In 2002, the UK MEDICAL RESEARCH COUNCIL recommended research to determine “the public perception of aesthetically unacceptable dental fluorosis.”

DENTAL FLUOROSIS is a disfigurement of teeth which affects large sections of populations exposed to fluorides, whether from air, water, supplements, toothpaste or from foods.

Internationally, dental professionals know that dental fluorosis causes emotional and psychological damage and has financial impacts on its victims and on society.

Despite the fact dental researchers have noted that “aesthetically unacceptable dental fluorosis” “can cause great psychological distress to the affected individual” (2.0% – 12.5% of children living in artificially fluoridated areas), they still recommend water fluoridation in conjunction with the use of fluoridated toothpaste, varnishes, etc.

The MRC is subscribing to the “classic public health trade-off” in which the teeth and wellbeing of hundreds of thousands of children in the UK (and millions elsewhere) are sacrificed in order to protect Government policy on water fluoridation.

Here is a list of some of the studies on the public and personal perception of dental fluorosis which have already been published.

What other results might the MRC expect to find? Could studies be DESIGNED to change the public perception of dental fluorosis in an attempt to make people believe that fluorosed teeth are OK?

See Abstract Number 9 which shows that first year dental students reacted negatively to photographs of dental fluorosis. Abstract Number 10 is a follow-up study conducted when the students were in their fourth year and demonstrates that the initial negative reaction had changed to a positive one!



Dental Fluorosis: Smile please – but don’t say ‘Cheese’
Very Mild Mild Moderate Severe
Examples of dental fluorosis

List of Abstracts

1. Spencer AJ, Slade GD, Davies M. Water fluoridation in Australia. Community Dent Health. 1996 Sep;13 Suppl 2:27-37.

The one health effect receiving attention is dental fluorosis. Two phenomena are altering the importance usually attached to dental fluorosis. First, anecdotal evidence among practitioners and media attention point to both awareness of and reaction to dental fluorosis in the community. Hoskin and Spencer (in preparation) found that South Australian children 10- to 17-years-old were able to recognize very mild and mild fluorosis and register changes in satisfaction with the colour and appearance of teeth. Even mild changes were associated with psycho-behavioural impacts. Hoskin and Spencer asked eight questions on psycho-behavioural impact, such as embarrassment of teeth or self consciousness because of the appearance of the teeth. . . .The most dramatic finding was the strength of the association of TISF score with psycho-behavioural impact was similar to that of crowding and overbite, both considered key occlusal traits driving the demand for orthodontic care. The community recognised dental fluorosis its impact as an adverse health effect of exposure to fluorides. Other researchers have also reported the ability of lay people to react to dental fluorosis in comparable populations.

2. Shaw WC, The influence of children’s dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am J Orthod 1981 Apr;79(4):399-415.

The hypothesis that children with a normal dental appearance would be judged to be better looking, more desirable as friends, more intelligent, and less likely to behave aggressively was upheld.

Also see: and Your teeth make a first impression –

3. Rodd HD, Davidson LE. The aesthetic management of severe dental fluorosis in the young patient. Dent Update 1997 Dec;24(10):408-11.

Department of Child Dental Health, University of Sheffield
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.

4. Astrom AN, Mashoto K. Determinants of self-rated oral health status among school children in northern Tanzania. Int J Paediatr Dent 2002 Mar;12(2):90-100.

Centre for International Health, University of Bergen, Bergen, Norway
OBJECTIVE: This study aimed to assess the perceived oral health status and to explore its relationship with clinically assessed dental fluorosis among school children in Arusha town, Tanzania. METHODS: A total of 478 students (mean age 15.7 years) completed questionnaires administered in the schools during May to July 2000. Clinical photos of the upper and lower incisors were taken under field conditions. A total of 461 slides were rated under laboratory conditions. The severity of dental fluorosis in the permanent maxillary central incisors was assessed using the Thylstrup & Fejerskov Index (TFI). RESULTS: The prevalence of dental fluorosis at TFI score > or = 2 was 74%. A total of 67% of boys and 70% of girls rated their teeth as yellow to brown, 58% of boys and 68% of girls (P < 0.05) confirmed dissatisfaction with their dental appearance. Kappa values of 0.40-0.44 were obtained between dental fluorosis (TFI > or = 2) and self-reported discoloration. The proportion of school children reporting dissatisfaction with oral condition and dental appearance increased with increasing TFI scores. Stepwise multiple logistic regression analysis explained 21% and 32% of the variance in the dissatisfaction with oral condition and dental appearance scores; TFI scores 11% and 15% of variation in points, and social and psychological variables 11% and 17%. CONCLUSION: Whereas dental fluorosis at different diagnostic cut-off points impacts self-rated oral health negatively, social and personal factors are as important in shaping the responses of school children to oral condition and dental appearance.

