INDICES USED FOR DENTAL FLUOROSIS

BYNITYA SHARMA

INTRODUCTION

INDEX : an index has been defined as a numerical value describing the relative status of a population on a graduated scale with definite upper and lower limits which is designed to permit and facilitate comparison with other populations classified by same criteria and methods.(Russel)

DENTAL FLUOROSIS : is a hypoplasia or hypomineralisation of tooth enamel or dentine produced by the chronic ingestion of excessive amounts of fluoride during the period when teeth are developing.

HISTORY

1888 : “KUHNS” described teeth of persons in areas of Mexico that were opaque, discolored and disfigured. (Kuhns1888; Moller 1982).

1901 Dr. Fredrick Mckay of Colorado USA discovered permanent stains on teeth of his patients which were referred as Colorado stains.

Mckay named then “mottled enamel”. An Assitant surgeon of U.S marine hospital service

reported similar condition in Italians emigrating from USA from Naples named it denti di chiaie. ( Eager 1901).

1916 Mckay and Black published a series of articles in dental cosmos.

In 1931 this condition of teeth was found to b correlated to fluoride content of drinking water. (Churchill 1931; Smith et al 1931)

1931 shoe leather survey by Trendley H. Dean

1934 DEAN’S FLUOROSIS INDEX was given by Trendley H.Dean

CLASSIFICATION OF FLUOROSIS MEASURING INDICES

FLUOROSIS

SPECIFIC

THYLSTRUP AND

FERJESKOV

DEAN’S INDEX

TOOTH SURFACE

INDEX FOR FLUOROSIS

FLUOROSIS RISK INDEX

DESCRIPTIVE

DEVELOPMENTAL DEFECTS OF ENAMEL

INDEX

JACKSON Al- ALOUSI INDEX

MURRAY SHAW INDEX

DEAN’S FLUOROSIS INDEX 1934; TRENDLEY H.DEAN

devised an index for assessing the presence and severity of mottled enamel.

The fluorosis index set criteria for

categorisation of dental fluorosis on a

7point scale.

Although no numbers were used it was

considered to be on ordinal scale.

Children who had not lived in the community

continously or had obtained domestic

water from other than public supply are

eliminated

Under his classification all those showing

hypoplasia other than mottling of enamel

were placed in normal category

SALIENT FEATURES

METHOD ( as implied by DEAN)

Each individual recieves a score corresponding to clinical appearance of two most affected teeth.• Examinations are made in good natural light

with the subject sitting facing the window

No specific information as to whether the teeth were cleaned or dried before examination is given• Mouth mirror and probes were utilised for

examination.

CLASSIFICATION AND CRITERIA

NO

RM

AL • The

enamel represents the usual transluceny semivitriform type of structure

• The surface is smooth, glossy and usually of pale creamy white color

QU

ES

TIO

NA

BLE

• Slight aberrations in translucency of normal enamel ranging from few white flecks to occasional white spots, 1-2mm in diameter.

VERY M

ILD • Small, opaque,

paper white ares are scatterd irregularily or streaked over the tooth surface

• Observed on labial and buccal surfaces ; <25% of teeth surface involved.

• Small pitted white areas are frequently found on summits of cusps

• No brown stain

MIL

D

• White opaque areas involve half of tooth surface.

• Surfaces of cuspids n bicuspids prone to attrition show thin white layers worn off and bluish shades of normal enamel

• Faint brown stains are apparent

MO

DER

ATE

• No change in form of tooth but all surfaces are involved

• Surfaces subjected to attrition are definitely marked

• Minute pitting is present on buccal n labial surfaces

MO

DER

ATELY

SEV

ER

E

• Smoky white appearance

• Pitting is more frequent and generally seen on all surfaces

• Brown stain if present has more hue and involves all surfaces

SEV

ER

E

• Form of teeth are affected.

