Aesthetic concerns of children and parents in relation to different classifications of the Tooth Surface Index of Fluorosis

Enamel Remineralisation with a Novel Sodium Fluoride-Infused Bristle Toothbrush

This study aims to investigate whether toothbrushes with fluoride-infused bristles have any (re)mineralisation effects on bovine enamel. Bovine incisors (N = 160) were extracted, and the buccal side of the crown was cut into dimensions of ~5 mm × 5 mm with a low-speed saw. These specimens were randomly allocated into four groups: half (80 teeth) were stored in demineralising solution (DM), and the other half were stored in deionised water (DW) for 96 h. Then, they were brushed with a force of 2.0 ± 0.1 N for five min with a manual toothbrush with either fluoride-infused (TF) or regular (TR) bristles. Microhardness (Vickers), X-ray diffraction (XRD), energy-dispersive X-ray spectroscopy (EDS), and scanning electron microscopy (SEM) were used to investigate the surfaces of the bovine enamel specimens before and after brushing. Two-way ANOVA was used to analyse the hardness data, and the pairwise comparison method was used to analyse the Ca/P ratio, for each group at α = 0.05. The results show that brushing with either of these toothbrushes increased the Vickers microhardness on DM and DW enamel (p < 0.001), whereas hydroxyapatite was revealed in all groups by XRD. The DM samples showed a significant increase (p < 0.05) in the Ca/P ratios after brushing with TR and TF. Conversely, under DW conditions, these ratios decreased significantly after brushing. In terms of the F atomic%, TF increased significantly. SEM revealed mineral deposition in the DM groups after toothbrushing. To conclude, toothbrushing effectively induces the microhardness of sound and demineralised enamel, while fluoride-infused bristles might be able to retain fluoride on the enamel surface.

Do various degrees of tooth decalcification affect orthodontists', general dentists' and laypersons' ratings of smile esthetics?

OBJECTIVES

To compare the effect of various degrees of decalcification after orthodontic treatment (white spot lesions) on orthodontists', general dentists', and laypersons' ratings of smile esthetics.

MATERIALS AND METHODS

Eight photographs representing incrementally altered tooth decalcification lesions of maxillary anterior teeth ranging from mild to severe were shown randomly to the study participants. Photographs were rated by a matched sample of orthodontists (N = 42), general dentists (N = 52), and laypeople (N = 58). A visual analogue scale (VAS) was used to assess perceptions of smile esthetics.

RESULTS

The three groups of raters could distinguish between different decalcification levels. Raters gave more negative scores as the decalcification level increased.

CONCLUSIONS

The three groups of raters were able to distinguish between various degrees of decalcification lesions. General dentists were the most critical of all groups when rating decalcification lesions.

Water fluoridation for the prevention of dental caries

BACKGROUND

Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation was initiated in the USA in 1945 and is currently practised in about 25 countries around the world; health authorities consider it to be a key strategy for preventing dental caries. Given the continued interest in this topic from health professionals, policy makers and the public, it is important to update and maintain a systematic review that reflects contemporary evidence.

OBJECTIVES

To evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries.To evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis.

SEARCH METHODS

We searched the following electronic databases: The Cochrane Oral Health Group's Trials Register (to 19 February 2015); The Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2015); MEDLINE via OVID (1946 to 19 February 2015); EMBASE via OVID (1980 to 19 February 2015); Proquest (to 19 February 2015); Web of Science Conference Proceedings (1990 to 19 February 2015); ZETOC Conference Proceedings (1993 to 19 February 2015). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization's WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on language of publication or publication status in the searches of the electronic databases.

SELECTION CRITERIA

For caries data, we included only prospective studies with a concurrent control that compared at least two populations - one receiving fluoridated water and the other non-fluoridated water - with outcome(s) evaluated at at least two points in time. For the assessment of fluorosis, we included any type of study design, with concurrent control, that compared populations exposed to different water fluoride concentrations. We included populations of all ages that received fluoridated water (naturally or artificially fluoridated) or non-fluoridated water.