5. J.L. URE-CIRETT, E.A. MARTEZ-MIER, G. MAUPOME, and A.E. SOTO-ROJAS, Impact of dental fluorosis on well-being of children’s by their parent’s perception in a pediatric dental practice in Mexico City. Fluorides and Fluorosis, IADR/AADR/CADR 80th General Session (March 6-9, 2002), San Diego.

Universidad Intercontinental, Mexico, 2 Indiana University School of entistry, USA, 3 Center for Health Research, USA
Objective: To assess the relationship between dental fluorosis (DF) and the esthetic perceptions of parents of the children who present it. Methods:Dental fluorosis may have an impact on personal well being (WB) because it affects appearance of teeth and face from an esthetic point of view. A questionnaire to measure impact of DF on WB was applied to parents of children ages 7 to 12 years that attended a pediatric dental practice. This included questions to assess self-representation of psychological WB caused by perceptions of dental appearance of their children and one question that differentiated among esthetic concerns derived from DF to conditions, such as, crowding, caries and periodontal disease. Front teeth were evaluated for DF using TSIF index. Parent’s answers to questions regarding their children’s WB were correlated with DF. Results: 28 parents answered the questionnaire, 32% and 82 % of the parents reported at least occasionally experiencing distress or being worried, respectively, because of the appearance of their children’s teeth. 18% thought that it hindered their children from smiling freely, 54% reported crowding in their children’s teeth and 39%reported them as unsatisfactory. 39% reported presence of stains in children’s teeth, compatible with DF. 71% of children had DF (TSIF >1); 64% had crowding of teeth Unpleasant color of children’s teeth was reported by 11%. There was a significant correlation between presence of DF in the children’s teeth and parent’s reported concerns (p < 0.05). Conclusion: For this sample of parents who attend this practice, perceptions of DF in their children’s teeth appear to have an impact on their WB.

6. A.E. SOTO-ROJAS, E.A. MART`EZ-MIER, G. MAUPOME, and J.L. URE-CIRETT. Impact of dental fluorosis on well-being in Mexico City children. Fluorides and Fluorosis, IADR/AADR/CADR 80th General Session (March 6-9, 2002), San Diego.

Universidad Intercontinental, Mexico, 2 Indiana University School of entistry, USA, 3 Center for Health Research, USA
Objective: To assess the relationship between dental fluorosis (DF) and esthetic perceptions that may affect well-being (WB) in children in Mexico City. Methods: Dental fluorosis (DF) may have an impact on personal WB because it affects appearance of teeth and face from an esthetic point of view. Using a questionnaire to measure DF impact on WB, 41 children ages 7 to 12 years attending a pediatric dental office were asked questions to (i) assess self-representation of psychological WB caused by perceptions of dental appearance, and (ii) differentiate among esthetic concerns derived from DF and other conditions (crowding, caries, periodontal disease). DF of anterior quadrant was evaluated using TSIF. Measures of WB were correlated to DF presence. Results: 66% and 81% of children reported experiencing at least occasionally distress or being worried, respectively, because of the appearance of teeth. 61% of the children stated the appearance hindered them from smiling freely, and 34% reported them as unsatisfactory. 59% reported their teeth were not straight and 20% believed they were unhealthy. 34% reported stains on their teeth compatible with DF; 66% had DF (TSIF >1); 63% had crowding of teeth. Unpleasant teeth color was reported by 20% of children. There was a significant correlation between DF and level of concern caused by dental appearance (p < 0.05). Conclusions: Children perceptions of DF appeared to have an impact on WB, as measured by a culturally appropriate research tool.

