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\def\RunningAuthor{Gheena S et al.}
\firstPage{1888}
\articleType{Original Article}
\receivedDate{03 Oct 2020}
\acceptedDate{09 Nov 2020}
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\title{\textbf{Knowledge and awareness about uses of fluoride among adults - a survey}}
\author{Sutharshan~G~S\textsuperscript{1},  
            Gheena~S\textsuperscript{*}\textsuperscript{2}, 
            Ganesh~Lakshmanan\textsuperscript{3}~\\[5pt]{\textsuperscript{1}Saveetha Dental College and Hospitals, Saveetha Institute of medical and technical sciences, Saveetha University, Chennai, Tamil Nadu, India}~\\{\textsuperscript{2}Department of Oral Pathology, Saveetha Dental College, Saveetha Institute of Medical and Technical science, Saveetha University, Chennai, Tamil Nadu, India}~\\{\textsuperscript{3}Department of Anatomy, Saveetha Dental College and Hospital, Saveetha Institute of medical and technical sciences, Chennai, Tamil Nadu, India}}

\begin{abstract}
Fluoride has been used for years to prevent dental caries. Tooth brushing reduces bacteria, hence reduces dental caries. Fluoride content in toothpaste helps to prevent dental caries. Dental caries are controlled in children who drink fluoridated water. The most effective way to prevent dental caries by topical fluoride application is through fluoridated toothpaste. The main aim of the study is to know and be aware of the uses of fluoride among adults. An online survey was conducted with a self-structured questionnaire comprising 15 questions related to the use of fluoride. The questionnaire was designed using the online survey platform "google forms". Descriptive analysis was carried out using the statistical software "SPSS software version 20". The results of the survey were represented in the form of pie charts and bar charts. Around 85\% of the population know and are aware of the use of fluoride. Awareness of the uses of fluoride is adequate among the adult population. So it is evident from this study that people are aware of the positive and negative impacts due to appropriate or inappropriate levels of fluoride in their daily consumption. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Awareness,\newline Dental Caries,\newline Fluoride,\newline Fluoridated Toothpaste,\newline Prevention
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Gheena~S~\\ Phone:\ +919884033777~\\  Email:\ gheena@saveetha.com
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\section{Introduction}
Fluoride supplements have been used for years to prevent dental caries. Fluoride has a preemptive effect in caries prevention and also certain levels of fluoride is present in saliva \unskip~\citep{921299:20662408,921299:20662412}. The most effective way to prevent dental caries through topical fluoride is through fluoridated toothpaste \unskip~\citep{921299:20662409,921299:20662401,921299:20662402}. Tooth brushing reduces bacteria, hence reduces dental caries and it is the reason for using toothpaste. The abrasive effects of toothpaste were extended. Oral hygiene was found to have a caries prevention effect and long-term compliance in oral self-care \unskip~\citep{921299:20662415,921299:20662435,921299:20662429}. 

Fluoridation of water is a basic procedure that ensures the presence of precise amounts of fluoride content in the drinking water so as to provide systemic and local benefits. Community water fluoridation is recommended by nearly all public health, medical, and dental organizations, because of its contribution to the large decline in cavities. School water fluoridation and school-based fluoride tablet programs both have been shown in many studies to be effective in preventing dental caries. Fluoride content in toothpaste helps to prevent dental caries \unskip~\citep{921299:20662433}. Dental caries are controlled in children who drink fluoridated water \unskip~\citep{921299:20662413,921299:20662406}. 

According to Rozier RG, Fluoride supplements should be prescribed only for children who are at high risk of developing caries and whose primary source of drinking water is deficient in fluoride \unskip~\citep{921299:20662431,921299:20662426}. According to Narendran S, deficiencies and ambiguity in respondent fluoride knowledge, as well as prescription practices, indicated a need for educational intervention \unskip~\citep{921299:20662405,921299:20662403}. According to Horowitz, dental diseases can be controlled and prevented using fluoride \unskip~\citep{921299:20662436}. The main aim of the study is to assess the knowledge and awareness about the uses of fluoride among adults. 
    
