ArticlePDF AvailableLiterature Review

Milk fluoridation for the prevention of dental caries


Abstract and Figures

The aim of this review is to give an overview of 55 years experience of milk fluoridation and draw conclusions about the applicability of the method. Fluoridated milk was first investigated in the early 1950s, almost simultaneously in Switzerland, the USA and Japan. Stimulated by the favourable results obtained from these early studies, the establishment of The Borrow Dental Milk Foundation (subsequently The Borrow Foundation) in England gave an excellent opportunity for further research, both clinical and non-clinical, and a productive collaboration with the World Health Organization which began in the early 1980s. Numerous peer-reviewed publications in international journals showed clearly the bioavailability of fluoride 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. These evaluations showed clearly that the optimal daily intake of fluoride in milk is effective in preventing dental caries. The amount of fluoride added to milk depends on background fluoride 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 fluoride can be delivered under controlled conditions. The cost of milk fluoridation programmes is low, about € 2 to 3 per child per year. Fluoridation of milk can be recommended as a caries preventive measure where the fluoride concentration in drinking water is suboptimal, caries experience in children is significant, and there is an existing school milk programme.
Content may be subject to copyright.
¹Department of Oral Biology, Semmelweis
University, Budapest, Hungary
²School of Dental Sciences, Newcastle
University, UK
3e Borrow Foundation, Padnell Road
Waterlooville, Portsmouth, UK
Corresponding author:
Jolán Bánóczy
Semmelweis University of Medicine
Department of Oral Biology
Nagyvárad ter 4
1089 Budapest
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:
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 eective 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 signicant, and there is an existing school milk
Key words: Caries prevention, Fluoride prevention, Milk uoridation,
Caries reduction, Community programmes.
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.
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 eect 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, aer 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,
aer 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-
tic 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
Acta Medica Academica 2013;42:156-167
e name of the foundation was changed in
2002 to ‘e Borrow Foundation’ (www.bor- 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. Dierent 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 aer 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 aer introduction of uoride-
based community preventive programmes.
A WHO document, published in 1999, oers
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 eect 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 eects were
considered more important. e consump-
tion of uoridated milk incorporated into
dental enamel inhibited demineralisation
and promoted remineralisation. In addition,
30-60 minutes aer 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.
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 classied 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 dierent 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, aer 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 eectiveness of milk uoridation
Study Year of study Authors
Caries prevention in:
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
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 aer
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. Aer 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 dierence
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 aer 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. Aer two years, a signicant 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 aer 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
aer 3 and 5 years were performed by den-
tists calibrated by a WHO epidemiologist.
Urine monitoring was carried out regularly.
Aer 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 signicant. Aer 10 years of
the programme, Atanassov and colleagues
recorded further signicant dierences in
the proportion of caries-free children and in
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
signicant. 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 ‘Mothers 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 aer (1) (Figure 3).
However, the programme was stopped
aer 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
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 dier from other
programmes. First, instead of using sodium
uoride they use sodium monouorophos-
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. Aer ve
years, the proportion of caries-free children
was higher in Codegua than in the control
La Punta, and mean dmfs values showed
signicant reductions in children in Code-
gua compared with children in La Punta.
However, examinations performed three
years aer cessation of the program showed
very small dierences, 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 monouorophosphate, 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 dicult
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
eect, 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
for weekends. Dentists calibrated to WHO
standards examined the children aer 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 eect 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. Aer four
years, no statistically signicant dierences
in dm and dmfs values of the two groups
were found. e DMFT and DFS values
were slightly, but not statistically signicant-
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 eect.
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 Seon, 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
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
signicant 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 eectiveness of milk
In the town of Voronezh, the eect 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 aer three
years, and revealed a statistically signicant
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
signicant caries reduction was observed.
Urinary uoride monitoring showed that the
daily consumption of 200 ml milk containing
2.5 ppm uoride is an eective 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.
cent caries reduction of 75% was recorded.