7. F. Wondwossen, A.N. str, A. B sen, R. tekle-Haimanot, Zenebe Melaku. PERCEPTION OF DENTAL FLUOROSIS AMONG ADOLESCENTS IN URBAN AREAS OF ETHIOPIA. The 3rd International Conference on fluoride and defluoridation of water. Chiang Mai, Thailand, November 2000.

Faculty of Dentistry, University of Bergen, Norway, and Faculty of Medicine, Addis Ababa University, Ethiopia
According to previous studies, dental fluorosis constitutes a public health problem, functionally and aesthetically, in the East African Rift Valley. The aim of the present study was to assess the perception of dental fluorosis among adolescents residing in two urban areas in Ethiopia: Addis Ababa, which has relatively low fluoride content in the drinking water (0.2 – 0.7 mg F/L) and Nazreth, with a fluoride concentration ranging form 1.2 to 8.9 mg/L. Students, aged 12 – 15 years, enrolled in two secondary schools in Addis Ababa (n=161) and two similar schools in Nazreth (n=178) responded to evaluative statements concerning the appearance of anterior maxillary teeth. Color photographs depicting dental fluorosis of different severity (Score 2, 3, 5 and 7 according to the Thylstrup/Fejerskov (TF) scoring system) were used as reference during structured interviews. Differences in the distribution of subjects according to place of residence, TF scores and perceived appearance of teeth were assessed using Chi-square tests. A majority of the students from Addis Ababa (89-96%) and Nazreth (64-100%) were dissatisfied with the appearance of even mildly fluorotic teeth (TF scores 2 and above). More than 70% of the students from both areas confirmed a need for dental advice concerning fluorotic teeth with TF> 2. Whereas only 2% of the students in Nazreth indicated that they would feel embarrassed with mildly fluorotic teeth (TF score 2), 23% of students in Addis Ababa admitted embarrassment with the same TF score. TF scores of 5 and 7 were found unacceptable both in Addis (38% and 56%) and in Nazreth)40% and 86%). Students in Addis, more frequently than their counterparts in Nazreth, indicated that TF score 5 ( 53% versus 26%)and TF score 7 ( 59% versus 33%) was caused by neglect of the children’s teeth. Students from both areas felt that teeth with TF scores > 2 would represent a disadvantage when going into adulthood. The present findings confirm that fluorotic enamel defects constitute a social problem among secondary school children resident in low-fluoride as well as in high-fluoride areas in Ethiopia.

8. Chikte UM, Louw AJ, Stander I. Perceptions of fluorosis in northern Cape communities. SADJ 2001 Nov;56(11):528-32

Department of Community Dentistry, University of Stellenbosch, Private Bag XI, Tygerberg, 7505
The objective of the study was to determine the perception of fluorosis in communities living in the Northern Cape Province of South Africa where there is a considerable range in fluoride levels of drinking water. The fluoride levels of the drinking water were categorised as suboptimal (0.40-0.60 ppmF), optimal (0.99-1.10 ppmF) or supra-optimal (1.70-2.70 ppmF). The teeth of 694 children aged 6, 12 and 15 years were examined. Dental fluorosis occurred among children of all ages in all areas studied. As anticipated there appears to be a direct relationship between fluoride levels in the drinking water and levels of dental fluorosis, and the severity of the condition increased with an increase in levels of fluoride in the water supplies. Children in low fluoride areas showed some form of mild fluorosis (37% very mild and 17% mild). However, 19% of this group experienced moderate or severe forms of fluorosis. In areas with optimal levels of fluoride 30% of children showed a questionable form of fluorosis and 21% mild fluorosis. Moderate or severe forms of fluorosis were recorded in 31% of children in the optimal fluoride area. The Community Fluorosis Index (CFI) scores for the sub-optimal and optimal areas were of medium public health significance and for the supra-optimal area of very high public health significance. Of concern is the high percentage of children (45%) in the supra-optimal area with severe forms of fluorosis. The awareness and concern for stains on teeth were mostly expressed by children with moderate or severe fluorosis. This study suggests that the proposed fluoride concentration (not more than 0.7 ppmF) prescribed in the Regulations on Fluoridating the Water Supplies for South Africa would minimise the risk of dental fluorosis.

