View
265
Download
9
Category
Preview:
Citation preview
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 3
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 4
Cara penyampaian Fluorida
ORAL HEALTH DIVISION, MOH, MALAYSIA 5
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.
ORAL HEALTH DIVISION, MOH, MALAYSIA 6
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 7
ORAL HEALTH DIVISION, MOH, MALAYSIA 8
• 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)
ORAL HEALTH DIVISION, MOH, MALAYSIA 9
Geographical areas with high natural fluoride levels (> 1.5 mg/l)
ORAL HEALTH DIVISION, MOH, MALAYSIA 10
Percentage of population receiving fluoridated water, including both artificial and natural fluoridation
ORAL HEALTH DIVISION, MOH, MALAYSIA 11
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.
ORAL HEALTH DIVISION, MOH, MALAYSIA 12
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 13
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)
ORAL HEALTH DIVISION, MOH, MALAYSIA 14
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)
ORAL HEALTH DIVISION, MOH, MALAYSIA 15
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.
ORAL HEALTH DIVISION, MOH, MALAYSIA 16
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 17
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 18
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 19
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 20
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 22
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)
ORAL HEALTH DIVISION, MOH, MALAYSIA 23
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)
ORAL HEALTH DIVISION, MOH, MALAYSIA 24
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, MALAYSIA 25
ORAL HEALTH DIVISION, MOH, MALAYSIA26
Achievement after 35 years of Fluoridation
Estimated population received fluoridated water, 2008
ORAL HEALTH DIVISION, MOH, MALAYSIA 27
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 28
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 29
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 30
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 31
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 32
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 33
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 34
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 35
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 36
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 37
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 38
Inequalities Persist By Location
ORAL HEALTH DIVISION, MOH, MALAYSIA 39
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 40
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
ORAL HEALTH DIVISION, MOH, MALAYSIA 41
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”
ORAL HEALTH DIVISION, MOH, MALAYSIA 42
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”.
ORAL HEALTH DIVISION, MOH, MALAYSIA 43
44
Working together to improve the nation oral health and quality of life
A lifetime of healthy smiles!
ORAL HEALTH DIVISION, MOH, MALAYSIA 45
Thank you for your attention
Recommended