DATA COLLECTION AND ANALYSIS

We used an adaptation of the Cochrane 'Risk of bias' tool to assess risk of bias in the included studies.We included the following caries indices in the analyses: decayed, missing and filled teeth (dmft (deciduous dentition) and DMFT (permanent dentition)), and proportion caries free in both dentitions. For dmft and DMFT analyses we calculated the difference in mean change scores between the fluoridated and control groups. For the proportion caries free we calculated the difference in the proportion caries free between the fluoridated and control groups.For fluorosis data we calculated the log odds and presented them as probabilities for interpretation.

MAIN RESULTS

A total of 155 studies met the inclusion criteria; 107 studies provided sufficient data for quantitative synthesis.The results from the caries severity data indicate that the initiation of water fluoridation results in reductions in dmft of 1.81 (95% CI 1.31 to 2.31; 9 studies at high risk of bias, 44,268 participants) and in DMFT of 1.16 (95% CI 0.72 to 1.61; 10 studies at high risk of bias, 78,764 participants). This translates to a 35% reduction in dmft and a 26% reduction in DMFT compared to the median control group mean values. There were also increases in the percentage of caries free children of 15% (95% CI 11% to 19%; 10 studies, 39,966 participants) in deciduous dentition and 14% (95% CI 5% to 23%; 8 studies, 53,538 participants) in permanent dentition. The majority of studies (71%) were conducted prior to 1975 and the widespread introduction of the use of fluoride toothpaste.There is insufficient information to determine whether initiation of a water fluoridation programme results in a change in disparities in caries across socioeconomic status (SES) levels.There is insufficient information to determine the effect of stopping water fluoridation programmes on caries levels.No studies that aimed to determine the effectiveness of water fluoridation for preventing caries in adults met the review's inclusion criteria.With regard to dental fluorosis, we estimated that for a fluoride level of 0.7 ppm the percentage of participants with fluorosis of aesthetic concern was approximately 12% (95% CI 8% to 17%; 40 studies, 59,630 participants). This increases to 40% (95% CI 35% to 44%) when considering fluorosis of any level (detected under highly controlled, clinical conditions; 90 studies, 180,530 participants). Over 97% of the studies were at high risk of bias and there was substantial between-study variation.

AUTHORS' CONCLUSIONS

There is very little contemporary evidence, meeting the review's inclusion criteria, that has evaluated the effectiveness of water fluoridation for the prevention of caries.The available data come predominantly from studies conducted prior to 1975, and indicate that water fluoridation is effective at reducing caries levels in both deciduous and permanent dentition in children. Our confidence in the size of the effect estimates is limited by the observational nature of the study designs, the high risk of bias within the studies and, importantly, the applicability of the evidence to current lifestyles. The decision to implement a water fluoridation programme relies upon an understanding of the population's oral health behaviour (e.g. use of fluoride toothpaste), the availability and uptake of other caries prevention strategies, their diet and consumption of tap water and the movement/migration of the population. There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES. We did not identify any evidence, meeting the review's inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries in adults.There is insufficient information to determine the effect on caries levels of stopping water fluoridation programmes.There is a significant association between dental fluorosis (of aesthetic concern or all levels of dental fluorosis) and fluoride level. The evidence is limited due to high risk of bias within the studies and substantial between-study variation.

Shades of Decay: The Meanings of Tooth Discoloration and Deterioration to Mexican Immigrant Caregivers of Young Children

The objective of this article is to investigate parental understanding of tooth discoloration and decay and their related care seeking for young, Mexican-American children. The research design entailed semi-structured, face-to-face interviews conducted in Spanish with a convenience sample of 37 Mexican immigrant mothers of young children in a low-income urban neighborhood. Five major color terms - white, off-white, yellow, brown, and black - were used to describe tooth discoloration, the causes of which were mainly unrecognized or attributed to poor oral hygiene and exposure to sweet substances. Mothers also described three major levels of deterioration of the structural integrity of teeth due to caries, from stains to decayed portions to entirely rotten. A trend was observed between use of darker discoloration terms and extensive carious lesions. Teeth described as both dark in color and structurally damaged resulted in seeking of professional care. The paper concludes with the finding that Spanish terms used to describe tooth discoloration and carious lesions are broad and complex. Mexican immigrant mothers' interpretations of tooth discoloration and decay may differ from dental professionals' and result in late care seeking. Increased understanding between dental practitioners and caregivers is needed to create educational messages about the early signs of tooth decay.

