Czytelnia Medyczna » Nowa Stomatologia » 1/2005 » Experience of a systemic fluoride prevention of caries among children of Belarus

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Fitomed
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Profesjonalny, stricte ręczny serwis narciarski Warszawa

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Tamara Terekhova, Tatyana Popruzhenko, Natalia Shakovets

Experience of a systemic fluoride prevention of caries among children of Belarus

Department of Pediatric Dentistry, Belorussian State Medical University, in Minsk Republic of Belarus

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THE PROBLEM OF DENTAL CARIES AMONG CHILDREN OF BELARUS

The tendency of decrease in the number of caries occurrences among children is observed in Belarus now as in the majority of the Eastern European countries, but the problem still remains. According to examinations conducted in 2000-2002 the prevalence of caries of primary teeth among two-year olds constituted 25% (0.79±0.09), three-year olds – 54.8% (2.22±0.07) and among 5-6 year olds – 95% (5.6±0.10). The prevalence of caries of permanent teeth among 12-year olds constituted 85.3% in urban areas, 94.2% in rural areas with intensity 3.04 ±0.08 and 4.27±0.09 correspondingly. The problem is aggravated by the fact that dentist services in the country are not able to provide the proper level of dentist help for children: this level amounts to 4.5% among two-year old children in urban areas, 29.3% among preschool children in urban areas and 8.3% in rural areas, for 12-year olds – 36% in urban and 11% in rural areas (1).

ESTIMATION AND ASSESSMENT OF THE LEVEL OF NATURAL FLUORIDE EXPOSURE AMONG CHILDREN

Natural sources of fluorides

One of the factors causing the high prevalence of caries among the population of Belarus is the low level of fluorides in drinking water: only 2% of water resources contain up to 0.4-0.5% ppmF, the remaining 98% contain 0.1-0.3 ppmF (2). The air of urban and rural areas of Belarus contains no more than 0.013 ppmF/m² , that adds to daily fluoride exposure of 4-6 year old children about 0.07 mgF (3). The content of fluorides in main food products constitutes about 0.4 (vegetables) – 0.6 (dairy products) – 1.3 (meat) – 1.6 (bread) mgF/kg (4). According to estimates, a daily food ration of preschool children in kindergartens contains about 1.10±0.23 mgF, and a home-cooked food ration of children contains – 0.9±0.31 mgF (5).

Fluoride exposure of preschool children calculated by intake of fluorides and excretion of fluorides with urine

According to the estimates the natural daily fluorine load of the Belarusian preschool children is composed of fluorides in air, drinking water and food¹ and constitutes from 0.4 to 1.2 mgF/day (6).

The values of kidney excretion of fluorides are calculated based on values of excretion of fluorides with urine among preschool children living in families and visting kindergarten and not having any additional sources of fluorides (see the table 1). The daily excretion of fluorides among children varies from 124±17.5 mkgF/day (in the Northern areas) to 223±12.9 mkgF/day (in the Central areas). If to think that kidney excretion of fluorides among children constitutes 50% of received fluorine, then the natural daily fluorine load of children corresponds to 0.24-0.45 mgF/day (7).

Table 1. Values of kidney excretion of fluorides among preschool children of Belarus under natural fluorine load conditions.

Values	Time of kidney excretion of fluorides
Values	after meal	nighttime	daytime
Content of fluoride in urine (mgF/litre)	0.41?0.03	0.19?0.02	0.25?0.02
Rate of kidney excretion of fluorides (mkgF/hour)	9.8?0.51	5.6?0.29	7.81?0.29

Among children living in orphanages the values of fluoride excretion are somewhat higher ([F]=0.34±0.02 mgF/litre, rate of kidney excretion being 17.74±1.36 mkgF/hour), therefore the fluoride load calculated by these values constitutes 0.3±0.8 mgF/day (8).

Estimation of fluoride exposure deficit among children

The biological effects of fluorides on populations of the protozoa were studied to determine the upper limits of the recommended by T. Martaller were optimal for our conditions. The factual load preschool children in Belarus corresponds to the lower limits of the optimum calculated by energy inputs and is lower than the higher limits by 0.5 mgF/day minimum.

EXPERIENCE OF USING WATER CONTAINING 1.0-1.5 MGF/LITRE FOR DENTAL CARIES PREVENTION

In 1964 the country´s government decided to start fluoridation of tap water in 10 cities of the country, in 1987 the country had 22 fluoridating systems. But this experience couldn´t be called successful as the content of fluorine in water was neither constant ([F]=0.6±1.6 ppm F) nor stable (uninterruptible fluoridation was accomplished only in two cities) nor all-embarcing (fluoridated water was available only to 10% of population). As the result the preventing potential of the method was not fullfilled and communal fluoridation of tap water was stopped as inexpedient.