• Pits are deeper and confluent

• Stains are widespread and range from choclate brown to almost black

Based on this index, Dean. Dixon and Cohen(1935) proposed that their classification should determine a mottled enamel index of a community for epidemiological purpose

negative

boderline Slight Mediu

m

Rather marke

d

Very marke

d

1939 Dean combined the “moderarely severe” and “severe” into a single category “severe”.

1942 Dean introduced the revised scale for fluorosis index where now he used the six point scale.

Deans revised index (1942)

NORMAL (0) The enamel represents the usual translucent semivitriform type of structure. The surface is smooth , glossy and usually of a pale, creamy white colour.

QUESTIONABLE(0.5) The enamel discloses slight aberrations from the translucency of normal enamel, ranging from a few white fleck to occasional white spots. This classification is used in those instances where a definite diagnosis of the mildest form of fluorosis is not warranted and a classification of “normal” not justified.

VERY MILD (1) Small, opaque, paper white areas scattered irregularly over the tooth , but not involving as much as approximately 25% of 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 bicuspids or second molars.

MILD (2)The white opaque areas in the enamel of teeth are more extensive but do not involves as much as 50% of tooth.

MODERATE (3) All enamel surfaces of the teeth are affected and surfaces subject to attrition show wear. Brown stain is frequently a disfiguring feature.

SEVERE (4) All enamel surfaces of the tooth are affected and hypoplasia is so marked that the general form of the tooth may be affected. The major diagnostic sign of this classification is discrete or confluent pitting. Brown stains are widespread and teeth often present a corroded-like appearance.

MODIFICATIONS

Moller (1965) in Denmark introduced three intermediate classifications and variations in the weightings to be ascribed to each category.

USES

Most widely used index to measure dental fluorosis.

Helped to indicate prevalence of moderate to severe fluorosis in many communities as

Sweden by Forsman in 1974 Austria by Binder in 1973 England by Murray et al(1956), Forrest

(1965), Goward (1976) USA by Galagan and Lamson (1953) India by Nanda et al (1974)

The National Survey of Children’s Dental Health in Ireland in 1984 measured fluorosis using Dean’s index to provide baseline data for future refernce.

( Whelton HP;Ketley CE;Mcsweeny F;O’Mullane DM;2004)

National Fluorosis Survey in USA in 1986-87 to note baseline values was done using Dean’s index.

LIMITATIONS

Does not give sufficient information on distribution of fluorosis withtin the dentition.

Isolated defects are not recorded. The distinction amongst the categories is unclear,

indistinct and lacking sensitivity. Even though Dean’s scale is ordinal , it involves

averaging of the scores which is inappropriate. (A. Rizan Mohamed,W. Murray Thomson;Timothy D.

Mackay, An epidemiological comparison of Dean’s index and the Developmental Defects of Enamel (DDE) index; JPHD ISSN 0022-4006)

COMMUNITY FLUOROSIS INDEX 1942 , based on the revised fluorosis

index scale , he developed a scoring system so as to derive a COMMUNITY FLUOROSIS INDEX .

On basis of the number and distribution of individual scores, a community index for dental fluorosis (Fci) can be calculated by the formula

Fci = sum of( no. of individuals*stastical weights)/

no. of individuals examined

0.0 – 0.4 0.4 – 0.5 0.5 – 1.0 1.0 – 2.0 2.0 – 3.0 3.0 – 4.0

Negative Borderline Slight Medium Marked Very Marked

RANGE OF SCORES FOR CFI

SIGNIFICANCE

It gives an indication of public health significance of fluorosis.

It was used by Galagan and Lamson (1953) in their investigation of climate and endemic fluorosis.

Minoguchi (1970) refined the above analysis to take into account the total fluoride content from the diet by a community.

Myers(1978) suggested a graphic method of abtaining optimal fluoride concentration by comparing CFI against water fluoride content at different temperatures.

THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS

1978 ; Thylstrup and Frejeskov suggested a 10point classification system designed to categorise the degree of fluorosis affecting buccal/lingual and occlusal surfaces.

SALIENT

FEATURES

Examination is done on a portable chair out in

daylight.