Percepção da fluorose dentária e avaliação da concordância entre pais e filhos: validação de um instrumento

Objetivou-se validar o Child's and Parent's Questionnaire about Teeth Appearance, avaliando as preocupações relacionadas à fluorose em 213 pares de pais/crianças (12 anos) de duas regiões brasileiras. A confiabilidade foi avaliada pelo alfa de Cronbach e pelo coeficiente de correlação intraclasse; e a validade de constructo e de critério, pela correlação de Spearman. Para comparar as duas regiões e avaliar a concordância pais/filhos, foi utilizado o teste t de Student. A consistência interna foi aceitável, e a confiabilidade teste-reteste, moderada a excelente. Houve correlação significativa entre percepção da fluorose moderada e severa e os dados clínicos e entre percepção da fluorose e preocupações dos indivíduos. Embora os pais de Rafael Arruda, Ceará, Brasil, tenham tido maior percepção da fluorose, o incômodo e a preocupação com a aparência foram maiores em Piracicaba, São Paulo. Os pais se mostraram mais incomodados, preocupados e insatisfeitos com a aparência dentária das crianças do que elas mesmas. Essa versão é válida e confiável para avaliar a percepção da estética dentária em crianças e em seus pais.

Comparison of dental esthetic perceptions of young adolescents and their parents

OBJECTIVES

To compare dental esthetic perceptions of adolescents at age 13 with those of parents and to assess associations with dental fluorosis.

METHODS

Adolescents aged 13 underwent dental examinations for fluorosis on maxillary anterior teeth using the Fluorosis Risk Index. Adolescents and parents completed questionnaires concerning satisfaction with adolescents' dental appearance. McNemar and Bowker tests of symmetry were used for comparisons of esthetics ratings between parents and adolescents. Comparison of satisfaction between subjects with fluorosis and subjects with no fluorosis was made using Cochran-Armitage Trend and Fisher's Exact tests.

RESULTS

From 376 adolescents included in the study, 26 percent had definitive fluorosis, mostly at a mild level. Fifteen percent of adolescents were dissatisfied with dental appearance, and concerns were mainly about color (45 percent) and alignment (35 percent). Adolescents were less satisfied with overall dental appearance (P < 0.001) and color (P = 0.048) and more concerned about tooth shape (P = 0.002) than were their parents. Fluorosis status (yes/no) was not significantly associated with adolescents' perceptions (P > 0.05). Parents of subjects with fluorosis were more dissatisfied with dental appearance (P = 0.014) and color (P < 0.001) than other parents. The number of maxillary anterior zones exhibiting fluorosis was negatively associated with adolescent (P = 0.03) and parent (P = 0.002) satisfaction.

CONCLUSION

Adolescents generally had less satisfaction with dental appearance and color, and were more concerned with tooth shape than were parents. For both parents and adolescents, decreased satisfaction was associated with the number of zones with definitive fluorosis.

Oral-health-related quality of life in schoolchildren in an endemic fluorosis area of Mexico

OBJECTIVE

To evaluate the oral-health-related quality of life (OHRQoL) of children living in an endemic hydrofluorosis area.

METHODS

Schoolchildren aged 8-10 years living in an area with 3.38 ppm F water concentration completed a validated Spanish version of the Child Perceptions Questionnaire (CPQ(8-10ESP)). World Health Organization (WHO) criteria were applied for the diagnosis of dental caries and malocclusion. Additionally, the Thylstrup and Fejerskov Index (TFI) was used for fluorosis diagnosis. CPQ(8-10ESP) scores and oral health status were analyzed using non-parametric tests and logistic regression models.