* The following two studies show how dental students become “desensitized” to dental fluorosis. In Study No. 9, first-year students don’t like what they see. By their fourth year in dental school, (Study No. 10), their perceptions have been changed!

9. McKnight CB, Levy SM, Cooper SE, Jakobsen JR, Warren JJ. A pilot study of dental students’ esthetic perceptions of computer-generated mild dental fluorosis compared to other conditions. J Public Health Dent 1999 Winter;59(1):18-23.

College of Dentistry, University of Iowa, USA
OBJECTIVES: Few studies have considered people’s opinions about the esthetics of dental fluorosis. Assessments of fluorosis esthetics can be confounded by differences in a number of clinical factors, including tooth shape, color, contour, and gingival status. This pilot study compared esthetic perceptions of mild fluorosis and other conditions using computer-generated images made from a base set of normal appearing teeth. METHODS: Entering dental students (n = 61) completed questionnaires about four sets of paired photographs. Three sets consisted of fluorotic teeth (very mild to mild) versus other conditions (diastema, isolated enamel opacity, “normal”/control) and the other pair compared two presentations of mild fluorosis (generalized versus limited to incisal one-third). Six questions, both qualitative and quantitative, were asked about each pair of photographs. RESULTS: Mild fluorosis was assessed less favorably than normal/control, midline diastema was less favorable than mild fluorosis, and mild fluorosis was less favorable than isolated opacity. CONCLUSIONS: This approach allows fluorosis to be better compared with other oral conditions because the images are standardized. Additional research with this method is warranted, including more variations in conditions, more comparisons, and other study populations.

10. Levy SM, Warren JJ, Jakobsen JR. Follow-up study of dental students’ esthetic perceptions of mild dental fluorosis. Community Dent Oral Epidemiol 2002 Feb;30(1):24-8.

Department of Preventive and Community Dentistry, University of Iowa College of Dentistry, Iowa City, IA 52242, USA
OBJECTIVES: Several studies have assessed people’s esthetic perceptions of dental fluorosis, suggesting that concerns may be greater than believed previously. Few studies have assessed dental students’ perceptions and none has done so over time. The purpose of this paper is to report on changes in dental students’ esthetic perceptions of dental fluorosis and other conditions. METHODS: Fourth-year dental students (n=45) completed questionnaires about computer-generated photographs of fluorosis and other conditions, using the same protocol as when they were entering dental students. Results were compared for each of the eight images at the individual level using paired statistical tests. RESULTS: Although many patterns were generally consistent, there were a substantial number of differences in results over time, concerning both the mild fluorosis and non-fluorosis images. In general, students tended to score both fluorosis and non-fluorosis images more favorably as fourth-year students. When rating images from very pleased (1) to very embarrassed (10), fourth-year students rated the images significantly more favorably than they had done as first-year students for normal/control, incisal third only dental fluorosis, and a more generalized, mild fluorosis. Similarly, with a visual analog scale from satisfactory (0) to unsatisfactory (69), fourth-year students reported significantly lower (more favorable) scores than they had done as first-year students for the normal/control, diastema/no fluorosis, more involved mild fluorosis, and incisal third only mild fluorosis. There were no obvious changes in the relative levels of favorable evaluation of fluorosis vs. the other conditions. CONCLUSIONS: Fourth-year dental students generally had more favorable esthetic perceptions of mild dental fluorosis and other conditions than they had reported as entering students.

11. Milsom KM, Tickle M, Jenner A, Peers A. A comparison of normative and subjective assessment of the child prevalence of developmental defects of enamel amongst 12-year-olds living in the North West Region, UK. Public Health 2000 Sep;114(5):340-4.

Chester and Halton Community NHS Trust, Department of Community Dentistry, Countess of Chester Hospital, Chester, UK
Analysis of data from a 1996-97 cross sectional epidemiological study of the dental health of a sample of 12-y-old children living in Crewe, in north west England was used to compare normative and subjective assessment of developmental defects of enamel. Five hundred and twenty two 12-y-old children from secondary schools in Crewe were examined. One hundred and eighty two children (34.8%), had home post codes within the optimally fluoridated part of Crewe. Using the Developmental Defects of Enamel Index, 178 children (34%) in Crewe were normatively identified as having enamel defects present on their upper incisors. Thirty five children (6.7%), were unhappy with the appearance of their upper incisors because of marks that would not brush off. Neither the normative nor the subjective assessment of enamel defects demonstrated any difference in prevalence between the fluoridated and non-fluoridated areas. In Crewe, one in 20 children normatively diagnosed as being free from enamel defects were unhappy with the appearance of their upper incisors because of marks that would not brush off. There are differences in perception between dental professionals and 12-y-old children over the presence and relevance of developmental defects of enamel. Further research is required if we are to understand the difference in professional and lay perceptions of developmental defects affecting upper incisor teeth.

