{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T17:52:57Z","timestamp":1779126777148,"version":"3.51.4"},"reference-count":187,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2024,5,1]],"date-time":"2024-05-01T00:00:00Z","timestamp":1714521600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001921","name":"Public Health Research programme","doi-asserted-by":"publisher","award":["NIHR128533"],"award-info":[{"award-number":["NIHR128533"]}],"id":[{"id":"10.13039\/501100001921","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journalslibrary.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:sec id=\"abs1-1\"><jats:title>Background<\/jats:title>\n<jats:p>Most water fluoridation studies were conducted on children before the widespread introduction of fluoride toothpastes. There is a lack of evidence that can be applied to contemporary populations, particularly adolescents and adults.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-2\"><jats:title>Objective<\/jats:title>\n<jats:p>To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults, using a natural experiment design.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-3\"><jats:title>Design<\/jats:title>\n<jats:p>Retrospective cohort study using routinely collected National Health Service dental claims (FP17) data.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-4\"><jats:title>Setting<\/jats:title>\n<jats:p>National Health Service primary dental care: general dental practices, prisons, community dental services, domiciliary settings, urgent\/out-of-hours and specialised referral-only services.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-5\"><jats:title>Participants<\/jats:title>\n<jats:p>Dental patients aged 12 years and over living in England (<jats:italic>n<\/jats:italic>\u2005=\u20056,370,280).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-6\"><jats:title>Intervention and comparison<\/jats:title>\n<jats:p>Individuals exposed to drinking water with a fluoride concentration \u2265 0.7\u2009mg F\/l between 2010 and 2020 were matched to non-exposed individuals on key characteristics using propensity scores.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-7\"><jats:title>Outcome measures<\/jats:title>\n<jats:p>Primary: number of National Health Service invasive dental treatments (restorations\/\u2018fillings\u2019 and extractions) received per person between 2010 and 2020. Secondary: decayed, missing and filled teeth, missing teeth, inequalities, cost effectiveness and return on investment.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-8\"><jats:title>Data sources<\/jats:title>\n<jats:p>National Health Service Business Services Authority dental claims data. Water quality monitoring data.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-9\"><jats:title>Primary outcome<\/jats:title>\n<jats:p>Predicted mean number of invasive dental treatments was 3% lower in the optimally fluoridated group than in the sub\/non-optimally fluoridated group (incidence rate ratio 0.969, 95% CI 0.967 to 0.971), a difference of \u22120.173 invasive dental treatments (95% CI \u22120.185 to \u22120.161). This magnitude of effect is smaller than what most stakeholders we engaged with (<jats:italic>n<\/jats:italic>\u2005=\u200550\/54) considered meaningful.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-10\"><jats:title>Secondary outcomes<\/jats:title>\n<jats:p>Mean decayed, missing and filled teeth were 2% lower in the optimally fluoridated group, with a difference of \u22120.212 decayed, missing and filled teeth (95% CI \u22120.229 to \u22120.194). There was no statistically significant difference in the mean number of missing teeth per person (0.006, 95% CI \u22120.008 to 0.021). There was no compelling evidence that water fluoridation reduced social inequalities in treatments received or missing teeth; however, decayed, missing and filled teeth data did not demonstrate a typical inequalities gradient. Optimal water fluoridation in England in 2010\u201320 was estimated to cost \u00a310.30 per person (excluding original setup costs). Mean National Health Service treatment costs for fluoridated patients 2010\u201320 were 5.5% lower per person, by \u00a322.26 (95% CI \u2212\u00a323.09 to \u2212\u00a321.43), and patients paid \u00a37.64 less in National Health Service dental charges per person (2020 prices).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-11\"><jats:title>Limitations<\/jats:title>\n<jats:p>Pragmatic, observational study with potential for non-differential errors of misclassification in fluoridation assignment and outcome measurement and residual and\/or unmeasured confounding. Decayed, missing and filled teeth data have not been validated. Water fluoridation cost estimates are based on existing programmes between 2010 and 2020, and therefore do not include the potentially significant capital investment required for new programmes.