Fluoride is usually our friend and it seems obvious that fluoride toothpaste has helped improve the oral health of many people world over. In certain parts of the world, the fluoridation of water has been actively encouraged as a public health
intervention to help improve oral health and prevent decay. For something that has been so beneficial to society, it seems to attract a lot of controversy and can be the cause of much debate. The recent attempt to fluoridate the water in Southampton is a good example of where health and politics can evoke anxieties on both sides. It’s unlikely that many other dental public health interventions would receive so much air time or such extensive media attention, perhaps an indication of how passionate professionals and the public are about the topic. During the Southampton debate, some of those opposed to water fluoridation suggested other alternatives such as targeted brushing schemes or fluoride varnish schemes.
Dental public health interventions form part of our everyday practising lives in primary care and it’s unlikely that a day goes by when most general dentists don’t refer to dental public health guidance. In the NHS, this is particularly important and the
guidance can sometimes feel like a mandatory requirement, especially when the local contract manager is expecting to see certain numbers of fluoride applications as part of contract monitoring. This sort of pressure can sometimes make dentists feel uneasy and it seems to go against the principle of individual prescribing rights. The application of fluoride in the dental setting is an intervention which should only be undertaken on the prescription of a dentist, therefore it has to be right for the patient receiving the intervention. It’s hard to know how a contract manager would be able to know what is right for an individual patient.
There have also been recent movements to train armies of dental nurses to deliver fluoride varnish schemes. In fact a number of local education and training boards and post graduate centres seem to be offering such courses for dental nurses at the moment and they appear to be relatively popular. This sort of activity does encourage use of skill mix and should help extend the duties of dental nurses in due course. The problem seems to be the evidence, the very basis on which the dental community is participating in this activity of applying fluoride varnish to every child that can jump. I am not a dental academic so cannot profess to have any special expertise in criticising the evidence, however even with my general understanding I have been reading some of the research papers which do not seem to support mass fluoride varnish schemes. In fact a publication in the Journal of Dental Research raises questions about the effectiveness of school based fluoride varnish schemes.
It appears as if we are all agreed that fluoride works and has some benefit for most patients and that for certain patients some additional fluoride helps them even more. However, society can’t seem to agree on whether or not water fluoridation is the solution when balancing the benefits and risks with cultural beliefs and attitudes. Professionally, we also seem to have
differences of opinion on the benefits of fluoride varnish schemes. In some parts of the country, the local agencies have
allocated a lot of resource to buying fluoride varnish and investing in dental providers to deliver the schemes. In fact the recently released results of the last oral health survey of five-year-olds seems to have precipitated this activity in yet more locations.
In my view, it would be helpful for policy makers and researchers to provide a balanced view on interventions such as population level fluoride varnish schemes so that dentists can have a fully informed discussion with their patients. The current mixture of guidance, policy and research can make this discussion difficult for dental professionals and patients.