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Our Position Statements

Community Water Fluoridation

Position Statement on Community Water Fluoridation

July 2017 (updated 2022)

Purpose
This document presents the Quality Improvement Group for Māori Oral Health Providers’ position on community water fluoridation. This Position Statement is evidence-based and supported by current literature (see below for Appendix); it will be reviewed annually and updated in light of new evidence.

 
It is expected that this Position Statement will be considered by local government bodies and District Health Boards when making decisions about community water fluoridation.


Quality Improvement Group for Māori Oral Health Providers (Quality Improvement Group)
The Quality Improvement Group is a board comprising oral health practitioners from the Māori oral health provider sector.  It was established by the Ministry of Health to provide advice about improving the oral health sector and, ultimately, the oral health of Māori people.


Position Statement

The Quality Improvement Group endorses community water fluoridation as it is a practical, effective, and safe means of protecting teeth and improving the oral health of all Māori.

Specifically:

 

  • Community water fluoridation at levels optimal for protecting teeth leads to oral health gains and improvement in health and well-being for all Māori, or all ages;

  • Evidence clearly demonstrates that tamariki Māori who live without community water fluoridation experience significantly more decay and receive more fillings than tamariki Māori living with community water fluoridation;

  • Evidence also demonstrates that community water fluoridation at levels optimal (range 0.7-1.0ppm) for protecting teeth and improving oral health is a safe health practice;
  • By improving Māori oral health and reducing oral health inequalities, educational achievement, sustained employment and other beneficial social outcomes are improved; consequently, community water fluoridation contributes to improving overall health and well-being for all Māori;

  • It is endorsed by numerous New Zealand and international health authorities including Te Ao Marama (the New Zealand Māori Dental Association), New Zealand Ministry of Health, Public Health Association of New Zealand, World Health Organization and the International Dental Federation.


The Quality Improvement Group acknowledges that:

  • Community water fluoridation is one measure in a range of strategies needed to address oral health inequities, and protect and improve Māori oral health status;

  • Fluoridation of community water supplies contributes to total fluoride intake, which in turn may contribute to fluorosis.  Fluorosis can be prevented by using the minimum optimal level of fluoride in the drinking water. In NZ, there have been no reports of serious fluorosis.
     

The Quality Improvement Group affirms it will:

  • Advocate to continue community water fluoridation or implement it where it is absent (if technically possible);

  • Reinforce the oral health benefits of community water fluoridation by endorsing recommendations concerning healthy kai; continued effort on improving equity of access to oral health services for pēpi, tamariki, rangatahi, pakeke, and kaumatua Māori; promoting regular dental check-ups; endorsing the application of fluoride varnish and use of fluoride mouth rinses where appropriate; and good oral health care practices in the home, including the use of fluoridated toothpaste;

  • Continue to monitor and evaluate the evidence on community water fluoridation and its impact on Māori oral health status.

 

Adopted by the Quality Improvement Group on 24 July 2017

 

Sugar Intake, 2017.

Position Statement on Free Sugars Intake

July 2017 (updated 2022)

Purpose

This document presents the Quality Improvement Group for Māori Oral Health Providers’ position on sugars intake.  This Position Statement is evidence-based and supported by current literature ( see below for Appendix); it will be reviewed annually and updated in light of new evidence. 

Quality Improvement Group for Māori Oral Health Providers (Quality Improvement Group)

The Quality Improvement Group is a board comprising oral health practitioners from the Māori oral health provider sector.  It was established by the Ministry of Health to provide advice about improving the oral health sector and, ultimately, the oral health of Māori people.

 

Position Statement

The Quality Improvement Group supports strategies, policies, and initiatives that will eliminate the harm of sugars on the oral health and well-being of Māori.

The Quality Improvement Group:

Acknowledges that sugars, also known as free sugars, is a key risk factor for dental caries and that reducing the consumption of sugars is one measure in a range of strategies to protect teeth and improve oral health. 

Endorses the World Health Organization recommendations to reduce the intake of sugars to 10% of total energy intake, and for further reduction in risk of dental caries to less than 5% total energy intake, throughout the life course.

