Available via license: CC BY-NC
Content may be subject to copyright.
156
¹Department of Oral Biology, Semmelweis
University, Budapest, Hungary
²School of Dental Sciences, Newcastle
University, UK
3e Borrow Foundation, Padnell Road
Waterlooville, Portsmouth, UK
Corresponding author:
Jolán Bánóczy
Semmelweis University of Medicine
Department of Oral Biology
Nagyvárad ter 4
1089 Budapest
Hungary
banoczy.jolan@dent.semmelweis-univ.hu
Tel.: + 36 1 303 2436
Fax.: + 36 1 303 2436
Received: 2 November 2012
Accepted: 29 January 2013
Copyright © 2013 by
Academy of Sciences and Arts
of Bosnia and Herzegovina.
E-mail for permission to publish:
amabih@anubih.ba
Milk uoridation for the prevention of dental caries
Jolán Bánóczy¹, Andrew Rugg-Gunn², Margaret Woodward3*
Fluoride and caries prevention
Review article
Acta Medica Academica 2013;42(2):156-167
DOI: 10.5644/ama2006-124.83
e aim of this review is to give an overview of 55 years experience of
milk uoridation and draw conclusions about the applicability of the
method. Fluoridated milk was rst investigated in the early 1950s,
almost simultaneously in Switzerland, the USA and Japan. Stimu-
lated by the favourable results obtained from these early studies, the
establishment of e Borrow Dental Milk Foundation (subsequently
e Borrow Foundation) in England gave an excellent opportunity for
further research, both clinical and non-clinical, and a productive col-
laboration with the World Health Organization which began in the
early 1980s. Numerous peer-reviewed publications in international
journals showed clearly the bioavailability of uoride in various types
of milk. Clinical trials were initiated in the 1980s – some of these can
be classed as randomised controlled trials, while most of the clinical
studies were community preventive programmes. Conclusion. ese
evaluations showed clearly that the optimal daily intake of uoride in
milk is eective in preventing dental caries. e amount of uoride
added to milk depends on background uoride exposure and age
of the children: commonly in the range 0.5 to 1.0 mg per day. An
advantage of the method is that a precise amount of uoride can be
delivered under controlled conditions. e cost of milk uoridation
programmes is low, about € 2 to 3 per child per year. Fluoridation of
milk can be recommended as a caries preventive measure where the
uoride concentration in drinking water is suboptimal, caries expe-
rience in children is signicant, and there is an existing school milk
programme.
Key words: Caries prevention, Fluoride prevention, Milk uoridation,
Caries reduction, Community programmes.
Introduction
e aim of this article is to describe the histo-
ry of milk uoridation and its place in caries
prevention. Individual studies have not been
referenced in this review as they are listed in
the WHO publication ‘Milk uoridation for
the prevention of dental caries’ (1).
Early investigations into uoridated milk
e idea of milk uoridation emerged, at
about the same time, in Japan (1952), in
Switzerland (1953) and the USA (1955). Early
investigations showed that uoride added to
milk does not change its taste or other char-
acteristics, is absorbed well, although slower
* e rst two authors are trustees of e Borrow Foundation (Waterlooville, UK) and the third is employed by the organisation
as the programme coordinator.
157
than from uoridated water. It was consid-
ered advantageous that uoride is added to
an important food for infants and small chil-
dren, and that consumption of uoridated
milk is not mandatory for everybody, only for
those who need it most and agree to receive
it. e caries preventive eect of uoride can
even be enhanced by the milk vehicle, due to
the cariostatic properties of the mineral, pro-
tein and fat content of milk.
e rst clinical results were reported
by Imamura in 1959, aer a ve-year study
of Yokohama schoolchildren. Milk or soup,
containing 2.0 to 2.5 mg sodium uoride,
was consumed at lunch-time, 150 to 180
days per year, by 167 children. Compared
with the control group, 29 to 34% caries re-
ductions were observed in the permanent
dentition. In Baton Rouge, Louisiana, USA,
Ruso and co-workers reported in 1962 on
3.5 years’ results in 129 (65 test and 64 con-
trol) children. In children consuming uori-
dated milk at school meals, 35% less caries
was recorded than in the control children;
in those who were 6 years old at the begin-
ning, the reduction was even larger at 70%.
