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Marino et al.
tially evaporated whole milk prior to the final drying process and concurrently with the
incorporation of other additives such as vitamins
and minerals. Disodium monofluorophosphate
used throughout this study was pharmacopoeia
grade, imported from Albright & Wilson, England.
The control community (La Punta) consumed the
same type of products, but without MFP addition.
Analyses of the distribution logs at the community
health centers were done throughout the study, to
evaluate whether the fluoridated milk was delivered constantly to the test community during the
scheme period.
Following the 1984 dietary fluoride supplementation (18, 19), the average daily F ingestion from
fluoridated milk products was estimated at 0.25 mg
F/day among children 023 months old; 0.5 mg F/
day for children 23 years old; and 0.75 mg F/day
for children 36 years old.
Batches of the fluoridated products were prepared every 6 months. The F concentrations in
these products were controlled (12) at INTAs laboratory before each batch was delivered to Codegua.
In addition, random samples of the fluoridated
products were also taken at the municipal storehouse and analyzed for quality control. Concentrations of F in the samples of fluoridated powdered
milk products were found to be within7% relative to their target values throughout the entire
period of this study.
The powdered milk products delivered through
PNAC are prepared using a 1:10 dilution with
boiled tap water. The fluoridated milk was delivered in March 1995. The target concentrations of
MFP were set at the following values: powdered
milk (2 kg/month) provided to infants (02 years
old) 28.5 mg MFP/kg; Purita cereal (1 kg/month)
given to children aged 23 years 114 mg MFP/
kg; Purita cereal given to children 36 years old
172 mg MFP/kg. The two cereal packages had similar presentation (vacuum-sealed plastic bags inside cardboard containers), but were different
colors.
Monitoring
Milk products and fluoride dosage
Milk distribution is the responsibility of the nutritionists at the local community health centers, as
part of normal PNAC procedures. Fluoridated
powdered milk and milk-cereal were prepared for
distribution in the test community by Loncoleche
S.A., a dairy company under contract to the Regional Health Authority, by adding MFP to par-
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Sample
The sample size was determined using Cohens criteria (25) to obtain an effect size of five-tenths (0.5)
[(raw control group mean raw test group mean)/
standard deviation] at the significance criterion of
0.05, and a power of 0.80. Following these criteria,
the minimum sample size was 50 participants in
both the control and test groups, for each age
group (25). This number represented about one
quarter of the population in each age group and
community.
Convenience samples of children in Codegua
and La Punta in each age group, between 3 and 6
years, were examined from those attending the
public kindergartens and primary schools. The exception was some children in the 3-year-old group
Statistical analysis
The results will be presented in four ways using agespecific estimates. Firstly, dmfs data in the test community and those from the control community were
compared at baseline. As no baseline data were
available for the control community, data collected
in 1997 were considered baseline data for this locality. Additionally, data collected between 1997 and
1999 were compared in the control group. Secondly,
data from 1994 and 1999 were compared in the test
community. The 1994 and 1999 samples were considered independent samples (28). This design corresponds to a one-group pretest-post-test design
with a non-equivalent control group (28, 29). A third
cross-sectional comparison was made between the
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Marino et al.
Table 1. Age-specific mean number of decayed, missing and filled tooth surfaces (dmfs) and standard deviations in 36-yearold children living in Codegua and La Punta (Rural Chile) by year of data collection
Codegua
Age
1994
1996
1997
1998
1999
3.11 (5.07)
(n27)
5.40 (8.10)
(n42)
13.75 (16.12)
(n55)
19.21 (12.94)
(n53)
3.47 (5.10)
(n43)
6.91 (6.64)
(n35)
6.07 (7.54)
(n41)
9.84 (9.15)
(n45)
0.67 (1.73)
(n45)
3.94 (5.60)
(n48)
5.62 (6.77)
(n78)
8.03 (9.82)
(n69)
1.62 (4.06)
(n48)
2.33 (4.87)
(n51)
5.73 (7.47)
(n45)
7.58 (6.93)
(n50)
1.52 (2.48)
(n60)
3.18 (7.27)
(n64)
3.03 (4.83)
(n66)
5.63 (6.23)
(n62)
2.25 (3.05)
(n40)
2.78 (3.58)
(n36)
7.44 (8.36)
(n52)
8.67 (8.57)
(n61)
2.89 (4.58)
(n46)
5.17 (4.95)
(n41)
6.95 (8.18)
(n63)
7.41 (9.03)
(n51)
3.85 (5.67)
(n59)
4.22 (5.00)
(n60)
5.61 (7.05)
(n59)
8.79 (8.89)
(n62)
4
5
6
La Punta
3
4
5
6
Results
In 1994, during baseline, 177 children, aged 36
years were examined in Codegua. In 1997, the first
year in which data could be collected from the control community, 189 children aged 36 years were
examined in that locality. Table 1 shows the sample
sizes for each group in each of the communities.