RESULTS

Two hundred and twelve schoolchildren participated in this study. The mean CPQ(8-10ESP) score was 12.98 (SD 11.4). General oral health was rated as "poor" in 14.6%, "fair" in 41.5%, "good" in 25.9%, and "very good" in 17.9% of the children. Regarding overall well-being, half (51.6%) of the children perceived that the condition of their mouths disturbs their quality of life (QoL). Children with dental fluorosis (TF >4) had a high CPQ(8-10ESP) score in all domains (P < 0.005). Additionally, children with DMFS + dmfs >5 had higher scores in the oral symptoms, functional limitation, and emotional well-being CPQ(8-10ESP) domains (P < 0.05). Applying a CPQ(8-10ESP) cutoff point of 32, the OR values for severe malocclusion, caries, and fluorosis were 5.2 (P = 0.034), 4.6 (P = 0.006), and 5.1 (P = 0.007), respectively.

CONCLUSIONS

Malocclusion, caries, and fluorosis were associated with a negative impact on children's QoL.

The aesthetic impact of enamel fluorosis on Irish adolescents

OBJECTIVES

To assess the impact of differing degrees of enamel fluorosis on dental aesthetics according to Irish adolescents. The same participants also aesthetically rated other variations in dental appearances including a carious lesion, bleached teeth and a demarcated opacity.

METHODS

One hundred and fifty adolescents examined seven identical template photographs of an attractive dental smile displaying varying levels of enamel fluorosis (TF1, TF2, TF3), a demarcated opacity, no fluorosis (TF0), anterior caries and very white or bleached teeth. By indicating their level of agreement or disagreement with five statements on a five-point Likert scale, the participants rated the aesthetic acceptability of each of the photographs.

RESULTS

Using paired t-tests with the Bonferroni correction, it was found that the photographs depicting the very white teeth and anterior caries were rated as the most and least aesthetically pleasing images, respectively. There was no significant difference in the ratings of the photographs displaying TF0, TF1 and TF2 levels of fluorosis indicating that these photographs were viewed similarly (P>0.002). The remaining two photographs (TF3 and the demarcated opacity) were rated similarly and significantly worse (P<0.002) than the photographs showing no or low grades of fluorosis (TF0, TF1 and TF2).

CONCLUSIONS

TF3 level of fluorosis represented the break point at which enamel fluorosis became aesthetically objectionable to these participants. Low grades of fluorosis (TF1 and TF2) were rated similarly to the photograph depicting no fluorosis (TF0).

Aesthetic perception of dental fluorosis--opinions of dentists and non-specialists

Aesthetic perception of the changes in teeth appearance is one of the factors that makes a person undertake a dental treatment.

OBJECTIVE

The aim of this study was to survey dentists' and non-specialists' aesthetic perception of dental fluorosis.

PATIENTS AND METHODS

We recruited 120 young people (age range 18-22 years with little knowledge of dental fluorosis and 120 randomly selected dentists. Evaluation of the abnormalities in the teeth aesthetic appearance was conducted using cards specially designed for the purpose.

RESULTS

The results suggest that changes in dental fluorosis, even in the mildest forms, are perceived as deviations in the aesthetic appearance of teeth. Non-specialists are more tolerant towards the changes characteristic of mild dental fluorosis compared with their reaction to other conditions that result in deviations in the type of dentition as a whole.

CONCLUSION

Further studies are needed to more precisely determine the role of aesthetic perception in determining the indications for the complex treatment of dental fluorosis.

A literature review of aesthetic perceptions of dental fluorosis and relationships with psychosocial aspects/oral health-related quality of life

Aesthetic perceptions and oral health-related quality of life concerning dental fluorosis have been assessed in several studies during the past two decades. However, no comprehensive review article summarizing the studies investigating this issue has been published.

OBJECTIVE

To assess the relationships between perceptions of dental appearance/oral health-related quality of life (OHRQoL) and dental fluorosis.

METHODS

The PubMed database was searched using the Medical Subject Headings (MeSH) for English-language studies from 1985 to March 2009. Thirty-five articles qualified for inclusion and then were classified into three categories based on the type of study approach: (i) respondent review of photographs and assessment concerning satisfaction/acceptance, (ii) respondent assessment of study subject's teeth concerning satisfaction/acceptance, and (iii) respondent assessments of the psychosocial/OHRQoL impact.

