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 Norain binti Abu Talib
Pengarah Kanan Kesihatan Pergigian
Kementerian Kesihatan Malaysia
ORAL HEALTH DIVISION, MOH, MALAYSIA

2. ORAL HEALTH DIVISION, MOH, MALAYSIA
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

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

4. Primary intervention of dental caries
Type of intervention
Challenges
Tooth structure
Ensure strong enamel structure
Good oral hygiene
(Dental Health education)
Knowledge and practice
How many of us brush and floss our teeth at least 2 times a day effectively everyday 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

5. Cara penyampaian Fluorida
Air minum (1945)
garam(1950)
susu(1959 )
pil/titisan(1960)
larutan (1943)
Ubat gigi(1945)
Kumur mulut (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.
World Health Assembly,2007 (WHA 60.17)
ORAL HEALTH DIVISION, MOH, MALAYSIA

7. Pengunaan fluorida diMalaysia
Pendekatan melalui penduduk
(systemik )
Pendekatan topikal
pemfluoridaan bekalan air minum boleh dimenafai oleh rakyat yang menerima bekalan air berfluorida.
Ubat gigi berfluorida ( ppm) – memerlukan pengawasan orang dewasa jika 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

8. 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

9. ORAL HEALTH DIVISION, MOH, MALAYSIA
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 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); )
ORAL HEALTH DIVISION, MOH, MALAYSIA

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

11. ORAL HEALTH DIVISION, MOH, MALAYSIA
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. ORAL HEALTH DIVISION, MOH, MALAYSIA
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

13. Dmf Teeth Per Child Nine Years After Fluoridation, Grand Rapids, Michigan16
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. dmf TEETH PER CHILD SARNIA, BRANTFORD AND STRATFORD1948 - 1959
AGE : YEARS
AGE : YEARS 8
1948 7
1959 6 5
DMF TEETH PER CHILD 4 3 2 1
SARNIA
BRANT-
FORD
STRATFORD
SARNIA
BRANT-
FORD
STRAT-
FORD
SARNIA NO FLUORIDE
BRANTFORD - FLUORIDATED SINCE 1945
STRATFORD - NATURALLY FLUORIDATED
ORAL HEALTH DIVISION, MOH, MALAYSIA

15. ORAL HEALTH DIVISION, MOH, MALAYSIA
Current Development
USA
2010 Healthy People – 75% received fluoridated water( %)
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. ORAL HEALTH DIVISION, MOH, MALAYSIA
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 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.
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,
ORAL HEALTH DIVISION, MOH, MALAYSIA

17. ORAL HEALTH DIVISION, MOH, MALAYSIA
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

18. ORAL HEALTH DIVISION, MOH, MALAYSIA
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

19. ORAL HEALTH DIVISION, MOH, MALAYSIA
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. ORAL HEALTH DIVISION, MOH, MALAYSIA
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
Source: Oral Health Division, MOH. Fluoride Enamel Opacities in 16-year-old Schoolchildren, 2000

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

23. ORAL HEALTH DIVISION, MOH, MALAYSIA
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

24. History of fluoridation in Malaysia
Year
Event
1957
first introduced in state of Johore
1959
Penang
1962
Sarawak
1964
Johor Study ( ) -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 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

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

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

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

29. ORAL HEALTH DIVISION, MOH, MALAYSIA
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
0.45
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

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

31. However, Caries Prevalence Remain High Among Children
WHO goal 50%
Age
Year
Caries Prevalence (%)
Pen. M'sia
Sarawak
Sabah
Malaysia
5 years
2005
73.5
88.8
81.1
76.2
6 years
1997
79.2
79.6
94.7
80.9
12 years
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

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

33. ORAL HEALTHCARE UTILISATION 15 years and above
Surveys
% utilise in last 1 year
% utilise in last 2 years
Public
Private
Others
Never 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% -
Responses from interviews
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
2.9
13.9
8.2
6.9
1.2
29.5
18.1 9 5
1.5
3.6
3.5
2.8
6.6
11.8
0.9
3.3
4.6
5.5
3.7 3
3.9 10 15 20 25 30 35
15-19
20-24
25-29
30-34
35-44
45-54
55-64
65+
Age group
Percentage caries free
1974
1990
2000
ORAL HEALTH DIVISION, MOH, MALAYSIA

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

36. ORAL HEALTH DIVISION, MOH, MALAYSIA
Caries Experience among Adults of Different Age Groups between Selected Countries
Country
Age group
Year
Dental Caries
Prevalence
Mean DMFT
Malaysia
15-19
2000
70.5
2.9
Singapore 18
1994
69.7
2.5
Indonesia
1995
83.5
2.7
Thailand 15
62.1
2.11
Philippines
93.7
6.3
35-44
96.1
12.1
1996
96.5
9.8
34-44
94.6
6.1
85.6
1998
91.7
15.0
Hong Kong
2001
97.5
7.4
65-74
95.2
23.2
65-69
99.4
17.0
65+
98.6
18.4
95.0
15.8
17.6
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%
88.3%
97.9%
96.3%
99.9%
100%
95.0%
96.7%
81.6%
4.3%
17.7%
4.7%
68.1%
Source: Oral Health Division, MOH
ORAL HEALTH DIVISION, MOH, MALAYSIA

39. 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

40. ORAL HEALTH DIVISION, MOH, MALAYSIA
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. ORAL HEALTH DIVISION, MOH, MALAYSIA
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

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. ORAL HEALTH DIVISION, MOH, MALAYSIA
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”.
Tambahan kepada teks berhubong dengan kertas kerja kemudiannya mencatatkan perkara berikut.
ORAL HEALTH DIVISION, MOH, MALAYSIA

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

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