In Winterthur, Switzerland, Ziegler and
Wirz reported a study where 0.22% sodium
uoride solution, prepared by pharmacies
in plastic bottles, was added by the parents
within the home to milk consumed by chil-
dren. Participants were 749 test and 553
control children who were 9 to 44 months
old at the start of the programme. In 1964,
aer six years, caries reductions were 17%
for the de index (number of decayed, ex-
tracted or lled primary teeth) and 30%
for the defs index (number of decayed, ex-
tracted or lled primary tooth surfaces) in
the primary dentition, and 64% for DMFT
(number of decayed, missing or lled per-
manent teeth) and 65 for DMFS (number of
decayed, missing or lled permanent tooth
surfaces) in permanent molars. e propor-
tion of caries-free children increased signi-
cantly in the uoridated milk group.
e Borrow Foundation
e establishment of a charity in England
by Edgar Wilfred Borrow (1902-1990) for
the promotion of milk uoridation in order
to prevent dental caries in children, brought
important progress in the eld of research
and clinical studies. E.W. Borrow (Figure 1),
a wealthy farmer and mechanical engineer in
south England, constantly interested in the
technical aspects of uoridation of milk, set
up a charity in 1971, named the “Borrow Den-
tal Milk Foundation”, for the above purposes.
e aims, summarized in 12 points, were
mainly “to promote and support research of
uoridated milk for human consumption by
the help of grants, equipment, lectures, scien-
tic publications, and to disseminate knowl-
edge about this method”. e aims of the orig-
inal ‘Trustees’ deed’ were extended in 1993 to
include “the support of activities on health
promotion and education,… and on healthy
nutrition, including milk and milk products”.
Figure 1 Edgar Wilfred Borrow – the founder of “The
Borrow Foundation”.
Jolán Bánóczy et al.: Milk uoridation
158
Acta Medica Academica 2013;42:156-167
e name of the foundation was changed in
2002 to ‘e Borrow Foundation’ (www.bor-
rowfoundation.org). In recognition of his hu-
manitarian services, E.W. Borrow received an
Honorary Doctorate from Lousiana Univer-
sity, USA, in 1983. Two of the authors of this
present review are two of the ve “Trustees”
of e Borrow Foundation.
e results of clinical and basic research
studies, supported by e Borrow Founda-
tion, have made the creation and extension
of milk uoridation programmes possible in
numerous countries of the world. Based on
discussions initiated in the 1980s between
e Borrow Foundation and the World
Health Organization (WHO), the Bulgarian
milk uoridation programme was initiated,
and a ‘Memorandum of Understanding’
was signed by e Foundation and WHO
in 1991; this has been renewed every three
years. As a result of this collaboration, a
book was published in 1996 (2), summariz-
ing the studies of basic and clinical research
into milk uoridation, and a revised edition
was published in 2009 (1).
eoretical considerations
Concerning the pathomechanism of uo-
rides, it is accepted that elevated uoride ion
concentrations at the dental plaque/enamel
border decrease the rate of demineralisation,
increase remineralisation, and reduce acid
production of dental plaque. However, the use
of milk as a vehicle, generated questions con-
cerning possible chemical reactions between
milk and uoride ions, bioavailability of sys-
tematically administered uoride in milk, and
interactions involving uoride in the oral cav-
ity (enamel, saliva, plaque and caries).
e results of basic studies on milk uo-
ridation have been published in more than
100 peer-reviewed papers, with increasing
frequency in the last 20 years. Based on these
studies, according to recent knowledge, the
greater part of uoride added to milk, forms
a soluble complex with the protein frac-
tion of milk, from which the uoride can
be liberated in ionic form, so that it is bio-
available. e absorption of uorides with
simultaneous food consumption is slower
than for uoride without food, and the pro-
portion absorbed depends on the calcium
content of the diet. Dierent types of milk
are drunk in communities around the world
– whole milk or low-fat milk, fresh, pasteur-
ised or sterilised milk, liquid or dried milk.
e bioavailability of added uoride has
been investigated in all of these, on the day
of milk processing and aer several days’
storage, and shown to be satisfactory.
