The effect of cessation of community water fluoridation on dental caries among children aged 5–6: a cross-sectional study

Background: Community Water Fluoridation (CWF) was implemented in Israel from 1981 to 2014. Following the discontinuation of fluoridation, there has been a debate about changes in the prevalence of of caries and dental treatments in Israel. This study aims to illustrate the effects of halting fluoridation on 5–6-year-old children, especially those from low socio-economic backgrounds. Methods: This cross-sectional study used data from the Maccabi-Dent database, covering the period from 2014 to 2019 for children aged 5 to 6. The dataset comprised 539,661 treatments. We compared the frequency of treatments carried out in 2014–2015, when fluoride was still active, with those conducted in 2016–2019, when the influence of CWF was no longer present. Statistical tests including Levene’s, analysis of variance (ANOVA), and post-hoc Games-Howell tests were conducted. Results: The frequency of dental treatments increased between 2014–2019 among children aged 5–6. When comparing the frequency of treatments with and without CWF, the number of restorations increased from 54,101 to 135,539, along with a 22% increase in dental checkups. There were significantly fewer treatments performed before the cessation of fluoridation (2014–2015) than after the cessation (2016–2019). Children from lower socioeconomic backgrounds underwent more dental treatments. Conclusions: This study indicates that Community Water Fluoridation reduces the incidence of dental caries, particularly evident in the significantly higher number of treatments among those from lower socioeconomic backgrounds.

Community water fluoridation; Public health; Dental caries; Socioeconomic; Fluoride

[1] Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. The Lancet. 2019; 394: 249–260.

[2] Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al. Dental caries. Nature Reviews Disease Primers. 2017; 3: 17030.

[3] Ribeiro AA, Paster BJ. Dental caries and their microbiomes in children: what do we do now? Journal of Oral Microbiology. 2023; 15: 2198433.

[4] Levy DH, Livny A, Sgan-Cohen HD, Yavnai N. The association between caries related treatment needs and socio-demographic variables among young Israeli adults: a record based cross-sectional study. Israel Journal of Health Policy Research. 2018; 7: 24.

[5] Yousaf M, Aslam T, Saeed S, Sarfraz A, Sarfraz Z, Cherrez-Ojeda I. Individual, family, and socioeconomic contributors to dental caries in children from low- and middle-income countries. International Journal of Environmental Research and Public Health. 2022; 19: 7114.

[6] Senevirathna L, Ratnayake HE, Jayasinghe N, Gao J, Zhou X, Nanayakkara S. Water fluoridation in Australia: a systematic review. Environmental Research. 2023; 237: 116915.

[7] Velez-León E, Pacheco-Quito EM, Díaz-Dosque M, Tobar-Almache D. Worldwide variations in fluoride content in beverages for infants. Children. 2023; 10: 1896.

[8] O’Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg-Gunn AJ, et al. Fluoride and oral health. Community Dental Health. 2016; 33: 69–99.

[9] Iheozor-Ejiofor Z, Worthington HV, Walsh T, O’Malley L, Clarkson JE, Macey R, et al. Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews. 2015; 2015: CD010856.

[10] Jullien S. Prophylaxis of caries with fluoride for children under five years. BMC Pediatrics. 2021; 21: 351.

[11] Tobias G, Findler M, Chackartchi T, Bernstein Y, Greenberg Parizer B, Mann J, et al. The effect of community water fluoridation cessation on children’s dental health: a national experience. Israel Journal of Health Policy Research. 2022; 11: 4.

[12] Zusman SP, Ramon T, Natapov L, Kooby E. Dental health of 12-year-olds in Israel—2002. Community Dental Health. 2005; 22: 175–179.

[13] Zusman SP. Water fluoridation in Israel: ethical and legal aspects. Public Health Reviews. 2012; 34: 6.

[14] Israel Ministry of Health. Facts about drinking water fluoridation, division of dental health (Hebrew). 2019. Available at: https://www.health.gov.il/Subjects/Environmental_Health/drinking_water/fluoridation/Documents/BSV_haflaraWater.pdf (Accessed: 17 December 2019).

[15] Natapov L, Sasson A, Zusman SP. Does dental health of 6-year-olds reflect the reform of the Israeli dental care system? Israel Journal of Health Policy Research. 2016; 5: 26.

[16] Shahrabani S, Benzion U, Machnes Y, Gal A. The use of dental services for children: implications of the 2010 dental reform in Israel. Health Policy. 2015; 119: 117–126.

[17] Israel Ministry of Health. Dental care for school children in the health basket (Hebrew). 2024. Available at: https://me.health.gov.il/parenting/raising-children/early-childhood-care/dental-and-oral-health/dental-care-for-school-children/ (Accessed: 03 January 2025).

[18] Barak S. Water fluoridation and public health. Harefuah. 2003; 142: 747–749, 806. (In Hebrew)

[19] McLaren L, Patterson SK, Faris P, Chen G, Thawer S, Figueiredo R, et al. Fluoridation cessation and children’s dental caries: a 7-year follow-up evaluation of Grade 2 schoolchildren in Calgary and Edmonton, Canada. Community Dentistry and Oral Epidemiology. 2021; 50: 391–403.

[20] Meyer J, Margaritis V, Mendelsohn A. Consequences of community water fluoridation cessation for Medicaid-eligible children and adolescents in Juneau, Alaska. BMC Oral Health. 2018; 18: 215.

[21] Abbass MMS, Mahmoud SA, El Moshy S, Rady D, AbuBakr N, Radwan IA, et al. The prevalence of dental caries among Egyptian children and adolescences and its association with age, socioeconomic status, dietary habits, and other risk factors: a cross-sectional study. F1000Research. 2019; 8: 8.

[22] Zhang T, Hong J, Yu X, Liu Q, Li A, Wu Z, et al. Association between socioeconomic status and dental caries among Chinese preschool children: a cross-sectional national study. BMJ Open. 2021; 11: 042908.

[23] Lennon MA, Whelton H, Sgan-Cohen HD. Need to put children’s oral health first in Israeli debate on water fluoridation. Community Dental Health. 2013; 30: 198–199.

[24] Kim HN, Kim JH, Kim SY, Kim JB. Associations of community water fluoridation with caries prevalence and oral health inequality in children. International Journal of Environmental Research and Public Health. 2017; 14: 631.

[25] Üstün N, Akgöl BB, Bayram M. Influence of COVID-19 pandemic on paediatric dental attendance. Clinical Oral Investigations. 2021; 25: 6185–6191.

[26] Choi SE, Mo E, Sima C, Wu H, Thakkar-Samtani M, Tranby EP, et al. Impact of COVID-19 on dental care utilization and oral health conditions in the United States. JDR Clinical & Translational Research. 2024; 9: 256–264.

[27] Akbari A, Khami MR, Beymouri A, Akbari S. Dental service utilization and the COVID-19 pandemic, a micro-data analysis. BMC Oral Health. 2024; 24: 16.

[28] Lee YL, Hu HY, Yen YF, Chu D, Yang NP, Chou SY, et al. Impact of the COVID-19 pandemic on the utilization of medical and dental services in Taiwan: a cohort study. Journal of Dental Sciences. 2021; 16: 1233–1240.

[29] Schwendicke F, Krois J, Gomez J. Impact of SARS-CoV2 (Covid-19) on dental practices: economic analysis. Journal of Dentistry. 2020; 99: 103387.