Fluorosis, epidemiology, indices and treatment

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Warren and Levy-1999-A review of fluoride dentifrice related to dental fluorosis.-Pediatr Dent-21-265-71-
Introduced to the commercial market 40 years ago, fluoride dentifrice now accounts for nearly all dentifrice purchased in the United States. During this same time, the prevalence and severity of dental caries has declined while dental fluorosis prevalence has increased. While the caries decline can be largely attributed to widespread fluoride dentifrice use, as well as many other sources of fluoride, several recent studies have attributed much of the increase in fluorosis prevalence to early use of fluoride dentifrice. This paper reviews these studies, as well as the efficacy of fluoride dentifrices with lower fluoride concentrations. Finally, recommendations regarding fluoride dentifrice to maintain caries prevention and reduce the risk of dental fluorosis are presented.,

Gopalakrishnan, et al.-1999-Prevalence of dental fluorosis and associated risk factors in Alappuzha district, Kerala.-Natl Med J India-12-99-103-
BACKGROUND: Fluorosis is considered endemic in 15 states of India. Dental fluorosis is the most convenient biomarker of exposure to fluoride. In Kerala, although the condition is reported to be endemic in the districts of Alappuzha and Palakkad, there are no systematic epidemiological studies evaluating dental fluorosis. We studied the prevalence of dental fluorosis among school children in Ambalappuzha taluk, Alappuzha district, Kerala and evaluated the contribution of potential risk factors.
METHODS: We conducted a community-based, cross-sectional survey of 1142 school children (630 girls, 512 boys) in the age group of 10-17 years, using a multistage random cluster sampling technique. A pre-tested structured questionnaire was used to assess exposure to various sources of fluoride. A dental specialist examined all the children to determine the presence or absence of dental fluorosis and graded the degree of dental fluorosis using Dean's Index. The water fluoride content in the study area was obtained from the district water authority department. Bivariate associations were examined using the Chi-square and Chi-square trend tests, while multiple logistic regression was used to evaluate the association of select risk factors with the presence or absence of dental fluorosis.
RESULTS: The overall prevalence of dental fluorosis in our study sample was 35.6% and the community fluorosis index was 0.69. The prevalence of dental fluorosis was higher in the urban compared to the rural areas (55.3% v. 16.8%; p < 0.001), and in girls compared to boys (39.2% v. 31.3%; p < 0.01). The prevalence of dental fluorosis was higher among children who consumed pipe water as compared to children who consumed well water (44.8% v. 12.7%; p < 0.001). We noted a step-wise increase in the prevalence of dental fluorosis with a corresponding increase in water fluoride content in different panchayats (p = 0.024). The principal factor associated with the presence of dental fluorosis was a high fluoride content of drinking water (OR 1.85, 95% Cl: 1.17-2.92). We did not observe any significant association between dental fluorosis and the intake of brick-tea, consumption of fish or the use of toothpaste.
CONCLUSION: Dental fluorosis is a public health problem in the Ambalappuzha taluk. Active steps must be taken to partially defluoridate the water before distribution to reduce the morbidity associated with dental fluorosis in this area. Similar surveys are required in other parts of India to identify areas with high water fluoride content and determine the extent and manner in which defluoridation can be carried out.,

Bardsen-1999-"Risk periods" associated with the development of dental fluorosis in maxillary permanent central incisors: a meta-analysis.-Acta Odontol Scand-57-247-56-
This systematic review of the dental literature (1966-98) concerns risk periods associated with dental fluorosis in the maxillary permanent central incisors. A literature search was organized through the MedLine and the ISI databases. In addition, one unpublished paper (in manuscript) was obtained, as well as one paper published before 1966. However, out of 143 catches, only 10 studies were included in this review. The main reason for exclusions was that the data presented did not meet the criteria given for the present meta-analysis. Among the included papers, 7 pertained to subjects whose exposure to fluoride started at different ages during the enamel formation (Group 1), and 3 were based on subjects who had been exposed from birth and then experienced an abrupt reduction in daily fluoride exposure at different ages during the amelogenesis period (Group 2). The meta-analysis for Group 1 found the odds ratio (OR) for dental fluorosis in children exposed to fluoride early in life (before 2 years of age) to be 7.24 (95% CI; 4.71-11.13) as compared to children exposed later in life (after 2 years of age). The meta-analysis for the studies in Group 2 found the overall OR to be 1.88 (95% CI; 1.35-2.61) for children who had a reduction in fluoride intake after 2 years of age, as compared to individuals who experienced reduction earlier (during the first 2 years). The studies from both groups were pooled and the duration of exposure to fluoride during the first 4 years of life was the independent variable. The meta-analysis now revealed an overall OR of 5.83 (95% CI; 2.83-11.94) for long periods of fluoride exposure (>2 out of the first 4 years) versus shorter periods of exposure (<2 out of the first 4 years of life) during the enamel formation in the maxillary central incisors. Based on the findings of the meta-analysis, no specific period of enamel formation is singled out as being the most critical for the development of dental fluorosis. The duration of fluoride exposure during the amelogenesis, rather than specific risk periods, would seem to explain the development of dental fluorosis in the maxillary permanent central incisor.,

