORD
SARNIA BRANT- STRAT-
FORD FORD FORD

SARNIA - NO FLUORIDE
BRANTFORD - FLUORIDATED SINCE 1945
STRATFORD - NATURALLY FLUORIDATED

ORAL HEALTH DIVISION, MOH, MALAYSIA 14

 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 15

 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
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,
16
Other benefits of water fluoridation
Kumar JV. Is water fluoridation still necessary? Adv Dent Res 20:8-12, July, 2008

Fluoridated

‘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
ORAL HEALTH DIVISION, MOH, MALAYSIA 17
Other benefits of water fluoridation
Kumar 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 18

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 19

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 20
 77.1 80.0
100.0 73.1
70.8 67.7
62.0

Subject’s
80.0

60.0

40.0 perception of
20.0 38.0 26.9
22.9
29.2
20.0
32.3
fluorosis
0.0
'Normal' V. mild Mild Moderate Severe Overall

Not satisfied Satisf ied

80
71.3
70 65.1
60

50
Percentage

40 34.9 Satisfied
28.7 Not satisfied
30

20

10
p<0.05
0
Normal Fluorosis
Source: Oral Health Division, MOH. Fluoride Enamel Opacities in 16-year-old Schoolchildren, 2000
21
Water Fluoridation in Malaysia

ORAL HEALTH DIVISION, MOH, MALAYSIA 22

Policy statement

“ Fluoridation of public water supplies

be instituted in West Malaysia as
soon as possible and further
recommends that an optimum level
of 0.7 ppm fluoride be maintained in
the reticulation system”
(MOH,1971)

ORAL HEALTH DIVISION, MOH, MALAYSIA 23

 History of fluoridation in Malaysia
Year Event
1957 first introduced in state of Johore
1959 Penang
1962 Sarawak
1964 Johor Study (1957-1964) -reduction of dental caries 60%
1969 MOH appointed committee to look on fluoridation of PWS
1972 Cabinet approval (optimum level-0.7 ppm)
1974 nationwide fluoridation
1995 discontinuation of fluoridation in Kelantan (about 50% coverage)
1999 discontinuation of Fluoridation in Terengganu (about 80%
coverage)
2004 optimum level reviewed to 0.5 ppm
2005 Implementation of optimum level 0.4-0.6 ppm
2006 reinstitution of fluoridation in Kelantan (Pasir Mas and Machang
District – 17.7% population coverage)
2008 reinstitution of fluoridation in Terengganu (Setiu District – 4.3%
population coverage)

ORAL HEALTH DIVISION, MOH, MALAYSIA 24

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 25

Achievement after 35
years of Fluoridation

ORAL HEALTH DIVISION, MOH, MALAYSIA

26
 Estimated population received
fluoridated water, 2008
120

100.0 99.9 98.0 98.0 98.0 97.9

100 96.7 96.3 95.3
88.3
81.6
80 75.0
68.1

60

40

20 17.7

4.7 4.3
0
... r
rli
s a an ng or k
b.
.. ah ng wak an ah nu A
tra ngo e lak u a o h e ra
m e d a n t
a b a Y SI
e b n h a g
Pu ela P M La Pi J P e K Pa
r el
a S ng LA
L/ S u riS Sa K re A
a
PK l
eg
e
Te M
W Pu N

ORAL HEALTH DIVISION, MOH, MALAYSIA 27

Number of Water treatment Plant with and
without Fluoridation System, 2008

ORAL HEALTH DIVISION, MOH, MALAYSIA 28

 Per Capita Cost/Year
18 Sept 1972 – ‘recurrent expenditure at 16 cents per
head of population served per year’
Malaysia 1992 1993 1994 1995 1996

RM 0.23 0.50 0.32 0.32 0.45

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 29

 Incremental Improvement Attributed To Appropriate
Use Of Fluorides And School Dental Programme

5 4.8
4.35
3.7
Mean DMFT

4
3.3
3
2.37
1.9
2

1 0.8
0.42
0
6-year-old 12-year-old 16-year-old

Age group
1970 1988 1997

However……
ORAL HEALTH DIVISION, MOH, MALAYSIA 30
 However, Caries Prevalence Remain High
Among Children WHO goal 50%

Age Year Caries Prevalence (%)

Pen.
Sarawak Sabah Malaysia
M'sia
5 years 2005 73.5 88.8 81.1 76.2

6 years 79.2 79.6 94.7 80.9

12 years 1997 57.1 72.6 80.5 60.9

16 years 72.8 82.4 93.2 75.5

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 Status 2008, Dec 2008

ORAL HEALTH DIVISION, MOH, MALAYSIA 31

 Caries Severity in Children < 18 Years from
Several Surveys in Malaysia
Mean dft
5 years 1995 na na na 5.8
5 years 20056 5.0 6.2 8.0 5.5
6 years 19973 3.8 3.9 6.3 4.1
Mean DMFT
12
19973 1.6 2.5 3.3 1.9
years
16
19973 2.8 3.7 6.7 3.3
years
Oral Health Division, MOH, Various surveys

ORAL HEALTH DIVISION, MOH, MALAYSIA 32

 ORAL HEALTHCARE UTILISATION
15 years and above

Surveys % utilise in % utilise in Public Private Others Never

last 1 year last 2 years visited

NOHSA (2000)1 25.2% 46.4% 50.0% 43.0% 0.5% 6.5%

NHMS III (2006)2 14.3% 26.5% 41.7% 50.7% 7.6% -

1. Oral Health Division, Ministry of Health Malaysia. The National Oral Health Survey of Adults 2000 (NOHSA
2000). November 2004
2. 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 33