Although there is some evidence elsewhere
that probiotics confer some caries-preven-
tive eect, the majority of this large eect 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 eects 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
benet was recorded from consumption of
probiotics, this eect 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 eect 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 benets.
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
Acta Medica Academica 2013;42:156-167
signicant and the eect was much less than
the statstically signicant eect 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 eect 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.
ere are now over a million children re-
ceiving uoridated milk (Table 2).
e eectiveness 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 eect in either dentition.
An evaluation aer 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
Year F milk
Number of
of children
Amount of milk
of uoride
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.
before the age of four years. In order to pro-
tect the permanent molar teeth, consump-
tion of uoridated milk is necessary during
and aer 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; Draing the article: ARG and
MW; Revising it critically for important intellectual
content: JB and AR.
Conict of interest: e authors declare that they
have no conict of interest.
1. Bánóczy J, Petersen PE, Rugg-Gunn AJ, editors.
Milk uoridation for the prevention of dental car-
ies. 2nd ed. Geneva: World Health Organization;
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.
5. Petersson LG, Magnusson K, Hakestam U, Baigi
A, Twetman S. Reversal of primary root caries le-
sions aer 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;
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-
eectiveness 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 benets. In: Watson RR, Gerald JK,
Preedy VR, editors. Nutrients, dietary supple-
ments, and nutriceuticals: cost analysis versus
clinical benets. 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 aer
cessation of a powdered milk uoridation pro-
gram. J Public Health Dent. 2004;64:101-5.
Jolán Bánóczy et al.: Milk uoridation
... Since the level of fluoride in drinking water may be insufficient to achieve the outcomes in childhood caries prevention, strategies for fluoride supplementation have been adopted in previous decades [12]. Fluorination of water [22] and dietary fluoride supplementation in salt [23] or milk [24] have been widely used to carry out this activity. ...
... The fluoride content of milk could play a role in improving the mineralization of teeth in children and preventing dental caries. Consequently, the consumption of fluoridated milk has been successfully promoted in many countries [24][25][26][27][28][29][30][31][32]. As a result, several authors have developed analytical methods aimed at assessing the fluoride levels in milk-based matrices. ...
Full-text available
Free fluoride ions are effective in combating caries in children, and their supplementation in milk has been widely used worldwide for this purpose. Furthermore, it is known that ionic fluoride added to milk is distributed among its components, but little is known about their quantitative relationships. This is likely due to the absence of an analytical protocol aimed at differentiating and quantifying the most important forms of fluorine present in milk. For the first time, a comprehensive protocol made up of six potentiometric methods devoted to quantifying the most important fractions of fluorine in milk (i.e., the free inorganic fluoride, the inorganic bonded fluorine, the caseins-bonded fluorine, the whey-bonded fluorine, the lipid-bonded fluorine, and the total fluorine) has been developed and tested on real samples. Four of the six methods of the procedure are original, and all have been validated in terms of limit of detection and quantification, precision, and trueness. The data obtained show that 9% of all fluorine was in ionic form, while 66.3% of total fluorine was bound to proteins and lipids, therefore unavailable for human absorption. Beyond applications in dental research, this protocol could be extended also to other foods, or used in environmental monitoring.
... Milk fluoridation has been reported to be successful in dental caries prevention, particularly in children as a community preventive programs in form of milk snacks (23,25). This community measure is supported by WHO in all global documents focused on caries prevention (26). The fluoridated milk is distributed in 200 ml packs containing 5 ppm fluoride, what corresponds to 1 mg of fluoride in the pack. ...
... Recently fluoridated milk is extensively used in Russian Federation, Great Britain, China and Bulgaria. The administration of fluoridated milk in children older than 3 years of age is regarded as the safe preventive method from the point of view of its ratio on total alimentary fluoride intake (26). No potential adverse effect of fluoridated milk was found (27). ...
