Within the international programme schemes are operating in seven countries.

Bulgaria

In 1988 the world's first large-scale milk fluoridation community project was established in Bulgaria, in the city of Plovdiv and the nearby town of Asenovgrad. Evaluation of this scheme provided encouraging results and milk fluoridation was also introduced in Varna.

More recently a National Steering Group has been formed to co-ordinate the further development of the programme in Bulgaria and one of the Group's priorities is to extend the benefit of fluoridated milk to other areas of the country. Further schemes have since been implemented in several principal cities: Shoumen, Veliko Turnovo, Stara Zagora, and Bourgas and with the ongoing schemes in Plovdiv and Varna, milk fluoridation now extends to include six regional centres and includes over 31,000 children. Established through the kindergarten system, the programme provides fluoridated milk or fluoridated yoghurt to children aged 3 - 7 on approximately 180-200 days per year. The volume and dose vary according to the age of the children.

A comprehensive evaluation study, involving six test sites and two control sites, is currently being conducted under the direction of the WHO and coordinated by the World Health Organization Collaborating Centre in Sofia.

Chile

The progress achieved in the milk fluoridation programme in Chile has been impressive. It now reaches 3,600 rural schools in 9 regions of the country, with the total number of participating children increasing to 235,000.

Water fluoridation plays a vital role in the prevention of dental disease in
Chile, but is only available to people living in urban or semi-urban areas.
The milk supplied to children in rural areas under the School Food Assistance Program, operated by the Junta Nacional de Auxilio Escolar y Becas (JUNAEB), therefore provides an excellent vehicle for the delivery of fluoride.

Milk fluoridation was first introduced to this country in 1994, with a pilot project implemented in the rural community of Codegua, in the VIth region. The positive results from the evaluation of this scheme led to development of a programme in the 1Xth region and the subsequent expansion of milk fluoridation in Chile. Interestingly, this is the only country which uses fluoridated powdered milk products. Another variation is in the fluoridating agent; disodium monofluorophosphate is used as opposed to sodium fluoride in the other locations.

From the outset, the Instituto de Nutricion y Tecnologia de los Alimenos(INTA), Santiago, has been instrumental in the development of milk fluoridation in Chile. It continues to play an important role with a commitment to further research in this field and through the ongoing technical support provided to JUNAEB.

China

A pilot project was conducted in the Haidian district of Beijing between 1994 and 1999. This involved the distribution of fluoridated milk to kindergarten children aged 3 - 6 years. The evaluation of the scheme, completed in 1999, showed positive results and generated considerable interest in the potential for the use of fluoridated milk in China.

The Foundation is now working closely with the University of Hong Kong, and in consultation with the National Committee for Oral Health, to develop stronger links with potential collaborators in China. Over a five year period, annual one month training courses are being run at the University to provide selected young dentists, from each of the country's six regions, with training in the principles of dental public health. This initiative began in July 2003 with the third course, which included seven dentists from mainland China, being completed in July 2005. It is hoped that this project will provide a network of dentists from the various regions with the necessary skills to assist in establishing the potential for milk fluoridation in China.

Peru

The Foundation was pleased to collaborate with the University of Trujillo and the University of Wales to develop a milk fluoridation scheme in Trujillo. Unfortunately the scheme which was introduced in 1999 was discontinued in 2005, as an increase in the community's exposure to fluoride was detected through the routine monitoring procedures. Further investigations revealed that fluoridated salt, commonly used in many other parts of Peru, had become available in local shops and markets. Whilst the studies indicated that the children involved in the scheme were not exposed to significantly higher levels of fluoride than those in neighbouring districts, the continuation of milk fluoridation could not be justified given the increase in the background levels in the community as a whole.

During its operation this scheme provided an interesting variation to others in that it was established under a national nutrition programme, the Programa del Vaso de Leche. Funded by the Peruvian government and administered by the local municipalities, milk directed towards children from poorer families is distributed through local community centres, known as "Mothers Clubs". They serve many functions, but with a universal theme of self-help, particularly in the interests and health of children. The use of this programme enabled fluoridated milk to reach children from weaning up to 14 years of age, and to be consumed on a daily basis. This was in contrast to other projects where participation is limited to the age groups attending kindergartens or schools, with consumption restricted to the number of days children are in attendance.

Russian Federation

The programme in the Russian Federation was introduced in 1994, with schemes being implemented in the cities of Voronezh, Maikop and Smolensk. This was developed through the kindergarten system, providing fluoridated fresh pasteurized milk to children aged 3 - 6/7 years.

A scheme implemented in the Republic of Tatarstan is reaching 14,500 kindergarten children. The supply of fluoridated milk is currently restricted to the city of Niznekamsk and the neighbouring community of Zelenodolsk although further expansion is planned. The Chief Dental Officers in seven districts of the principal city, Kazan, and a further ten districts within the region are to be consulted on the need and potential for milk fluoridation. In parallel to this, it is hoped that permission can be obtained to produce fluoridated UHT milk to facilitate the development of the scheme.

Thailand

The milk fluoridation programme in Thailand, developed under the direction of the Department of Health (DOH), has expanded rapidly since its launch in 2000 and currently involves over 400,000 children at three sites.

The DOH has worked closely with the Bangkok Metropolitan Administration (BMA) to establish the scheme in the capital city and under an integrated health programme, the provision of fluoridated milk has been extended to all schools, reaching over 320,000 children. The scheme in Bangkok has benefited from considerable support from the Royal Chitralada Projects, a unique agricultural and research development initiative established by King Bhumibol Adulyadej in the grounds of his Chitralada Palace. The production of fluoridated milk was established here, and the staff have continued to play an essential role in the development of the scheme, and indeed, the wider programme in Thailand.
Three further schemes are in operation: in Chumphon, where there are 15,000 children involved, in Surat Thani 5,000, and in Khon Kaen over 60,000. The introduction of fluoridated UHT milk, produced in Khon Kaen by the Dairy Farming Promotion Organization of Thailand (DPO), has played a major role not only in expansion locally, but also in the schemes in Bangkok and Chumpon.

United Kingdom

Milk was first used as a vehicle for fluoride in the UK in 1993, in St Helens, Merseyside. The successful implementation of this demonstration scheme generated considerable interest and led to the development of the UK programme currently involving over 42,000 children aged 3 - 11 from sixteen local authority districts. The use of established school milk systems has been a key factor in the success of the programme. Another has been the reconfiguration of existing resources within the health authorities to manage the schemes.

A strong focus on communications has also proved to be an important aspect of the programme. The formation of the National Milk Fluoridation Network Group has provided the opportunity for those working at all levels within the programme to share experiences and support one another in the development of their respective schemes. This has been complemented by the establishment of a smaller group, dedicated to the needs of project workers, concentrating on the practical aspects of schemes faced by those working at an operational level.