Warren, et al.-1999-Fluorosis of the primary dentition: what does it mean for permanent teeth? [see comments]-J Am Dent Assoc-130-347-56-
BACKGROUND: The prevalence of fluorosis of the permanent teeth has increased during the past few decades in the United States and Canada. However, primary-tooth fluorosis has been largely overlooked, because it is often difficult to recognize. This article describes primary-tooth fluorosis, both as characterized in the literature and as seen clinically.
METHODS: The authors review and summarize previous studies of primary-tooth fluorosis and discuss its etiology. In addition, the authors describe the condition, based on findings from the literature, and their own experiences in characterizing it as part of a longitudinal investigation of fluoride exposures, dental fluorosis and dental caries.
RESULTS: Several studies indicate that primary-tooth fluorosis can be prevalent and severe in areas of very high water fluoride concentrations. In these areas, primary-tooth fluorosis is likely the result of both pre- and postnatal exposures. Studies have documented that primary-tooth fluorosis does occur in areas with optimal or suboptimal water fluoride concentrations, and that in these settings primary-tooth fluorosis is most likely caused by postnatal exposures and is seen most commonly in the primary molars. Primary-tooth fluorosis, however, is often more difficult to identify than fluorosis in permanent teeth, and clinicians may be unfamiliar with its characteristics and may not recognize its somewhat subtle appearance.
CONCLUSIONS: Primary-tooth fluorosis may be related to occurrence of fluorosis in the permanent dentition, so that its recognition by the clinician should raise awareness of possible increased risk for the permanent dentition. CLINICAL IMPLICATIONS: The detection of primary-tooth fluorosis in a young child should prompt the clinician to carefully review the child's past fluoride exposures and current fluoride practices, as well as those of any younger siblings.,

Pendrys-1999-The differential diagnosis of fluorosis.-J Public Health Dent-59-235-8-
Following the introduction of the first fluorosis index by Dean, a series of fluorosis indexes were introduced. While they may differ in the specific way fluorosis is categorized, they all nevertheless use the same underlying diagnostic signs--originally described by Dean, Black, and McKay--that were causally linked to the development of enamel in areas with above-optimum fluoride in the drinking water. Underlying the various fluorosis indexes is the belief that specific clinical diagnostic criteria, based upon established clinical signs, can be utilized to differentiate fluorotic from nonfluorotic enamel opacities. These criteria repeatedly have been substantiated in studies in which the presence of enamel fluorosis, identified by clinical differential diagnosis, has been associated with fluoride exposure history. Further, to whatever extent nonfluorotic opacities have been misdiagnosed as fluorosis, observed estimates of association derived from analytical studies will have been underestimated.,

Den-1999-Biological mechanisms of dental fluorosis relevant to the use of fluoride supplements.-Community Dent Oral Epidemiol-27-41-7-
Fluorosis occurs when fluoride interacts with mineralizing tissues, causing alterations in the mineralization process. In dental enamel, fluorosis causes subsurface hypomineralizations or porosity, which extend toward the dentinal-enamel junction as severity increases. This subsurface porosity is most likely caused by a delay in the hydrolysis and removal of enamel proteins, particularly amelogenins, as the enamel matures. This delay could be due to the direct effect of fluoride on the ameloblasts or to an interaction of fluoride with the proteins or proteinases in the mineralizing matrix. The specific mechanisms by which fluoride causes the changes leading to enamel fluorosis are not well defined; though the early-maturation stage of enamel formation appears to be particularly sensitive to fluoride exposure. The development of fluorosis is highly dependent on the dose, duration, and timing of fluoride exposure. The risk of enamel fluorosis is lowest when exposure takes place only during the secretory stage, but highest when exposure occurs in both secretory and maturation stages. The incidence of dental fluorosis is best correlated with the total cumulative fluoride exposure to the developing dentition. Fluoride supplements can contribute to the total fluoride exposure of children, and if the total fluoride exposure to the developing teeth is excessive, fluorosis will result.,