Full-text available
Caries incidence and prevalence have decreased significantly over the last few decades due to widespread use of fluoride. However, an increase in the prevalence of dental fluorosis has been reported in both fluoridated and non-fluoridated communities. Care must be taken to ensure that a balance between the optimal fluoride preventive effect at the individual and community level and minimal risk of dental fluorosis is maintained. This review describes the main sources of fluoride intake that have been identified: fluoridated drinking water, dietary fluoride supplement, and topical forms comprising toothpastes, rinses, gels and varnishes. The cited data were taken from meta-analytic studies and reports from Cochrane database systematic reviews up to December 2019. Efficiency, but safety, of topically applied fluorides in individual home care is dependent on the degree of compliance of individuals/parents and on the level of competence of providers of preventive counselling. The broad spectrum of these resources allows individualization of fluoride prevention based on risk analysis of caries attack and taking into consideration other preventive measures.
... Peak intensities after sputter cleaning decreased for F. At 460 s, the C10-F1 group showed a peak (arrow) at approximately 685 eV, whereas the C0-F1 group did not. Casein exists in micelles that stabilize calcium (Ca) and phosphate (P) ions in milk 24) . Salivary proteins, including statherins, histatins, and PRP, form protein-Ca complexes that suppress apatite growth 25) . ...
... Milk fluoridation to prevent dental caries has been extensively examined since the early 1950s 24,28) . The optimal daily intake of F from milk effectively prevents dental caries. ...
Full-text available
The aim of the present study was to investigate the effects of casein in a remineralization solution on enamel remineralization. Bovine blocks were demineralized for 21 days, then, allocated into four groups. The specimens were remineralized for 21 days in the following artificial saliva solutions: 1) 0 μg/mL casein, 0 ppm fluoride (F) (C0–F0); 2) 0 μg/mL casein, 1 ppm F (C0–F1); 3) 10 μg/mL casein, 0 ppm F (C10–F0); and 4) 10 μg/mL casein, 1 ppm F (C10–F1). Micro-CT analyses were performed once a week. Specimens were characterized by scanning electron microscopy (SEM) and x-ray photoelectron spectroscopy (XPS). The present results suggest that casein by itself inhibits remineralization, whereas the coexistence of casein and F promotes the remineralization of caries bodies by interrupting mineral deposition on the enamel surface.
... The results of the studies showed that the level of the child's general health did not significantly affect the changes in most indicators in the enamel-plaque-saliva system, which is consistent with the results of other authors [23,24]. The change in the indicators of local immunity in children who are often ill, compared with those who are rarely ill, was expressed in an increase in the content of Ig G and Ig A in the oral fluid, both in children with I and III degrees of caries activity. ...
... However, fluoride delivery through fluoridated milk will not be efficient compared to other fluoride delivery methods. Fluoride tends to bond with calcium and form an insoluble complex, making fluoride absorption difficult (26,27). ...
Full-text available
Abstract Background: Fluoride can arrest dental caries and prevent its progression. The most important advantage of fluoride is that there is no need for cavity preparation; in this respect, it eliminates the utilization of air motors. Furthermore, it provides a good choice for younger children without cooperation ability and patients requiring special care. This study aimed to review the literature about fluoride and to advise public health specialists about the types of fluoride and that fluoride is still a right and safe choice in the COVID-19 pandemic. Methods: Through a search in electronic databases containing Medline, Scopus, Web of Science, and PubMed, a total of one hundred forty-two systematic reviews and original articles in the period of 2008-2021 were selected. The following keywords were used: pediatric dentistry, coronavirus, oral health, tooth remineralization, COVID-19, fluoride, dental fluorosis, and preventive dentistry. Results: Data from selected papers was extracted and classified to evaluate the importance of fluoride in the prevention of dental caries. Fluoride has been selected as a good choice for the prevention and control of dental caries during the coronavirus pandemic. Conclusion: The research has focused on increasing the awareness of public health specialists, advising them that any type of fluoride use is expedient and safe during the COVID-19 pandemic. Keywords: Pediatric dentistry, Oral health, COVID-19, Fluoride, Tooth remineralization, Dental fluorosis
... At the country level, Australia, Chile, and Thailand had the highest volume of co-sourced articles on milk fluoridation. Overall, this shows that most of the research outputs on milk fluoridation were related to the countries with past/current histories of implementation of milk fluoridation programs [15]. In addition, similar observations were made concerning the citation patterns of these outputs ( Figure 8A-D). ...
