Dental fluorosis is caused by excessive fluoride intake during tooth development and results in hypomineralization of enamel. It ranges from mild to severe. Several indexes exist to measure and classify fluorosis severity, including Dean's Index and the Tooth Surface Index of Fluorosis. Risk factors include age, water fluoridation, fluoride supplements, and toothpaste usage. Mild to moderate fluorosis may be associated with lower caries rates.

1. Dental Fluorosis
Distribution and Measurement
PDS 372
Dr. Asim Al-Ansari

2. Introduction
• What is dental fluorosis (DF)?
– Hypomineralization of the dental enamel
– caused by the excessive ingestion of fluoride during
tooth development (pre-eruptive stage)
– Retention of enamel proteins and production of
fluoroapatite
– Critical age is about 22 months to 5-7 years of age

3. Introduction
• What is dental fluorosis (DF)?
– Severity is related to quantity and frequency (timing)
• Dose-response relationship
– Clinical appearance ranges from mild to severe

4. • Prevalence of Fluorosis

5. Introduction
• Prevalence of Fluorosis
6-7
12-13
15-19
20-29
35-44
65-74
Total
Normal
92%
72
66
62
67
80
75
Questionable
3
9
13
13
9
5
8
V. Mild
1.7
6
10
10
11
4
5
Mild
1.9
6
6
7
9
5
5
Moderate
1
4
3
5
3
2.5
3
1.5
1.5
2
1.5
2
Severe

6. Introduction
• Prevalence of Fluorosis

7. Introduction
• Prevalence of Fluorosis

8. Introduction
• Prevalence of Fluorosis

9. Risk Factors for Dental Fluorosis
• Age
– Young children are more prone to Fluorosis (the
pre-eruptive period).
• Race or ethnicity
– no evidence of difference
• Socio-economic status (SES)
– exposure to F from toothpastes may vary
according to SES

10. Risk Factors for Dental Fluorosis
• Fluoridated Water
– Water fluoridation is “the controlled adjustment
of fluoride concentration in public water supply to
the optimum level that will prevent dental caries”
– In U.S., 7 – 16% of children in areas with
fluoridated water have mild to moderate fluorosis

11. Risk Factors for Dental Fluorosis
• Fluoride dietary supplement
– Tablets or drops have good role in preventing
caries
– More supplements means more fluorosis

12. Risk Factors for Dental Fluorosis
• Fluoride toothpaste
– Children can swallow 0.3 – 0.5g of F at each
brushing
– Studies were able to confirm that
• Over use is associated with increased risk of fluorosis
• Early use is also associated with fluorosis
– The threshold for fluorosis:
• 0.03 to 0.1mg F/kg

13. Fluorosis and Caries
• Do people with fluorosis have less caries?
– In mild to moderate fluorosis >>> less caries
– Severe fluorosis >>> higher risk of caries

14. ?

15. Measuring Dental Fluorosis

16. Measuring Dental Fluorosis
• What is a measure (or measurement)?
– Quantification of observations
• What is “index”?
– Is a scale with upper and lower limits with scores
corresponding to specific criteria

17. Measuring Dental Fluorosis
• How can we measure fluorosis?
– Dean’s Fluorosis Index
– Community Fluorosis Index (CFI)
– Tooth Surface Index of Fluorosis
– Fluorosis Risk Index

18. Dean’s Fluorosis Index
• Introduced in early1930s
• Seven-point ordinal scale

19. Dean’s Fluorosis Index
• Introduced in early1930s
• Seven-point ordinal scale
• In 1942, it was revised to be a six-point scale

20. Dean’s Fluorosis Index
•
•
•
•
•
Introduced in early1930s
Seven-point ordinal scale
In 1942, it was revised to be a six-point scale
Each tooth is rated according to the scale
The individual’s score depends on the two
most severely affected teeth
• Commonly used in “prevalence” studies due
to its simplicity

21. Measuring Dental Fluorosis
• How can we measure fluorosis?
– Dean’s Fluorosis Index
– Community Fluorosis Index (CFI)
– Tooth Surface Index of Fluorosis
– Fluorosis Risk Index

22. Community Fluorosis Index (CFI)
• Modification of the Dean’s Index
• Numerical value is given to each category
• Its mainly used for comparative studies

23. Measuring Dental Fluorosis
• How can we measure fluorosis?
– Dean’s Fluorosis Index
– Community Fluorosis Index (CFI)
– Tooth Surface Index of Fluorosis (TSIF)
– Fluorosis Risk Index

24. Tooth Surface Index of Fluorosis (TSIF)
• Developed in 1984
• Measures the prevalence and severity of fluorosis
that is of public health significance
• More sensitive than Dean’s Index in identifying
the mildest forms of fluorosis
• A scale from 0 – 7 to each tooth surface in the
mouth
• No need to dry teeth
• It can be used in primary and permanent
dentitions

25. Tooth Surface Index of Fluorosis (TSIF)
Scale
Description
0
No evidence of Fluorosis
1
2
Definite evidence of F. white areas less than onethird of enamel
White area at least 1/3 but less than 2/3
3
At least 2/3 of visible surface
4
Enamel staining in addition to any of the above
5
Discrete pitting w/o staining
6
Discrete pitting with staining
7
Confluent (fused) pitting, large areas of enamel
may be missing or affected

26. Measuring Dental Fluorosis
• How can we measure fluorosis?
– Dean’s Fluorosis Index
– Community Fluorosis Index (CFI)
– Tooth Surface Index of Fluorosis
– Fluorosis Risk Index

27. Fluorosis Risk Index
• Designed for use in analytic studies
• Help identify risk factors for fluorosis
• Relates the risk factor to the developmental
stage

28. Fluorosis Risk Index
• Divides the buccal and occlusal surfaces of
each tooth into four zones based on the age at
which calcification begins
• Each zone is classified as
– Class 1: formation began in 1st year of life
– Class 2: formation began 3-6 years of life

29. Summary
• Fluorosis is a dose-response condition
– More F at critical period of tooth development,
more fluorosis
• Fluorosis can be controlled with proper use of
fluorides
• Different indexes are used to classify Fluorosis