Sapov, et al.-1999-A laboratory assessment of enamel hypoplasia of teeth with varying severities of dental fluorosis.-J Oral Rehabil-26-672-7-
The effect of lifelong exposure to drinking-water containing fluoride on tooth enamel microhardness was investigated. Dental fluorosis of teeth from adult subjects, who lived continuously since birth in areas characterized by the hot climate of India, supplied by drinking-water containing between 0.5 and 8.7 parts/10 F, was estimated by the Dean score. Tooth enamel sections were examined from the enamel surface towards the dentino-enamel junction (DEJ) for microhardness. Separated enamel crowns were pulverized and analysed for fluoride. Regarding the distribution of the fluoride concentrations in the drinking-water, we selected a partition below and above 0.8 parts/10 F as a criterion for comparison between the results. Tooth enamel of humans from Israel living in a drinking-water area containing about 0.5 parts/10 F was also examined. Positive associations were evident between fluoride in drinking-water, fluoride concentrations in the bulk enamel and fluorosis selection. A significantly high inverse relationship was evident between the fluoride concentration of the drinking-water and the subsurface enamel microhardness. In similar fluoride-concentration drinking-water areas of India and Israel the microhardness of the subsurface enamel was less for the Indian teeth. The microhardness of the enamel near the DEJ for the three different water fluoride-concentration areas was not significantly different.,

Selwitz, et al.-1998-Dental caries and dental fluorosis among schoolchildren who were lifelong residents of communities having either low or optimal levels of fluoride in drinking water.-J Public Health Dent-58-28-35-
OBJECTIVE: This paper reports findings for dental caries and dental fluorosis in 8-10- and 13-16-year-old schoolchildren who were lifelong residents of communities having either naturally occurring low (Broken Bow and Holdrege, NE; < 0.3 ppm) or optimal (Kewanee, IL; 1 ppm) levels of fluoride in drinking water.
METHODS: Findings are reported for participants who received both dental caries and dental fluorosis examinations (n = 495). The DMFS and TSIF indices, respectively, were used to assess dental caries and dental fluorosis.
RESULTS: The mean DMFS score adjusted for age, sealant presence, and fluoride use was significantly lower in Kewanee (1.8) than was the adjusted mean caries score in either Holdrege (2.9) or Broken Bow (3.6). Adjusted mean DMFS scores in Broken Bow and Holdrege were not statistically different. The mean percent of fluorosed tooth surfaces per person, adjusted for age and use of dietary fluoride supplements, was similar in the three communities (approximately 15%); more than 80 percent of tooth surfaces in all participants were fluorosis-free.
CONCLUSIONS: Findings from the present study suggest that water fluoridation still is beneficial and that dental sealants can play a significant role in preventing dental caries. In addition, findings from this survey appear to support the premise that the difference in dental fluorosis prevalence between fluoridated and nonfluoridated communities has narrowed considerably in recent years.,

Lalumandier and Rozier-1998-Parents' satisfaction with children's tooth color: fluorosis as a contributing factor [published erratum appears in J Am Dent Assoc 1998 Sep; 129(9):1212]-J Am Dent Assoc-129-1000-6-
The authors surveyed parents of 708 patients in a pediatric dental practice about their satisfaction with the color of their children's teeth and factors associated with their level of satisfaction. Overall, 43 percent of parents were dissatisfied with their children's tooth color, and 78 percent of children had a Tooth Surface Index of Fluorosis, or TSIF, score greater than 0. The worst TSIF score was the only factor associated with parent satisfaction.,

Bardsen and Bjorvatn-1998-Risk periods in the development of dental fluorosis.-Clin Oral Investig-2-155-60-
In order to study the age-related susceptibility to dental fluorosis, 40 children who had been lifelong consumers of moderate- to high-fluoride water (0.55-8.48 mg F/l) were examined, as well as a group of older siblings (n = 40) who were born 6 months to 6 years before the fluoride-containing drinking water was introduced to the household. Background information was obtained through a structured questionnaire. Dental fluorosis was scored according to the TF index. Among the 80 children examined, the permanent incisors were erupted in 66, while 67 had permanent first molars present. As compared to their older siblings, the prevalence of dental fluorosis was significantly higher in the children who had consumed moderate-to high-fluoride water throughout their lives. In a multiple regression analysis, the variable "age when introduced to moderate- to high-fluoride water" came out as the only significant risk factor associated with dental fluorosis. This variable was divided into three categories according to the first exposure to moderate- to high-fluoride drinking water (1) 0-12 months of age, (2) 13-24 months of age and (3) after 24 months of age. Category 3 was used as the reference group. Fluoride exposure starting during the 1st year of life showed the highest odds ratio as compared to exposure only after 2 years of age. The findings indicate that early mineralizing teeth (central incisors and first molars) are highly susceptible to dental fluorosis if exposed to fluoride from the first and--to a lesser extent--also from the 2nd year of life.,

