Dental Caries (Cavities): Community Water Fluoridation

Analytic Framework [PDF - 249 kB]

Summary Evidence Table - Effectiveness Review [PDF - 437 kB]

Summary Evidence Table - Economic Review [PDF 173 kB]

The Community Preventive Services Task Force recommendation on community water fluoridation is based on evidence from the following:

• 28 studies about the effect of CWF on caries; 16 about oral health disparities, and 117 about dental fluorosis -- most of which were included in an existing systematic review (McDonagh 2000, search period 1966-1999; 26 studies on caries; 13 on oral health disparities; 88 on fluorosis)
• 2 studies on caries; 3 on oral health disparities and 29 on fluorosis (search period 1999-2012)

Systematic Review of Public Water Fluoridation

• McDonagh M, Whiting P, Bradley M, Cooper J, Sutton A, Chestnutt I, Misso K, Wilson P, Treasure E, Kleinjen J. A Systematic Review of Public Water Fluoridation. National Health Service Centre for Reviews and Dissemination. York(UK): University of York; 2000. Available at URL: http://www.nhs.uk/Conditions/Fluoride/Documents/crdreport18.pdf [PDF - 1.10 MB] .

Studies from the Updated Search

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained n several publications).

Acharya S. Dental caries, its surface susceptibility and dental fluorosis in South India. International Dental Journal 2005;55(6):359–64.

Alarcon-Herrera M, Martin-Dominguez I, Trejo-vazquez R, Rodriguez-Doza S. Well water fluoride, dental fluorosis, bone fractures in the Guadiana Valley of Mexico. Fluoride 2001;34(2):134–49.

AlDosari AM, Akpata ES, Khan N. Associations among dental caries experience, fluorosis, and fluoride exposure from drinking water sources in Saudi Arabia. Journal of Public Health Dentistry 2010;70(3): 220–6.

Awadia A, Birkeland J, Haugejorden O, Bjorvatn K. Caries experience and caries predictors - a study of Tanzanian children consuming drinking water with different fluoride concentrations. Clinical Oral Investigations 2002;6(2):98–103.

Beltrán-Aguilar ED, Griffin SO, Lockwood SA. Prevalence and trends in enamel fluorosis in the United States from the 1930s to the 1980s. Journal of the American Dental Association 2002;133;157–65.

Chandrashekar J, Anuradha KP. Prevalence of dental fluorosis in rural areas of Davangere, India. International Dental Journal 2004;54:235–9.

Ekanayake L, Van Der Hoek W. Dental caries and developmental defects of enamel in relation to fluoride levels in drinking water in an arid area of Sri Lanka. Caries Research 2002;36(6):398–404.

Ermiş RB, Koray F, Akdeniz BG. Dental caries and fluorosis in low- and high-fluoride areas in Turkey. Quintessence International 2003;34(5):354–60.

Franzolin SdeO, Gonçalves A, Padovani CR, Francischone LA, Marta SN. Epidemiology of fluorosis and dental caries according to different types of water supplies. Ciencia Saude Coletiva 2010;15 Suppl 1: 1841–7.

Gray MM, Davies-Slowik J. Changes in the percentage of 5-year-old children with no experience of decay in Dudley towns since the implementation of fluoridation schemes in 1987. British Dental Journal 2001;190:30–2.

Grobleri SR, Louw AJ, van Kotze TJ. Dental fluorosis and caries experience in relation to three different drinking water fluoride levels in South Africa. International Journal of Paediatric Dentistry / the British Paedodontic Society [and] the International Association of Dentistry for Children 2001;11(5): 372–9.

Harding MA, Whelton H, O'Mullane DM, Cronin M, Warren JJ. Primary tooth fluorosis in 5-year-old schoolchildren in Ireland. European Journal of Paediatric Dentistry Official Journal of European Academy of Paediatric Dentistry 2005;6:155–61.

Indermitte E, Saava A, Karro E. Exposure to high fluoride drinking water and risk of dental fluorosis in Estonia. International Journal of Environmental Research and Public Health 2009;6:710–21.

