Dear Mr. Denise Duijster,

Thank you for your interesting and informative response. The attachments are useful, especially the Beijing Declaration.

I'm sure there must be a close monitoring of the program, from the fluoride use point-of-view.

Just one query: are there any local regulations of Cambodia, Indonesia and Lao PDR, on the use of fluoride toothpaste?

Kind regards,

F H Mughal

Dear Mr. F.H. Mughal,

Thank you for your interest in our paper, and for your comment regarding the safety of fluoride toothpaste use for children. I have reviewed the documents you sent, and I’m happy to provide you with information why we promote the use of fluoride toothpaste in the Fit for School programme.

Fluorides have been used since the 1940’s for the prevention and reduction of tooth decay, the most common disease of mankind. Their use has been evaluated in many studies in different contexts; the trials provided overwhelming evidence that long-term exposure to low-concentrations of fluorides is associated with a clear reduction of tooth decay. Several Cochrane reviews of the literature (the highest level of evidence in public health) concluded and confirmed that the caries-preventive benefits of fluorides are firmly established. In addition, there is no credible evidence that fluoride toothpaste is associated with any adverse health effects.

Fluorides can be delivered through different methods, including fluoridation of water, salt or milk, the use of fluoride toothpaste or through the application of gels or varnishes. Fluoride toothpaste is the most widespread and accepted form of fluoride use globally, and according to the World Health Organization “the most realistic and effective means to reduce the burden of tooth decay in populations”. The preventive effect of fluoride toothpaste is almost exclusively topical, which explains its efficacy. Typical formulations of fluoride toothpaste contain 1,000 to 1,500 ppm fluoride, as specified by the International Standards Organisation (ISO) in standard No 11609:2017.

In 2007, the Beijing Declaration “A call to action to promote oral health by using fluoride” was formulated by experts from WHO, the FDI World Dental Federation, the International Association for Dental Research (IADR) and the Chinese Stomatological Association. The expert consensus was that twice daily use of fluoride toothpaste should be recommended to prevent tooth decay. To prevent children from swallowing large quantities of toothpaste, it was recommended that a pea-size amount of toothpaste is used and that children up to the age of 6 years are supervised by an adult. They concluded that fluoride toothpaste is safe to use, also irrespective of exposures to other sources of fluoride, and that the main focus of oral health promotion efforts should be to increase availability and affordability toothpaste. The results of our Fit for School programme evaluation also confirm that fluoride toothpaste is an acceptable and effective method to help prevent tooth decay in high-risk children in Southeast Asia. The Regional Oral Health Strategy of the WHO Southeast Asian Regional Office emphasizes the promotion of fluoride toothpaste and the establishment of group toothbrushing programmes in schools as priority areas.

I have attached the Cochrane review, two WHO reports and the Beijing Declaration for your reference. I hope I have addressed your question, and otherwise please do not hesitate to contact me.

Kind regards,

Denise Duijster
(D.Duijster@acta,nl)

Dear Doreen,

The paper, which you have linked, is interesting. It contains some useful points that I like.

The paper says that water scarcity, limited access to improved sanitation and lack of personal hygiene at home and in school significantly contributes to the immense burden of preventable childhood diseases, such as diarrhoea, acute respiratory infections, intestinal worms and dental caries. This reflects the situation in the rural areas of Sindh province, Pakistan.

The paper found that the toothbrushing intervention significantly contributed to the prevention of dental caries in children. A clear asset of the study was that it describes real-life implementation research to assess whether a combination of relevant and already proven health and WASH interventions is effective in improving child health when delivered in schools as an integrated hygiene promotion package.

The study provides important learning points for future evaluation research, which points the way forward for also incorporating intermediary measures of behavioural outcomes and indicators of implementation quality, in addition to health indicators, in order to evaluate and understand how WinS programmes possibly lead to health benefits through implementation processes and their potential effect on hygiene habit formation.

The study suggests that even the most effective and simplest of health interventions, such as toothbrushing with fluoride toothpaste (daily toothbrushing with 0.3 ml of toothpaste, containing 1450 ppm free available fluoride), handwashing with soap or deworming plausibly depend on implementation quality to reach their full beneficial potential.

I was, however, alerted by the words “fluoride toothpaste” in the above paragraph. The reason: it is widely believed that fluoride in toothpaste is not good for the children. I have compiled some publications below, and I would request Dr. Bella Monse, et al., to kindly have a detailed look at these documents, and let me have their comments.

F H Mughal
PS: This system cannot take too many links, though strange as it may sound, I have the links in the attachment

Dear SuSanA forum members,

The FIT programme assessment study (FIT-PAS) in Cambodia, Indonesia and Lao PDR was conducted from 2012 to 2014 in partnership with the Academic Centre for Dentistry Amsterdam, University College London, New York University, University of Jena, and Ministries of Education in Cambodia, Indonesia and Lao PDR.
Over the initial two-year implementation, the FIT programme lead to improved access to handwashing facilities with water and soap and stimulated healthy hygiene practices such as individual handwashing with soap at critical times. Furthermore, FIT supported the implementation of the national deworming program in each of the countries. Last but not least, FIT was seen to reduce development of new dental caries by 24%.
Further information on the longitudinal study in Cambodia, Indonesia and Lao PDR highlighting the background, methodology and results can be found here. www.fitforschool.international/wp-conten...aper_in_BMC_2017.pdf

Thanks and best regards,

Doreen Mbalo on behalf of Dr. Bella Monse.