MalDent Project / Smileawi collaboration with the Water Futures Programme sheds light on groundwater fluoride risk

‘Networking’, ‘partnerships’ and ‘collaboration’ are words that are used frequently in the context of international development. Those of us in Scotland who are engaged in projects with Malawian partners are extremely fortunate that there are many initiatives to support joint working. In addition to the direct and generous leadership of Scottish Government in this arena, the Scotland Malawi Partnership and its sister organization the Malawi Scotland Partnership play a pivotal role. Their input is evidenced by this story of a collaboration which is starting to bear fruit and shows great potential in two important areas of the Sustainable Development Goals – safe water supplies (SDG 6) and good oral health (SDG 3).

In October 2018 I attended the Annual General Meeting of the Scotland Malawi Partnership, held in the Student Union of the University of Glasgow.

Where it all started – the Scotland Malawi Partnership AGM at the University of Glasgow Student Union

Whilst there, I met Ieuan Isaac from the Rotary Club of Ayr, who discussed with me the work of the club on a water borehole project at a Malawian village, delivering sustainable water to over 700 residents. Their project had received valuable assistance from Professor Bob Kalin, based at the University of Strathclyde. Ieuan asked if I would be prepared to address the Ayr Rotary Club members about the MalDent Project, which I was delighted to do.

Purely by chance, on the date that was set for my brief address (26th February 2019), Dr Mwapatsa Mipando, Principal of the University of Malawi College of Medicine, was in Scotland and he accompanied Niall Rogerson and I to Ayr, where we gave a joint presentation and answered questions.

Bob Kalin was in the audience. Bob is the Director of the Climate Justice Fund: Water Futures Programme (WFP), which is funded by the Scottish Government. Following the formal part of the evening, Bob, Mwapatsa, Niall and I had a very interesting discussion about potential synergies between the MalDent Project and the Water Futures Programme in the context of the fluoride content of water.

With Mwapatsa, Bob and Niall, after our fledgling discussions about mutual interests

For readers who don’t have a dentistry background, fluoride is of great importance to dental health. At appropriate concentrations (0.7 – 1.2 parts per million), fluoride in drinking water strengthens tooth enamel and reduces the risk of dental decay. Some places have sufficient fluoride in natural water sources whilst in some geographic locations fluoride is added to the water supply. If the drinking water is low in fluoride, then regular brushing with fluoride-containing toothpaste has been shown to provide added protection. However, excessive fluoride in drinking water interferes with the formation of enamel when children’s teeth are developing, resulting in an appearance of the teeth which can be unsightly.

Dental fluorosis in a Malawian school pupil. Photo courtesy of Nigel & Vicky Milne

In an unrelated series of discussions, Nigel and Vicky Milne, the founders of Smileawi, had approached Glasgow Dental School for support with a child oral health survey which they were keen to undertake in some of the schools based in Malawian villages that they visited regularly to support dental healthcare. Furthermore, they wondered whether any of our senior students may be interested in participating. As regular readers of the blog will know from previous posts, this all went ahead, and as part of the preparations we linked the Smileawi team with Bob Kalin and one of his PhD students, Marc Addison, who is studying fluoride in groundwaters in Malawi.

Nigel and Vicky enjoying a training session delivered by David Conway and Lorna Macpherson in preparation for their child oral health survey

Marc provided the Smileawi team with fluoride-measuring kits to assess the water in the boreholes at each of the six schools they visited, though it is important to recognise that it is the fluoride content in village water supplies where the children live during the period of tooth formation that is of critical importance. At one of these schools, in Dedza District in Central Malawi, they identified a higher level of fluoride than in the others. In this same school they also identified a significant number of children with dental fluorosis, quite unlike the clinical picture in the other five schools.

Vicky Milne and Paula Houston testing borehole water for its fluoride content in one of the schools

Once all the epidemiological data collected by the Smileawi team had been checked for accuracy, they were passed in anonymised format to Marc, to consider in the context of his work to predict groundwater vulnerability to geogenic fluoride risk. Recently, Marc contacted us to review the outcome of his cross-referencing, which has proved very exciting.