The age-specific mean number of decayed, filled
and missing primary surfaces in children from Codegua and La Punta by year are shown in Table 1.
Although there was some variation in the mean
dmfs values at the different measurement points, in
the control community, these differences were not
statistically significant between 1997 and 1999. Data
from 1994 in the study community were not statistically different to the 1997 values in the control community, with the exception of the 6-year-old group
(P0.001).
438
1994
3.11 (5.07)
5.40 (8.10)
13.75 (16.12)
19.21 (12.94)
11.78 (13.69)
1999
1.52
3.18
3.03
5.63
3.35
(2.48)
(7.27)
(4.83)
(6.23)
(5.68)
Reductiona
Pb
51%
41%
78%
71%
72%
0.06
0.05
0.01
0.01
0.01
Mann-Whitney test.
La Punta
Codegua
3
4
5
6
36
3.85
4.22
5.61
8.79
5.65
1.52
3.18
3.03
5.63
3.35
(5.67)
(5.00)
(7.05)
(8.89)
(7.08)
(2.48)
(7.27)
(4.83)
(6.23)
(5.68)
Reductiona
Pb
61 %
25 %
46 %
36 %
41%
0.01
0.01
0.05
0.05
0.01
Mann-Whitney test.
Discussion
Results obtained after 4 years of milk fluoridation
indicate that it is possible to reduce the prevalence
and severity of childrens dental caries in their primary dentition. This is especially true for those
children either born after the start of this program,
or aged around 1 year when it started. The latter
group includes those children who were truly free
from caries when they started receiving fluoridated
milk. Data obtained in clinical examinations of 3
6-year-old children in Codegua showed that the
decrease in the mean number of tooth surfaces af-
Table 4. Percentage of children free from dental caries history by age: comparisons between 1994 and 1999 of the trial in the
study community (Codegua); between 1997 and 1999 of the trial in the control community (La Punta) and between the study
community and the control community in (1999)
Codegua
La Punta
b
La Punta Codegua
Age (years)
1994
(%)
1999
(%)
Pa
1997
(%)
1999
(%)
Pa
1999
(%)
1999
(%)
Pa
3
4
5
6
36
40.7
33.3
21.8
3.8
22.0
63.3
53.1
50.0
27.4
48.4
0.05
0.05
0.01
0.01
0.01
42.5
38.9
23.1
16.4
28.0
37.3
31.7
33.9
16.1
29.6
NSc
NSc
NSc
NSc
NSc
37.3
31.7
33.9
16.1
29.6
63.3
53.1
50.0
27.4
48.4
0.01
0.05
NSc
NSc
0.01
439
Marino et al.
440
Acknowledgments
This study was funded by a grant received from the Borrow
Dental Milk Foundation (BDMF), and done under the sponsorship and technical and administrative assistance of the
World Health Organization (WHO), and the Oral Health Department of the Chilean Ministry of Health. The authors
would like to acknowledge the support and cooperation received from the Regional Health Service (6th Region), and
Dr. Olaya Fernandez, Chief Dental Officer, Ministry of
Health, Chile. In particular, we would like to acknowledge
the Community Health Center and the Municipality of Codegua, the staff of the day care centers and schools involved in
this project for their assistance during the collection of the
data. We are also indebted to the educational authorities of
the Municipalities of Codegua and San Francisco de Mostazal. Finally, thanks to the anonymous reviewers for their suggestions and comments.
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