External Control of Fluoridation in the Public Water Supplies of Brazilian
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Rosário et al. BMC Oral Health (2021) 21:410 https://doi.org/10.1186/s12903-021-01754-2 RESEARCH ARTICLE Open Access External control of fuoridation in the public water supplies of Brazilian cities as a strategy against caries: a systematic review and meta-analysis Bárbara Souza Martins Rosário1, Henrique Damian Rosário2, Walbert de Andrade Vieira3, Graziela Oro Cericato4, Diego Figueiredo Nóbrega5, Cauane Blumenberg6, Fernando Neves Hugo7, Márcio Magno Costa8 and Luiz Renato Paranhos9* Abstract Background: Among the methods currently available to provide fuoride in population levels, fuoridated water is the most successful for presenting high efcacy, safety and good cost–beneft. However, recent studies on external control have shown great variability of fuoride concentrations in the water from treatment stations in Brazilian cities, which must present concentration between 0.6 and 0.8 mg/L to be considered acceptable in most cities. Thus, this study aimed to perform a systematic review of the literature to assess the adequacy of fuoride concentration in the water in Brazilian cities using external control. Methods: The protocol was registered in PROSPERO. Six databases were used as primary search sources and three databases were used to partially capture the "gray literature". Only observational studies that assessed the fuoride concentration of artifcially fuoridated water from the public supply network were included. The JBI Critical Appraisal Tools for Systematic Reviews was used to assess the risk of bias of the studies. A proportion meta-analyses using random-efect models were performed. The heterogeneity between studies was determined by I2 statistic. Meta- regressions were conducted to identify relevant moderators to be used in stratifed meta-analyses. Publication bias was investigated by Egger’s tests. Results: The search provided 2038 results, from which 14 met the eligibility criteria and were included in the data extraction of the review. Overall, the water samples were collected from 449 diferent sources in three Brazil- ian regions. Thirteen studies presented a low risk of bias. The mean concentration of fuoride ranged from 0.17 to 0.89 ppmF. The meta-analyis demonstrated that more than half of the water samples analyzed had fuoride concen- tration levels outside the acceptable range (56.6%; 95% CI 45.5; 67.3), with high heterogeneity. Conclusion: More than half of the public water supply analyzed in the studies selected had fuoride concentration levels outside the acceptable range, which may afect the risk of developing oral diseases in the Brazilian population, having an important impact on public health. *Correspondence: [email protected] 9 Division of Preventive and Community Dentistry, School of Dentistry, Universidade Federal de Uberlândia (UFU), Campus Umuarama, Av. Pará, 1720, Bloco 2G, sala 1, Uberlândia, MG 38405-320, Brazil Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Rosário et al. BMC Oral Health (2021) 21:410 Page 2 of 13 Keywords: Fluoridation, External control, Water treatment Background use values between 0.6 and 0.8 ppm [16]. Terefore, it In 1942, it was found that natural fuoride in public is imperative that besides the operational control per- water supplies could reduce the prevalence of dental formed by the sanitation company in charge there is an caries in diferent populations [1]. Tereafter, the sci- external control of the quality of water provided to con- entifc evidence constructed over the following decades sumers, performed by an independent institution, not recognized fuoride as the most successful agent used involved in the fuoridation process [14]. Recent results for caries prevention and control in Dentistry [2–5]. of individual studies on external control have shown Several systematic reviews show clear evidence that great variability of fuoride concentrations in the water the presence and addition of fuoride in the water [2], from treatment stations in Brazilian cities [17–20], dentifrices [3], gels [5], or varnishes [4] can reduce the which may compromise the beneft of this major pub- prevalence of dental caries. lic health measure on caries control or even cause den- Among the methods currently available to provide tal fuorosis, when fuoride concentration is below or fuoride in population levels, fuoridated water is the above the optimum, respectively. most successful for presenting high efcacy, safety [2] Tus, this study aimed to perform a systematic review and good cost–beneft [6]. Moreover, the addition of of the literature to assess the adequacy of fuoride con- fuoride in the water supply is considered a socially centration in the artifcially fuoridate water in Brazilian equitable measure because it benefts the entire popu- cities using external control. lation with access to piped water [7]. Te addition of fuoride in the public water supply was initially proposed in 1945 by the United States Methods and since then it has been recommended by the World Protocol and registration Health Organization as a key strategy to prevent den- Te protocol was registered at the International Pro- tal caries [8]. Brazil has the second largest fuorida- spective Register of Systematic Reviews (PROSPERO) tion system for public water supplies in the world, only database, under number CRD42019120870 (http:// www. after the United States [9]. However, diferent from the crd. york. ac. uk/ PROSP ERO). Tis systematic review was United States, Brazil does not have a national surveil- reported according to the Preferred Reporting Items for lance system and although adding fuoride in the public Systematic Reviews and Meta-Analyses (PRISMA) [21] water supply is mandatory since 1974 [10], it is esti- and conducted according to the Joanna Briggs Institute mated that only 50% of the Brazilian population has (JBI) Manual [22]. access to fuoridated water [11]. Furthermore, fuoride can occur naturally in water. Te percentage of the Brazilian population supplied Study design and eligibility criteria with naturally fuoridated water is unknown. However, Tis study is based on the following research question: the report of moderate and severe fuorosis (associ- “Does the public water supply systems from Brazilian cit- ated with the consumption of water containing natural ies provide water with ideal fuoride concentrations?”. fuoride in high concentrations) is rare and generally Tis systematic review included cross sectional stud- associated to the consumption of groundwater [12]. In ies reporting on the external control of artifcial fuorida- regions where fuoride occurs naturally, the Brazilian tion of the public water supply in Brazilian cities and the Ministry of Health defnes the value of 1.5 ppm F as the frequency of water samples with fuoride levels within maximum allowed limit [13]. or outside the acceptable range, without restrictions of Te beneft of fuoridation in public water supplies year or language. Te inclusion criteria included studies depends on the continuity of such measure over time that analyzed at least one water sample per month for and on the regular maintenance of "optimal" fuoride 12 months [14]. Moreover, only studies using the elec- concentrations in the water [14]. Optimal concentration trometric method to measure fuoride concentration is one that can produce the maximum beneft in caries were selected. Tis method uses a specifc electrode for prevention and control combined with a minimum risk fuoride ion coupled to a potentiometer. Te electrode is of developing dental fuorosis [15]. Te optimal content calibrated with standard fuoride solutions to allow meas- of fuoride may vary according to temperature, location, uring and comparing the concentration of fuoride in and volume of water ingestion, but most Brazilian cities water samples in a proper standard curve [23]. Te ion- specifc electrode presents accurate and fast results, and Rosário et al. BMC Oral Health (2021) 21:410 Page 3 of 13 it is considered the "gold standard" for this type of analy- OATD were used to partially capture the "gray literature". sis [24]. A manual search was also performed through a systema- Te exclusion criteria were: (1) studies outside the tized analysis of the references of the eligible articles. All objective; (2) literature reviews, case reports, letters to steps were performed to minimize selection and publica- the editor, editorials, indexes, abstracts, and reports; (3) tion biases.