Benefits l Fluoridation Facts 29 public health measures — either community water fluoridation or salt fluoridation. The United States has implemented water fluoridation. The U.S. Food and Drug Administration has not approved fluoridated salt for use in the U.S. Early studies evaluating the effectiveness of salt fluoridation conducted in Columbia, Hungary and Switzerland indicated that fluoride delivered via salt might produce a reduction in tooth decay similar to that seen with optimally fluoridated water.88,89 When all salt destined for human consumption (both domestic salt and bulk salt that is used by commercial bakeries, restaurants, institutions, and industrial food production) is fluoridated, the decay-reducing effect could be comparable to that of water fluoridation over an extended period of time.88,89 When only domestic salt is fluoridated, the decay-reducing effect is diminished.88 Studies conducted in Costa Rica, Jamaica and Mexico in the 1980s and 1990s also showed significant reductions in tooth decay. However, it was noted that these studies did not include other variables that could have contributed to the reductions.88 The fact that salt fluoridation does not require a centralized piped water system is of particular value in countries that do not have such water systems. Fluoridated salt is also a very cost-effective public health measure. For example, in Jamaica, where all salt destined for human consumption is fluoridated, the use of fluoridated salt was reported to reduce tooth decay by as much as 84% at a cost of 6 cents per person per year.87 In some cases, the cost to produce fluoridated salt is so low that for consumers, the cost of fluoridated salt is the same as for nonfluoridated salt.90 The implementation of salt fluoridation has unique challenges not incurred with water fluoridation. Sources of salt, the willingness of local manufacturers to produce fluoridated salt or the need to import fluoridated salt would need to be studied. Because fluoridated salt should only be consumed by the public in areas with a naturally low level of fluoride, it would be necessary to completely map the naturally occurring levels of fluoride and devise a plan to keep fluoridated salt out of the areas with moderate to high naturally occurring fluoride (to aid in reducing the risk of dental fluorosis). Additionally, a plan would need to be developed to monitor the fluoride level in urine of those consuming fluoridated salt starting with a baseline before implementation and including follow-up testing on a regular basis. While salt fluoridation typically is not implemented through a public vote, it would be necessary to gain the cooperation of salt manufacturers and institutions of all kinds that would use salt in their food preparation.89 Additionally, educational efforts would need to be directed at health professionals and health authorities to avoid referendum approaches and identify enabling regulations.83 In a number of European countries, consumers have a choice of purchasing either fluoridated or nonfluoridated salt for use in the home. While it has been argued that, unlike water fluoridation, this option to purchase fluoridated or nonfluoridated salt allows for personal choice, studies indicate that fluoridated salt is not as effective a public health measure when only a small portion of the population opts to purchase and use the product.88 For example, in France, fluoridated salt for home use became available to the consumer by decree in 1986, while nonfluoridated salt remained available for purchase. By 1991, with an aggressive public health campaign, the market share of fluoridated salt was 50% and it reached a high of 60% in 1993. Then the public health campaign ended. By 2003, the market share had decreased to 27%.82,91 It has been suggested that, in order to be a successful public health measure that effectively reaches those who are disadvantaged, approximately 70% of the population needs to use fluoridated salt. Conversely, usage rates less than 50% should be considered as having minimal effect on public health.82 While the situation described in Europe allows for personal choice, salt programs in the Americas where all salt destined for human consumption is fluoridated would seem at odds with the issue of personal choice, yet the program is apparently working well with fluoridated salt well accepted by the public.92 A number of studies have shown an increase in the occurrence of dental fluorosis in areas where salt fluoridation programs have been implemented. For example, a 2006 cohort study examined the prevalence and severity of dental fluorosis in children before and after the implementation of salt fluoridation in Campeche, Mexico, in 1991.93 The study showed, that while 85% of the dental fluorosis identified was categorized as very mild, children born in 1990-1992 were more likely to have dental fluorosis than those born in the period 1986-198993 A study published in 2009 of children in Jamaica