Kanagaratnam S, Schluter P, Durward C, Mahood R, Mackay T. Enamel defects and dental caries in 9-year-old children living in fluoridated and nonfluoridated areas of Auckland, New Zealand. Community Dentistry and Oral Epidemiology 2009;37(3):250–9.

Machiulskiene V, Baelum V, Fejerskov O, Nyvad B. Prevalence and extent of dental caries, dental fluorosis, and developmental enamel defects in Lithuanian teenage populations with different fluoride exposures. European Journal of Oral Sciences 2009;117(2):154–60.

Macpherson LMD, Conway DI, Gilmour WH, Petersson LG, Stephen KW. Photographic assessment of fluorosis in children from naturally fluoridated Kungsbacka and non-fluoridated Halmstad, Sweden. Acta Odontologica Scandinavica 2007;65:149–55.

Maupomé G, Clark DC, Levy SM, Berkowitz J. Patterns of dental caries following the cessation of water fluoridation. Community Dentistry and Oral Epidemiology 2001;29(1):37–47.

McGrady MG, Ellwood RP, Srisilapanan P, Korwanich N, Worthington HV, Pretty IA. Dental fluorosis in populations from Chiang Mai, Thailand with different fluoride exposures - paper 1: assessing fluorosis risk, predictors of fluorosis and the potential role of food preparation. BMC Oral Health 2012;12(1):16.

Narbutaité J, Vehkalahti MM, Milciuviené S. Dental fluorosis and dental caries among 12-yr-old children from high- and low-fluoride areas in Lithuania. European Journal of Oral Sciences 2007;115(2): 137–42.

Peres MA, Antunes JLF, Peres KG. Is water fluoridation effective in reducing inequalities in dental caries distribution in developing countries? Recent findings from Brazil. Sozial und Praventivmedizin 2006;51:302–10.

Pontigo-Loyola AP, Islas-Márquez A, Loyola-Rodríguez JP, Maupome G, Marquez-Corona ML, Medina-Solis CE. Dental fluorosis in 12- and 15-year-olds at high altitudes in above-optimal fluoridated communities in Mexico. Journal of Public Health Dentistry 2008;68(3):163–6.

Riordan PJ. Dental fluorosis decline after changes to supplement and toothpaste regimens. Community Dentistry and Oral Epidemiology 2002;30(3):233–40.

Ruan JP, Yang ZQ, Wang ZL, Astrøm AN, Bårdsen A, Bjorvatn K. Dental fluorosis and dental caries in permanent teeth: rural schoolchildren in high-fluoride areas in the Shaanxi province, China. Acta Odontologica Scandinavica 2005;63:258–65.

Stephen KW, Macpherson LM, Harper Gilmour W, Stuart RA, Merrett MC. A blind caries and fluorosis prevalence study of school-children in naturally fluoridated and nonfluoridated townships of Morayshire, Scotland. Community Dentistry and Oral Epidemiology 2002;30(1):70–9.

Sudhir KM, Prashant GM, Subba Reddy VV, Mohandas U, Chandu GN. Prevalence and severity of dental fluorosis among 13- to 15-year-old school children of an area known for endemic fluorosis: Nalgonda district of Andhra Pradesh. Journal of the Indian Society of Pedodontics and Preventive Dentistry 2009; 27(4):190–6.

Tabari ED, Ellwood R, Rugg-Gunn AJ, Evans DJ, Davies RM. Dental fluorosis in permanent incisor teeth in relation to water fluoridation, social deprivation and toothpaste use in infancy. Br Dent J 2000; 189(4):216–20.

Warren JJ, Levy SM, Kanellis MJ. Prevalence of dental fluorosis in the primary dentition. Journal of Public Health Dentistry 2001;61(2):87–91.

Whelton H, Crowley E, O'Mullane D, Donaldson M, Kelleher V, Cronin M. Dental caries and enamel fluorosis among the fluoridated and non-fluoridated populations in the Republic of Ireland in 2002. Community Dental Health 2004;21(1):37–44.