\section{Materials and Methods}
An online survey was conducted with a self-structured questionnaire with a sample size of 100 comprising dental students. The questionnaire consisted of questions related to awareness about the uses of fluoride and finally, questions related to established facts. The participants were given a short introduction about the awareness of the uses of fluoride. The questionnaire was validated in a standard manner. Measures such as a selection of participants randomly, steps to prevent asking irrelevant questions to the participants, placing restrictions over participant population and age groups are taken to minimise the bias occurring in sampling. The questionnaire was designed using the online survey platform ``google forms''. For statistical analysis, data was initially entered in Microsoft excel sheet and analysed using IBM SPSS Software version 20.0. Descriptive statistics were expressed by means of frequency. Percentage and chi-square analysis for gender responses  were also carried out using the same statistical software. The results of the survey were represented in the form of pie charts and bar charts.
    
\section{Results and Discussion}
In this study, the results are collected, analyzed and discussed. A majority of 85\% of respondents were aware and understood the advantages and disadvantages of fluoride. The outright results prove it.


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\caption{\boldmath {Pie chart depicts the responses to the question that fluoride exists in all water supplies naturally. }}
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\caption{\boldmath {Bar chart represents the association between the gender of the participants and awareness about the fact towards sources of fluoride. }}
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\caption{\boldmath {Pie chart shows responses to the question from birth until the age of 18 drink fluoridated city water for most of our water needs. }}
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\caption{\boldmath {Pie chart depicts the responses for awareness about fluoridated water preventing tooth decay. }}
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\caption{\boldmath {Pie chart depicts the distribution of responses to drinking government distributed public, or corporation water resources causes dental fluorosis. }}
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\caption{\boldmath {Pie chart depicts the responses to drinking public, or corporation water causes skeletal fluorosis. }}
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\caption{\boldmath {Pie chart depicts the responses on dental fluorosis leading to dental caries. }}
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\caption{\boldmath {Pie chart shows the responses to fluoride application could prevent tooth decay. }}
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\caption{\boldmath {Depicts responses to the fact that a pregnant woman ingested with a high dose of fluoridated water; it affects the teeth development of the foetus. }}
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\caption{\boldmath {Pie chart depicts that percentage distribution on the consumption of prescribed fluoride supplements}}
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\caption{\boldmath {Bar chart represents the association between the gender of the participants and awareness about the fact that fluoride affects the thyroid gland. }}
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\caption{\boldmath {Bar chart represents the association between the gender of the participants and the use of fluoridated toothpaste during 0-10 years. }}
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\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/5e0866f1-030d-4839-abc5-e4c8b3210a14-upicture13.png}{\includegraphics{images/5e0866f1-030d-4839-abc5-e4c8b3210a14-upicture13.png}}{}
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\caption{\boldmath {Pie chart depicts the responses of participants for the fact that the consumption of well water could prevent caries. }}
\label{f-4ba52147270f}
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\begin{figure}[!htbp]
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\makeatother 
\caption{\boldmath {Bar chart represents the association between the gender of the participants and awareness about the benefits of the fluoride water to lower socio-economic backgrounds. }}
\label{f-710b9dd0aff2}
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\makeatother 
\caption{\boldmath {Depicts the responses of participants that bottled water is fluoridated. }}
\label{f-828b0ebc6c06}
\end{figure}
\egroup
Figure~\ref{f-b512af8580a6} depicts that fluoride exists in all water supplies naturally. 78\%(blue) have knowledge of fluoride existence, 4\%(green) have partial knowledge about it and 18\%(red) do not have knowledge of fluoride existence. Figure~\ref{f-6bac81909d99} Bar chart represents the association between the gender of the participants and awareness about the sources of fluoride. The association between the variables was analyzed using Chi-square test (Pearson's Chi-square value - 6.711; P-value - 0.035 ({\textgreater}0.05)) and was found to be statistically not significant. The X-axis represents the gender of the participants and Y-axis represents the number of responses. Out of 42\% of the participants who are aware, 33\% constitutes male and 9\% constitutes female. Figure~\ref{f-60ad1f545705} shows knowledge and awareness on the consumption of fluoridated city water for most of our water needs from birth until the age of 18. 57\%(blue) had drunk the fluoridated city water, 39\%(red) didn't drink fluoridated city water and 4\%(green) didn't know that they had drunk fluoridated city water or not. Figure~\ref{f-e8e54cf1abc1} depicts an awareness of fluoridated water. 44\%(blue) were aware of fluoridated water, 40\%(red) were not aware of fluoridated and 16\%(green) were partially aware of fluoridated water prevents tooth decay. Figure~\ref{f-29c934455a2e} depicts that drinking public water causes dental fluorosis. 37\% (blue) of participants know that it causes dental fluorosis; 43\% (red) of participants don't know that public water causes dental fluorosis and 20\%(green) of participants partially know that public water causes skeletal fluorosis. 