As Belarus has extensive supplies of undrground waters with natural optimal and increased content of fluorides (0.9-3.5 ppmF), their extraction and further sale of bottled water has been actively conducted according to the project of group caries prevention using water containing 1.1 ppm F. This water (0.5 litre/man a day) was used daily over two years for cooking food and as beverages for children. The average daily level of fluoride excretions with urine increased up to 46.28±0.92 mkgF/hour. The expenditures for purchase and shipment of water constituted 0.8$/man a year. The clinical effectiveness of the project corresponded to the reduction of caries occurrence in the groups of children with different caries resistance on 46.4±60.1% lvel (9).

USE OF FLUORIDATED TABLE SALT FOR DENTAL CARIES PREVENTION

Table salt as the source of fluorides

Traditions of use of table salt in preschool establishments and home cooking. The helath service of the Republic of Belarus recommends using 3 g of table salt as the part of the daily consumed food products list for children from one to one and a half years old, 5 g for children from one and a half to 3-years old, from 3-years old and older – 8 g a day.

In reality a Belarusian child gets from 0,6 to 2,0 g of the so-called "table” salt with every main meal². the actual daily intake of table salt with daily food ration cookted with adding of table salt in kindergartens constitutes from 3.3 to 9.1 g/day (5.9±1.4 g/day). The daily home cooked food ration for children contains about 3.53±1.65 g of "home” table salt. Almost all children get no more than 8 g of "home” table salt every day.

Content of fluorides in fluoridated salt ("Mozyrsol”) over different periods under different storage conditions. Fluoridated salt has been produced by the Belarusian enterprise Mozyrsol JSC since 1991. The table salt of "extra” class is enriched by potassium fluoride (KF)³ by aqueous method. Concentration of fluoride-ion in the salt varies within the limits defined by technical norms: 250±100 mgF/kg. Content of fluorides hardly changes for at least over one year when stored in factory package orin an open container.

Fluoride exposure control by means of consumption of fluoridated table salt by preschool children

When consuming fluoridated salt the profile of daily excretion repeats the one by natural fluoride exposure, but is on a higher level. It is certain that in order to receive the actual data about daily fluoride excretion, the reduced methods of research based on nighttime, daytime (8-hour, 13-hour) and 16-hour urine analyses, can be used along with 24-hour urine analyses. When consuming salt containing from 150 to 180 mgF/kg, the average rate of fluoride excretion with children´s urine fluctuates from 23.4±1.31 to 48.53±0.92 mkgF/hour (Figure 1.). The calculated values of a daily fluoride exposure by these conditions are in the range from 1.3±0.03 to 1.7±0.02 mgF/day, that corresponds to the conservative limits optimal fluoride exposure.

Figure 1. Renal fluoride excretion in 5-years old children consuming customary or fluoridated salt containing 150 mgF/kg.

Risk factors of fluoride overdose among children of Belarus

During fluoride exposure control among preschool children consuming fluoridated salt the cases were revealed when the daily consumption exceeded 2 mgF/day. The questionnaire analysis showed the following factors of fluoride exposure overdose risk:

a) 26.2% of families use toothpastes containing 1000-1500 ppmF for dental hygiene of children under three years old, in 73.4% of cases more than 1.0 g of toothpaste is used for brushing teeth 57.5% of parents do not control the process of brushing teeth (10);

b) 62.5% of children in the country consume bottled water containing 1.9-3.5 ppmF, 20.1% of children drink 150+130.2 ml of this water daily (11);

c) 95.9%-100% of children in urban and rural areas have home-cooked picled vegetables and marinades in their food rations, 20.3%-57.1% of children consume that daily that adds 0.1-0.4 mgF/day in case of using fluorised salt (12).

Preventive effectiveness of use of fluoridated table salt

By regular consumption of fluoridated table salt the following actual changes (p<0.001) in children´s oral cavity were noticed:

– changes of saliva acidity: the number of children with pH<6.2 decreased two times over three years of using the salt from 42% to 18%;

– decrease of viscosity of saliva: the number of children with viscosity more than 1.4 decreased from 16 to 34%;

– changes of macro- and microelements concentration in saliva: increase of amount of calcium (from 60.58±1.39 to 62.40±1.25 mg/liter), phosphorus (from 181.76±1.71 to 190.24±3.33 mg/liter) and fluoride (from 0.047±0.003 to 0.072±0.002 mg/liter) in saliva;

– increase of remineralising potential of saliva: the number of children with high potential increased from 9 to 25%, with low potential decreased from 60 to 44%;

– changes of mineral structure of enamel of children teeth that cut before fluoridated salt consumption (increase in Ca/P ratio from 2.27 to 3.14, decrease of chlorine, carbon, zinc, iron, chrome, magnesium, aluminum and sodium quantity);

– increase of enamel resistance to acidic dissolving: dissolution indicators decreased by 1/3;

– decrease of the number of streptococcus in saliva (from 1.40x10⁶±0.2x10⁶ KOE/ml to 1.17x10⁶ ± 0.11x10⁶ KOE/ml) and lactobacillus (from 0.61x10⁴ ± 11x10⁴ KOE/ml to 0.92x10⁴ ± 0.12x10⁴ KOE/ml) by preserving normal biocenosis.