Whelton H, Crowley E, O'Mullane D, Donaldson M, Cronin M, Kelleher V. Dental caries and enamel fluorosis among the fluoridated and non-fluoridated populations in the Republic of Ireland in 2002. Community Dental Health 2006;21(1),37–44.

Economic Review

Centers for Disease Control and Prevention. Water fluoridation and costs of Medicaid treatment for dental decay--Louisiana, 1995-1996. MMWR 1999;48(34):753-7.

Ciketic S, Hayatbakhsh MR, Doran CM. Drinking water fluoridation in South East Queensland: a cost-effectiveness evaluation. Health Promotion Journal of Australia 2010;21(1):51-6.

Cobiac LJ, Vos T. Cost‐effectiveness of extending the coverage of water supply fluoridation for the prevention of dental caries in Australia. Community Dentistry and Oral Epidemiology 2012;40(4): 369-76.

Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. Journal of Public Health Dentistry 2001;61(2):78-86.

Kumar JV, Adekugbe O, Melnik TA. Geographic variation in Medicaid claims for dental procedures in New York State: role of fluoridation under contemporary conditions. Public Health Reports 2010;125(5):647-54.

Maupome G, Gullion CM, Peters D, Little SJ. A comparison of dental treatment utilization and costs by HMO members living in fluoridated and nonfluoridated areas. Journal of Public Health Dentistry 2007;67(4):224-33.

O’Connell JM, Brunson D, Anselmo T, Sullivan PW. Costs and savings associated with community water fluoridation programs in Colorado. Prev Chronic Dis 2005;2:A06.Available from URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459459/pdf/PCD2SIA06.pdf

Tchouaket E, Brousselle A, Fansi A, Dionne PA, Bertrand E, Fortin C. The economic value of Quebec’s water fluoridation program. Journal of Public Health 2013;21(6):523-33.

Texas Health Department. Water Fluoridation Costs in Texas: Texas Health Steps (EPSDT-Medicaid). Report to fulfill House Concurrent Resolution 145, Texas 75^th Legislature; May 2000. Available at URL: www.dshs.state.tx.us/dental/pdf/flstudy.pdf.

Wright JC, Bates MN, Cutress T, Lee M. The cost‐effectiveness of fluoridating water supplies in New Zealand. Australian and New Zealand Journal of Public Health 2001;25(2):170-8.

CDC’s High-Impact in 5 years initiative recommends water fluoridation based on evidence it reduces the prevalence of dental caries within five years and has economic value.

In 2012, electronic searches of the literature were conducted by a public health librarian in the databases listed below. Search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. The types of documents searched in the databases included journal articles, books, book chapters, reports, conference papers, and dissertations. In addition, the bibliographies of all reviewed articles were used to identify any further literature.

Search Strategy

OHG Trials Register via Cochrane Register of Studies (Searched 8/21/12)

1. ((fluorid* or flurid* or fluorin* or flurin*))
2. water*
3. (#1 and #2)

CENTRAL via The Cochrane Library (to issue 7, 2012)

1. MeSH descriptor Fluoridation this term only
2. MeSH descriptor Fluorides explode all trees
3. MeSH descriptor Fluorine this term only
4. (fluorid* in All Text or fluorin* in All Text or flurin* in All Text or flurid* in All Text)
5. (#1 or #2 or #3 or #4)
6. MeSH descriptor Dietary supplements this term only    
7. MeSH descriptor Water supply this term only
8. water* in All Text
9. (#6 or #7 or #8)   
10. MeSH descriptor Tooth demineralization explode all trees
11. (caries in All Text or carious in All Text)
12. (teeth in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
13. (tooth in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
14. (dental in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
15. (enamel in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
16. (dentin in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
17. (root* in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text))
18. MeSH descriptor Dental plaque this term only
19. ((teeth in All Text or tooth in All Text or dental in All Text or enamel in All Text or dentin in All Text) and plaque in All Text)
20. MeSH descriptor Dental health surveys explode all trees         
21. ("DMF Index" in All Text or "Dental Plaque Index" in All Text)
22. (#10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #21)
23. (#5 and #9 and #22)