Supports, and affirms it will advocate for, strategies and policies that reduce the availability and access to, and promotion and consumption of, kai and beverages containing sugars, particularly sugar-sweetened beverages; and encourages the availability and access to, and promotion and consumption of, healthy kai and beverages. 

Reinforces the oral health benefits of such strategies and policies by endorsing recommendations for community water fluoridation, and the appropriate use of other protective measures including fluoridated toothpastes, and where indicated, fluoridated mouth rinses and varnishes; continued effort on improving equity of access to oral health services for pēpi, tamariki, rangatahi, pakeke, and kaumatua Māori, and the promotion of regular dental check-ups and good oral health care practices in the home.

Will monitor and evaluate the impact of sugars, and strategies to reduce their consumption, on oral and general health.

 

Adopted by the Quality Improvement Group on 24 July 2017

Appendix Background and evidence base for Position Statement on Community Water Fluoridation July 2017 Poor oral health is a major concern for Māori, ranging from tamariki to older Māori.1 Across all age groups, Māori are consistently and significantly more likely to have had greater lifetime experience of dental caries that non-Māori, and are significantly less likely to be caries free and to have teeth removed as a result of dental caries.2–4 Of greatest concern is the large proportion of tamariki Māori, especially those under 5y, requiring dental treatment (including often multiple extractions) under general anaesthetic; they are two and a half times as likely as non-Māori children to be admitted to hospital for dental care.5 In 2015/16, approximately 11,000 tamariki Māori (aged 1-14y) reported having a tooth removed due to decay in the previous 12 months, almost as twice as likely as non-Māori (RR, 1.7).4 Further, a greater proportion of older Māori are retaining their natural teeth, and expected to do in the future.2 The annual incidence of dental caries among older Māori, is likely similar to that of adolescents.6 Poor oral health and oral health inequalities substantially impact Māori health and well-being, and is associated with substantial personal, social and economic costs.2,3,7 Preventing dental caries, improving oral health, and reducing inequalities are key priorities for Māori.1 Overwhelming evidence demonstrates that community water fluoridation is one of the most effective and efficient means of reducing and controlling the occurrence of dental caries in communities with >1000 people.8,9 People living in non-fluoridated areas are significantly more likely to have more dental caries, and greater severity of dental caries, than people living in fluoridated areas.8,9 Community water fluoridation reaches all people in the community, and has particular benefits for children and the most vulnerable (Māori are over-represented in the vulnerable population as they are more likely to live in poverty and be impacted by material disadvantage.1). As such, community water fluoridation improves the oral health of all age groups and contributes to the reduction of oral health inequalities.8,9 Such improvements are over and above the use of other fluoridated products such as toothpastes, mouth rinses and varnishes.8,9 Fluoride is naturally present in most water sources. Low levels of fluoride added to the water for the purposes of improving oral health have been shown to be safe. 8,9 The fluoride derived from the fluorosilicates added to the water for CWF are the same as the fluoride from other products used to benefit oral health.8,9 References 1.Robson, B. et al. Oranga- Waha - Oral Health Research Prioirities for Māori low-income adults, kaumātua, and Māori with disabilities, special needs and chronic health conditions. (Te Rōpū Rangahau Hauora a Eru Pōmare, 2011). 2.CBG Health Research Ltd. Our Older People’s Oral Health: Key Findings of the 2012 New Zealand Older People’s Oral Health Survey. (CBG Health Research Ltd, 2015). 3.Ministry of Health. Our Oral Health: Key findings of the 2009 New Zealand Oral Health Survey. (Ministry of Health, 2010). 4.Ministry of Health. Annual Update of Key Results 2015/16: New Zealand Health Survey. (Ministry of Health, 2016). 5.Craig, E. et al. The Health Status of Children and Young People in New Zealand. (Ministry of Health, 2011). 6.Thomson, M. Epidemiology of oral health conditions in older people. Gerodontology 31, 9–16 (2014). 7.Sheiham, A. Oral health, general health and quality of life. World Health Organ. Bull. World Health Organ. Geneva 83, 644 (2005). 8.Office of the Prime Minister’s Chief Science Advisor & Royal Society of New Zealand. Health effects of water fluoridation: A review of the scientific evidence A report on behalf of the Royal Society of New Zealand and the Office of the Prime Minister’s Chief Science Advisor. (Royal Society of New Zealand, 2014). 9.Department of Health and Human Services. Statement on the evidence supporting the safetly and effectiveness of community water fluoridation. (Centers for Disease Control and Prevention, 2017).