Plane mirror n

probes are used Prior to

examination the teeth are dried

with cottonwool

rolls

THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS

0 . 1

Normal translucency of enamel remains after prolonged air – drying

Narrow white lines located corresponding to the perikymata.

Score Criteria

2 Smooth surfaces; More pronounced lines of opacity which follow the perikymata. Occasionally, confluence of adjacent lines.

Occlusal surfaces: Scattered areas of opacity of 2mm in diameter and pronounced opacity of cuspal ridges.

Score Criteria

3 Smooth surfaces: Merging and irregular cloudy areas of opacity. Accentuated drawing of perikymata often visible between opacities.

Occlusal surfaces : Confluent areas of marked opacity. Worn areas appear almost normal but usually circumscribed by a rim of opaque enamel.

Score Criteria

4 Smooth surfaces: The entire surface exhibits marked opacities 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.

Score Criteria

5 Smooth and Occlusal surfaces: Entire surface displays marked opacity with focal loss of outermost enamel (pits) 2mm in diameter.

Score Criteria

6

7

Smooth surfaces: Pits are regularlyarranged in horizontal bands 2mm in vertical extension.Occlusal surfaces: Confluent areas 3mm in diameter exhibit loss of enamel. Marked attritionSmooth surfaces: Loss of outermost enamel in irregular areas involving half of the entire surface.Occlusal surfaces: Changes in the morphology caused by the merging pits and marked attrition.

Score Criteria

8

9

Smooth and Occlusal surfaces: Loss of outermost enamel involving half of the surface.Smooth and Occlusal surfaces: Loss of main part of enamel with change in anatomic appearance of surfaces. Cervical rim of almost unaffected enamel is often noted

Score Criteria

Advantages

It attempts to validate the visual appearance against the histological defect.

Most sensitive of all fluorosis measuring indices. Granath et al. (1985), comparing the DEAN and

T-F indexes, concluded that the latter was more detailed and sensitive because it was based on biological aspects where there is an increase in hypo mineralization with a simultaneous increase in the depth of the enamel surface in direction of the amelo-dentin junction.

Cleaton-Jones and Hargreaves (1990) compared the three fluorosis indexes (DEAN, T-F and TSIF) in deciduous dentition, reporting that the prevalence of fluorosis in individual teeth was more frequently diagnosed with the T-F index. They concluded that the T-F index is the most indicated for work where detailed information about the problem is required. 

USES To assess the impact of enamel fluorosis in three

communities examined in project FLINT.( Sigourjon’s H et al 2004)

Clark et al 1993 showed an increasing level of dissatisfaction by both parents and children with appearance as the child’s TSIF index grade rose.

Burger et al. (1987), recommended the T-F index for future field studies, due to the facility of use and better defined criteria. 

Disadvantages

Clarkson (1989) reported that in TF index drying of teeth creates an unnatural situation due to which changes in score 1 and 2 are very minor.

The aesthetic significance of these changes are questionable.

TOOTH SURFACE FLUOROSIS INDEX

It was developed by HOROWITZ et al. in 1984 at National Institute of Dental Research U.S.A

AIMOvercome the

shortcomings of Dean’s index and

assess the prevalence of fluorosis from a

tooth surface prospective.

Enamel shows no evidence of fluorosis

Enamel shows definite evidence of fluorosis namely areas with parchment-white colour that total less than one third of the visible enamel surface. Includes fluorosis confined only to incisal edges of anterior teeth and cusp tips of posterior teeth (Snow capping)

Numerical scoreDescriptive Criteria

0

1

2

3

4

Parchment – white fluorosis totals at least 1/3 of the visible enamel surface, but less than 2/3

Parchment – white fluorosis totals at least 2/3 of visible enamel surface.

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.

5

6

7

Discrete pitting of 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 intact enamel. The pitted area is usually stained or differs in colour from the surrounding enamel.

Both discrete pitting and staining of the intact enamel exist.