Erdogan-1998-The effectiveness of a modified hydrochloric acid-quartz-pumice abrasion technique on fluorosis stains: a case report.-Quintessence Int-29-119-22-
Endemic dental fluorosis is a form of enamel hypoplasia characterized by moderate-to-severe staining of the tooth surface. Since 1916, numerous investigators have used hydrochloric acid alone on fluorosis stains. More recently, 18% hydrochloric acid-pumice microabrasion has been used to achieve color modification. The main disadvantage of this procedure is the high concentration and low viscosity of hydrochloric acid, which can cause damage to oral and dental tissues. To eliminate this problem, quartz particles can be mixed with the hydrochloric acid. The quartz particles prevent the hydrochloric acid from flowing uncontrollablely by altering it to a gel-like form. A modified 18% hydrochloric acid-quartz-pumice abrasion technique was used to remove fluorine stains from vital teeth in a teenager.,

McKnight, et al.-1998-A pilot study of esthetic perceptions of dental fluorosis vs. selected other dental conditions.-ASDC J Dent Child-65-233-8, 229-
The prevalence of fluorosis has increased over the past fifty years, and with this increase, esthetic concerns pertaining to fluorosis should also be taken into consideration. Canadian, Australian, and British studies have explored perceptions concerning enamel fluorosis, but no studies in this area have been published from the United States. In the previous studies, esthetic concerns resulting from fluorosis generally were not compared with the esthetic perceptions of other conditions such as isolated opacities, tetracycline staining, or various types of malocclusion. In the present investigation, respondents answered written questions about paired photographs, one of fluorotic teeth and the other with one of the other conditions. Results show that not only is fluorosis noticeable, but it may be more of an esthetic concern than the other conditions.,

Heintze, et al.-1998-Urinary fluoride levels and prevalence of dental fluorosis in three Brazilian
cities with different fluoride concentrations in the drinking water.-Community Dent Oral Epidemiol-26-316-23- Urine samples from three daytime periods were collected from 545 5-50-year-old residents of three different Brazilian cities: Garca had fluoridated drinking water since 1973, Bauru since 1975 and Itapolis was not fluoridated. Dental fluorosis was examined in 985 5-24-year-olds using the Thylstrup-Fejerskov index (TF). The subjects were asked to estimate their daily intake of liquids and frequency of beverage consumption. The analysis of 94 water samples showed high variations in the fluoride content of the drinking water. The mean fluoride concentration of the water samples in Garca was 0.9 mg/L (range 0.75-1.2), in Bauru 0.64 mg/L (range 0.01-1.3), and in Itapolis 0.02 mg/L. Mean urinary fluoride concentration was 1.31 mg/L (s 0.61) in Garca, 0.88 mg/L (s 0.49) in Bauru, and 0.39 mg/L (s 0.21) in Itapolis. Self-reported daily liquid intake was not related to urinary fluoride concentration. The mean prevalence of fluorosis was 13.3% in Garca, 6.8% in Bauru, and 1.7% in Itapolis, with mainly categories TF 1 and TF 2 being recorded. Subjects with dental fluorosis tended to show a higher mean urinary fluoride concentration but the difference was not statistically significant. The study showed that fluoride exposure measured by urinary fluoride excretion was within the range expected for the level of fluoride concentration in the drinking water. However, enamel fluorosis tended to be markedly lower than expected. This study revealed that fluoride levels in the two cities with fluoridated drinking water were variable. To optimise anticaries benefits and minimise the risk of fluorosis greater control of the fluoride dosing of the drinking water is required.,

Matsuo, et al.-1998-Mechanism of toxic action of fluoride in dental fluorosis: whether trimeric G proteins participate in the disturbance of intracellular transport of secretory ameloblast exposed to fluoride.-Arch Toxicol-72-798-806
- In enamel fluorosis model rats treated with sodium fluoride, secretory ameloblasts of incisor tooth germs exhibited disruption of intracellular trafficking. We examined whether heterotrimeric G proteins participated in the disruption of vesicular trafficking of the secretory ameloblast exposed to fluoride, using immunoblotting and pertussis toxin (IAP)-induced adenosyl diphosphate (ADP)-ribosylation for membrane fractions of the cell. Immunoblotting of crude membranes, post supernatants of the ameloblast, with anti-G(alpha i3/alpha o) and anti-G(alpha s) antibodies showed that Gi3 or Go proteins existed in the secretory ameloblast, but Gs protein did not. Immunoblotting of the subcellular membrane fractions indicated that the Gi3 or Go proteins were located in the Golgi membrane, but were not in the rough endoplasmic reticulum (rER) membrane. Autoradiograph of IAP-induced ADP-ribosylation, however, showed the existence of IAP-sensitive G proteins both in rER and Golgi membranes. Fluoride treatment decreased the G proteins bound to both membranes. These findings indicate that different G proteins, both of which are IAP-sensitive, are present in the rER and Golgi apparatus, and suggest that these G proteins participate in the disturbance of intracellular transport of the secretory ameloblast exposed to fluoride.,