Because urine is the main vehicle for excre-
tion of uoride, analysis of 24 hour urine ex-
cretion is presently the best marker of uoride
intake (3). Recording of uoride excretion in
urine over 24 hours has been recommended
before and aer introduction of uoride-
based community preventive programmes.
A WHO document, published in 1999, oers
detailed guidelines for the method and calcu-
lations: based on these, the optimal uoride
concentration in milk and the appropriate in-
take of uoride can be determined.
e systemic eect of uorides in milk is
supported by numerous experimental data.
However, by the 1980s, the opinion as to how
uoride acts to prevent dental caries was go-
ing through a change: even with the use of
systemic uoride agents, topical eects were
considered more important. e consump-
tion of uoridated milk incorporated into
dental enamel inhibited demineralisation
and promoted remineralisation. In addition,
30-60 minutes aer ingestion of uoridated
milk, both the levels of uoride in whole sa-
liva and dental plaque increase as a conse-
quence of the presence of uoridated milk in
the mouth and increased concentrations of
uoride in salivary secretions following the
absorption of ingested uoride. us, uo-
ride in milk acts both systemically and topi-
cally, in the same way as uoride in water.
159
Clinical evaluations
Long-term human studies with uoridated
milk on children, undertaken in about twelve
countries have been reported in numerous
peer-reviewed papers. Only some of these
studies can be classied as RCTs (randomised
controlled trials) according to the criteria used
in evidence-based medicine; the others can be
classed as community-based programmes. In
the following paragraphs, the main features of
the evaluations of these milk uoridation pro-
grammes in dierent countries of the world
will be summarized, but without the detailed
numerical results which can be found in the
relevant literature (1, 4, 5) (Table 1).
Scotland: Glasgow
Due to the strong criticism of the early clini-
cal studies (for example, small numbers of
participants, lack of baseline examinations,
etc.), Stephen and colleagues initiated in
Glasgow in 1976, a double blind clinical
trial on 4 ½ and 5 ½ year old schoolchil-
dren. e group of test children consumed
200 ml milk each school day (about 200 days
per year), containing 1.5 mg uoride, while
the control group received plain milk. e
results published in 1984, aer ve years, re-
ported a 36% reduction in DMFT and a 48%
reduction in DMFS values for the rst per-
manent molars which were not yet erupted at
baseline in the test group compared with the
control group. Fluoride excretion in urine
was monitored constantly during the study.
(1) is evaluation (together with the Volgo-
grad programme by Maslak: see later) is one
of the programmes accepted as an RCT by
the Cochrane Centre for Systematic Reviews.
Table 1 List of published reports of studies into the eectiveness of milk uoridation
Study Year of study Authors
Caries prevention in:
Primary
teeth
Permanent
teeth
Yokohama, Japan 1952 – 1956 Imamura, 1959 - +
Baton Rouge, USA 1955 –1959 Ruso et al., 1962 - +
Winterthur, Switzerland 1958 – 1964 Wirz, 1964; Ziegler, 1964 + +
Agudos, Brazil 1976 – 1979 Lopes et al., 1984 - -
Glasgow, UK 1976 –1981 Stephen et al, 1981; Stephen et al., 1984 - +
Fót, Hungary 1979 –1990 Bánóczy et al., 1983; Bánóczy et al., 1985;
Gyurkovics et al.,1992 + +
Louisiana, USA 1982 – 1985 Legett et al., 1987 - +
Bethlehem, Israel 1983 –1986 Zahlaka et al., 1987 + +
Asenovgrad, Bulgaria 1988 – 1993 Pakhomov et al., 1995; Atanassov et al., 1999 + +
Codegua, Chile 1994 –1999 Mariño et al., 2001 + -
Voronezh, Russia 1994 – 2004 Pakhomov et al., 2005 + -
Wirral, UK 1995 – 2003 Riley et al., 2005 - +
Beijing, China 1997 –1999 Bian et al., 2003 + -
Knowsley, UK 1997 – 2001 Ketley et al., 2003 - -
Volgograd, Russia 1998 –2002 Maslak et al., 2004 + +
Araucania, Chile 1999 – 2002 Weitz and Villa, 2004 - +
Umeå, Sweden 2006 – 2007 Steckén-Blicks et al., 2009 + -
Ljungby, Sweden 2006 – 2008 Petersson et al., 2011 - +
Jolán Bánóczy et al.: Milk uoridation
160
Acta Medica Academica 2013;42:156-167
Hungary: Fót
In the ‘Children’s City’ of Fót, a milk uori-
dation programme was initiated by Bánóc-
zy, Zimmermann and colleagues in 1979,
involving about 1000 children aged 2 to18
years (1). e results were published aer
2, 3 and 10 years (1982-1992). e children
drank for breakfast milk or cocoa, contain-
ing 0.4 mg uoride for kindergarten children
and 0.75 mg uoride for the schoolchildren.