12. Moss SJ. The case for retaining the current supplementation schedule. J Public Health Dent 1999 Fall;59(4):259-62

Health Education Enterprises, New York, NY 10017, USA
Following ingestion of dietary fluoride, microquantities of fluoride return to the mouth in saliva, but in quantities large enough to facilitate the maintenance and reparative functions of enamel. Dietary fluoride supplements alone are unlikely to be the cause of the reported increase in fluorosis. Compliance continues to be extremely poor and few children use supplements for more than a year and a half. The amount of background fluoride resulting from dietary fluoride supplements appears to be very small. Considering the almost ubiquitous presence of fluoride dentifrice and the strong possibility of additional unintentional fluoride ingestion from many sources, the present fluorosis data is too amorphous to use as a basis for making reasonable risk/benefit evaluations. Very mild and mild fluorosis is not a serious problem for either the clinician or the patient. By altering the present recommended dosage we may deprive children from receiving a proven effective dose. One cannot make a risk/benefit decision concerning an esthetic problem without involving the patient’s perception as well as the caries score. The apparent severity of the milder forms of fluorosis lessens with age and a community fluorosis index should be used only on populations who are older than 15 years.

13. Mwaniki DL, Courtney JM, Gaylor JD. Endemic fluorosis: an analysis of needs and possibilities based on case studies in Kenya. Soc Sci Med 1994 Sep;39(6):807-13.

Kenya Medical Research Institute, Medical Research Centre, Nairobi
The decline in prevalence of dental caries in the western world is largely ascribed to the protective role of fluoride in water. However, in several Third World regions, its presence in excessive amounts has been detrimental to the health of resident communities due to the resulting endemic dental and skeletal fluorosis. As a prelude to introduction of preventive intervention among the affected communities, there is need to assess knowledge and perception, and affordable and effective possibilities. The results of such an assessment which was based on response of mothers from two affected communities showed that objectionable dental fluorosis was not viewed as a common health problem in the context of other more common diseases. A reawakening of interest and concern was evident when issues pertaining to oral health were addressed. Dental fluorosis was viewed as an important problem because of its unfavourable effects on an individual’s personality by between 60.4 and 84.3% of the respondents. While 60% and over of the respondents attributed the problem to water, knowledge on perceived methods of prevention of fluorosis were significantly lower. Only 12% of respondents from a relatively higher income group were instituting relevant preventive strategies. Although defluoridation of water had been instituted in one area, problems relating to wrong choice of water for defluoridation to inadequate distribution of the defluoridated water were evident. Education of the communities on methods of reducing fluoride ingestion and the significance of the defluoridated water, rationalizing the distribution of defluoridated water, facilitating collection of rain water, protection of available low fluoride surface water from contamination with agro-chemicals and household defluoridation were recommended.

14. Rozier RG. Epidemiologic indices for measuring the clinical manifestations of dental fluorosis: overview and critique. Adv Dent Res 1994 Jun;8(1):39-55.

Department of Health Policy and Administration, University of North Carolina, Chapel Hill 27599
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.

15. van Palenstein Helderman WH, Mkasabuni E. Impact of dental fluorosis on the perception of well-being in an endemic fluorosis area in Tanzania. Community Dent Oral Epidemiol 1993 Aug;21(4):243-4.

Department of Community and Preventive Dentistry, Faculty of Dentistry, University of Dar es Salaam, Tanzania

16. Hawley GM, Ellwood RP, Davies RM. Dental caries, fluorosis and the cosmetic implications of different TF scores in 14-year-old adolescents. Community Dent Health 1996 Dec;13(4):189-92,Comment in: Community Dent Health. 2000 Dec;17(4):261-2.

Dental Health Unit, University of Manchester, UK
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.

