Association between Community Water Fluoridation and Severe Dental Caries Experience in 4-Year-Old New Zealand Children

Importance: Robust contemporary epidemiologic evidence for the population-wide efficacy of reticulated community water fluoridation is required. Objective: To evaluate whether community water fluoridation is associated with the national rates of severe caries among 4-year-old children in New Zealand after accounting for key sociodemographic characteristics. Design, Setting, and Participants: This was a near whole population-level, natural, geospatial cross-sectional study of 4-year-old children who had a health and development assessment as part of the nationwide B4 School Check screening program conducted in New Zealand between July 1, 2010, and June 30, 2016. The extracted database included 391677 children. However, geospatial information was missing for 18558 children, another 32939 children were unable to be geospatially matched, 5551 children resided in areas with changing fluoridation status, and 58786 children had no oral health screen recorded, leaving 275843 (70.4%) eligible children. Data were released in August 2019; statistical analysis was performed from September 2019 to December 2019. Exposures: Community water fluoridation status from 2011 through 2016. Main Outcomes and Measures: Severe caries experience derived from the "lift the lip" oral health screening. Analyses were adjusted for age, sex, ethnicity, area-level deprivation, and residential location differences. Multilevel mixed-effects logistic regression models were used. Sensitivity analyses based on multiple imputed data were undertaken to measure any differential influence of missing data. Results: In the eligible sample of 275843 children, the median age was 4.3 years (interquartile range, 4.1-4.6 years), 141451 children (51.3%) were boys, and 153670 children (55.7%) resided within fluoridated areas. Severe caries were identified for 24226 children (15.8%) in fluoridated and 17135 children (14.0%) in unfluoridated areas, yielding an unadjusted odds ratio of 0.93 (95% CI, 0.90-0.95). However, in the adjusted analyses, children residing in areas without fluoridation had higher odds of severe caries compared with those within fluoridated areas (odds ratio, 1.21; 95% CI, 1.17-1.24). The population attributional fraction associated with unfluoridated community water was 5.6% (95% CI, 4.7%-6.6%) in a complete case analysis. Conclusions and Relevance: This study finds that community water fluoridation continues to be associated with reduced prevalence of severe caries in the primary dentition of New Zealand's 4-year-old children.