Confluent pitting of the enamel surface exist. Large areas of enamel may be missing and anatomy of tooth altered. Dark brown stain is usually present.

Intent to use

TSIF index - studies in which an aesthetic basis is desired for defining case and it may be used where risk factors are identified or when the teeth may not be cleaned and dried. (Antonio Carlos PEREIRA Ben-Hur Wey MOREIRA 1999)

It doesnot have questionable category as in Dean’s index and is based on the premise that any sign of fluorosis regardless of extent is positive for a case

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. .( R.Gary Rozier 1999)

FLUOROSIS RISK INDEX

Introduced by DAVID G. PENDRYS in 1990

AIMTo improve researcher’s ability to relate

the risk of fluorosis to developmental stage of permanent dentition at the time of exposure to fluorosis.

FR1- those begin to form in first year of life

FR2- those who donot begin to

form until 2nd year of life

Surface zones which donot come under above groups are

left unassigned

ENAMEL ZONES

Incisal edges of 11 21 32 31 41 42 and occlusal tables of 16 26 36 46.

Cervical third of incisors,middle third of canines, occlusal table,incisal third and middle third of bicuspid and 2nd molars

FR 1 •1O

FR 2 •48

UNASSIGNED •54

112

SCORING CRITERIA

NEGATIVE FINDING SCORE =0

Complete absence of any white spots or

striations.

QUESTIONABLE

SCORE = 1

White spots, striations or

fluorotic defects that cover 50% or less surface

zone

SCORE = 7

Any surface that has an opacity that appears to be a non fluoride opacity

POSITIVE FINDING

SCORE = 2

A surface zone with greater

than 50% of zone

displaying parchmen

t white striations.

Incisal edges and occlusal tables with

greater than 50% of surface

marked by

snowcapping

SCORE = 3

Surface zone with greater

than 50% of zone

that displays pitting, staining

and deformity

SURFACE ZONE

EXCLUDEDSCORE = 9

Incomplete eruption ,

orthodontic appliances and bands,

surface crowned or restored,

gross plaque and debris

CLASSIFICATION 1

CASES

Subject who has a positive score

on 2 or more enamel surface

zones

CONTROLS

Subject who has no positive or questionable scores on any

enamel surface zones

To obtain the FRI score for each individual the scores of classification 1 and 2 are combined into one summary score.

USES

Risk factors for enamel fluorosis in a fluoridated population. (Pendrys DG, Katz RV, Morse DE. 1994)

Risk factors for enamel fluorosis in a nonfluoridated population. (Pendrys DG, Katz RV, Morse DE1999)

The Iowa Fluoride Study(2005) (Steven M. Levy; Liang Hong,; John J.

Warren, Barbara Broffitt,)

DEVELOPMENTAL DEFECTS OF INDEX

The developmental defects of enamel was developed by “ FDI – Commission on Oral Health, Research and Epidemiology” in 1982 to avoid need for diagnosing fluorosis before recording enamel opacities.

PROCEDURE

Tooth surface is inspected

visually and defective areas

are tactilely explored with a

probe.

Natural or artificial light

Teeth should receive a

prophylaxis and be dried at

time of examination

CODING AND CRITERIA

Unerupted, missing, heavily restored , bacle decayed , fractured teeth and teeth or tooth surfaces which for any other reason cannot be classified with defects must be coded ‘X’.

Permanent teeth are number coded. Primary teeth are letter coded. When in doubt the tooth surface should be

scored ‘normal’. when an abnormality is present but cannot be

classified into listed categories, it should be scored as ‘other defects’.

