MEASURING DENTAL

FLOUROSIS
DR.NASEER AHMED
Fluorine: some initial comments
In pure form, fluorine, is a very reactive gas (found in
small amounts in nature).

But fluoride also exists widely in minerals , bound to

metals as fluorides (e.g., sodium fluoride).

Whether or not fluorine is a trace element essential

to human health is still debated, but in tiny amounts
it protects teeth from bacterial decay and promotes
bone growth.
Use Of Flouride Compounds :
Fluorides are used in human health applications in
very low concentrations (on the order of parts per
million) .

Fluorides such as sodium fluoride (NaF), sodium

fluorophosphate (SMFP), and tin fluoride (SnF 2),are
common ingredients in toothpaste.
Cont…
The World Health Organization (WHO), and some

other health organizations recommend fluoridation of

municipal water supplies to a level between 0.7 and
1.2 ppm (so average of about 1 ppm).
Cont…
Fluorine joins with carbon to form a class of

compounds known as fluorocarbons. Some of these

compounds, such as dichlorodifluoromethane
(CF2Cl2), were widely used in air conditioning and

refrigeration systems and in aerosol spray cans.

Where does our fluoride come from ?
Fluoride occurs in natural waters and food
(especially cereals, fruit, meat, fish, tea).

• In some areas, water in hot springs is enriched in

dissolved fluoride.

• Groundwater that has interacted extensively with

fluoride-bearing bedrock (marine deposits and
especially those hosting hydrothermal deposits) can
be enriched in dissolved fluoride.
How does fluoride treatment prevent tooth decay ?

Human teeth (and bones) are primarily composed of

the mineral calcium hydroxyapatite.

Calcium hydroxyapatite has the chemical formula:

Ca5[(PO4)3OH].

• One of the main components of this mineral is the

hydroxyl ion (an ion of oxygen and hydrogen with a
charge of –1
Cont…..
Fluoride (also an ion with a charge of –1) substitutes

for the hydroxyl ion, producing calcium fluoroapatite

with the chemical formula: Ca5[(PO4)3F].

Calcium fluoroapatite is chemically stable than

calcium hydroxyapatite in acid environment of the

mouth.
Cont…
Calcium fluoroapatite dissolves at pH of 4.5.

Calcium hydroxyapatite dissolves at pH of 5.5.

This means that a higher concentration of calcium

fluoroapatite in tooth enamel decreases tooth
dissolution, and therefore can decrease the
incidence of tooth decay.
Cont….
 low-dose fluoride supplementation is also being

used, on an experimental basis, to reduce the

incidence of bone fractures in people affected by

osteoporosis (fluoride strengthen bones for the same

reason as in teeth).
But too much fluoride is bad :

Excessive intake of fluoride (above about 1 ppm)

can lead to dental and skeletal fluorosis (disorders of

tooth and skeletal development related to too much

fluorine).
Cont….
Excess intake of fluoride can also lead to thyroid
disorders.

The most common cause of fluorosis is high fluoride

intake via water (generally groundwater).
Dental fluorosis :

Excessive intake of fluoride damages enamel

forming cells , leading to abnormal development of
teeth.

Dental fluorosis is of particular concern during

childhood when teeth are actively formed.

Dental fluorosis leads to decrease in mineral

contents and increase the porosities in enamel
structure.
Cont….
Fluoridation of water must be undertaken with

caution (taking into account natural concentrations of

fluoride in the water supply).

Degrees of dental fluorosis:
Cont…
Cont….
DEAN’S FLOUROSIS INDEX :
H.T. Dean's fluorosis index was first published in 1934.

 The index underwent two changes, appearing in its

final form in 1942.

This form became the most universally accepted

classification system for dental fluorosis.
 Dean's Index :
Classification Criteria – description of enamel
Normal Smooth, glossy, pale creamy-white translucent surface

Questionable A few white flecks or white spots

Very Mild Small opaque, paper white areas covering less than 25% of the tooth
surface

Mild Opaque white areas covering less than 50% of the tooth surface

Moderate All tooth surfaces affected; marked wear on biting surfaces; brown stain
may be present

Severe All tooth surfaces affected; discrete or confluent pitting; brown stain
present
Community Fluorosis Index :
The Community Fluorosis Index (CFI) is a way of

measuring the burden of dental fluorosis in a

population. Instead of just measuring the overall
prevalence of fluorosis (i.e., what percentage of people
have fluorosis), it takes into account the severity of the
fluorosis that is occurring. The CFI is thus a
measurement of both prevalence + severity.
How the CFI Is Calculated :
The CFI is calculated based on the following point

scale for the different categories of dental fluorosis

(using the Dean Index).

Cont…
Questionable Fluorosis = 0.5 points

Very Mild Fluorosis = 1 point

Mild Fluorosis = 2 points

Moderate Fluorosis = 3 points

Severe Fluorosis = 4 points

Cont…
After determining how many people have these types

of fluorosis, the points are added up and divided by

the number of patients examined.