Full-text available
Fluoridated-milk schemes have been developed and implemented in many countries to prevent dental caries. This study aimed to evaluate the impact/influence of scientific publications, researchers, and institutions conducting research on milk fluoridation; to explore the international and inter-institutional collaboration and illustrate scientific output trends; and to pinpoint research hotspots in milk fluoridation research. This bibliometric analysis of original research articles on milk fluoridation includes all of the original articles published in peer-reviewed journals systematically extracted from the SCOPUS database. In total, 108 articles were included in this study, with a total of 11,789 citations. A majority (67.6%) of these articles were in the subject area of ‘dentistry’, 22.2% externally funded, 14.8% published in the journal, Caries Research, 7.4% authored/co-authored by Twetman S, 6.5% by authors from Universidad de Chile, and the UK had the highest output (24.1%). The network visualizations showed that those countries with current/past histories of implemented milk fluoridation programs were interconnected on the network visualization map, and they were predominantly the hotspots for original research on milk fluoridation. This study also identified inequalities in research outputs on the topic. With the current enormous global burden of dental caries in children, particularly in low- and middle-income countries, there is an urgent need for greater and more equitable funding of milk fluoridation research globally
... The Research Committee of the Canadian Dental Association reported that milk consumption was linked with risk reduction of caries [94]. Cow's milk contains lactose, but lactose is the least cariogenic of the common dietary sugars [95], in addition milk contains another substance including calcium phosphate and casein that have an important role in preventing caries Therefore, we concluded that there is no relationship between drinking milk before bed and dental caries, rather, milk protects against caries. There was no significant association between dental caries and intake of supplements, which might indicate that dental caries development is normally a slow process with several years of delay before the activity is observed, for example, the level of serum [25(oH) D] at time of caries scoring may or may not be representative of the period when caries symptoms are developed [96]. ...
Full-text available
Original Research Article Dental caries is the most common disease in children and up to eight times more prevalent than asthma ranked the second among all the common diseases in the world. The food habits and some types of food play an important role in induce dental caries. The objective of this study is to assess the relationship between, dietary intake, dietary habits, oral hygiene practices and dental caries during childhood. A cross-sectional study was conducted on a sample of 150 children that were selected at random from public hospitals in Benghazi, Libya. Data was obtained by using a questionnaire containing information about the number of carious teeth, dietary intake, habits and oral hygiene habits. The relationship between the risk factors and dental caries was modelled using, Statistics Package Social Science (SPSS). There was a significant statistical difference in the average dental caries among children at (P<0.05) according to sugar amount consumption (P=0.02), as well as to tooth brushing per day (P= 0.03). The average dental caries decreased with increase in times of tooth brushing per day. The prevalence of dental caries in children was an average of 3 carious lesions. Socio-demographic factors, dietary and oral hygiene habits were associated with dental caries.
... No other public health intervention can reduce dental caries of the general public as effectively as CWF. Milk fluoridation is also efficient with attached conditions [27] and salt fluoridation may induce hypertension as an adverse effect [25]. Fluoride supplementation holds a higher risk of harmful effects [26] and dental sealants are limited to individual beneficiaries. ...
Full-text available
Community water fluoridation (CWF), a long-established public health intervention, has been studied for scientific evidence from both of yea and nay standpoints. To justify CWF with scientific evidence inevitably leads to ethical justification, which raises the question of whether oral health is of individual concern or social responsibility. As dental caries is a public health problem, public health ethics should be applied to the topic instead of generic clinical ethics. From both pro- and anti-fluoridationists’ perspectives, CWF is a public health policy requiring a significant level of intervention. Thus, there needs to take further considerations for justifying CWF beyond the simple aspect of utility. For further ethical considerations on CWF, three caveats were suggested: procedural justice, social contexts, and maintenance of trust. The process to justify CWF should also be justified, not simply by majority rule but participatory decision-making with transparency and pluralistic democracy. Social contexts are to be part of the process of resolving conflicting values in public health interventions. Public trust in the dental profession and the oral healthcare system should be maintained over the considerations. This article suggests accountability for reasonableness as a framework to consider infringement by CWF for public justification of its implementation.