e sodium uoride solutions were pre-
pared by the Pharmacy of Semmelweis Uni-
versity in closed glass bottles, then added to
the milk in the kitchen of the home, stirred
thoroughly for 15 minutes, and consumed
within 30 minutes by the children. Aer ve
years, in the test group (165) children com-
pared with a control group, a considerable
caries reduction was observed in both the
primary and permanent dentitions. In 7 to
10 year old children, these percentage reduc-
tions were 54% in DMFT and 53% in DMFS
values. e reduction in the total permanent
dentition was 60% for DMFT and 67% for
DMFS; the highest reductions were found in
the children who had consumed uoridated
milk from 2 to 3 years of age. e dierence
between the caries prevalence of the test and
control groups was, in spite of loss of chil-
dren from the study, still statistically signi-
cant aer 10 years.
USA: Lousiana, Baton Rouge
In the second Lousiana community pro-
gramme, begun in 1982, schoolchildren
consumed uoridated milk, containing co-
coa and sugar, for lunch for two or three
years. Aer two years, a signicant caries
reduction was observed in the permanent
dentition: however, due to the loss of chil-
dren, three year results could not be evalu-
ated (1).e organiser of the experiment,
Legett, planned also to establish a research
institute for milk uoridation which, how-
ever, could not be realised.
Israel: Bethlehem
Zahlaka and colleagues reported in 1987 the
results of a study on 273 children who were
aged 4 to 7 years at baseline and who had
consumed uoridated milk for three years.
e uoridated milk was produced from milk
powder, and the dissolved milk contained 1
mg uoride per litre. A 63% caries reduction
was observed in both the primary and per-
manent dentitions aer three years (1).
Bulgaria: Asenovgrad
One of the most extensive milk uoridation
programmes was initiated by Pakhomov and
colleagues in Bulgaria in 1988 with the sup-
port of WHO (1). e objective was to see if
such a programme was feasible under every-
day life conditions. Bulgaria seemed to be an
excellent choice for this community-based
programme due to the regular consumption
of milk and milk products (for example, yo-
ghurt) by children. e city Asenovgrad in
south Bulgaria was selected as the test com-
munity and the nearby city of Panaguriche
as the control community; later, Karlovo be-
came the control community. e uoridated
milk was produced and transferred from the
Plovdiv dairy, in plastic bags for each child
containing 1 mg uoride per day. About
3,000 children aged 3 to 10 years entered the
programme in Asenovgrad (Figure 2).
e caries examinations at baseline and
aer 3 and 5 years were performed by den-
tists calibrated by a WHO epidemiologist.
Urine monitoring was carried out regularly.
Aer ve years, mean dm values were 52%
lower in the test group children aged 6 ½
years and 40% lower in the 8 ½ year olds.
e reductions in mean DMFT in these
two age groups were 89% and 79% – statis-
tically highly signicant. Aer 10 years of
the programme, Atanassov and colleagues
recorded further signicant dierences in
the proportion of caries-free children and in
161
mean DMFT (1) values of the test and con-
trol groups. In some communities there is a
preference for uoridated yoghurt.