TOOTH SURFACE INDEX OF FLUOROSIS :
Score = 0: Enamel shows no evidence of fluorosis.

Score = 1: Enamel shows definite evidence of fluorosis,

namely areas with parchment-white color that total
less than one-third of the visible enamel surface.
This category includes fluorosis confined only to
incisal edges of anterior teeth and cusp tips of
posterior teeth (“snowcapping”).
Cont….
Score = 2: Parchment-white fluorosis totals at least
one-third of the visible surface, but less than two-
thirds.

Score = 3: Parchment-white fluorosis totals at least

two-thirds of the visible surface.
Cont….
Score = 4: Enamel shows staining in conjunction with

any of the preceding levels of fluorosis. Staining is

defined as an area of definite discoloration that may

range from light to very dark brown.

Cont…
Score = 5: Discrete pitting of the enamel exists,

unaccompanied by evidence of staining of intact

enamel. A pit is defined as a definite physical defect in
the enamel surface with a rough floor that is
surrounded by a wall of intact enamel. The pitted area
is usually stained or differs in color from the
surrounding enamel.
Cont…
Score = 6: Both discrete pitting and staining of the
intact enamel exist.

Score = 7: Confluent pitting of the enamel surface

exists. Large areas of enamel may be missing and the
anatomy of the tooth may be altered. Dark-brown
stain is usually present.
THYLSTRUP-FEJERSKOV INDEX :
Score Criteria
0 Normal translucency of enamel remains after prolonged air-drying.

1 Narrow white lines corresponding to the perikymata.

2 Smooth surfaces: More pronounced lines of opacity that follow the

perikymata. Occasionally confluence of adjacent lines.Occlusal
surfaces: Scattered areas of opacity <2 mm in diameter and
pronounced opacity of cuspal ridges.

3 Smooth surfaces: Merging and irregular cloudy areas of

opacity.Occlusal surfaces: Confluent areas of marked opacity. Worn
areas appear almost normal but usually circumscribed by a rim of
opaque enamel.
Cont…
4 Smooth surfaces: The entire surface exhibits marked opacity or
appears chalky white. Parts of surface exposed to attrition appear
less affected. Occlusal surfaces: Entire surface exhibits marked
opacity. Attrition is often pronounced shortly after eruption.
5 Smooth surfaces and occlusal surfaces: Entire surface displays
marked opacity wtih focal loss of outermost enamel (pits) <2 mm
in diameter.

6 Smooth surfaces: Pits are regularly arranged in horizontal bands <2

mm in vertical extension.Occlusal surfaces: Confluent areas <3 mm
in diameter exhibit loss of enamel. Marked attrition.

7 Smooth surfaces: Loss of outermost enamel in irregular areas

involving <1/2 of entire surface.Occlusal surfaces: Changes in the
morphology caused by merging pits and marked attrition.
Cont…
8 Smooth and occlusal surfaces: Loss of outermost enamel
involving >1/2 of surface.

9 Smooth and occlusal surfaces: Loss of main part of enamel

with change in anatomic appearance of surface. Cervical rim
of almost unafffected enamel is often noted.
Summary Of T.F Index :
The Thylstrup–Fejerskov (TF) index classifies dental

fluorosis in terms of its absence (TF 0) through to the

presence of opaque lesions (TF 3), which blend to
overtake the entire surface of the enamel, thereby
producing the appearance of white chalk (TF 4). In
more advanced stages, there is a gradual loss of enamel
and anatomical dental deformities (TF 5–9).”
FLUOROSIS RISK INDEX :
It is designed for use in Analytical Studies that seeks
to identify the risk factors for fluorosis.

This Index recognises that the risk of fluorosis is

related to flouride exposure at particular stages of
dentition development.
Developmental defects of dental enamel
index :
The DDE Index has been used a number of times since

its introduction, but the large amount of data

gaenerated has lead to problems in presenting results
in a meaningful fashion.
Russell addressed the same issue of distinguishing

b/w milder form of fluorosis and non-flouride enamel

opacities.
Cont…..
Characteristics of Milder forms of Non-fluoride opacities
enamel opacities fluorosis
Area Affected Near tips of cusps or Centred in smooth
incisal edges surfaces, may affect entire
crown

Shape of lesion Resembles line shading in Often round or oval

pencil sketch.. Lines
follows incremental lines
in enamel.
Cont…
Characteristics of Milder forms of Non-fluoride opacities
enamel opacities fluorosis

Demarcation Shades off imperceptably Clearly differentiated

in to surrounding enamel from adjacent enamel
Color Slightly more opaque Creamy yellow to dark
than normal enamel reddish orange
Teeth Affected Most frequent on teeth Any tooth may be
that calcify slowly. affected. Usually one to
three teeth affected.
Gross hypoplasia None . Absent to severe. Rough
smooth enamel surface enamel surface.
Detection Invisible under strong Seen easily under strong
light source. light.
QUOTE OF THE DAY …..
LIFE IS THE MOST DIFFICULT EXAM…..

Many people fail because they try to copy others , not

realizing that every one has a different question paper.