Objective To compare the mineral density (MD) of non-fluoridated-milk (non-F-milk), fluoridated-milk (F-milk), adjunctive to 1000-ppm-fluoride dentifrice (FD), and 1000-ppm-FD alone of proximal artificial enamel carious lesions (AECL) in high caries-risk patients. Materials and methods This double-blind, cross-over in situ study comprised seven high caries-risk volunteers. Orthodontic brackets with one slab of AECL were fixed randomly to each volunteer per phase. The study comprised three experimental periods with a 7-d wash-out period using FD between sessions; (1) A four-week tooth brushing with FD 2×/day by all subjects as a control. The participants were then randomly allocated to (2) drinking 2.5-ppm-F-milk 1×/day or (3) non-F-milk 1×/day, adjunctive to tooth-brushing with FD for 4-weeks. The subjects crossed over from each type of milk and continued the same protocol for another four weeks. After each phase, the MD of each specimen was analyzed using micro-computed tomography (Micro-CT). Results The baseline MD was not significantly differences (p = .653). When brushing with FD and drinking F-milk, the MD gain was significantly higher (11.68 ± 2.89%) compared with brushing with FD and drinking non-F-milk (4.59 ± 1.78%) (p = .003) or brushing with FD alone (5.30 ± 2.10%) (p = .003). Conclusions F-milk adjunctive to FD significantly increased MD gain compared with non-F-milk + FD or FD alone.
Full-text available
Contemporary biological markers assess present, or very recent, exposure to fluoride: fluoride concentrations in blood, bone surface, saliva, milk, sweat and urine have been considered. A number of studies relating fluoride concentration in plasma to fluoride dose have been published, but at present there are insufficient data on plasma fluoride concentrations across various age groups to determine the 'usual' concentrations. Although bone contains 99% of the body burden of fluoride, attention has focused on the bone surface as a potential marker of contemporary fluoride exposure. From rather limited data, the ratio surface-to-interior concentration of fluoride may be preferred to whole bone fluoride concentration. Fluoride concentrations in the parotid and submandibular/sublingual ductal saliva follow the plasma fluoride concentration, although at a lower concentration. At present, there are insufficient data to establish a normal range of fluoride concentrations in ductal saliva as a basis for recommending saliva as a marker of fluoride exposure. Sweat and human milk are unsuitable as markers of fluoride exposure. A proportion of ingested fluoride is excreted in urine. Plots of daily urinary fluoride excretion against total daily fluoride intake suggest that daily urinary fluoride excretion is suitable for predicting fluoride intake for groups of people, but not for individuals. While fluoride concentrations in plasma, saliva and urine have some ability to predict fluoride exposure, present data are insufficient to recommend utilizing fluoride concentrations in these body fluids as biomarkers of contemporary fluoride exposure for individuals. Daily fluoride excretion in urine can be considered a useful biomarker of contemporary fluoride exposure for groups of people, and normal values have been published.
Full-text available
To determine the prevalence and severity of enamel fluorosis in the permanent dentition of children aged 6-9 years old exposed to fluoride through a milk fluoridation programme in Codegua, Chile. A survey was conducted in 2002 of a sample of school children living in Codegua (n = 215) and La Punta, the control community (n = 206) to compare enamel fluorosis data with those obtained in 1994. Dean's criteria were followed to assess enamel fluorosis. It was found that 16.4% of the children aged 6-9 years from Codegua had questionable fluorosis in 2002, while in 1999 10.3% were classified in this category. In addition, 7.9% and 1.3% of the children in 2002 and 1994, respectively, had at least very mild fluorosis. These increments were not observed in the control community. Comparison of mean community fluorosis indices (CFI) between the children in 2002 (CFI = 0.18) and those in 1994 (CFI = 0.06) was found to be significant (p < 0.001). For La Punta, no statistically significant results were observed (CFI 0.16 vs. 0.15). Present results indicate that, although there was an expected increase in the prevalence and severity of enamel fluorosis after four years of fluoride exposure, the CFI for Codegua in 2002 is well below the upper limit of the CFI range associated with a public health concern. Therefore, if the average daily fluoride ingestion was adjusted to more appropriate doses at the time of mineralisation of anterior permanent teeth, this would minimise the increase in the prevalence of enamel fluorosis without loosing the dental caries preventive effect of F.