The mail clinical result of using fluoridated table salt was the decrease of primary teeth caries occurrences among preschool children. The prevalence of caries of primary teeth decreased by 12.56±0.65% over four years of using fluoridated salt. The reduction of caries occurrences in different age groups constituted from 40 to 80% (13).

The rduction of primary teeth caries occurrences among children with different levels of caries resistance constitued 39.67-53.36% over two years of using fluoridated salt, that is a little less affective than the fluoridated tap water project using water with 1.18 ppmF (9). Over four years of implementation of the project the decrease of teeth caries intensity by 32.80%, decrease of intensity of caries of teeth surface by 29.64%, reduction of increase of caries intensity using the above values constituted accordingly 73.05 and 90.59% were observed (13).

The positive influence of regular consupmtion of fluoridated salt on somatic of children has also been noticed: the decreased by 29.5% in respiratory diseases among children and reduction of illness period by 2-3 days were noticed (13).

Economic effectiveness of fluoridated table salt usage

Expenditures for caries prevention using fluoridated salt are equal to the difference between the price for fluoridated and common salt that constitutes 0.25$/child a year. The real expenditures for puchares of salt and potential expenditures for treatment of prevented caries under the conditions of state dental clinics are correlated 1:80. Thus the projects with usage of fluoridated salt are more profitable economically than potentially more effective but very consuming and not successful in practice communal and other group/individual projects with usage of water with optimal fluorine content.

CONCLUSION

The conducted research allows for recommending of the further usage of fluoridated table salt in the state National program of dental caries prevention among children of the Republic of Belarus.

¹Taken that 90% of fluorides from water and 35-80% of fluorides from food are assimilated.

²With exclusion of salt in bread and sausage products, almost all amount of table salt is added in dishes for children either at home or at children establishments and thus can be related to as „home” table salt.

³Toxicological research showed that the choice of KF as a reagent for salt enrichment is the best choice, as KF is more biologically proper fluoride than NaF. Consumption of table salt with KF in the amount corresponding to the amount of 10 g/day consumed by an adult has a stimulating effect on biological organism and is more efficient than consumption of salt with NaF or a salt-free diet.

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Piśmiennictwo

1. Melnikova EI.: Epidemiology of dental of dental disesases and level of dental care to the children of the Republic of Belarus. Sovremennaya stomatologia 2000, 4:34-36. 2.Gelfer E.A., Rudik V.A.: Fluorides in drinking water and the problem of water fluoridation. Zdravoohranenie Belarusi 1971, 7:64-66. 3.Popruzhenko T.V., Saley G.V.: Assessment of aerogenus fluorides´ load on Belarusian population. Sovremennaya stomatologia 2000, 3:32-34. 4.Shulyakovskaya O.V., et al.: Fluorides´ quantity in main foods from different regions of the Republic of Belarus. Sovremennaya stomatologia 2000, 4:37-38. 5.Popruzhenko T.V.: Fluorides in daily food ration in kindergartens in the Republic of Belarus. Zdravoohranenie Belarusi 2001, 10:16-18. 6.Popruzhenko T.V.: Additional home sources of fluorine load on children. Oral health of a child 2001, 68-71. 7.Popruzhenko T.V.: The Experiences of organization of the monitoring fluorine loading, children consuming fluoridated salt. New technologies in dentistry 2003, 59-61. 8.Shakovets N.V.: the control of daily fluorine load during systemic and combined fluoride prevention. Actual problems of present-day medicine 1998, 104-105. 9.Shakovets N.V.: Clinical efficiency of natural fluoridated water PROTERA intake. Abstracts of 4 joint meeting of IADR 2000, 114. 10.Popruzhenko T.V.: The use of fluoride toothpaste among Belorusin children. Novoe v stomatologii 2001, 2:87-90. 11.Melnichenko E.M., et al.: Fluorides in bottled waters of food market of the Republic of Belarus. Sovremennaya stomatologia 2000, 3:44-45. 12.Reznikova L.G., Shulyakovskaya O.V.: The fluoride content in of home-cooked pickled products, prepared with using fluoridated salt. Health and environment 2002, 169-170. 13.Melnichenko E.M., Terekhova T.N.: Scientific substantiation and experience of caries prevention in children of preschool age with fluoridated salt in the Republic of Belarus. Sovremennaya stomatologia 1998, 3:5-13.

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