17. Rahmatulla AH. Clinical evaluation of two different techniques for the removal of fluorosis stains. Egypt Dent J 1995 Jul;41(3):1287-94.

Department of Removable Prosthetic Dental Sciences, King Saud University, College of Dentistry
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.

18. Welbury RR, Shaw L. A simple technique for removal of mottling, opacities and pigmentation from enamel. Dent Update 1990 May;17(4):161-3.

Department of Child Dental Health, The Dental School, Newcastle upon Tyne
Mottling of teeth can have significant psychological impact on patients–particularly on adolescents, who may be subjected to much unkind teasing. A number of procedures have been suggested for removal of mottling and stains. The authors describe a simple and quick technique using a paste of hydrochloric acid and pumice, and on the basis of their clinical and laboratory experience suggest it as a treatment of first choice.

19. Riordan PJ. The place of fluoride supplements in caries prevention today. Aust Dent J 1996 Oct;41(5):335-42.

Health Department of Western Australia
There are very few scientifically good clinical trials of fluoride supplements, and those that can be considered methodologically adequate suggest that the contribution of fluoride supplements to caries prevention is slight. This may be partly a consequence of the fact that fluoride is much more widely available today than was the case a generation ago when fluoride toothpaste was not widely used and water fluoridation was not fully implemented. Although some families are conscientious in their use, compliance with fluoride supplement recommendations is generally poor over longer periods, making them a poor public health measure. There is substantial evidence that supplements cause dental fluorosis when used in accordance with recommendations for infants and small children. If the public becomes concerned about dental fluorosis as an aesthetic problem, all fluoride use may be put at risk. Supplements should no longer be recommended for caries prevention in children in areas with little fluoride in water but may be useful for persons with intractable caries risks. If supplements are recommended for children, a more cautious dosage schedule should be used. The fact that supplements have been recommended uncritically for many years on the basis of inadequate research raises questions about the standards of dental science.

20. Clark DC, Hann HJ, Williamson MF, Berkowitz J. Aesthetic concerns of children and parents in relation to different classifications of the Tooth Surface Index of Fluorosis. Community Dent Oral Epidemiol. 1994 Dec;22(6):461-4.

Department of Clinical Dental Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, Canada
Increasing prevalence of dental fluorosis for children both from fluoridated and non-fluoridated communities are now well documented. Along with recent studies purporting possible adverse health effects from fluorides, this proven public health intervention is again being challenged. This study was undertaken to determine the prevalence of dental fluorosis for children from fluoridated and non-fluoridated areas in British Columbia. In addition, children and parents were provided with an opportunity to express concerns about the aesthetics of the child’s anterior teeth. Children from representative schools in two communities were surveyed using the Tooth Surface Index of Fluorosis (TSIF). Questionnaires were sent home to parents to detail their child’s use of various fluoride preventive practices and residence histories. Completed questionnaires were returned and exams were performed on 1131 children. Of those examined, 60% had dental fluorosis on at least two tooth surfaces, only 8% had scores ranging from “2” to “6”, and 52% were classified with a score of “1”. Parental and child ratings on the aesthetics or color of the child’s teeth suggests that there are few children with aesthetic problems in the TSIF category of “1”. While concerns of parents were more common, the actual source of those concerns was not assessed in the questionnaire. Not unexpectedly, children with fluorosis on anterior teeth ranging between TSIF scores of “2” to “6” appear to have increased concerns about tooth color. Data from children with confirmed residence histories from fluoridated communities suggest that the occurrence of aesthetic problems in these children is rare.

21. Griffin SO, Beltran ED, Lockwood SA, Barker LK. Esthetically objectionable fluorosis attributable to water fluoridation. Community Dent Oral Epidemiol 2002 Jun;30(3):199-20.