RESULTS

There were varied results from earlier studies focused on satisfaction/acceptance of very mild to mild fluorosis. More recent studies with methodological improvements to assess impact on quality of life clearly showed that mild fluorosis was not a concern. Furthermore, mild fluorosis was sometimes associated with improved OHRQoL. Severe fluorosis was consistently reported to have negative effects on OHRQoL.

CONCLUSION

Because dental fluorosis in the United States and other nations without high levels of naturally-occurring fluoride is mild or very mild, with little impact on OHRQoL, dental professionals should emphasize the appropriate use of fluorides for caries prevention and preventing moderate/severe fluorosis.

Bleaching a devital primary tooth using sodium perborate with walking bleach technique: a case report

Nowadays, both children and parents place a greater value on appearance and aesthetics than has previously been the case. Primary teeth with intrinsic discoloration may be treated by a number of methods, including facings and abrasion. However, dental bleaching may offer a safer alternative that can be completed with less chair time and without harming dental structures. This case report describes the treatment of a darkened primary tooth of a 4-year-old boy with sodium perborate using the walking bleach technique and its 1-year clinical and radiographical follow-up. During this 1-year follow-up period, no signs of any pathology were observed either clinically (sensitivity to percussion or palpation, fistulae, color change) or radiographically (external or internal root resorption, apical radiolucency). In this study, using sodium perborate with the walking bleach technique is found to be successful in whitening primary teeth and can be recommended as a safe alternative for the bleaching of devital primary teeth with intrinsic discoloration.

Relative esthetic importance of orthodontic and color abnormalities

OBJECTIVE

To assess the relative importance of an orthodontic esthetic index, dental fluorosis and nonfluoride opacities, with respect to parents' satisfaction with their children's dental esthetics.

MATERIALS AND METHODS

Dental examinations of Iowa Fluoride Study participants assessed fluorosis and nonfluoride opacities in the mixed dentition. Dental casts of 200 randomly selected subjects were scored using the Dental Aesthetic Index (DAI) criteria. Parent satisfaction was assessed via multiple items on a questionnaire. Associations were evaluated using logistic regression.

RESULTS

Nineteen percent of parents were somewhat or very dissatisfied with their children's dental esthetics. Overall DAI score was positively associated with dissatisfaction (P < .001), as was fluorosis (P = .003).

CONCLUSIONS

In addition to changes related to DAI scores, parent esthetic satisfaction decreased with the presence of fluorosis. Dental professionals should address both the issues of tooth positioning and color aberration with respect to dental esthetics.

Patient- and population-reported outcomes in public health dentistry: oral health-related quality of life

At present no process is in place in the United States to comprehensively monitor the national burden of oral diseases from the perspective of oral health-related quality of life (OHRQoL), yet available evidence shows that a substantial percentage of the adult population rates their oral health poorly. This article reviews applications of OHRQoL in dental public health. The authors specifically review its use, contributions, and needed advances in: (1) monitoring the impacts of oral diseases on OHRQoL at the national level, and in public health surveillance at the state and local levels; (2) treatment outcomes research and program evaluation; and (3) clinical practice.

Oral Health-Related Quality of Life of Children by Dental Caries and Fluorosis Experience

OBJECTIVE

To evaluate the oral health-related quality of life (OHRQoL) of children by dental caries and fluorosis status.

METHODS

A random sample of South Australian 8- to 13-year-old children was selected. Caries data were collected from school dental service records to group children by combined deciduous and permanent tooth caries experience. Children were examined for fluorosis using the Thylstrup and Fejerskov (TF) Index to form groups by fluorosis scores on maxillary central incisors. Occlusal traits were recorded using the Dental Aesthetic Index. Children and their parents completed the Child Perception Questionnaire (CPQ) and the Parental Perception Questionnaire (PPQ) and a global rating of oral health (OH). OHRQoL indicators, rating OH as Excellent/Very good, and mean overall CPQ/PPQ scores were compared between groups by fluorosis scores and caries experience. Multivariate models were generated for both OH and CPQ/PPQ indicators.