 Dental Caries Prevalence among Malaysian Adults
from Various Surveys

35

30 29.5
Percentage caries free

25

20
18.1
15
13.9

10 11.8
8.2 9
6.9 5.5
3.9 3.7
5 4.6 3.3 3 5
6.6 2.9
2.9 1.5
2.8 3.5 3.6 1.5 1.2 0.9
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 34

Inequalities persist

30
25.2
23.5
25
22.8
20.7 20.3 20.1
20
Mean DMFT

17.8

14.5 15.6 15.4

15 12.9
11.5 12.1 12.1
10.9
10 8.8 9.1 8.4
6.2 6.9
4.6 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

ORAL HEALTH DIVISION, MOH, MALAYSIA 35

 Caries Experience among Adults of Different
Age Groups between Selected Countries
Dental Caries
Country Age group Year
Prevalence Mean DMFT
Malaysia 15-19 2000 70.5 2.9
Singapore 18 1994 69.7 2.5
Indonesia 18 1995 83.5 2.7
Thailand 15 2000-2001 62.1 2.11
Philippines 15-19 1995 93.7 6.3
Malaysia 35-44 2000 96.1 12.1
Singapore 35-44 1996 96.5 9.8
Indonesia 34-44 1995 94.6 6.1
Thailand 35-44 2000-2001 85.6 6.1
Philippines 35-44 1998 91.7 15.0
Hong Kong 35-44 2001 97.5 7.4
Malaysia 65-74 2000 95.2 23.2
Singapore 65-69 1996 99.4 17.0
Indonesia 65+ 1995 98.6 18.4
Thailand 65+ 2000-2001 95.0 15.8
Hong Kong 65-74 2001 99.4 17.6
Source: WHO Oral Health Country/Area Profile Programme
ORAL HEALTH DIVISION, MOH, MALAYSIA 36
 Caries Prevalence (%) 12-year-olds
80
60
40
20
0
ya ur or r n
rli
s
cc
a ah ra
k ng ng n ak u n h
si
a
j a m
p n g
o ho bil a e a ed e na ha bua aw g an n ta
a ba y
u tra Lu el
a J
e m P al K P
P e P a L a ar ng el
a S al
a
a S S M S e K M
P
a l i FT er
FT Ku g er T
e
FT N

3
Caries Experience (DMFT) 12-year-olds
2.5
2
1.5
1
0.5
0

Health Information Management System, MOH, 2007

ORAL HEALTH DIVISION, MOH, MALAYSIA 37

 Water Fluoridation Programme Population Coverage, 2008

98.0%
98.0%
88.3% 4.7%

17.7%

97.9% 4.3% 68.1%

96.3%

99.9% 81.6%

100%

95.0%

Source: Oral Health Division, MOH

98.0%
96.7%

ORAL HEALTH DIVISION, MOH, MALAYSIA 38

 Inequalities Persist By Location

Age Group Urban Rural

5 years (2005) 69.3% 85.6%

12 years 55.6% 66.5%

ORAL HEALTH DIVISION, MOH, MALAYSIA 39

 Differences in Dental Caries Experience (DMFT) among 16-
year-old Schoolchildren between Fluoridated (F) and Non-
Fluoridated (NF) Areas

5 5 4.2
4.0
4 4
3 2.7 3
2 2 1.3
1 1
0 0
F NF F NF

Oral Health Division, Ministry of Health Oral Health Division, Ministry of Health
Malaysia. National oral health survey of school Malaysia. Fluoride enamel opacities in 16-year-
children 1997 (NOHSS ’97), 1998 old school children, June 2001

ORAL HEALTH DIVISION, MOH, MALAYSIA 40

Penutup
Pemfluoridaan bekalan air minum masih relevan dan terbukti
sebagai kaedah yang kos efektif dalam mencegah karies gigi
diMalaysia.
– Karies gigi dental caries is very common
– Ketidaksamaan Kesihatan pergigian berterusan
– >95% of the population menerima bekalan air paip
– Paras fluorida dalam air yang belum dirawat adalah rendah

Walaubagaimanapun semua agensi perlu memainkan peranan dan

memberi sokongan padu untuk menjalankan program ini supaya dapat
meningkatkan kesihatan pergigian serta kualiti hidup masyarakat.
- Menentukan paras optimum fluorida
- Pastikan liputan masyarakat pertingkatkan
- Pastikan fluorida dapat dikekalkan diretikulasi

ORAL HEALTH DIVISION, MOH, MALAYSIA 41

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 42

 25 April 1972
“ Jema’ah Menteri bersetuju bahawa Kementerian
Kesihatan boleh melancarkan rancangan
membuboh floraid kepada bekalan air dengan
segera dengan tidak payah menerima
persetujuan daripada Kerajaan-Kerajaan Negeri.
Walau bagaimana pun, Kerajaan-Kerajaan Negeri
patut juga diberitahu di atas tindakan yang
demikian”.

ORAL HEALTH DIVISION, MOH, MALAYSIA 43

Working together to improve the nation
oral health and quality of life

A lifetime of healthy smiles!

44
Thank you for your attention

ORAL HEALTH DIVISION, MOH, MALAYSIA 45