BLACKPOOL COUNCIL
DEPARTMENT OF PUBLIC HEALTH
Briefing paper: Introduction of fluoridate milk for primary school children
This paper describes a proposal for the introduction of fluoridated milk as part of the free school breakfast initiative. The proposal to offer fluoridated milk to primary school children in Blackpool has been supported by Blackpool’s Health and Wellbeing Board following discussion at their meeting on 21st August 2013. This paper provides further details of the proposed scheme, including findings emerging from consultation with schools, for consideration by the Council’s Executive.
Why is dental health important?
Good oral heath contributes to general wellbeing. It affects the ability of an individual to eat, speak and socialist without active disease, discomfort or embarrassment [1]. Poor dental health can have a significant impact on daily living causing pain and sepsis, and loss of school time. Treatment can require hospitalisation and use of general anaesthesia.
Dental health of children in Blackpool Council
The dental health of children in Blackpool is considerably worse than average ( As is the case with other non-communicable diseases, tooth decay is associated with deprivation [2].
A useful way of assessing dental health is to look at the number of decayed, missing and filled teeth, using the dmft index for baby teeth or DMFT index for permanent teeth. This is done routinely through nationally coordinated dental health surveys carried out every few years for five year olds and twelve year olds.
More than one in three five year olds (37%) in Blackpool has at least one decayed, missing or filled teeth (dmft). The average number of dmft amongst these children is 3.85.This is higher than the national average of 31% having an average of 3.45 dmft.
Almost half of twelve year olds (43%) in Blackpool have at least one decayed, missing or filled teeth (DMFT). The average number of DMFT these children have is 2.49. Again this is higher than the national average of 33.4% having an average 2.21 DMFT.
Approaches to improving children’s dental health
The ability of fluoride to prevent tooth decay is irrefutable. This is based on evidence from almost a century’s worth of research [3]. Although there are various means by which fluoride can be applied to teeth, the most cost effective method in population-wide interventions has been found to be through water fluoridation [4]. The water supply available for use by the population of Blackpool however does not contain the optimum level of fluoride required to bring about the beneficial effects of decay prevention in teeth. Blackpool Council has previously agreed to support water fluoridation. However, complex legislative processes, technical analysis of water flows in the region and the initial cost outlay required, makes the consideration of a new water fluoridation scheme for Blackpool unviable in the current economic climate. The effects of tooth decay on the affected individuals and their families as well as the burden on society call for the need for the consideration of alternative methods to water fluoridation.
There are currently ten school based milk fluoridation schemes operating in the UK (including Manchester, Knowsley and the Wirral in the North West) and over 40,000 children in nursery, primary and special schools drinking fluoridated milk.
Research evidence base
The use of alternative methods of applying fluoride to the teeth in population-wide interventions where water fluoridation is not available is endorsed by the World Health Organisation (WHO). The use of fluoride milk (milk to which fluoride has been added to provide protection from tooth decay) is one of the alternative population-wide fluoride interventions recommended by the WHO.
A WHO review of the research evidence found 15 studies of the effectiveness of fluoridated milk in preventing dental decay taking place in 10 countries [5]. Eight studies showed a preventative effect in primary teeth and 10 studies showed a preventative effect in permanent teeth. Locally, an evaluation of the scheme on the Wirral showed that 13% less children experienced dental decay and 16% less children developed active decay in their permanent teeth.
Various studies have been carried out over the years to assess the effectiveness of fluoride milk in tooth decay prevention. There have been three exhaustive appraisal, synthesis and summary of the available literature conducted to date (systematic reviews). The first of these systematic reviews [6] concluded that there is insufficient evidence to show the effectiveness of fluoridated milk in preventing tooth decay. The other two subsequent systematic reviews [7, 8], reported that although fluoride milk was found to be beneficial in prevention or reduction of tooth decay, these findings were based on low quality scientific evidence. Other researchers have however reported that operational and process issues that impair the implementation of fluoride milk schemes may be confounders in evaluating the effectiveness of fluoride milk in preventing tooth decay [9]. Improving the effectiveness of fluoride milk in preventing tooth decay may therefore be dependent on ensuring optimally implemented schemes which are run as part of a whole settings approach.
Proposal for a dental milk scheme in Blackpool
Blackpool Council has a successful scheme offering free breakfast for all children attending primary schools in their area. This scheme is one of the largest of its kind in the UK. As part of this scheme, children receive milk daily on each school day. This whole settings approach as well as the infra-structure, systems and processes which are already in place as result of breakfast scheme obviate substantial difficulties experienced by other schemes and thus provides the near optimal situation that has been proposed as a way of improving the effectiveness of fluoride milk in preventing tooth decay. The Blackpool scheme therefore offers a unique opportunity for the implementation of a fluoride milk scheme embedded in an existing successful breakfast scheme in Blackpool primary schools.
A fluoridated milk scheme would form an important component of the overall oral health strategy and will complement existing work within the town to promote good oral health. There is a well-established Oral Health team in Blackpool delivering oral health promotion in schools and early-years settings including the Smile 4 Life campaign, as well as the provision of fluoride toothpaste by health visitors and broader work to promote healthy eating.