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-12\"><jats:title>Conclusions<\/jats:title>\n<jats:p>Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects, which may not be meaningful for individuals, and we could find no evidence of a reduction in social inequalities. Existing water fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower National Health Service treatment costs. These relatively small savings should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-13\"><jats:title>Future work<\/jats:title>\n<jats:p>National Health Service dental data are a valuable resource for research. Further validation and measures to improve quality and completeness are warranted.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-14\"><jats:title>Trial registrations<\/jats:title>\n<jats:p>This trial is registered as ISRCTN96479279, CAG: 20\/CAG\/0072, IRAS: 20\/NE\/0144.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-15\"><jats:title>Funding<\/jats:title>\n<jats:p>This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in <jats:italic>Public Health Research<\/jats:italic>; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.<\/jats:p>\n<\/jats:sec>","DOI":"10.3310\/rfqa3841","type":"journal-article","created":{"date-parts":[[2024,5,24]],"date-time":"2024-05-24T11:22:10Z","timestamp":1716549730000},"page":"1-147","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Effect of fluoridated water on invasive NHS dental treatments for adults: the LOTUS retrospective cohort study and economic evaluation"],"prefix":"10.3310","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9965-9371","authenticated-orcid":true,"given":"Deborah","family":"Moore","sequence":"first","affiliation":[{"name":"Division of Dentistry, The University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9050-7926","authenticated-orcid":true,"given":"Blessing","family":"Nyakutsikwa","sequence":"additional","affiliation":[{"name":"Division of Dentistry, The University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2972-7911","authenticated-orcid":true,"given":"Thomas","family":"Allen","sequence":"additional","affiliation":[{"name":"Manchester Centre for Health Economics, The University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emily","family":"Lam","sequence":"additional","affiliation":[{"name":"Independent Patient and Public Engagement Representative"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1372-0440","authenticated-orcid":true,"given":"Stephen","family":"Birch","sequence":"additional","affiliation":[{"name":"Manchester Centre for Health Economics, The University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5348-5441","authenticated-orcid":true,"given":"Martin","family":"Tickle","sequence":"additional","affiliation":[{"name":"Division of Dentistry, The University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6298-4189","authenticated-orcid":true,"given":"Iain A","family":"Pretty","sequence":"additional","affiliation":[{"name":"Division of Dentistry, The University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7003-8854","authenticated-orcid":true,"given":"Tanya","family":"Walsh","sequence":"additional","affiliation":[{"name":"Division of Dentistry, The University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"6221","published-online":{"date-parts":[[2024,5]]},"reference":[{"key":"key2024052416420500_ref1-bib1","doi-asserted-by":"crossref","first-page":"1211","DOI":"10.1016\/S0140-6736(17)32154-2","article-title":"Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990\u20132016: a systematic analysis for the Global Burden of Disease Study 2016","volume":"390","author":"Abajobir","year":"2017","journal-title":"Lancet"},{"key":"key2024052416420500_ref2-bib2","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1016\/S0140-6736(19)31146-8","article-title":"Oral diseases: a global public health challenge","volume":"394","author":"Peres","year":"2019","journal-title":"Lancet"},{"key":"key2024052416420500_ref3-bib3","volume-title":"8: Access and Barriers to Care \u2013 A Report from the Adult Dental Health Survey 2009","author":"The Information Centre for Health and Social Care","year":"2011"},{"key":"key2024052416420500_ref4-bib4","volume-title":"Improving Dental Care and Oral Health \u2013 A Call to Action","author":"NHS England","year":"2014"},{"key":"key2024052416420500_ref5-bib5","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1038\/sj.bdj.2013.991","article-title":"Permanent dentition caries through the first half of life","volume":"215","author":"Broadbent","year":"2013","journal-title":"Br Dent J"},{"key":"key2024052416420500_ref6-bib6","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1177\/0022034514553978","article-title":"The interplay between socioeconomic inequalities and clinical oral health","volume":"94","author":"Steele","year":"2015","journal-title":"J Dent Res"},{"key":"key2024052416420500_ref8-bib8","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1186\/1471-2458-14-863","article-title":"A reappraisal of the quantitative relationship between sugar intake and dental caries: the need for new criteria for developing goals for sugar intake","volume":"14","author":"Sheiham","year":"2014","journal-title":"BMC Public Health"},{"key":"key2024052416420500_ref10-bib10","volume-title":"National Diet and Nutrition Survey. 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