The Glasgow Dental School team is briefed by the Strathclyde team – exciting news

In summary, the school in Dedza is located in an area where Marc’s work has predicted that an underground hot spring is buried beneath sediment. The relevance of this is shown in the whisker plot below, because the water that emanates from hot springs contains very high levels of fluoride.

Geogenic fluoride risk classification

At present, the Malawi drinking water standard is 6 mg/l, a concentration which can cause both dental and skeletal fluorosis. In due course, through a staged process, the ambition is to reduce that standard to the WHO drinking water standard of 1.5mg/l.

In light of the hard work put in by the Smileawi team to gather the epidemiological data, Bob and Marc kindly agreed to repeat their presentation for Nigel and Vicky Milne on the evening of 28th October 2020.

Nigel and Vicky Milne see the results of their labours

It was as exciting for the Smileawi team as it had been for us to see how these separate pieces of work in two distinct disciplines had come together in a complementary way.

Marc demonstrates and discusses a geological map of Malawi

Gaining an understanding of how the underlying geology could impact on fluoride levels in drinking water, which in turn has a very significant effect on dental health (for good or bad, depending on concentration), was extremely enlightening.

A cross-sectional map of the geology in the area of the school whose pupils showed a high prevalence of dental fluorosis

Despite the fact that Bob and Marc had already provided a presentation summarising these results on two occasions for us, there was to be a third time! A major strand of ongoing work for the MalDent Project is its involvement in the development of a national Oral Health Policy with the Government of Malawi Ministry of Health & Population. The fourth meeting of the policy task force was scheduled for Thursday 5th November, and with the agreement of the chair, Dr Nedson Fosiko, we invited Bob and Marc to deliver a presentation to the task force members. At Bob’s suggestion, we also invited Modesta Kanjaye, who is the Director of Water Resources at the Ministry of Forestry and Natural Resources.

Bob gave an initial, brief overview of the Climate Justice Fund: Water Futures Programme, to provide context for the task force members

He showed a series of slides, including an illustrated description of the extensive mapping of water points that has been completed.

Following Bob’s introduction, Marc described his PhD studies on fluoride levels in the Malawian water supply.

What is striking, as we had heard in Marc’s previous presentations, is the very wide variation in levels of fluoride across the country, which are totally dependent on the underlying geology.

Marc has very recently published a paper on his work, entitled Predicting groundwater vulnerability to geogenic fluoride risk: a screening method for Malawi and an opportunity for national policy redefinition, which interested readers can download here. Further papers are in preparation.

The relevance of these wide fluoride level fluctuations to dental health is substantial. There will be areas of the country where the natural fluoride level is optimal for dental caries prevention, others where additional fluoride (eg from regular supervised toothbrushing with a fluoride-containing toothpaste) would be recommended and some areas in which excessive levels are causing dental fluorosis. We have now added geographic distribution of drinking water fluoride levels to the situational analysis the Oral Health Policy Task Force is currently undertaking, to inform the policy content.

To illustrate the complexity of the problem, Bob showed a graph of the various water points in the villages surrounding the school in which children with fluorosis were identified by the Smileawi team. All of these points are now being tested for their fluoride content, in an attempt to identify the specific water sources that are responsible for the fluorosis in the children.

Multiple sources of drinking water in the villages surrounding the school

In summary, this joint work is mutually supportive. From the perspective of the MalDent Project, our increased understanding of the geographic distribution of the varying fluoride levels in drinking water will inform both the design of the forthcoming national child oral health survey and the content of the oral health policy. From the perspective of the Water Futures Programme, epidemiological data that we gather from the national child oral health survey and related dental research programmes can act as a proxy to help the team focus its efforts on fluoride reduction in water supplies to those water points most likely to require attention. Furthermore, the engagement of both the Ministry of Health & Population and the Ministry of Forestry & Natural Resources in ongoing discussions provides key central links within the Government of Malawi.

Since this story started with the Ayr Rotary Club and the kind invitation from Ieuan Isaacs to one of their meetings, we should perhaps close on the same theme. I took a photo of this plaque in the Savoy Park Hotel on the evening that Mwapatsa and I spoke to the members there.

Those initial discussions with Bob Kalin have turned into a substantial and valuable collaboration. In line with Rabbie Burn’s exhortation – we caught the moments and we’re putting them to good use.

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