Clark and Berkowitz-1997-The influence of various fluoride exposures on the prevalence of esthetic problems resulting from dental fluorosis.-J Public Health Dent-57-144-9-
OBJECTIVES: This study sought to determine the prevalence of esthetic problems due to dental fluorosis, and determine the relationship of different fluoride exposure histories to the occurrence of these problems.
METHODS: In 1993-94 2,715 children in grades 2 and 3 and 3,297 adolescents in grades 8 and 9 were examined by four dentists. Questionnaires detailing exposures to various fluoride technologies were collected from 3,022 of these study participants. Esthetic ratings of the participants' maxillary anterior teeth were made by the examiners, the participants themselves, and their parents using questionnaires designed for this purpose.
RESULTS: Data indicate that 46 percent of the participants had dental fluorosis. Only 40 percent had fluorosis on anterior maxillary teeth. The prevalence of esthetic problems ranged from about 1 percent to 4 percent, depending on how an esthetic problem was defined. Esthetic problems as defined by the participant were more prevalent for the "over 11" age group. Logistic regression results demonstrated significant associations between several of the classifications of esthetic problems and the use of fluoride supplements and dentifrices, and exposure to fluoridated water during the third year of life.
CONCLUSIONS: Results suggest that the prevalence of esthetic problems is low in the communities surveyed, and that exposure to any number of fluoride technologies in the third year of life can increase a child's risk for this problem.,

Holloway and Ellwood-1997-The prevalence, causes and cosmetic importance of dental fluorosis in the United Kingdom: a review.-Community Dent Health-14-148-55-
OBJECTIVES: To determine the prevalence of fluorosis and other developmental defects of enamel (DDE) in the United Kingdom over the last 40 years. To examine the risk factors that may have influenced the prevalence of fluorosis. DESIGN: All relevant publications between 1956-1995 on the prevalences of DDE and fluorosis in the UK were critically reviewed in addition to publications from other countries where these added substantial information about the risk factors involved in the latter.
RESULTS: The likely overall prevalence of DDE in the UK is approximately 40 per cent of which diffuse opacities account for about half. In areas benefiting from water fluoridation the overall prevalence of DDE is around 70 per cent with diffuse opacities accounting for two thirds. No substantial evidence of increases in either DDE or fluorosis could be identified. Risk factors for fluorosis include inappropriate use of fluoride supplements and fluoride toothpaste during early childhood and life-time residence in an optimally fluoridated area.
CONCLUSIONS: Fluorosis does not appear to be of public health concern in the UK at present. However, the inadequacies of the data and paucity of in-depth studies highlight the need for further co-ordinated research using agreed methods of monitoring prevalence, multivariate analysis to identify risk factors and a societal norm to discover its cosmetic impact.,

Rodd and Davidson-1997-The aesthetic management of severe dental fluorosis in the young patient.-Dent Update-24-408-11-
The prevalence of dental fluorosis appears to be on the increase. Although in its mild form the condition is not considered to be of cosmetic significance, the more severe forms can cause great psychological distress to the affected individual. This article discusses the prevalence and mechanisms of dental fluorosis, and the aesthetic management of severe fluorosis in the young patient.,

Hawley, et al.-1996-Dental caries, fluorosis and the cosmetic implications of different TF scores in 14-year-old adolescents.-Community Dent Health-13-189-92-
The aims of this study were to determine the opinions of a group of adolescents about the cosmetic acceptability of a range of fluorosis, investigate the prevalence and severity of fluorosis in the sample and consider the extent to which fluorosis levels were related to their dental caries experience. A random sample of 534 14-year-old pupils from the non-fluoridated industrial city of Manchester were examined for caries and fluorosis. Each subject then examined six photographs of upper anterior teeth showing a range of TF scores 0-4 and were asked to rate the appearance of each as either very poor, poor, acceptable, good or very good and to indicate whether they would request treatment if their teeth were so affected. Four hundred and seventy-six subjects (89 per cent) had TF scores of 0. Of the 58 subjects (11 per cent) with fluorosis, 27 (5 per cent) scored TF = 1; 22 (4 per cent) TF = 2; 7 (1 per cent) TF = 3 and one subject scored TF = 4. The subjects who had no fluorosis had a mean DMFT of 3.0 which was significantly higher than the mean of 2.2 among those with any fluorosis. The proportion of subjects who rated the photographs as poor or very poor fell from 29 per cent for TF score 0 to 15 per cent for TF score 2 and then increased to 92 per cent for TF score 3. The responses of the subjects regarding their desire for treatment matched closely with their opinions on appearance; the majority of subjects expressed concern over the appearance of teeth with TF scores of 3 and higher. It is concluded that the prevalence of aesthetically objectionable dental fluorosis was low and that mild fluorosis was associated with a lower risk of dental caries and a more acceptable appearance. It is essential that a balanced view of the relative benefits and risks of the use of fluorides is maintained and proven benefits are not overwhelmed by largely unfounded aesthetic concerns.,

