oral health division, moh, malaysia 1 datin dr norain binti abu talib pengarah kanan kesihatan...

ORAL HEALTH DIVISION, MOH, MALAYSIA

1

Datin Dr Norain binti Abu TalibPengarah Kanan Kesihatan Pergigian

Kementerian Kesihatan Malaysia

Symposium Pengurusan dan Peroditan Industri Air 20092 - 3 November 2009

SACC, Shah Alam, Selangor

Water Fluoridation – A Public Health Approach in Caries

Prevention in Malaysia

Norain AT , Norlida A

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


masa

Permukaan gigi

karies

makanan

Plakbacteria

Etiologi karies gigi

Primary intervention of dental caries

Type of intervention Challenges

Tooth structure Ensure strong enamel structure

Good oral hygiene(Dental Health education)

Knowledge and practiceHow 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


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)

Systemik Topikal

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.


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 (1000-1500ppm) – 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



• 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

Pemfluoridaan bekalan air minum

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)


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


Percentage of population receiving fluoridated water, including both artificial and natural fluoridation


80–100% 60–80% 40–60% 20–40% 1–20% <1% unknown

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/lUSA – 0.7 – 1.2 ppm Australia – 0.6 – 1.1 ppmHong Kong – 0.6 ppmSingapore – 0.6 ppmMalaysia – 0.5 ppm

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


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

AGE

12

8

4

16

AURORA(Natural fluoridation)

GRAND RAPIDS(before fluoridation)

DM

F T

EE

TH

PE

R C

HIL

D

GRAND RAPIDS(9 years after fluoridation)


dmf TEETH PER CHILDSARNIA, BRANTFORD AND STRATFORD1948 - 1959

SARNIA - NO FLUORIDEBRANTFORD - FLUORIDATED SINCE 1945STRATFORD - NATURALLY FLUORIDATED

9

76543210

8 19481959

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

SARNIA BRANT-FORD

STRATFORDSTRAT-FORD

BRANT-FORD

SARNIA

DM

F T

EE

TH

PE

R C

HIL

D

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)


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.


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

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


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

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


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


Dental Fluorosis

Subject’s perception of fluorosis

21

62.0

73.1 77.170.8

80.0

67.7

38.0 26.922.9

29.220.0

32.3

0.0

20.0

40.0

60.0

80.0

100.0

'Normal' V. mild Mild Moderate Severe Overall

Not satisf ied Satisf ied

Normal Fluorosis0

10

20

30

40

50

60

70

80

65.171.3

34.928.7

SatisfiedNot satisfied

Per

cent

age

p<0.05

Source: Oral Health Division, MOH. Fluoride Enamel Opacities in 16-year-old Schoolchildren, 2000


Water Fluoridation in 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)


History of fluoridation in Malaysia Year Event1957 first introduced in state of Johore1959 Penang1962 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 ppm2005 Implementation of optimum level 0.4-0.6 ppm2006 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)


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, MALAYSIA26

Achievement after 35 years of Fluoridation

Estimated population received fluoridated water, 2008


WPKL/P

utra...

Selan

gor

Perlis

Mel

aka

Labuan

Pulau P

inan

g

Johor

Perak

Neger

i Sem

b...

Kedah

Pahan

g

Saraw

ak

Kelan

tan

Sabah

Teren

gganu

MALAYSIA

0

20

40

60

80

100

120

100.0 99.9 98.0 98.0 98.0 97.9 96.7 96.3 95.3

88.381.6

68.1

17.7

4.7 4.3

75.0

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


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.’

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


However……

0.8

3.7

4.8

0.42

2.37

4.35

1.9

3.3

0

1

2

3

4

5

6

6-year-old 12-year-old 16-year-old

Age group

Me

an

DM

FT

1970 1988 1997

However, Caries Prevalence Remain High Among Children


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

WHO goal 50%

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 years

19973 1.6 2.5 3.3 1.9

16 years

19973 2.8 3.7 6.7 3.3

Oral Health Division, MOH, Various surveys

ORAL HEALTHCARE UTILISATION15 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% -

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

Dental Caries Prevalence among Malaysian Adults from Various Surveys


2.9

13.9

8.26.9

1.2

29.5

18.1

9

5

1.51.5

3.63.52.86.6

11.8

2.90.9

3.34.6

5.5 3.733.9

0

5

10

15

20

25

30

35

15-19 20-24 25-29 30-34 35-44 45-54 55-64 65+

Age group

Per

cen

tag

e ca

rie

s fr

ee

1974 1990 2000

Inequalities persist


6.2

20.3

17.8

14.5

8.8

11.5 12.1

20.7

25.223.5

15.612.9

10.99.1

6.9

4.6

22.8

20.1

15.4

12.1

8.4

4.42.9

6

0

5

10

15

20

25

30

15-19 20-24 25-29 30-34 35-44 45-54 55-64 65+

Age Group

Mea

n D

MF

T

1974 1990 2000

Caries Experience among Adults of Different Age Groups between Selected Countries


Country Age group YearDental Caries

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

FT Put

raja

ya

FT Kua

la L

umpu

r

Selan

gor

Joho

r

Neger

i Sem

bila

n

Perlis

Mal

acca

Kedah

Perak

Penan

g

Pahan

g

FT Lab

uan

Saraw

ak

Teren

ggan

u

Kelan

tan

Sabah

Mal

aysia

0

20

40

60

80

Caries Prevalence (%) 12-year-olds

FT Put

raja

ya

Selan

gor

FT Kua

la L

umpu

r

Neger

i Sem

bila

n

Joho

r

Kedah

Perlis

Mal

acca

Perak

Penan

g

Pahan

g

Teren

ggan

u

FT Lab

uan

Saraw

ak

Kelan

tan

Sabah

Mal

aysia

0

1

2

3Caries Experience (DMFT) 12-year-olds

Health Information Management System, MOH, 2007


98.0%

88.3%

97.9%

96.3%

99.9%

100%

95.0%

98.0%

96.7%

81.6%

4.3%

17.7%

4.7%

68.1%

98.0%

Water Fluoridation Programme Population Coverage, 2008

Source: Oral Health Division, MOH


Inequalities Persist By Location


Age Group Urban Rural

5 years (2005) 69.3% 85.6%

12 years 55.6% 66.5%

0

1

2

3

4

5

F NF

2.7

4.0

0

1

2

3

4

5

F NF

1.3

4.2

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


PenutupPemfluoridaan 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


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”


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”.


44

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

A lifetime of healthy smiles!


Thank you for your attention

oral health division, moh, malaysia 1 datin dr norain binti abu talib pengarah kanan kesihatan...

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