Division of Oral Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
OBJECTIVE: We compared estimates of fluorosis prevalence and risk attributable to fluoridation using an index applied to the entire dentition and to the maxillary anterior teeth. We also estimated the prevalence of perceived esthetic problems attributable to current fluoridation policy (Attributable Burden). METHODS: Fluorosis prevalence estimates were obtained from the National Survey of Oral Health in US School Children (1986-87) for the 1839 survey children aged 12 -14 years who were scored for fluorosis, had never received fluoride drops or tablets, and had lived in only one home. For each child we calculated Dean’s fluorosis index, and an anterior fluorosis index (value of the highest scored maxillary anterior tooth). We used each index to calculate risk of fluorosis attributable to fluoridation by subtracting at each level of severity the prevalence of fluorosis among those living in low fluoride areas (F <or= 0.3 ppm) from the prevalence among those living in optimally fluoridated areas (0.7 ppm F <or=1.2 ppm). Findings from five published studies were used to calculate risk of perceived esthetic problem attributable to fluorosis, by severity, i.e. the difference in the mean percentage of respondents who were satisfied with the appearance of their teeth with and without fluorosis. Finally, Attributable Burden was estimated by summing the products of risk of perceived esthetic problems attributable to fluorosis and risk of fluorosis attributable to fluoridation for each level of fluorosis severity. RESULTS: Prevalence of fluorosis, very mild or greater, was 26% with Dean’s Index, which was significantly higher than the 18% figure calculated with the anterior index. Using the anterior index, fluoridation was a risk factor for very mild (attributable risk = 15%) and mild fluorosis (attributable risk = 3%). Risk of fluorosis (very mild or greater) attributable to fluoridation was significantly higher when calculated from prevalence estimates using Dean’s Index than estimates calculated with the anterior index (24% versus 18%). The mean values of risk of perceived esthetic problems attributable to very mild and mild fluorosis were 9% and 33%, respectively. CONCLUSION: We found that approximately 2% of US schoolchildren may experience perceived esthetic problems which could be attributed to the currently recommended levels of fluoride in drinking water. The findings further suggest that both estimates of fluorosis prevalence and risk of fluorosis attributable to fluoridation will be higher when calculated with an index applied to the entire dentition. Data were unavailable for fluoridated toothpaste and diluted formula consumption, thus the risk of fluorosis attributable to fluoridation may be overestimated if consumption was higher in fluoridated areas. The risk of perceived esthetic problems attributable to fluoridation must be weighed against its lifetime benefits and the associated costs of alternative solutions such as educating parents about appropriate toothpaste use and lowering the fluoride content of children’s toothpaste.

22. McKnight CB, Levy SM, Cooper SE, Jakobsen JR. A pilot study of esthetic perceptions of dental fluorosis vs. selected other dental conditions. ASDC J Dent Child 1998 Jul-Aug;65(4):233-8, 229.

College of Dentistry, University of Iowa, Iowa City, USA
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.

23. Riordan PJ. Perceptions of dental fluorosis. J Dent Res 1993 Sep;72(9):1268-74.

Dental Services, Health Department of Western Australia, Como
Mild dental fluorosis has long been accepted as a side-effect of water fluoridation and, more recently, has been recognized as a consequence of the use of other fluoride-based caries-preventive strategies. Traditionally, dental health professionals have not seen this as being of public health importance, but members of the public have not been asked their opinion. The purpose of the present study was to gather the opinions of lay groups concerning the appearance of the teeth of children with various degrees of fluorosis. Twenty-eight children, born in 1978, who had earlier participated in a study of fluorosis in Perth (Western Australia), allowed 110 observers to look at their upper central incisors under good viewing conditions. Fluorosis in these teeth ranged from TF score 0 (no fluorosis) to TF score 3. The observers were university students, parents, public servants, or dentists. They responded to statement items about the appearance of the teeth. The results, based on just over 3000 responses, showed that lay and dental observers could distinguish between different fluorosis levels. In response to a statement that the teeth appeared pleasing, a large majority agreed when the TF score was 0, but agreement declined as the TF score increased; when the TF score was 3, most people disagreed. Similarly, observers felt that the appearance would increasingly embarrass the child as the TF score increased. Observers, except the dentists, tended to feel that higher TF scores indicated neglect on the part of the child.

24. P.G. Colon, Removal of Tooth Stains in Prisoner Rehabilitation, Dental Survey Publications, Vol: 48: No 22, 1972.

Federal Correctional Institution, Terminal Island, San Pedro California (1972)
The stains of endemic Dental Fluorosis can have a tremendous psychological impact on the patient. Perhaps this might be a contributory factor in the psychological make-up of the individual who displays anti-social behavior. If so, it might be possible to effect change by removing the stains. Many patients [convicts] have been pleased with the results [bleaching of teeth], and even displayed a willingness to smile.