Brazil and Peru
From Agudos in Brazil, Lopes and col-
leagues reported in 1984 a small milk uo-
ridation study lasting 16 months. However,
due to the short period, the results were not
signicant. In Peru, a milk uoridation pro-
gramme started in the early 2000s, based on
the government programme ‘vaso de leche’,
which provides one glass of milk for children
each day. e programme was controlled by
the University of Trujillo. e children re-
ceived their milk in ‘Mother’s clubs’, where
a uoride solution prepared by the pharma-
cies was added to fresh milk brought in by
farmers, stirred thoroughly for 15 minutes,
and consumed shortly aer (1) (Figure 3).
However, the programme was stopped
aer a few years because of the expanding
use of uoridated salt in that community,
before any evaluation was made. e en-
croachment of uoridated salt was detect-
Figure 2 Bulgaria program: kindergarten children drinking uoridated milk.
Figure 3 Peru program: uoridated milk –after stir-
ring- distributed at the “mothers club”.
Jolán Bánóczy et al.: Milk uoridation
162
Acta Medica Academica 2013;42:156-167
ed before the community was aware of the
presence of uoridated salt, by monitoring
of urinary uoride excretion.
Chile: Codegua and Araucania
e Chilean milk uoridation programmes
possess two features which dier from other
programmes. First, instead of using sodium
uoride they use sodium monouorophos-
phate which, according to Villa and col-
leagues, has good bioavailability and other
technical advantages and, second, the uo-
ride is added to powdered milk.
e rst investigation took place in Co-
degua involving infants and young children,
and took advantage of the ‘national nutri-
tion complementing programme’ (PNAC)
which has been in existence for more than
50 years. Under this scheme, every Chilean
child, from birth to two years of age, receives
two kilogrammes of milk powder every
month, while children aged 2-6 years receive
monthly one kilogramme of milk powder
with cereals. e PNAC programme covers
90% of the child population. e uoridated
milk pilot programme was organised and
evaluated by Villa, Mariño and colleagues in
1994 in the rural areas of Codegua (test) and
La Punta (control). Children between 0 and
6 years of age consumed daily, for four years,
0.25, 0.5 or 0.75 mg uoride mixed into the
milk powder, according to their age-group.
Fluoride-containing toothpaste was avail-
able and urine monitoring for uoride ex-
cretion was performed regularly. Aer ve
years, the proportion of caries-free children
was higher in Codegua than in the control
La Punta, and mean dmfs values showed
signicant reductions in children in Code-
gua compared with children in La Punta.
However, examinations performed three
years aer cessation of the program showed
very small dierences, pointing to the ne-
cessity of continuous maintenance of caries
preventive programmes.(1).
In the IXth region of Chile, a new uori-
dated milk programme started in 1999 with
about 35000 children aged 6 to 14 years who
were participating in the national powdered
milk programme (see above). In the com-
munity of Araucania, 6, 9 and 12 years old
children received milk powder containing
sodium monouorophosphate, while the
control children received milk powder with-
out added uoride. e control children
were already participating in a community
preventive programme in which they re-
ceived applications of a high-uoride gel.
Examinations showed, historically, reduc-
tions in caries of 24 to 27% in children aged
9 and 12 years, which was similar to the re-
sults of the uoride gel programme. Because
the uoride gel programme was dicult
to administer (it involved gel application
by health professionals), the milk-powder
uoridation programme has now been in-
troduced into the majority of the Chilean
regions as part of the caries preventive pro-
gramme for 6-14 year old children living in
rural communities. While the main cities in
Chile receive optimally uoridated water as
a public health measure, milk uoridation is
provided in the rural areas where water uo-
ridation is technically not possible, in order
to ensure equity.
China: Beijing
Due to the increasing caries prevalence in
some parts of China, a milk uoridation
programme was introduced between 1994-
1997 for Chinese kindergarten children in a
district of Beijing. An evaluation showed no
eect, probably due to the high amount of
sugar (7-10%) added to milk. In the second
phase of the programme, therefore, no sugar
or only small amount of sugar was added
to the pasteurized milk which contained
2.5 ppm uoride and which was consumed
everyday in kindergartens. In addition,
children brought home uoridated milk
163
for weekends. Dentists calibrated to WHO
standards examined the children aer 21
months, recording also arrested caries. e
mean dm value in the test group showed
a 69% reduction compared with the control
(1). ese results showed that uoridated
milk, when consumed daily, was able to
prevent caries in the primary dentition and
stop active dentinal caries from progressing,
probably due to the topical eect of uori-
dated milk. e study may also indicate the
importance of not adding sucrose to milk
(or other drinks).
