Bottled Water a Risk Factor for Early Childhood Caries

From Medscape Medical News
Crina Frincu-Mallos, PhD

November 18, 2009 (Philadelphia, Pennsylvania) — Drinking bottled water was the only modifiable risk factor related to early childhood caries (ECC) in a retrospective investigation presented here at the American Public Health Association 137th Annual Meeting by Rosalia A. Mendoza, MD, MPH, assistant professor in the Department of Family and Community Medicine at the University of California at San Francisco.

The study was prompted by the fact that 62% of children referred to an oral health clinic in the San Francisco area had caries by the age of 2 years. More than half of them drank bottled water, from which fluoride is usually removed, together with impurities, by reverse osmosis.

Currently, 69% of the American population lives in communities served by fluoridated public water supply systems, according to the Centers for Disease Control and Prevention.

"There appears to be a protective effect of drinking the fluoridated tap water over drinking bottled water" (odds ratio [OR], 0.59; P = .07), Dr. Mendoza reported.

In their retrospective analysis, Dr. Mendoza and colleagues aimed to identify risks and protective factors associated with untreated ECC at an urban San Francisco Family Health Center, which serves more than 8000 children 5 years and younger annually. ECC seem to be more prevalent among African American and Latino children in the San Francisco area.

Living in Fluoridated Communities Does Not Translate Into Fluoride Exposure

Between June 2006 and April 2009, 239 children (114 girls and 125 boys), 70% of whom were Latino, were referred to the oral health screening clinic at a San Francisco Family Health Center by family medicine physicians. The physicians had identified cavitated and noncavitated caries. They also interviewed parents about the oral health status of the child and the child's behavior. The investigators looked for ECC risk factors, such as more than 3 sugary snacks or drinks consumed per day, and ECC protective factors, such as whether the parent sees a dentist regularly, the child's teeth are brushed with fluoride toothpaste, and the child drinks tap water.

Drinking bottled water was "the only associated and modifiable risk factor" that the investigators found.

Family medicine physicians have an "important role during the early screening and referral to dentists," said Dr. Mendoza in an interview with Medscape Public Health & Prevention. "Frequent visits in the first and second year of life, following the vaccine schedule for preventive care," can be used to incorporate early regular oral care.

"We are very successful [in] detecting some of the modifiable risk behaviors and protective behaviors," said Dr. Mendoza. For instance, bottled water vs tap water preferences and practices are currently not part of state surveys.

Interestingly, "there also appears to be an association between a dental home and caries prevalence in this community," Dr. Mendoza observed.

At-Home Water Filtration Recommended

Dr. Mendoza and colleagues are trying to assess how well immigrant families understand the importance of fluoride. "Do they know that fluoride is part of their tap water, the municipal water, which is free?" she said. Her team wants to find out what the barriers are "that we need to overcome in our health promotion to facilitate greater tap water consumption in this community."

Most families believed that milk or water is a healthier choice than juice, she said, but "they chose to use bottled water, not water from the tap, to add to formula milk or to aguas frescas."

At the core of the practice of giving bottled water to children seems to be the perception that "the water [in the United States] is not safe. If you do live in a rental property, if you know there is sediment in the tap water or if you don't like the taste, how do you address that?" asked Dr. Mendoza: "You use a filter!"

Need for Monitoring of Tap Water Drinking Habits

Next, the researchers are going to "push the importance of bottled water preferences and practice into our national and state surveys," said Dr. Mendoza.

"In our local community, we are going to be looking at ways that we can do successful public health promotion around these identified areas in immigrant practices and beliefs around bottled water," she added.

"It was interesting to see how family physicians can deliver the message that fluoridated water can help protect teeth from caries," said Jeffrey Johnston, public health analyst in the Office of Operations, Health Resources and Services Administration in Rockville, Maryland, who attended the meeting. "Hopefully, now we can implement some service-delivery changes," he concluded.

Dr. Mendoza and Mr. Johnston have disclosed no relevant financial relationships.

American Public Health Association (APHA) 137th Annual Meeting: Abstract 204297. Presented November 8, 2009.