Objective: to assess enamel fluorosis (EF) prevalence and severity in a potentially high risk population using a two-step assessment system. Jamaica has had salt fluoridation since 1987. Methods: In March-April 2000, 492 Jamaican school children (age 11-14 years) were visually screened by trained dental nurses for the presence of opacities consistent with EF in permanent teeth from upper right to upper left second bicuspids. Screenings were done using tongue depressors and flashlight. Presence of any fluorosis-like opacities in 2+ teeth was the inclusion criterion. In May 2001, children with opacities were reexamined by a trained dentist who recorded EF using Dean's Index. All clinical assessments were done after consent and assent of parents and children. Additional data on F exposure from drinking water, F supplements, and F toothpaste were obtained via self-administered questionnaires completed by parents. The sample included children living in areas with natural F in two categories: higher F (HIF, n=254, median 0.21, mode 0.27) and lower F (LOF, n=58, median 0.13, mode 0.13). Results: Of 116 children with screened opacities, 96 were confirmed by dentist's examination (82.8%), 7 were false positives (6%); 14 children were not available for reexamination. Overall EF prevalence in this non-representative sample was 20% (96/478) including the questionable category. Logistic modeling of any fluorosis identified two risk factors: natural F in water (LOF/HIF, OR=6.6, 95%CI: 1.5-28.8) and use of F supplements (OR=6.1, 95%CI: 1.9-20.3). EF was present among those drinking water with < 0.10 ppm F and no early childhood-recalled history of supplement use or toothpaste eating, suggesting a contribution of F in salt and/or insufficient control of F from multiple sources. Conclusion: In salt fluoridation programs, natural F in the water and supplement use increase the risk of EF.

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