United Kingdom: Knowsley and Wirral
A milk uoridation programme was
launched in 1997 in Knowsley by Ketley and
colleagues, where 4060 three to ve year old
children (mean age 4.7 years), consumed,
each day, milk containing 0.5 mg uoride;
the control children in Skelmersdale drank
plain milk. e number of days the chil-
dren received milk was about 180 days per
year. Caries evaluation was made, based on
BASCD (British Association for the Study of
Community Dentistry) criteria. Aer four
years, no statistically signicant dierences
in dm and dmfs values of the two groups
were found. e DMFT and DFS values
were slightly, but not statistically signicant-
ly, smaller in the 7 to 9 year old children of
the test group, than in the control. e as-
sumption for these results was that the dose
of uoride in the milk was too low and that
the period of consumption was not long
enough to show an eect.
In a second evaluation in the Wirral re-
gion of north-west England, examinations,
using the same BASCD criteria, were made
by Riley and colleagues in 2003 on 5700 chil-
dren who were at least 5 years old when they
entered the uoridated milk programme.
Data for the four permanent molars were
compared between 773 children who had
been drinking uoridated milk for six years
at least, and 2052 children from Seon, who
had received milk without added uoride.
Caries prevalence in the test group was 13%
less in the primary dentition and 16% less in
the permanent dentition. e mean DMFT
value showed a reduction of 31%, and the
mean DFS a 37% reduction, compared with
the control (1).
Russia: Volgograd and Voronezh
Milk uoridation programmes in Russia
started in 1993 as a collaboration between
the WHO and e Borrow Foundation, with
participants initially in three communities –
Voronezh, Maykop and Smolensk – and later
on in Volgograd and several communities
in Tatarstan (Figure 4). Kouzmina and col-
leagues evaluated three year results in 1999
for 15000 participating children, and report-
ed caries reductions between 55 and 68%.
Figure 4 Measurement of the uoride solution in the
Russian program.
Jolán Bánóczy et al.: Milk uoridation
164
Acta Medica Academica 2013;42:156-167
e second milk uoridation pro-
gramme in Russia was in Volgograd, and
this was evaluated by Maslak and colleagues
in a three year study involving children who
were caries-free when entering the pro-
gramme at 3 years of age. In this double-
blind evaluation, undertaken by examiners
calibrated according to WHO criteria, on
75 test and 91 control children, statistically
signicant reductions were recorded, both
in dm and DMFT values, and in longitu-
dinal as well as cross-sectional comparative
analyses. According to the evaluation by the
Cochrane Centre for Systematic Reviews,
this study, as well as that of Stephen and col-
leagues in Scotland, is accepted as an RCT
and as evidence for the eectiveness of milk
uoridation.
In the town of Voronezh, the eect of a
10 year milk uoridation programme was
evaluated on 15000 kindergarten children in
two horizontal comparative analyses. Pak-
homov and colleagues compared data from
335 test and 175 control children aer three
years, and revealed a statistically signicant
reduction in dm values and an increase
in caries-free children in the test group. In
a second analysis, data from 3, 6, 9 and 12
year old children were compared cross-sec-
tionally with baseline data, and a statistically
signicant caries reduction was observed.
Urinary uoride monitoring showed that the
daily consumption of 200 ml milk containing
2.5 ppm uoride is an eective caries preven-
tive method and that the uoride intake cor-
responded to physiological norms (1).
ailand: Bangkok and other communities
A well-organized milk uoridation pro-
gramme for children started in ailand
in the year 2000 with the help of e Royal
Chitralada Projects a unique centre for ag-
ricultural and research development, initi-
ated by His Royal Highness King Bhumibol
Adulyadej. An evaluation is in progress. e
project now includes all schoolchildren in
Bangkok, and seven other provinces in ai-
land, reaching nearly a million children in
total (Figures 5 and 6).