Gupta, et al.-1996-Reversal of fluorosis in children.-Acta Paediatr Jpn-38-513-9- Large
populations consume fluoride-contaminated water, especially in developing countries. The toxic effects of fluorosis take three forms: clinical, skeletal and dental. Research thus far indicates that the manifestations of fluorosis are irreversible. However, it has been observed that the ingestion of calcium, vitamin C or vitamin D, individually, is effective in protection from fluoride toxicity to a certain extent. Therefore, a double blind control trial was conducted to examine the effect of a combination of calcium, vitamin D3 and ascorbic acid supplementation in fluorosis-affected children. In the present study, 25 children were selected from an area consuming water containing 4.5 p.p.m. of fluoride, All the children were in the age group 6-12 years and weighed 18-30 kg. They were graded for clinical, radiological and dental fluorosis and relevant biochemical parameters. Grade I skeletal fluorosis and all grades of the manifestation of dental and clinical fluorosis were observed. The children were given ascorbic acid, calcium and vitamin D3 well below the toxic dosages in a double blind manner using lactose as a placebo. Follow up revealed a significant improvement in dental, clinical and skeletal fluorosis and relevant biochemical parameters in these children. Thus, the study indicated that fluorosis can be reversed, at least in children, by a therapeutic regimen that is fairly cheap, simple and easily available and without any side effects.,

Clark-1995-Evaluation of aesthetics for the different classifications of the Tooth Surface Index of Fluorosis.-Community Dent Oral Epidemiol-23-80-3- The prevalence of dental fluorosis for
children both from fluoridated and non-fluoridated communities has increased dramatically in some regions of North America. This study evaluated the aesthetics of dental fluorosis for school-aged children from a reference population of 1131 children. The methodology from the Social Acceptability Scale of Occlusal Conditions (SASOC), part of the Dental Aesthetics Index (DAI), was used to assess fluorosis-related aesthetics. Pairs of semantic differentiated adjectives adapted from SASOC were used to rate fifty 35 mm slides of anterior teeth. Sampling of children from the different categories of the Tooth Surface Index of Fluorosis (TSIF) on anterior permanent teeth was weighted to permit sufficient numbers of slides for the different classifications of the TSIF. Each slide was presented to a stratified random sample of pairs of parents and children who were participants in the original study. A convenience sample of dental professionals was also included. Analysis compared different classifications of "affected" slides (non-zero TSIF scores), with the mean aesthetic score computed from all "non-affected" slides (TSIF = 0). Results from children, parents, and professionals showed that there were highly significant differences between ratings of low and high TSIF scores. The only non-significant differences were between TSIF 4 and TSIF 5 & 6, which all three groups did not distinguish, as well as TSIF 1 versus TSIF 2 & 3, which children could not distinguish.,

Rahmatulla-1995-Clinical evaluation of two different techniques for the removal of fluorosis stains.-Egypt Dent J-41-1287-94- Dental fluorosis or mottled enamel manifest itself as a brown,
gray or black discolourations on the external enamel surfaces of the permanent teeth. The causative factor has been found to be the ingestion of fluorine in the drinking water more than 1 pp.m. In its most severe form the enamel discolouration provide a very displeasing appearance. Many times friends and relatives tease the patient that these stains are associated with smoking and/or poor oral hygiene. Such unwarranted, lose and inflicting personal remarks leads an individual into a severe psychological depression. A clinical study was under taken with its aims and objectives to evaluate the efficaciousness of 18% hydrochloric acid with pumice and McInnes solution with pumice in fighting the various forms of fluorosis stains and also observe and record their actions and reactions with the patients and the vitalities of the treated teeth.,