Appendix Background and evidence base for Position Statement on Free Sugars Intake July 2017 Poor oral health is a major concern for Māori, ranging from tamariki to older Māori.1 Across all age groups, Māori are consistently and significantly more likely to have had greater lifetime experience of dental caries that non-Māori, and are significantly less likely to be caries free and to have teeth removed as a result of dental caries.2–4 Of greatest concern is the large proportion of tamariki Māori, especially those under 5y, requiring dental treatment (including often multiple extractions) under general anaesthetic; they are two and a half times as likely as non-Māori children to be admitted to hospital for dental care.5 In 2015/16, approximately 11,000 tamariki Māori (aged 1-14y) reported having a tooth removed due to decay in the previous 12 months, almost as twice as likely as non-Māori (RR, 1.7).4 Further, a greater proportion of older Māori are retaining their natural teeth, and expected to do in the future.2 The annual incidence of dental caries among older Māori, is likely similar to that of adolescents.6 Poor oral health and oral health inequalities substantially impact Māori health and well-being, and is associated with substantial personal, social and economic costs.2,3,7 Preventing dental caries, improving oral health, and reducing inequalities are key priorities for Māori.1 Evidence demonstrates an association between dental caries and both the amount and frequency of consumption of free sugars,1–5 that is all added sugars (added to foods by the manufacturer, cook or consumer) plus the sugars that are naturally present in honey, syrups, fruit juices and fruit juice concentrates. It does not include sugar naturally present in milk or whole fruit and vegetables.5 Free sugars are a risk factor for all dentate Māori regardless of age, but particularly tamariki and older Māori, and the most vulnerable. Consumption of free sugars is higher among Māori and the most vulnerable than other population groups.2,6 Many of the foods and beverages with added sugars are cheaper, more accessible, widely available and ubiquitously promoted, than healthy foods and beverages.7–9 Free sugars consumption is also associated with obesity, type 2 diabetes mellitus, cardiovascular disease and some cancers. Māori are also disproportionately burdened by such conditions.10,11 Sweet drinks The Quality Improvement Group is particularly concerned about the consumption of sweet drinks. Sugar-sweetened beverages (SSBs) substantially contribute to free sugars consumption and are a key risk factor for dental caries.1–4 They also displace the consumption of healthy drinks, substantially contribute to energy intake with little or no nutrient benefit, and are particularly associated with obesity and type 2 diabetes mellitus.12,13 Children and young people are the greatest consumers of SSBs.2,6 Both SSBs and artificially-sweetened beverages (ASBs) are highly acidic and have the potential to erode tooth enamel, making teeth more vulnerable to dental caries, its consequences and other dental issues.14 Emerging evidence also suggests that ASBs stimulate sweet taste receptors and contribute to glucose intolerance, and therefore, should not be promoted as healthy alternatives to SSBs.15,16 The World Health Organization guidelines on free sugars for children and adults (and quality of evidence) are:5 •Reduce the intake of free sugars throughout the life course (strong evidence); •Reduce the intake of free sugars to less than 10% of total energy intake (strong evidence); •For further health benefits, to reduce the intake of free sugars further to below 5% of total energy intake (conditional evidence). This recommendation is made based on the positive dose-response relationship between free sugars intake below 5% of energy intake and dental caries. Strategies to reduce the consumption of free sugars that would benefit all Māori of all ages, from tamariki Māori to older Māori, include:7 •Providing, and ensuring the accessibility of, nutrition information and guidelines; •Introducing fiscal measures (including a tax) that increases the retail price of SSBs by at least 20%;17 •Implementing the Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children18 to reduce the exposure of tamariki Māori to, and the power of, the marketing of foods