Former Yugoslav Republic of Macedonia
In October 2009 the Ministry of Health in-
troduced a milk uoridation programme in
the Former Yugoslav Republic of Macedonia
which was promoted as one of the measures
to be applied under a national strategy for
prevention of oral diseases in children aged
0 to 14 years.
e scheme was established through
the kindergarten system, and involved ap-
proximately 7,700 children aged 3 to 5 years,
who received 200 ml uoridated UHT milk
on school days. Although the programme
ceased in 2011 when Government funding
for school milk was decentralised to local
Figure 5 Thailand program: schoolchildren consum-
ing uoridated milk during a break.
165
cent caries reduction of 75% was recorded.
Although there is some evidence elsewhere
that probiotics confer some caries-preven-
tive eect, the majority of this large eect is
likely to be due to the addition of uoride.
e second Swedish trial investigated
prevention of dental caries in root surfaces
of teeth in older people. e main outcome
of this trial by Petersson and colleagues (5)
and published in 2011, was the healing (rem-
ineralisation or hardening) of early lesions.
Again, addition of uoride and probiotic
bacteria to milk was investigated but, un-
like the Umeå study, there were four paral-
lel groups, so that the independent eects of
uoride and probiotics could be investigat-
ed. 160 healthy subjects aged 58 to 84 years
took part: the study period was 15 months.
e quantity of milk drunk was 200ml per
day and the level of uoride supplementa-
tion was 5.0 mg F/litre. Although some
benet was recorded from consumption of
probiotics, this eect was not statistically
Figure 6 Thailand program: schoolchildren consuming uoridated milk during a break.
municipalities, there is a will for the pro-
gramme to be reinstated as part of a wider
health promoting project, “Healthy Food for
Healthy Childhood”.
Sweden: Umeå and Ljungby
Stecksén-Blicks and colleagues (4) carried
out an evaluation of the eect of supplement-
ing milk with uoride and probiotic bacteria
which was provided to pre-school children
in day care centres: the results were pub-
lished in 2009. It was conducted near Umeå,
northern Sweden, where there is a culture of
using probiotics for general health benets.
248 children aged 1 to 5 years attending
14 day care centres entered the study. e
centres were randomly assigned to test and
control. Children in the test group received
150ml of milk containing 2.5 mgF/litre and
probiotic bacteria while the control group
received standard milk. e double-blind
intervention lasted 21 months when a per
Jolán Bánóczy et al.: Milk uoridation
166
Acta Medica Academica 2013;42:156-167
signicant and the eect was much less than
the statstically signicant eect of uoride.
Safety considerations
Numerous studies in several countries have
demonstrated that ingestion of uoride add-
ed to milk is well within WHO guidelines for
young and older children: this conclusion is
based on WHO guidelines for urinary uo-
ride excretion (6). One of the advantages of
milk uoridation is that a precise amount
of uoride is added to milk and provided
to children each day. Follow up studies, by
Mariño and colleagues (7), of children who
took part in the Codegua study in Chile (see
above) showed no adverse eect on the ap-
pearance of permanent front teeth which
had been forming at the time the children
were receiving their uoridated milk.
Cost of milk uoridation programmes
ere have been several economic evalua-
tions of the milk uoridation programme
in Chile (8, 9). ese conclude that the pro-
gramme costs about €1.20 to €2.40 per child
per year. is gure is very similar to the
gure of £1.25 (€1.50) per child per year in
the UK milk uoridation programme and
34.06 ai baht (€ 0.86) per child per year
in ailand.
Conclusions
ere are now over a million children re-
ceiving uoridated milk (Table 2).
e eectiveness of milk uoridation
in preventing dental caries is supported by
about 18 clinical studies reported in numer-
ous papers. Of these, nine demonstrated
caries prevention in primary teeth and 12
in the permanent dentition (Table 1). Two
studies showed no eect in either dentition.
An evaluation aer cessation of a pilot milk
uoridation programme in Chile, caries in-
cidence increased (10). Four RCTs showed
caries reductions, and evaluations of the
several community programmes pointed to
the feasibility of the method under real life
conditions. is evidence from clinical stud-
ies is underpinned by much research which
demonstrates the bioavailibility of uoride
added to milk and the biological plausibil-
ity of milk uoridation. Milk uoridation is
safe and the cost is low.