Figure~\ref{f-d6ba66b62e6f} depicts that drinking public water causes skeletal fluorosis. 53\% (blue) of participants know that it causes skeletal fluorosis, 21\% (red) of participants don't know about it and 26\% (green) of participants partially know that public water causes skeletal fluorosis. Figure~\ref{f-88ee08b584cc} depicts that dental fluorosis can lead to dental caries. 58\% (blue) of participants agree, 22\% (red) of participants disagree and 20\% (green) partially agree to it. Figure~\ref{f-fe558ebec34c} shows that fluoride application could prevent tooth decay. 37\% (blue) of participants know that it prevents tooth decay, 37\% (red) of participants unaware and 26\% (green) partially aware of it. Figure~\ref{f-dd3523840a8d} depicts awareness of the fact that if a pregnant woman ingested a high dose of fluoridated water, it affects the development of teeth in the foetus. 44\% (blue) of participants aware, 22\% (red) of participants unaware about it, 34\% (green) partially aware of it.  Figure~\ref{f-66c6dab2b2e1} depicts that prescription of fluoride supplements. 48\% (blue) of participants consumed pills, 36\% (red) of participants had not consumed pills. 

Figure~\ref{f-160547ce1179} shows a Bar chart representing the association between the gender of the participants and awareness about the fact that fluoride affects the thyroid gland. The association between the variables was analyzed using Chi-square test (Pearson's Chi-square value - 5.176; P-value - 0.075 ({\textgreater}0.05)) and was found to be statistically significant. The X-axis represents the gender of the participants and Y-axis represents the number of responses. Out of 54\% of the participants who are aware, 34\% constitutes male and 20\% constitutes female. Figure~\ref{f-92a70d572c46}: Bar chart represents the association between the gender of the participants and the use of fluoridated toothpaste during 0-10 years. The association between the variables was analyzed using Chi-square test (Pearson's Chi-square value - 10.184; P-value - 0.006 ({\textless}0.05)) and was found to be statistically significant which clearly indicates the majority of males are more aware of the use of fluoridated toothpaste during the age period of 0-10 years than females. The X-axis represents the gender of the participants and Y-axis represents the number of responses. Out of 44\% of the participants who are aware, 37\% constitutes male and 7\% constitutes female. Figure~\ref{f-4ba52147270f} depicts the fact that the consumption of fluoridated well water could prevent caries. 61\% (blue) are aware that consuming fluoridated well water could prevent caries, 23\% (red) unaware and 16\% (green) partially aware that consumption of well water could prevent caries. Figure~\ref{f-710b9dd0aff2}: Bar chart represents the association between the gender of the participants and awareness about the fluoride water benefits lower socio-economic backgrounds. The X-axis represents the gender of the participants and Y-axis represents the number of responses.  Out of 37\% of the participants who are aware, 30\% constitutes male and 7\% constitutes female. The association between the variables was analyzed using Chi-square test (Pearson's Chi-square value - 7.237; P-value - 0.027({\textgreater}0.05)) and was found to be statistically significant. Hence the majority of males are more aware that fluoride water benefits people of lower socio economic backgrounds than females. Figure~\ref{f-828b0ebc6c06} depicts that bottled water is fluoridated. 59\% (blue) were aware that bottled water is fluoridated, 17\% (red) were aware that bottled water is fluoridated and 24\% (green) were ambiguous on the awareness that bottled water is fluoridated. 

