Pre-webinar polls: (open-ended questions) 1. What has been your experience in finding/using evidence related to water fluoridation? 2. How do you use research evidence to inform your practice?
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Poll question #4:When searching for evidence, where do you look first? Clinical Guidelines (e.g. National Guidelines Clearinghouse)GoogleGoogle ScholarHealth-evidence.caPubMed
Poll Question #5Do you know the difference between a Systematic Review and a Literature Review?YesNo
FINAL Polls: 6 and 7Did you find the information presented today helpful?YesNo Was this information new to you?Yes No
Community Water Fluoridation: What's the Evidence?
This webinar has been made possible with support from the Canadian Institutes of Health Research Welcome! Fluoridation:What’s the evidence? You will be placed on hold until the webinar begins.The webinar will begin shortly, please remain on the line.
What’s the evidence? This webinar will focus on a number of sources of information, including a systematic review featured on Health Evidence: http://www.health-evidence.ca/articles/show/15981
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This webinar has been made possible with support from the Canadian Institutes of Health Research Welcome! Fluoridation:What’s the evidence?
The Health Evidence Team Kara DeCorby Heather Husson Jennifer Yost Administrative Director Project Manager Guest PresenterMaureen DobbinsScientific DirectorTel: 905 525-9140 ext 22481E-mail: firstname.lastname@example.org Lori Greco Robyn Traynor Lyndsey McRae Knowledge Broker Research Coordinator Research Assistant
What is www.health-evidence.ca? Evidence inform Decision Making
Why use www.health-evidence.ca? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
Relevance Criteria: Addresses impact of water fluoridation in the context of developed countries Produced within the last 15 years English-language
Search Strategy: Searched review-level evidence in public health related to fluoridation on health-evidence.ca Reviewed reference lists of relevant reviews
Evidence Reviewed: PHAC: Drinking Water Fluoridation in Canada: Review and Synthesis of Published Literature, 2011 Quebec PH: Water Fluoridation: An Analysis of the Health Benefits and Risks, 2007 Australian Government, NHMRC: A Systematic Review of the Efficacy and Safety of Fluoridation, 2007 NHS Centre for Reviews and Dissemination: A Systematic Review of Water Fluoridation, 2000
Is it a Systematic Review? Is there a methods section? Does the methods section outline a search strategy? Are there inclusion criteria given? Did the reviewers assess relevance systematically? Did the reviewers conduct a quality assessment?
Literature Reviews: Quebec PH: Water Fluoridation: An Analysis of the Health Benefits and Risks, 2007 No methodology reported PHAC: Drinking Water Fluoridation in Canada: Review and Synthesis of Published Literature, 2011 Report some inclusion/exclusion criteria Report some searching methodology No quality assessment
Systematic Reviews: Australian Government, NHMRC: A Systematic Review of the Efficacy and Safety of Fluoridation, 2007 Major Strength: Includes systematic reviews and primary studies Major Limitation: Quality assessment (lack of information about # of reviewers and criteria) Minor Limitation: Search strategy (English-only, limited number of databases)
Systematic Reviews: NHS Centre for Reviews and Dissemination: A Systematic Review of Water Fluoridation, 2000 Health Evidence Quality Rating: 9 Major Strength: Meta-analyses, when appropriate Minor Limitation: Quality assessment (criteria for case-control studies devised by reviewers)
Water Fluoridation is Effective Significantly increases the percentage of caries-free children by 15.4% Range from as little of a 10.8% increase to as much as 20.1% increase [95% Confidence Interval (CI)] Six children need to receive fluoridated water for one additional child to be caries-free Range from five children to as many as nine children [Number Needed To Treat (NNT)]
Water Fluoridation is Effective Significantly decreases the number of decayed, missing, filled teeth (dmft/DMFT score) by 2.3 teeth Range from a decrease of1.8 teeth to as many as 2.8 teeth [95% Confidence Interval (CI)] Based on moderate quality, moderate risk of bias evidence Across children of all ages
Water Fluoridation is Safe Significant increase in the prevalence of fluorosis Flouride levels of 1.0ppm and 1.2ppm versus 0.4ppm Prevalence of fluorosis causing “aesthetic concern” No significant difference between fluoride levels of 0.7ppm, 1.0ppm, and 1.2pmm versus 0.4ppm
Water Fluoridation is Safe No significant increase in the prevalence of bone fractures Unable to be determined for the prevalence of cancer (all causes, osteosarcoma, bone, thyroid) Based on lowest quality evidence with high risk of bias Across children of all ages
Overall ConsiderationsDrinking water fluoridationClinically important increase in the prevalence of caries-freechildren of all agesSmall number of children need access in order for one childto be caries-freeNo statistically significant increase in fluorosis of aestheticconcerns with increasing fluoride levels or bone fracturesEvidence suggesting there is a relationship between waterfluoridation and other health outcomes is low quality evidenceNote: Consistent across “Evidence Reviewed”
General ImplicationsPublic health should support the fluoridation ofdrinking waterAmong all children of all agesAt levels that are unlikely to cause to fluorosis and fluorosisof “aesthetic concern”
Practice & Policy Implications Support policies for the fluoridation of drinking water at safe levels of fluoridation Be aware of community fluoridation status Be aware of the average daily intake of water by the and the intake of fluoride from other sources Communicate evidence on the effectiveness and harms associated with drinking water fluoridation to communities considering initiating drinking water fluoridation continuing drinking water fluoridation
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