A Steering Group has met to scope the implementation of the scheme and oversee implementation, subject to approval. This group is led by a Public Health Specialist and includes Dental Public Health experts from Public Health England, representatives from the Borrow Foundation, an internationally renowned charity supporting milk fluoridation schemes, and Head of Cateringfrom Blackpool Council’s Leisure and Operation Services Department.
All primary school children in Blackpool are offered milk as part of the free school breakfast scheme. The process of adding fluoride to milk is straightforward and there is not expected to be any additional cost to offering dental milk. A number of dairies, including the current supplier, now have the capability to supply dental milk.
Consultation and engagement
Consultation with Head Teachers was conducted through the Free School Breakfast Steering Group; with Milk Fluoridation included as a standing agenda item. Head Teacher representatives on the Group have been pivotal in establishing a communication link between the schools, and the Public Health Team.
An initial consultation period was undertaken throughout December; with extensive engagement activity with parents taking place throughout the early part of 2014.
Consultation is currently being conducted with Primary School Head Teachers and Parents through a number of approaches:
- Milk Fluoridation article in Your Blackpool December 13 (circulated to 70,000 households) for information.
- The Public Health Team staged a promotional stand at the Blackpool Schools event in November, and sought teachers view on Milk Fluoridation and consent issues; with a general support demonstrated for the scheme.
- Public Health have commenced a programme of 1:1 telephone discussions with Head Teachers, with an offer from the Public Health Team to attend a variety of forums, e.g. at coffee mornings, school meetings, Children’s centers to engage with a representative sample of parents, and teachers.
- Results from the consultation activity with Head Teachers suggest that they are generally in favor of the Milk Fluoridation scheme, and are happy to distribute information to parents.
- At 1:1 telephone discussion Head Teachers were asked about the consent process; the consensus so far is that an ‘opt-out’ about approach to consent is appropriate for the scheme.
- Engagement Activities with Parents are scheduled to take place throughout January, February, and March 2014.
- A Milk fluoridation information Fact sheet has been developed to distribute to parents; and Head Teachers have suggested they would like to have information to place on their school web pages.
Other key stakeholders will be briefed at the beginning of 2014 (GP’S, General Dental Practitioners, Health Visitors, School Nurses, Catering staff to enable them to support parents in discussion.
Evaluation of fluoridated milk scheme
As the implementation of fluoride milk within the exiting Blackpool breakfast scheme as a population-wide intervention should control for the confounders of many of previous research, the intervention should have better chance of making a difference to the dental health of the children in Blackpool. An evaluation will be carried out to assess the effectiveness of fluoride milk in preventing tooth decay in these circumstances.
Key points on fluoridated milk
- Freedom of choice
The proposal is to offer fluoridated milk universally to all children, unless parents indicate that they prefer their children to receive non-fluoridated milk. Parents will be provided will information to assist them in making this choice.
- Fluoridated milk is not a medicine
The addition of sodium fluoride to milk is provided for under the ‘REGULATION (EC) No 1925/2006 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL on the addition of vitamins and mineral and of certain other substances to foods’ (with fluoride listed as a permitted mineral in ANNEX I and sodium fluoride listed as one of the permitted ‘mineral substances’ in ANNEX II).
- Fluoridate milk is safe
Fluoridated milk is safe. It delivers a precise amount of fluoride to each child and there is no evidence of fluorosis of public health significance due to drinking fluoridated milk.
- Fluoride compound
The fluoride compound used is sodium fluoride; British Pharmacopoeia (BP) standard.
Fluoride in milk has been shown to behave similarly to fluoride in water the mode of preventing decay in that ingestion decreases enamel demineralisation and increases enamel remineralisation.
The manufacture of fluoridated milk in involves simple production techniques and all the products have been shown to be stable throughout their shelf-life.
- WHO endorsement
The WHO recommends milk fluoridation. A WHO resolution made during the 60th World Health Assembly in Geneva, May 2007, urging member states to respond to a series of recommendations for the improvement of oral health including the administration of fluoride (which refers to milk as one of several vehicles).
Dr Arif RajpuraLynn Donkin
Director of Public HealthPublic Health Specialist
9th January 2014
References
1.Davies, G.M., Summary of: the dental health of three-year-old children in Greater Glasgow, Scotland. Br Dent J, 2010. 209(4): p. 176-7.
2.Department of Health, An Oral Health Strategy for England. London, 1994
3.Burt, B.A., Fifty years of water fluoridation. Br Dent J, 1995. 178(2): p. 49-50.
4.Burt, B.A., Fluoridation and social equity. J Public Health Dent, 2002. 62(4): p. 195-200.
5.Banoczy J, Petersen PE, Rugg-Gunn AJ. Milk fluoridation for the prevention of dental caries. World Health Organisation, Geneva 2009. (available online at )
6.Yeung, C.A., et al., Fluoridated milk for preventing dental caries. Cochrane Database Syst Rev, 2005(3): p. CD003876.
7.Australian NHMRC Systematic Review. 2007. A systematic review of the efficacy and safety of fluoridation. Canberra: National Health Medical Research Council
8.Cagetti, M.G., et al., A systematic review on fluoridated food in caries prevention. Acta Odontol Scand, 2013. 71(3-4): p. 381-7.
9.Foster, G. and M. Tickle, Optimizing school-based healthpromotion programmes: Lessons from a qualitative study of fluoridated milk schemes in the UK. Health Education Journal, 2012. 0(0): p. 1-9.
1 | Page