Giambro, et al.-1995-Characterization of fluorosed human enamel by color reflectance, ultrastructure, and elemental composition.-Caries Res-29-251-7- Mature fluorosed human
enamel has been described as a subsurface enamel hypomineralization, with porosity increasing relative to the degree of fluorosis. The purpose of the current study was to quantitatively measure the color of the fluorosed enamel by light reflectance, and to further characterize the enamel by scanning electron microscopy. Teeth with varying degrees of fluorosis were obtained and divided in groups of mild, moderate and severe fluorosis using Dean's index for fluorosis. The color of the labial enamel surface was measured using a Minolta Chroma Meter CR241 (Minolta, Ramsey, N.J., USA). The teeth were further characterized for elemental composition using an energy-dispersive spectrometer, and imaged in both secondary and backscattered electron modes. The results of this study showed that the moderately and severely fluorosed enamel contained an uneven distribution of areas which were more electron-absorbent with a relatively increased carbon content. The changes in the physical characteristics of the teeth could be quantitated by measurements of light reflectance. The color of the teeth was significantly different between groups, with all groups significantly different than normal.,

Mabelya, et al.-1994-Comparison of two indices of dental fluorosis in low, moderate and high fluorosis Tanzanian populations.-Community Dent Oral Epidemiol-22-415-20- This study aimed
at comparing the Thylstrup-Fejerskov index (TFI) and the Dean's Index (DI) which were applied on three communities with different severity of dental fluorosis. A total of 1565 children aged between 11 and 18 yr with a mean age of 14.7 were examined for dental fluorosis with the TFI and 1155 of these children were also examined with the DI. The measurement error for the TFI was 0.50 (10 scale point) compared to 0.53 for DI (6 scale point). The Kappa values and the measurement-remeasurement correlation appeared to be better for the TFI. No difficulties were encountered in applying the TFI in contrast to the DI, which caused uncertainties in assessing the "questionable" and "very mild" scores, and this may explain the relatively better reproducibility of the TFI. The correspondence between both indices was determined. TFI 0 corresponded well with DI 0. The conversion values for TFI 1, 2, 3 and 4 into DI scores were 0.3, 0.8, 1.4 and 2.4 respectively. The TFI 5-9 corresponded with DI score 4. TFI could discriminate the severe forms of dental fluorosis which were categorized in Dean's highest score 4. TFI was able to reveal more dental fluorosis than DI in communities with minor and moderate dental fluorosis. In the community with severe dental fluorosis where more than 85% of all teeth exhibited a DI > or = 1, both indices revealed a comparable prevalence of dental fluorosis. The TFI is considered a near ideal instrument.,

Angmar-Mansson, et al.-1994-Strategies for improving the assessment of dental fluorosis: focus on optical techniques.-Adv Dent Res-8-75-9- In its milder forms, enamel fluorosis is
characterized clinically by diffuse opacities. The appearance is due to optical properties of a subsurface or surface porous layer with lower mineral content. These areas usually have texture and color similar to those of initial caries lesions but generally another shape and location. Therefore, several optical methods, previously used to diagnose initial caries lesions, were applied to fluoride-induced opacities on extracted premolars and on incisors of four subjects in vivo. These methods included light-scattering measurements, white light illumination, violet light illumination, ultraviolet illumination, and laser fluorescence. Video images were captured with a charge-coupled-device (CCD) camera, digitized, and computer-processed. It is concluded that the light-scattering monitor can be used for the determination of the local porosity of fluorotic enamel and that the laser fluorescence method might be developed into a method applicable for the assessment of the severity of enamel fluorosis.,

Kingman-1994-Current techniques for measuring dental fluorosis: issues in data analysis.-Adv Dent Res-8-56-65- The currently popular scoring systems used to diagnosis fluorosis use
different measurement units, evaluate variable numbers of sites per person, and involve non-comparable groupings of clinical symptoms. Although none of these factors is related to the level of fluoride exposure in the examined population, their combined effect produces fluorosis prevalence values for a population which vary considerably among and within these scoring systems. Intrinsic factors for a scoring system include the inclusion of a questionable category, the minimal level of fluorotic involvement, and the number of affected sites within a subject required for case definition. Thus, a case definition of fluorosis for each scoring system, although not mandatory, would certainly be desirable so that dental epidemiologists and clinical investigators can interpret fluorosis scores relative to risk assessment. On the other hand, ratios of fluorosis prevalence magnitudes, as evidenced by odds ratios, can be more stable between scoring systems when groups with different fluoride exposure levels are compared. There is a strong correlation between extent and specific measures of fluorosis severity for Dean's Index (DI) and the Tooth Surface Index of Fluorosis (TSIF) scoring system, as well as within each scoring system separately. Parallel patterns in fluorosis severity were found among groups with different fluoride exposure on severity levels of fluorosis may be better understood by using relative measures rather than by using differences in severity levels.,

