/51

METHOD OF MEASURING DENTAL FLUOROSIS

Dental Flourosis:

Dental flourosis = hypomineralization of the dental enamel caused by excessive

ingestion of fluoride during tooth development

Depending on the quantity of fluoride ingested, and upon timing of the

ingestion, the clinical appearance of flourosis can range from barely noticeable to

a severe and ugly brown stain with pitting and flaking “تساقط” of friable

enamel"هش"

Dean's early investigations of flourosis found that the condition was widespread

and occurred in varying degrees of severity. So he first developed an index of

dental flourosis

Dean’s Flourosis Index = the most commonly used system for categorizing

dental flourosis where ratings are assigned on a seven point ordinal scale:

normal, questionable, very mild, mild, moderate, moderately severe, and severe

Dean used this seven point scale for his Flourosis Index for some time, but he then

combined the moderately severe and severe categories into a single "severe"

category

Dean had revised his Flourosis Index into the six point ordinal scale (including

"normal") that is still used today

Dean's criteria for the revised version of the Flourosis Index are:

Normal The enamel represents the usual translucent type of structure. The surface is

smooth, glossy, and usually of a pale creamy white color

Questionable The enamel discloses slight aberrations “ رافات بسيطةإنح ” from the

translucency of normal enamel, ranging from a few white flecks to

occasional white spots

This classification is utilized in those instances where a definite diagnosis

of the mildest form of flourosis is not warranted and a classification of

"normal" not justified

Very mild Small, opaque, paper-white area scattered irregularly over the tooth

but not involving as much as approximately 25% of the tooth surface

Frequently included in this classification are teeth showing no more than

about 1-2 mm of white opacity at the tip of the summit of the cusps of

the bicuspids or second molars

Mild The white opaque areas in the enamel of the teeth are more extensive but

do not involve as much as 50% of the tooth

/52

Moderate All enamel surfaces of the teeth are affected, and surfaces subject to

attrition show marked wear

Brown stain is frequently a disfiguring feature

Severe Includes teeth formerly classified as "moderately severe" and "severe" All

enamel surfaces are affected and hypoplasia is so marked that the

general form of the tooth may be altered. The major diagnostic sign of

this classification is the discrete or confluent pitting. Brown stains are

widespread and teeth often present a corroded appearance

Community Flourosis Index (CFI) is an index arbitrarily defined by Dean as a

seven point ordinal scale again ranging from negative and borderline to marked

and very marked

Dean later added numerical weights to these categories to derive a numerical

Community Flourosis Index

Dean related this index to the concentration of fluoride in a water supply and

was able to show a linear correlation “increased fluoride in drinking water

increases incidence of flourosis”

Dean also subjectively related his numerical Community Flourosis Index scale

to what he termed "the public health significance" of flourosis

With studies of flourosis being carried out in many regions of the world, Dean's

Flourosis Index inevitably became modified to meet specific needs, such as

increasing its sensitivity at the higher end of the scale for studies in areas

where flourosis was more severe than any Dean had to deal with

Thylstrup - Fejerskov is a modification of Dean's index and has a stronger

biological basis than Dean's more or less arbitrary index

Thylstrup - Fejerskov scores were related to histological features of the enamel

Thylstrup - Fejerskov modification of Dean's index has been widely and

successfully used

The criteria for Thylstrup-Fejerskov is:

- 0 Normal translucency of enamel

- 1 Narrow white lines

- 2 Smooth surfaces: More pronounced lines of opacity

Occlusal surfaces: Scattered areas of opacity <2 mm in diameter

- 3 Smooth surfaces: cloudy areas of opacity

Occlusal surfaces: marked opacity

/53

- 4 Smooth surfaces: The entire surface exhibits marked opacity

or appears chalky white

Occlusal surfaces: Entire surface exhibits marked opacity.

- 5 Smooth surfaces and occlusal surfaces: Entire surface displays

marked opacity with 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 <2 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

- 8 smooth and occlusal surfaces: loss of outermost enamel

involving > 1/2 surface

- 9 smooth and occlusal surfaces: loss of main part of main part

of enamel with change in anatomic appearance of surface

Tooth Surface Index of Flourosis (TSIF) was developed then

Tooth Surface Index of Flourosis is probably more sensitive than Dean's index

for the mildest forms of flourosis

Tooth Surface Index of Flourosis ascribes a score on a 0 to 7 scale to each tooth

surface in the mouth whereas Dean's index applies only to the two worst teeth

in the mouth

Criteria of Tooth Surface Index of Flourosis:

0 Enamel shows no evidence of flourosis

1 Enamel shows definite evidence of flourosis “areas with

parchment-white color” that total less than one-third of the

visible enamel surface

This category includes flourosis confined only to incisal edges of

anterior teeth and cusp tips of posterior teeth

"snow capping"

2 Parchment-white flourosis at least one third of the visible surface,

but less than two thirds

3 Parchment-white flourosis total at least two thirds of the visible

surface

/54

4 Staining is defined as an area of definite discoloration that may

range from light to very dark brown

5 Discrete pitting of the enamel exists, unaccompanied by evidence

of staining

6 Both discrete pitting and staining of the Intact enamel exit

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

Flourosis Risk Index seeks to achieve greater sensitivity by recognizing that

the risk of flourosis is related to fluoride exposure at particular stages of

dentition development

Flourosis Risk Index divides the buccal and occlusal surfaces of each

permanent tooth into four zones, and selectively assigns each zone into one of

two classifications, based on the age at which calcification begins

When Flourosis Risk Index is related to the history of fluoride exposure, flourosis

that develops during the maturation phase of enamel can be differentiated

from that which develops earlier

Wider use of Flourosis Risk Index is likely in studies on flourosis risk factors

One potential criticism of all these indexes is that bias is possible because a

diagnosis of flourosis is required before the condition is scored

Developmental Defects of Dental Enamel index (DDE) was developed to score

enamel opacities “regardless of origin” to avoid any such bias

Developmental Defects of Dental Enamel index has been used a number of times

since its introduction, but the large amount of data generated has led to

problems with presenting results in a meaningful fashion

Modifications of the Developmental Defects of Dental Enamel index were

suggested to make it simpler

On that same issue of distinguishing between milder forms of flourosis and non-

fluoride enamel opacities then an accurate history of drinking water locations, as

well as use of fluoride tablets, toothpaste, and rinses, should all be sought by

practitioners as aids to diagnosing the nature of enamel disturbances in patients

/55

Clinically how to differentiate dental flourosis from other conditions?

In dental flourosis areas that are affected usually on the tips of the

cusps called snow capped pattern because first to develop is the tip,

shape of the lesion will be like pencil scratch no demarcation but it

doesn’t overlap with adjacent enamel, the color will be chalky white

or frosty white

On clinical chair you focus a strong light on the area it will be

invisible under strong light

It happens on slowly calcified teeth like canine, premolars, 2nd

molars and 3rd molars

Dental flourosis is glazy “يلمع”

Dental flourosis is resistant to caries