According to O~Jensen, the most effective way to administer fluoride is through the regular use of fluoride toothpaste \unskip~\citep{921299:20662407,921299:20662421} (Figure~\ref{f-92a70d572c46}). Hence using fluoridated toothpaste helps in the prevention of caries. This survey helps us to know the awareness that the use of fluoride at a minimum level in toothpaste prevents dental caries \unskip~\citep{921299:20662414,921299:20662411,921299:20662420} (Figure~\ref{f-6bac81909d99}). Parnell C explained in their study about the advantages of using fluoride and the use of fluoride \unskip~\citep{921299:20662434,921299:20662422,921299:20662423}. Fluoride toothpaste helps in the prevention of dental caries \unskip~\citep{921299:20662419,921299:20662424} (Figure~\ref{f-e8e54cf1abc1}). Suppose excess intake of fluoride content causes dental fluorosis (Figure~\ref{f-29c934455a2e}) and skeletal fluorosis (Figure~\ref{f-d6ba66b62e6f}). 

Dental fluorosis is caused by taking in too much fluoride over a long period when the teeth are forming. Only children aged 8 years and younger are at risk because this is when permanent teeth are developing and children older than 8 years, adolescents, and adults cannot develop dental fluorosis. The study done by Lubon AJ relates about training rural women and children to improve access to oral health awareness programs in remote villages \unskip~\citep{921299:20662417,921299:20662404} (Figure~\ref{f-dd3523840a8d}, Figure~\ref{f-66c6dab2b2e1}). 

The previous study conducted was successful in creating awareness for rural people, mainly for pregnant women. Because if pregnant women drink fluoridated water, it can make kids less intelligent \unskip~\citep{921299:20662410,921299:20662428}. \unskip~\citep{921299:20662432,921299:20662416} If pregnant women ingest a high dose of fluoridated water, it affects the tooth development of the fetus \unskip~\citep{921299:20662427,921299:20662425} (Figure~\ref{f-dd3523840a8d}).

The limitations associated with the study is the limited sample size and therefore is not representative of the population by large. Water sources tested in the rural areas had lower fluoride concentration than the recommended level of 0.5 mg/L fluoride in water. Hence, a significant amount of fluoride should be supplemented to meet the biological needs.

Survey of a wider population to increase awareness on the uses of fluoride-containing dentifrices and community water fluoridation. The main aim is to prevent or decrease dental caries in all areas and reduce the incidence of dental caries \unskip~\citep{921299:20662418}. In future strategies should be made to utilize media more effectively for oral health education \unskip~\citep{921299:20662430}. Dental treatments are expensive; in the future, the cost of dentistry will be reduced. Thus, the extension of preventive dentistry is still indispensable.
    
\section{Conclusion}
Within the limits of the present study, awareness and knowledge among the participants about the usage of fluoride are analysed and the study concludes that the majority of the population are aware of the uses of fluoride and the level needed to prevent themselves from Dental Caries. So it is evident from this study that people are aware of the positive and negative impacts due to the level of fluoride in their daily routine and in preventing diseases.  
\section*{Acknowledgement}We thank Saveetha Dental College for providing us with the support to conduct the study.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.
    

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