30 American Dental Association showed similar results.94 Jamaica began a fluoridated salt program in 1987. In 1999, an area around St. Elizabeth was found to have a high prevalence of dental fluorosis. Examiners returned in 2006 to re-evaluate students in the area. While their results indicated a slightly reduced tooth decay experience for 6-year-olds in 2006 compared to 6-year-olds in 1999, they also found that 6-year-olds also had a higher prevalence of dental fluorosis in 2006 than the 6-year-olds examined in 1999. In addition to the implementation of salt fluoridation, other factors including the use of increased use of fluoridated toothpaste and mouthrinses could have played a role.94 However, both of these studies point out the need to carefully monitor fluorides from multiple sources especially when implementing fluoridated salt programs. Fluoridated milk has been suggested as another alternative to community water fluoridation in countries outside the United States. Studies on the effectiveness of milk fluoridation have been carried out in numerous countries, including but not limited to, Brazil, Bulgaria, China, Israel, Japan, Russia and the United Kingdom.95 Many of these studies have found milk fluoridation programs to be an efficient and cost- effective method to prevent cavities.95 For example, a 2001 study of Chilean preschoolers using fluoridated powdered milk and milk derivatives resulted in a 41% reduction in the number of primary decayed missing and filled tooth surfaces as compared to the control group that did not receive fluoridated milk.96 Additionally, in the same study, the proportion of decay free children increased from 22% to 48% in the study group after four years of implementing the program.96 In 2004, the dental health of school children from the northwest of England, who were enrolled in the school milk fluoridation program, was compared to children with similar characteristics who were not consuming fluoridated milk.97 The average age of the children in the study was 11 years old. In order to participate in the study, participants chosen for the test group were required to have been receiving fluoridated milk for a minimum of 6 years. First permanent molars were examined for tooth decay experience. Results from the study indicated that children consuming fluoridated milk had less tooth decay experience (1.01 DMFT) than the children who did not receive fluoridated milk (1.46 DMFT).97 A study of community milk programs in Bulgaria examined children at age 3 and again at age 8.98 The study indicated that tooth decay experience was substantially lower in the cohort of children who had received fluoridated milk in school for five years compared with the cohorts of children who had received milk in school without fluoride added. At the end of the five-year trial in 2009, tooth decay experience was lower in children who received fluoridated milk (5.61 dmfs and 0.48 DMFS) than in the control community children who received milk with no fluoride (9.41 dmfs and 1.24 DMFS).98 In these two examples “dmfs” is the mean number of decayed, missing or filled tooth surfaces on primary (or baby) teeth while “DMFS” is the mean number of decayed missing or filled tooth surfaces on permanent teeth. Studies completed on milk fluoridation to date largely target children. There has been only a very small number that have looked at the role fluoridated milk might play for adults. These studies have largely examined fluoridated milk and its possible effect on root decay. For example, a study published in 2011 and conducted in Sweden indicated that fluoridated milk could be of value in remineralizing early tooth decay in root surfaces.99 It was estimated that as of 2013, more than one million children worldwide were receiving fluoridated milk.94 The majority of studies conducted have indicated that fluoridated milk is effective in preventing tooth decay under certain conditions. It is most effective if the consumption of fluoridated milk starts before 4 years of age and continues until the permanent teeth are present in the mouth. Most successful programs are conducted through schools where the natural fluoride levels in water are low and children are able to consume fluoridated milk for a minimum of 200 days a year.95 While these conditions prevent fluoridated milk from being recommended as a public health measure for an entire community, fluoridated milk might be the most appropriate and effective means of fluoride exposure for children in some circumstances.