MEDLINE via OVID (March 5, 2012 to August 21, 2012)

1. Fluoridation/                         
2. exp Fluorides/                                  
3. Fluorine/                               
4. (fluorid$ or fluorin$ or flurin$ or flurid$).mp.                       
5. or/1-4                       
6. Dietary supplements/                                   
7. Water supply/                                   
8. water$.mp.                           
9. or/6-8                       
10. exp TOOTH DEMINERALIZATION/                                  
11. (caries or carious).mp.                                
12. (teeth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                  
13. (tooth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                  
14. (dental adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                  
15. (enamel adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                  
16. (dentin$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                  
17. (root$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.                                  
18. Dental plaque/                                  
19. ((teeth or tooth or dental or enamel or dentin) and plaque).mp.                 
20. exp DENTAL HEALTH SURVEYS/                       
21. ("DMF Index" or "Dental Plaque Index").mp.                                  
22. or/10-21                               
23. case reports.pt.                                
24. Comment/                            
25. Letter/                                   
26. Editorial/                               
27. or/23-26                               
28. exp animals/ not humans.sh.                                   
29. 5 and 9 and 22                                 
30. 29 not (28 or 27)

EMBASE via OVID (March 5, 2012 to August 21, 2012)

1. Fluoridation/                         
2. exp Fluoride/                        
3. Fluorine/                               
4. (fluorid$ or fluorin$ or flurin$ or flurid$).ti,ab.                                  
5. or/1-4                       
6. Diet supplementation/                                  
7. Water supply/                                   
8. water$.ti,ab.                         
9. or/6-8                       
10. exp Dental caries/                            
11. (caries or carious).ti,ab.                               
12. (teeth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.                                  
13. (tooth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.                                  
14. (dental adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.                                  
15. (enamel adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.                                  
16. (dentin$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.                                  
17. (root$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).ti,ab.                                  
18. Tooth plaque/                                   
19. ((teeth or tooth or dental or enamel or dentin) and plaque).ti,ab.                
20. ("DMF Index" or "Dental Plaque Index" or "dental health survey*").ti,ab.   
21. or/10-20                               
22. 9 and 21                               
23. exp animals/                        
24. exp human/                          
25. 24 not 23                              
26. 22 and 25

ZETOC Conference Proceedings (Whole Database)

fluoride AND water AND caries
fluoridation AND water AND caries
fluoride AND water AND carious
fluoridation AND water AND carious
fluoride AND water AND dental
fluoridation AND water AND dental
fluoride AND water AND tooth
fluoridation AND water AND tooth
fluoride AND water AND teeth
fluoridation AND water AND teeth

Web of Science Conference Proceedings (1990 to November 2, 2012)

1. TS=(fluorid* or fluorin* or flurin* or flurid*)
2. TS=water*
3. TS=(caries or carious)                                 
4. TS=(teeth and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))   
5. TS=(tooth and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
6. TS=(dental and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
7. TS=(enamel and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
8. TS=(dentin* and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
9. TS=(root* and (cavit* or caries* or carious or decay* or lesion* or deminerali* or reminerali*))
10. TS=((teeth or tooth or dental or enamel or dentin) and plaque)
11. TS=("DMF Index" or "Dental Plaque Index")
12. #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11
13. #1 and #2 and #12

Proquest (To November 5, 2012)

ab(water*) AND ab(caries OR carious OR dental OR tooth OR teeth OR plaque)

Economic Review

The search for economic evidence included the following bibliographic databases: PubMed, Centres for Reviews and Dissemination – University of York (CRD-YORK),EconLit (EBSCOhost), Embase (OVID), ERIC (ProQuest), Social Sciences Citation Index SSCI (Web of Science), and WorldCat. In addition, reference lists of included studies were screened and subject matter experts were solicited for additional articles.

Search terms and strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software.