Full-text available
This paper assesses the cost-effectiveness of a community dental caries prevention programme, targeting pre-school children living in non-fluoridated rural areas of Chile. The results of a community trial to measure the effects of using fluoridated powdered milk and milk-cereal to prevent dental caries, together with the cost of running the programmeme, were used to determine its cost-effectiveness when compared to the status-quo alternative. In the experimental community, fluoridated milk products were given to approximately 1,000 children aged between six months and six years, using the standard National Complementary Feeding Programme available in Chile. The control group received the milk products only. Dental caries status was recorded at the beginning and end of the programme in both communities using WHO criteria. The costs that would be incurred by such a programme, using a societal perspective, were identified and measured. Children who received fluoridated products had significantly lower mean levels of dental caries than those who had not. This improvement was achieved with a yearly cost of RCH (1999) $1,839.75 per child (1 US$ = RCH (1999) $527.70). On average, this programme resulted in a net societal savings of RCH (1999) $2,695.61 per diseased tooth averted after four years when compared to the control group. While the analysis has inherent limitations as a result of its reliance on a range of assumptions, the findings suggest that there are important health and economic benefits to be gained from the use of fluoridated milk products in non-fluoridated rural communities in Chile.
This volume brings together current concepts relating to the use of fluoride in dentistry. In contributions written by expert authors, data from this large and complex field have been assembled into a clear sequence and presented in a lucid fashion. The first section deals with the sources of fluoride intake and its metabolism, in order to fully understand fluoride toxicity and the importance of monitoring intake. The second section focuses in more detail on modes of fluoride application and the mechanisms by which this ion interacts with the oral environment to cause a remarkable reduction in dental caries. The role of fluoride in the prevention of dental erosion is also elucidated. The complex mechanisms by which fluoride exerts its effects are described with clarity and the entire text is accompanied by particularly useful illustrations. As a clear up-to-date summary of current thinking in the field, this book will be essential reading for research workers and postgraduate students. Established researchers and teachers in both clinical and basic sciences will find it to be a valuable addition to their libraries, and clinicians will be able to better evaluate the current scientific evidence on the advantages as well as the hazards of fluoride in dentistry.
Milk fluoridation represents an example of the use of potential nondental resources in achieving oral health objectives. For the situations equivalent to those prevailing in Chile, milk fluoridation would be successful within the setting of existing food programs, largely acceptable to the community, likely to be sustainable with minimal external input, and could be readily integrated into the food program activities. From a societal perspectives, milk-fluoridation produce health improvements in a cost-effective way. From an economic perspective, it offers good value for money for public health programmes. This study estimates that a milk-fluoridation programme targeting children living in nonfluoridated areas of rural Chile would have savings to the society, and that the concerned with dental caries averted would implied health gains to the community. Public health policy and practice have the potential of bringing considerable monetary and human benefits. There is a lack of studies evaluating the economic as well as the health consequences of community-based dental caries prevention in developing countries.
