32 l © 2025 American Dental Association
Section 1: Effectiveness and Benefits
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.153 For example, in France, fluoridated salt for home use became
available to the consumer by decree in 1986, while non-fluoridated 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%.148,156 It has been suggested that to be a successful public health measure that
effectively reaches those who are disadvantaged, approximately 70% of the population needs to
use fluoridated salt.150 Conversely, usage rates less than 50% should be considered as having minimal
effect on public health.150
Occurrence of Dental Fluorosis with Salt Fluoridation
Numerous 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 study157 examined the
prevalence and severity of dental fluorosis in children before and after the implementation of salt
fluoridation in Campeche, Mexico, in 1991. 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 1986–1989.157
A study published in 2009158 of children in Jamaica showed similar results. Jamaica began a fluoridated
salt program in 1987. In 1999, an area around St. Elizabeth was found to have 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 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 increased use of fluoridated toothpaste and mouthrinses could have played a
role.158 However, both studies point out the need to carefully monitor fluorides from multiple sources,
especially when implementing fluoridated salt programs.
Fluoridated Milk
Fluoridated milk has been suggested as another alternative to community water fluoridation in
countries outside the Unites States. Studies on the effectiveness of milk fluoridation have been
carried out in numerous countries, including Brazil, Bulgaria, China, Israel, Japan, Russia, and the United
Kingdom.159 Many of these studies have found milk fluoridation programs to be an efficient and cost-
effective method to prevent cavities.159 For example, a 2001 study160 of Chilean preschoolers using
fluoridated powdered milk and milk derivatives reported a 41% reduction in the number of primary
tooth decayed missing and filled surfaces as compared to the control group that did not receive
fluoridated milk.160 Additionally, in the same study, the proportion of decay-free children increased
from 22% to 48% in the study group after 4 years of implementing the program.160
In 2004, the dental health of schoolchildren from the northwest of England, who were enrolled in the
school milk fluoridation program, was compared to that of children with similar characteristics who
were not consuming fluoridated milk.161 The average age of the children in the study was 11 years.
To partake 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).161
Section 1: Effectiveness and Benefits
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.153 For example, in France, fluoridated salt for home use became
available to the consumer by decree in 1986, while non-fluoridated 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%.148,156 It has been suggested that to be a successful public health measure that
effectively reaches those who are disadvantaged, approximately 70% of the population needs to
use fluoridated salt.150 Conversely, usage rates less than 50% should be considered as having minimal
effect on public health.150
Occurrence of Dental Fluorosis with Salt Fluoridation
Numerous 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 study157 examined the
prevalence and severity of dental fluorosis in children before and after the implementation of salt
fluoridation in Campeche, Mexico, in 1991. 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 1986–1989.157
A study published in 2009158 of children in Jamaica showed similar results. Jamaica began a fluoridated
salt program in 1987. In 1999, an area around St. Elizabeth was found to have 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 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 increased use of fluoridated toothpaste and mouthrinses could have played a
role.158 However, both studies point out the need to carefully monitor fluorides from multiple sources,
especially when implementing fluoridated salt programs.
Fluoridated Milk
Fluoridated milk has been suggested as another alternative to community water fluoridation in
countries outside the Unites States. Studies on the effectiveness of milk fluoridation have been
carried out in numerous countries, including Brazil, Bulgaria, China, Israel, Japan, Russia, and the United
Kingdom.159 Many of these studies have found milk fluoridation programs to be an efficient and cost-
effective method to prevent cavities.159 For example, a 2001 study160 of Chilean preschoolers using
fluoridated powdered milk and milk derivatives reported a 41% reduction in the number of primary
tooth decayed missing and filled surfaces as compared to the control group that did not receive
fluoridated milk.160 Additionally, in the same study, the proportion of decay-free children increased
from 22% to 48% in the study group after 4 years of implementing the program.160
In 2004, the dental health of schoolchildren from the northwest of England, who were enrolled in the
school milk fluoridation program, was compared to that of children with similar characteristics who
were not consuming fluoridated milk.161 The average age of the children in the study was 11 years.
To partake 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).161