PubMed, Searched: 11/26/2013
Results: 360

#1 "fluoridation"[mesh] or "fluorides"[mesh] or "fluorine"[mesh] or fluorid*[all fields] or fluorin*[all fields] or flurin*[all fields] or flurid*[all fields]

#2 "dietary supplements"[mesh] or "water supply"[mesh] or water*[all fields]

#3 (("teeth" OR "tooth" OR “dental” OR "enamel" OR "root" OR "roots" OR dentin*) AND  ( "caries"[all fields] or "carious"[all fields]  or decay* or lesion* or demineral* or remineral*))

#4 “dental plaque"[mesh] OR "tooth demineralization"[mesh] OR “caries” OR “carious”

#5 (("teeth" OR "tooth" OR "enamel" OR "root" OR "roots" OR dentin*) AND “plaque”))

#6 "dental health surveys"[mesh] OR "dmf index" or "dental plaque index"

#7 "case reports"[Publication Type] OR "Comment" [Publication Type] OR "letter"[Publication Type] OR "editorial"[Publication Type]

#8 "economics" [Subheading] OR "Economics"[Mesh] OR "Cost-Benefit Analysis"[Mesh] OR  "Health Expenditures"[Mesh] OR "Capital Expenditures"[Mesh]  OR "Cost of Illness"[Mesh] OR "Cost Savings"[Mesh] OR "Health Care Costs"[Mesh] OR "Quality-Adjusted Life Years"[Mesh] OR "Fees, Dental"[Mesh] OR economic[Title/Abstract] OR economic*[title/abstract] OR "cost"[Title/Abstract] or "costs"[title/abstract] or "costly"[title/abstract] OR  benefit*[title/abstract] OR "dollar"[Title/Abstract] or "dollars"[title/abstract] OR "expenditure"[Title/Abstract] or "expenditures"[title/abstract] OR "wtp"[Title/Abstract] OR "willingness to pay"[Title/Abstract] OR increment*[Title/Abstract] OR "sensitivity analysis"[Title/Abstract] OR "sensitivity analyses"[Title/Abstract] OR "breakeven"[Title/Abstract] OR "break even"[Title/Abstract] OR "discount rate"[Title/Abstract] OR "discount rates"[Title/Abstract] OR "lost productivity"[Title/Abstract] OR "value"[Title/Abstract] OR "qaly"[Title/Abstract] OR "daly"[Title/Abstract] OR "quality adjusted life years"[Title/Abstract] OR "quality adjusted life yr"[Title/Abstract] OR "quality adjusted lifeyears"[Title/Abstract] OR "disability adjusted life"[Title/Abstract] OR "disability adjusted life expectancy"[Title/Abstract] OR "disability adjusted life year"[Title/Abstract] OR "disability adjusted life year estimates"[Title/Abstract] OR "disability adjusted life year loss"[Title/Abstract] OR "disability adjusted life year loss rates"[Title/Abstract] OR "disability adjusted life years"[Title/Abstract] OR "disability adjusted life years daly"[Title/Abstract] OR treatment saving[Title/Abstract] OR "treatment savings"[Title/Abstract] OR "dental fee"[Title/Abstract] OR "dental fees"[Title/Abstract] OR "money"[Title/Abstract] Filters: Publication date from 1995/01/01 to 2013/12/31

#9 "humans"[mesh]

#10 "Animals"[Mesh] OR "Animal Experimentation"[Mesh]

#11 #1 AND #2

#12 #3 OR #4 OR #5 OR #6  

#13 #10 NOT #9

#14 #11 AND #12 AND #8

#15 #14 NOT #13

#16 #15 NOT #7

CRD-YORK NHS EED, Searched: 12/2/2013
Results: 50

Results for: ((fluorid* or fluorin* or flurin* or flurid*)) and ((Economic evaluation:ZDT and Bibliographic:ZPS) OR (Economic evaluation:ZDT and Abstract:ZPS)) IN NHSEED FROM 1995 TO 2013

EconLit (EBSCOhost), Searched: 12/2/2013
Results: 25
Search modes - Boolean/Phrase, 1995-2013