and beverages with free sugars; in particular, implementing regulations to restrict unhealthy food and beverage marketing; •Implementing interpretive front-of-pack labeling, particularly on SSBs, and appropriate educational support; •Requiring the creation of healthy food environments in the various settings in which Māori live, work and play, by establishing food and beverage policies in (but not only) early childhood education centres, schools and tertiary education institutions; Kura Kaupapa Māori; marae; hospitals and other health care locations; workplaces; sport and community events; and public amenities and facilities; and instituting mandatory standards for the provision of food and beverages in public-sector settings. •Implementing kura/school-based programmes that encourage healthy eating; •Measures that provide equitable access to the social determinants of health. The Quality Improvement Group supports the following: •The National DHB Food and Drink Environments Network National 2016 Healthy Food and Drink Policy; •Ministry of Health 2015 Eating and Activity Guidelines for New Zealand Adults; •Ministry of Health 2015 Childhood Obesity Plan; •WHO Commission on Ending Childhood Obesity Report7 recommendations; •WHO Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children.18 Reducing the consumption of free sugars is only one strategy in a range of strategies to reduce the risk of dental caries. While exposure to fluoride (through community water fluoridation or direct application through varnishes, toothpastes and mouth rinses) protects the teeth and reduces the risk of dental caries, it does not prevent it absolutely; people exposed to fluoride are still at risk of developing dental caries.5 Other key preventive measures include good oral health practices in the home. References 1.Ministry of Health. NZ Food NZ Children: Key results of the 2002 National Children’s Nutrition Survey. (Ministry of Health, 2003). 2.Ministry of Health. A Focus on Nutrition: Key findings from the 2008/09 NZ Adult Nutrition Survey. (Ministry of Health, 2011). 3.Vartanian, L. R., Schwartz, M. B. & Brownell, K. D. Effects of Soft Drink Consumption on Nutrition and Health: A Systematic Review and Meta-Analysis. Am. J. Public Health 97, 667–675 (2007). 4.Tahmassebi, J. F., Duggal, M. S., Malik-Kotru, G. & Curzon, M. E. J. Soft drinks and dental health: A review of the current literature. J. Dent. 34, 2–11 (2006). 5.World Health Organization. Guideline: Sugars intake for adults and children. (WHO, 2015). 6.Ministry of Health. NZ food NZ children: Key results of the 2002 national children’s nutrition survey. (Ministry of Health, 2003). 7.WHO. Report of the Commission on Ending Childhood Obesity. (World Health Organization, 2016). 8.Institute of Medicine of the National Academies, Committee on Food Marketing and the Diets of Children and Youth. Food Marketing to Children and Youth: Threat or Opportunity? (Institute of Medicine of the National Academies, 2006). 9.Cairns, G., Angus, K., Hastings, G. & Caraher, M. Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite 62, 209–215 (2013). 10.Ministry of Health. Health Loss in New Zealand 1990–2013 A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study. (Ministry of Health, 2016). 11.Ministry of Health. Annual Update of Key Results 2015/16: New Zealand Health Survey. (Ministry of Health, 2016). 12.Malik, V. S., Schulze, M. B. & Hu, F. B. Intake of Sugar-Sweetened Beverages and Weight Gain: A Systematic Review. Am. J. Clin. Nutr. 84, 274–288 (2006). 13.Malik, V. S., Popkin, B. M., Bray, G. A., Després, J.-P. & Hu, F. B. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation 121, 1356–1364 (2010). 14.Jaeggi, T. & Lussi, A. in Dental Erosion 20, 9–16 (Karger, 2006). 15.Borges, M. C. et al. Artificially Sweetened Beverages and the Response to the Global Obesity Crisis. PLoS Med. San Franc. 14, (2017). 16.Fowler, S. P. et al. Fueling the Obesity Epidemic? Artificially Sweetened Beverage Use and Long-term Weight Gain. Obesity 16, 1894–1900 (2008). 17.WHO. Fiscal policies for diet and prevention of noncommunicable diseases: technical meeting report, 5-6 May 2015, Geneva, Switzerland. (World Health Organization, 2016). 18.World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. (World Health Organization, 2010).

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