25. Nyaora Moturi WK, Tole MP, Davies TC – “The Contribution of Drinking Water Towards Dental Fluorosis: A Case Study of Nyoro Division, Nakuro District, Kenya”, Environmental Geochemistry and Health 24:123-130 (2002)

More than 80% of respondents felt that dental fluorosis is a problem, because of (i) the unsightly nature of teeth, (ii) it is difficult to chew with mottled teeth as they are susceptible to breakage, (iii) induces shyness, especially of teenage girls. However, 74% of the respondents knew neither the cause of dental fluorosis, nor the remedies for the problem.

26. Mothusi, B. Psychological Effects of Dental Fluorosis. Department of Health, North West Province, South Africa.

The trauma experienced by young people with dental fluorosis is depressingly apparent in a SOUTH AFRICAN study conducted by the North West Province Department of Health: “The psychological effect in terms of the unsightly, brown-stained teeth, has induced the adolescents with fluorosed teeth to demand that these teeth be extracted and replaced with dentures.”

27. Clark DC, Hann HJ, Williamson MF, Berkowitz J. Aesthetic concerns of children and parents in relation to different classifications of the Tooth Surface Index of Fluorosis. Community Dent Oral Epidemiol 1993 Dec;21(6):360-4.

Completed questionnaires were returned and exams were performed on 1131 children. Of those examined, 60% had dental fluorosis on at least two tooth surfaces, only 8% had scores ranging from “2” to “6”, and 52% were classified with a score of “1”. Parental and child ratings on the aesthetics or color of the child’s teeth suggests that there are few children with aesthetic problems in the TSIF category of “1”. While concerns of parents were more common, the actual source of those concerns was not assessed in the questionnaire. Not unexpectedly, children with fluorosis on anterior teeth ranging between TSIF scores of “2” to “6” appear to have increased concerns about tooth color.

28. Clark DC. Evaluation of aesthetics for the different classifications of the Tooth Surface Index of Fluorosis. Community Dent Oral Epidemiol. 1995 Apr;23(2):80-3.

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.

29. Mrs. Nipaphan Osiriphan, Master of Public Health, Examining Committee Assist., Prof. Dr. Komkham Pattanaporn, Chairman, Lect. Chalermpong Chittaisong, Member, Assoc. Prof. Dr. Pacharawan Srisilapanan, Member, Assoc. Prof. Anchalee Dusadeepan, Member.

Perception of Dental Fluorosis among People Residing in Tambon Doi Tao Changwat Chiang Mai
The objectives of this study were to study the severity of dental fluorosis status, people perception, oral impacts affecting daily performance of dental fluorosis in people and compare level of dental fluorosis status estimated by using Dean’s index and the perception of people residing in Tambon Doi Tao, Ampur Doi Tao, Changwat Chiang Mai. One hundred and seventy four subjects comprised of lay persons, students, health personnel and headmen of villages, were recruited using multistage sampling technique. Data were collected by oral examination using Dean’s and TSIF index of dental fluorosis and interviewing for subjects’ perception by using interview form. OIDP index was used to assess their oral impacts affecting daily performance and the pictures of dental fluorosis were used to compare status level estimation. Data were analyzed by using descriptive statistics, binomial and Spearman’s correlation coefficient techniques.

The results revealed that the severity of dental fluorosis of the samples were in a range of questionable to severe levels. Subjects’ perception of their dental fluorosis status was in medium level. Dental fluorosis status affected daily performance in 24.1% of the samples, in two performances: contacting with people and smiling. Smiling impact was statistical significantly related to the severity of dental fluorosis examined by Dean’s index (p < 0.05). There was statistical significantly difference in status estimation between Dean’s index and subjects’ judgement (p < 0.05). Severity of dental fluorosis which subjects considered to be a problem and need to be solved, were at moderate to severe level. Health personnel and the headmen of villages accepted that dental fluorosis was a prioritized problem in their community but they lacked of knowledge in this issue.

This study indicated that preventing and solving dental fluorosis in this area should begins with providing information of dental fluorosis to the community, encouraging them to solve their problems holistically and providing technical support from the government.

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