TYPE OF DEFECT

• OPACITY• HYPOPLASIA• DISCOLORAT

ION

NUMBER

• SINGLE• MULTIPLE

DEMARCATION

• DEMARCATED

• DIFFUSE

LOCATION OF DEFECTS

• GINGIVAL OR INCISAL HALF

• OCCLUSAL• CUSPAL• WHOLE

SURFACE

MODIFICATIONS

Clarkson J.J and O’Mullane D.M in 1989 modified the DDE to be used in one of the two manners

General purpose epidemiology studies Screening surveys

General purpose epidemiological studies

NORMAL DEMARCATED OPACITY White/cream Yellow/brown DIFFUSE OPACITY Diffuse lines Diffuse patchy Diffuse confluent Confluent +Staining+loss

Of Enamel

Code 0

Code 1 Code 2

Code 3 Code 4 Code 5

Code 6

HYPOPLASIA Pits Missing enamel ANY OTHER

DEFECTS

Code 7 Code 8 Code 9

Extent of defect

Normal < 1/3rd

At least 1/3rd < 2/3rd

At least 2/3rd

Code 0 Code 1 Code 2 Code 3

Screening surveys

NORMAL DEMARCATED

OPACITY DIFFUSE OPACITY HYPOPLASIA PITS OTHER DEFECTS

CODE 0 CODE 1 CODE 2

CODE 3 CODE 4

In UK, DDE has been the most frequently used index

However since it is not fluorosis specific , it is difficult to analyze prevalence of fluorosis from this index.

YOUNG’S CLASSIFICATION OF ENAMEL FLUOROSIS

Developed by YOUNG M.A in 1973. Similar classification was developed by

Al-Lousi et al in 1975. Principle

Recording of any condition once

defined must be made on baisi of

that definition and not on basis of

presumed etiology.

TYPE A

• White areas less than 2mm in diameter

TYPE B

• White areas of > 2mm diameter

TYPE C

• Colored areas <2mm in diameter irrespective of white areas.

TYPE D

• Colored areas of <2mm diameter irrespective of area covered

TYPE E

• Horizontal white lines irrespective of there being any non linear lines

TYPE F

• Colored or white lines or areas associated with pits or hypoplastic areas

MURRAY AND SHAW’S CLASSIFICATION OF ENAMEL FLUOROSIS Developed by Murray J.J and Shaw L in

1979. Based on young’s classification with two

modificationsColored

flecks and patches

were combined into one group

Occlusal and

lingual/palatal surfaces were also included

REFERENCES

Whelton HP;Ketley CE;Mcsweeny F;O’Mullane DM; A review on fluorosis in European Union:prevelance risk factors and aesthetic issues,CDOE2004,32;9-18.

Antonio Carlos PEREIRA ;Ben-Hur Wey MOREIRA; Analysis of Three Dental Fluorosis Indexes Used in Epidemiologic Trials, Braz Dent J (1999) 10(1): 1-60

Pendrys DG, Katz RV, Morse DE. Risk factors for enamel fluorosis in a fluoridated population. Am J Epidemiol 1994;140:461-71.

Pendrys DG, Katz RV, Morse DE. Risk factors for enamel fluorosis in a nonfluoridated population. Am J Epidemiol1996;143:808-15.

R.G Rosier, Epidemiologic Indices for Measuring the Clinical Manifestations of Dental Fluorosis: Overview and Critique; ADR June 1994 vol. 8 no. 1 39-55.

A. Rizan Mohamed;W. Murray Thomson, ;Timothy D. Mackay; An epidemiological comparison of Dean’s index and the Developmental Defects of Enamel (DDE) index; doi: 10.1111/j.1752-7325.2010.00186.x

Steven M. Levy; Liang Hong; John J. Warren;Barbara Broffitt; Use of the Fluorosis Risk Index in a Cohort Study:The Iowa Fluoride Study;JPHD Vol. 66, No. 2, Spring2006.

David G. Pendrys; Analytical Studies of Enamel Fluorosis: Methodological Considerations.oxford journals Vol. 21, No. 2.

Chankanka O, Levy SM, Warren JJ, Chalmers JM. A literature review ofaesthetic perceptions of dental fluorosis and relationships with psychosocialaspects ⁄ oral health-related quality of life.CDOE 2010. 38: 97–109

R. Gary Rozier; The Prevalence and Severity of Enamel Fluorosis in North American Children; Vol. 59, No. 4, Fall 1999