Based on these published studies, it
seems that to obtain good results with milk
uoridation, even in the primary dentition,
the programmes should start early, possibly
Table 2 The international programme
Country
Year F milk
programme
began
Number of
participating
children
Age-range
of children
(y)
Amount of milk
(ml)
Amount
of uoride
(ml)
Bulgaria* 1988 31000 3 to 7
100 0.5
150 0.75
200 0.5
United Kingdom 1993 32000 3 to 11 189 0.5
Russian Federation 1994 39000 3 to 11 200 0.5
Chile 2000 220000 6 to 14 200 0.85
Thailand 2000 982188 3 to 12 200 0.5
Former Yugoslav Republic
of Macedonia† 2009 7700 3 to 6 200 0.5
*As at 2008; programme under review; †As at 2011; programme under review.
167
before the age of four years. In order to pro-
tect the permanent molar teeth, consump-
tion of uoridated milk is necessary during
and aer their eruption too. e amount of
uoride added to milk is decided depending
on age and background exposure to uoride:
the amount is commonly about 0.5 mg per
day for young children and around 1.0 mg
per day for older children. e introduction
of milk uoridation programmes should be
considered where the uoride content of
drinking water is low, where a regular school
milk system is working and where the chil-
dren are able to consume the uoridated
milk for at least 200 days in a year.
Authors’ contribution: Conception and design: JB
and ARG; Acquisition, analysis and interpretation of
data: ARG and MW; Draing the article: ARG and
MW; Revising it critically for important intellectual
content: JB and AR.
Conict of interest: e authors declare that they
have no conict of interest.
References
1. Bánóczy J, Petersen PE, Rugg-Gunn AJ, editors.
Milk uoridation for the prevention of dental car-
ies. 2nd ed. Geneva: World Health Organization;
2009.
2. Stephen KW, Bánóczy J, Pakhomov GN, editors.
Milk uoridation for the prevention of dental car-
ies. Geneva: World Health Organization/Borrow
Dental Milk Foundation; 1996.
3. Rugg-Gunn AJ, Villa AE, Buzalaf MAR. Contem-
porary biological markers of exposure to uoride.
In: Buzalaf MAR, editor. Fluoride and the oral en-
vironment. Monogr Oral Sci. Basel: Karger; 2011.
p. 37-51.
4. Stecksén-Blicks C, Sjöström I, Twetman S. Ef-
fect of long-term consumption of milk supple-
mented with probiotic lactobacilli and uoride
on dental caries and general health in preschool
children: a cluster-randomized study. Caries Res.
2009;43:374-81.
5. Petersson LG, Magnusson K, Hakestam U, Baigi
A, Twetman S. Reversal of primary root caries le-
sions aer daily intake of milk supplemented with
uoride and probiotic lactobacilli in older adults.
Acta Odontol Scand. 2011;69:321-7.
6. Marthaler TM. Monitoring of renal uoride ex-
cretion in community prevention programmes on
oral health. Geneva: World Health Organization;
1999.
7. Mariño R, Villa A, Weitz A, Guerrero S. Preva-
lence of uorosis in children aged 6-9 years-old
who participated in a milk uoridation pro-
gramme in Codegua, Chile. Community Dent
Health. 2003;20:143-8.
8. Mariño R, Morgan M, Weitz A, Villa A. e cost-
eectiveness of adding uorides to milk-products
distributed by the National Food Supplement Pro-
gramme (PNAC) in rural areas of Chile. Commu-
nity Dent Health. 2007;24:75-81.
9. Mariño R, Fajardo J, Morgan M. Economic evalu-
ation of dental caries prevention programs using
milk and its products as the vehicle for uorides:
cost versus benets. In: Watson RR, Gerald JK,
Preedy VR, editors. Nutrients, dietary supple-
ments, and nutriceuticals: cost analysis versus
clinical benets. New York: Springer Science;
2011. p. 143-60.
10. Mariño RJ, Villa AE, Weitz A, Guerrero S. Car-
ies prevalence in a rural Chilean community aer
cessation of a powdered milk uoridation pro-
gram. J Public Health Dent. 2004;64:101-5.
Jolán Bánóczy et al.: Milk uoridation