S11
S5 OR S9

S10
S5 OR S9

S9
S1 AND S8

S8
S2 OR S3 OR S4 OR S6 OR S7

S6
fluorid* or fluorin* or flurin* or flurid*

S5
fluoridation of water

S4
teeth or plaque

S3
dental or tooth

S2
caries or carious

S1
Water

Embase (OVID), Searched: 12/3/2013
Results: 17

1
fluoridation/

2
exp "economic aspect"/

3
exp "cost benefit analysis"/

4
2 or 3

5
1 and 4

6
limit 5 to (exclude medline journals and yr="1995 -Current")

ERIC (ProQuest), Searched: 12/3/2013
Results: 259

Search modes - Boolean/Phrase, 1995-2013

S8
S4 AND S7 

S7
(economic* or cost* or expenditure* or utility or dollar* or wtp or "willingness to pay" or increment ) OR ( "lost productivity" or "sensitivity analysis" or breakeven or "break even" or discount* or value or qaly or daly or fee or fees or saving or savings or money ) OR ( "quality adjusted life" or "disability adjusted life" ) 

S4
S1 OR S2 OR S3 

S3
caries or carious or dental or teeth or tooth or "oral health" 

S2
fluoridation of water 

S1
fluorid* OR flurid* OR fluorin* OR flurin* 

Social Sciences Citation Index SSCI (Web of Science), Searched: 11/26/2013
Results: 34

# 10

# 8 AND #9
Databases=SSCI Timespan=1995-2013                        

# 9
TS=(cost*) or TS=(benefit*) or TS=(utility) or TS=(expenditure*) or TS=(dollar*) or TS=(wtp) or TS=(willingness near/2 pay) or TS=(increment*) or TS=(lost near/1 productivity) or TS=(sensitivity near/1 analysis) or TS=(breakeven) or TS=(break near/1 even) or TS=(discount*) or TS=(value) or TS=(qaly) or TS=(daly) or TS=(quality near/1 adjusted near/1 life) or TS=(disability near/1 adjusted) or TS=(treatment near/1 saving*) or TS=(dental near/1 fee*) or TS=(money)

#8
#6 AND #7

# 7
#3 OR #4 OR #5                        

# 6
#1 AND #2                      

# 5
TS=(DMF near/1 index)                

# 4    
TS=(caries) or TS=(cavit*) or TS=(carious) or TS=(decay*) or TS=(lesion*) or TS=(demineral*) or TS=(reminerali*)                        

# 3    
TS=(tooth) or TS=(teeth) or TS=(dental) or TS=(enamel) or TS=(dentin*) or TS=(root*)                        

# 2    
TS=(water*)                    

# 1    
TS=(fluorid*) or TS=(fluorin*) or TS=(flurin*) or TS=(flurid*)

WorldCat (Worldcat.org), Searched: 12/3/2013
Results: 42

Kw: fluorid* kw:water kw:economic*

Kw: fluorid* kw:water kw:cost*

Embase (OVID), Searched: 12/3/2013
Results: 17

1
fluoridation/

2
exp "economic aspect"/

3
exp "cost benefit analysis"/

4
2 or 3

5
1 and 4

6
limit 5 to (exclude medline journals and yr="1995 -Current")

Centers for Disease Control and Prevention. 2010 Water Fluoridation Statistics. Retrieved from http://www.cdc.gov/fluoridation/statistics/2010stats.htm . Accessed August 2, 2013.

Centers for Disease Control and Prevention. Engineering and administrative recommendations for water fluoridation, 1995. MMWR 1995;44(RR-13):1-40.

McDonagh M, Whiting P, Bradley M, Cooper J, Sutton A, Chestnutt I, Misso K, Wilson P, Treasure E, Kleinjen J. A Systematic Review of Public Water Fluoridation. National Health Service Centre for Reviews and Dissemination. York(UK): University of York; 2000. Available at URL: http://www.nhs.uk/Conditions/Fluoride/Documents/crdreport18.pdf.