To evaluate the effect of milk supplemented with fluoride and/or probiotic bacteria on primary root caries lesions (PRCL) in older adults. After informed consent, 160 healthy subjects, 58-84 years of age, with at least two PRCL were recruited and randomly assigned to one of four parallel study groups drinking 200 ml milk once daily for 15 months. Group A consumed standard milk (placebo); Group B ingested milk supplemented with 5 ppm F and probiotic bacteria (Lactobacillus rhamnosus LB21, 10(7) CFU/mL); Group C drank milk with only probiotic bacteria and group D milk contained only fluoride. Primary endpoints were Root Caries Index (RCI) and electric resistance measurements (ECM) carried out by one blinded single examiner. Secondary endpoints were mutans streptococci and lactobacilli counts in saliva and plaque estimated with chair-side tests. Data were compared within and between groups with non-parametric tests. The drop out rate was 38%. At baseline there were no statistical differences between the groups. Significantly higher numbers of RCI reversals were found in groups B, C and D compared with group A (p < 0.05). The mean ECM values increased significantly (p < 0.05) in all groups except for the placebo group A, indicating that remineralization occurred. The effect was most beneficial in the two groups that contained fluoride. No significant alterations were displayed regarding the microbial counts. No severe adverse effects were reported during intervention. Daily intake of milk supplemented with fluoride and/or probiotic bacteria may reverse soft and leathery PRCL in older adults.
The aim of this study was to evaluate the effect of milk supplemented with probiotic bacteria and fluoride on caries development and general health in preschool children. Children 1-5 years of age (n = 248) attending 14 day care centres with 27 units in northern Sweden entered the study. The centres were randomly assigned to two parallel groups: children in the intervention group were served 150 ml milk supplemented with Lactobacillus rhamnosus LB21 (10(7) CFU/ml) and 2.5 mg fluoride per litre for lunch while the control group received standard milk. The double-blind intervention lasted for 21 months (weekdays) and data were collected through clinical examinations and questionnaires. The primary outcome was caries increment and secondary outcomes were measures of general health. The dropout rate was 25%. The mean baseline caries experience was 0.5 dmfs in the intervention units and 0.6 in the control units and after 21 months 0.9 and 2.2 (p < 0.05). The number of days with sick leave was similar in both groups but the children of the intervention units displayed 60% fewer days with antibiotic therapy (mean 1.9 vs. 4.7 days) and 50% less days with otitis media (0.5 vs. 1.0) (p > 0.05). In children who had participated during the whole 21-month intervention, fewer days with otitis media were reported (0.4 vs. 1.3 days, p < 0.05). No serious side effects were reported. It is concluded that daily consumption of milk containing probiotic bacteria and fluoride reduced caries in preschool children with a prevented fraction of 75%. Additional beneficial health effects were evident.
The milk fluoridation scheme established in Codegua, Chile, between 1994 and 1999 demonstrated the effectiveness of powdered milk as a community-based vehicle for fluoride to prevent dental caries. The present study aimed to compare caries prevalence in both the Codeguan control and test communities, three years after ending fluoride distribution through the powdered milk fluoridation scheme, to assess whether the benefits of such milk fluoridation were still present in the test community. Children 3-6 years old living in Codegua (test community) and La Punta (control community) were examined for dental caries at their educational facilities by three trained and calibrated examiners using natural light, dental mirrors, and sickle probes. Differences in caries prevalence (dmfs) by year of the study were tested for statistically significant differences using the Mann-Whitney U test. Findings from Codegua (1999-2002) indicate that the dental caries experience increased in all age groups following the termination of powdered milk fluoridation. These differences reached levels of statistical significance in the 3-, 4-, and 5- year old group (P < .03). Comparing results from Codegua and La Punta (2002), no statistically significant differences were found. Termination of the powdered milk fluoridation scheme resulted in a deterioration of the dental health of children. After three years, dental caries prevalence was higher than that reached at the end of the scheme and equivalent to that of the control community without fluoride exposure. These results emphasize the need to establish and maintain an alternative mechanism of community-based fluoridation of proven effectiveness for the prevention of dental caries in communities where water fluoridation is not available.
Monitoring of renal fluoride excretion in community prevention programmes on oral health. Geneva: World Health Organization
  • T M Marthaler
Marthaler TM. Monitoring of renal fluoride excretion in community prevention programmes on oral health. Geneva: World Health Organization; 1999.