Fejerskov, et al.-1994-Dental tissue effects of fluoride.-Adv Dent Res-8-15-31- It is now well-established that a linear relationship exists between fluoride dose and enamel fluorosis in
human populations. With increasing severity, the subsurface enamel all along the tooth becomes increasingly porous (hypomineralized), and the lesion extends toward the inner enamel. In dentin, hypomineralization results in an enhancement of the incremental lines. After eruption, the more severe forms are subject to extensive mechanical breakdown of the surface. The continuum of fluoride-induced changes can best be classified by the TF index, which reflects, on an ordinal scale, the histopathological features and increases in enamel fluoride concentrations. Human and animal studies have shown that it is possible to develop dental fluorosis by exposure during enamel maturation alone. It is less apparent whether an effect of fluoride on the stage of enamel matrix secretion, alone, is able to produce changes in enamel similar to those described as dental fluorosis in man. The clinical concept of post-eruptive maturation of erupting sound human enamel, resulting in fluoride uptake, most likely reflects subclinical caries. Incorporation of fluoride into enamel is principally possible only as a result of concomitant enamel dissolution (caries lesion development). At higher fluoride concentrations, calcium-fluoride-like material may form, although the formation, identification, and dissolution of this compound are far from resolved. It is concluded that dental fluorosis is a sensitive way of recording past fluoride exposure because, so far, no other agent or condition in man is known to create changes within the dentition similar to those induced by fluoride. Since the predominant cariostatic effect of fluoride is not due to its uptake by the enamel during tooth development, it is possible to obtain extensive caries reductions without a concomitant risk of dental fluorosis.,

Stookey-1994-Review of fluorosis risk of self-applied topical fluorides: dentifrices, mouthrinses and gels.-Community Dent Oral Epidemiol-22-181-6- The literature on the risks of
dental fluorosis and the benefits from the use of fluoride dentifrices, mouthrinses and self-applied gels has been briefly reviewed. While there are several studies that have investigated the impact of dentifrices on the development of dental fluorosis, results are mixed. Although there is far less research investigating the relationship between the use of mouthrinses and dental fluorosis, the available evidence generally fails to identify this technology as one of the major causes of dental fluorosis. Although there is little direct evidence to suggest that the use of self-applied fluoride gels contributes to the development of dental fluorosis, ingestion of fluoride from these systems is of genuine concern and their use by preschool age children is not recommended.,

Den-1994-Dental fluorosis: its use as a biomarker.-Adv Dent Res-8-105-10- Several epidemiological studies, beginning with those of Dean and co-workers in the 1940's, clearly
demonstrate the relationship between dental fluorosis in humans and the level of fluoride in water supplies. These studies and others have shown that, in a population, there is a direct relationship among the degree of enamel fluorosis, plasma and bone fluoride levels, and the concentration of fluoride in drinking water. However, dental fluorosis is a reflection of fluoride exposure only during the time of enamel formation, somewhat limiting its use as a biomarker. In addition, the degree of fluorosis is dependent not only on the total fluoride dose, but also on the timing and duration of fluoride exposure. At the level of an individual response to fluoride exposure, factors such as body weight, activity level, nutritional factors, and the rate of skeletal growth and remodeling are also important. These variables, along with an individual variability in response to similar doses of fluoride, indicate that enamel fluorosis cannot be used as a biological marker of the level of fluoride exposure for an individual.,

Rozier-1994-Epidemiologic indices for measuring the clinical manifestations of dental fluorosis: overview and critique.-Adv Dent Res-8-39-55- Several indices have been used to
describe the clinical appearance of dental fluorosis. The purpose of this paper is to describe and compare the three principal ones in use today: those developed by Dean (1934, 1942), Thylstrup and Fejerskov (1978), and Horowitz et al. (1984). A recent index (Fluorosis Risk Index) developed by Pendrys (1990) is also included in this review. The continued use of Dean's classification system and derived index (CFI) for more than a half century is testimony to its simplicity and utility. The index has been criticized because the unit of analysis is the person, because criteria are unclear for some categories, or that they lack sensitivity, particularly for severe fluorosis, and because of the way in which data are summarized and reported. The Thylstrup and Fejerskov Index is appealing to clinicians and epidemiologists alike in that it corresponds closely to histological changes that occur in dental fluorosis and to enamel fluoride concentrations, thereby having biological validity. The TSIF described by Horowitz et al. makes a useful contribution because it provides clearer diagnostic criteria and provides for an analysis based on esthetic concerns. The Fluorosis Risk Index appears to be particularly useful for analytical epidemiologic studies, because it is designed to permit a more accurate identification of associations between age-specific exposures to fluoride and the development of dental fluorosis. All three indices in common use today provide useful indices for the study of dental fluorosis. The utility of the Fluorosis Risk Index will be determined as it receives wider use. The selection of one of these indices for use in an epidemiologic study depends in large measure on the purpose of the study. Research needs to continue on the validity of these indices, particularly for mild fluorosis, and on the public's perception of the cosmetic appearance of teeth with different severity levels of fluorosis.