RESULTS

Two hundred forty-two children (43.0 percent) had 0 decayed, missing, and filled primary and permanent tooth surface (dmfs/DMFS), while 170 (23.9 percent) had 5+ dmfs/DMFS. The prevalence of TF scores 1, 2, and 3 were 14.5, 9.5, and 1.9 percent, respectively. The proportion of children/parents rating OH as Excellent/Very good was significantly associated with children's caries experience. That proportion increased when fluorosis severity increased from a TF score of 0 to 2, but decreased with a TF of 3. Having low caries experience and better dental appearance were associated with parents' perception of good OH. Having mild fluorosis and more acceptable appearance were significant factors for children's perception of good OH. Caries and malocclusion were associated with lower OHRQoL, while having a TF score of 2 was associated with better OHRQoL in multivariate models for overall CPQ/PPQ scores.

CONCLUSION

Caries and less acceptable appearance showed a negative impact, while mild fluorosis had a positive impact on child and parental OHRQoL.

Perception of dental fluorosis and other oral health disorders by 12-year-old Brazilian children

AIM

The aim of this study was to verify the perception of dental fluorosis as an oral health problem by 12-year-old Brazilian children and to evaluate if they were able to detect other oral disorders.

METHODOLOGY

The sample consisted of 401 schoolchildren. Firstly, clinical examinations were performed using a visual method under natural light. After that, children answered a questionnaire with the purpose of assessing the self-perception of their oral health problems. Next, the volunteers were shown a photo album containing 24 photographs, and had to match each photo with a severity scale.

RESULTS

The prevalence of fluorosis was 18.2%; 81.8% of this total in fluorosis scale T-F 1. Of the 401 children, 48.9% (n = 196) answered oral health problems related to concerns, such as aesthetic appearance or pain. Among them, only two children, both with fluorosis T-F 2, correlated their problems with the presence of stained teeth. As regards the photo album analysis, the children considered photos showing fluorosis T-F 7-9 as the most severe, whereas the photo of an orally healthy patient was considered the least severe.

CONCLUSION

Children did not show negative perception of dental fluorosis, except for dental fluorosis at severe levels (T-F 7-9), and were mainly able to detect aesthetic or pain-related problems.

Changes in dental fluorosis following the cessation of water fluoridation

OBJECTIVES

To determine changes in the prevalence of dental fluorosis, and in perceptions of aesthetic concerns due to dental fluorosis after water fluoridation ceased.

METHODS

Schoolchildren in second and third grades were examined in 1993-94, 1996-97 and 2002-03 to determine changes in the prevalence of dental fluorosis following fluoridation cessation of the public water supplies in 1992. The Thylstrup-Fejerskov Index (TFI) was used to quantify dental fluorosis. Perceptions of aesthetics were assessed by questionnaires which were sent home to parents. Residence and dental histories were confirmed on all children to determine the extent of exposure to all types of fluorides. Comparisons between the three surveys were used to establish the influence of fluoridated water and other fluoride sources on the occurrence and severity of dental fluorosis. Aesthetic ratings from parents were used to assess the aesthetic conditions of maxillary anterior teeth across the three surveys.

RESULTS

When fluoride was removed from the water supply in 1992, the prevalence and severity of TFI scores decreased significantly from the 1993-94 survey cycle when compared with the 1996-97 and 2002-03 survey cycles. The use of fluoride supplements and fluoride dentifrice also decreased during this study period. Analyses were unable to determine the influence of these different fluoride exposures on the changes in TFI scores over time. Comparisons of aesthetic ratings from parents between survey cycles failed to show any significant differences.

An assessment of teenagers' perceptions of dental fluorosis using digital simulation and web-based testing

OBJECTIVES

To develop a new model to establish teenagers' perceptions of the aesthetic impact of fluorosis, in the context of overall facial appearance. This web-based model was used to compare different degrees of fluorosis at any one distance, while also comparing the same level of fluorosis at different 'distances'.

METHODS

A 14-year-old subject was used as the model face. Different degrees of fluorosis were 'built-up' on this subject's teeth using digital simulation. A web-based questionnaire showed 30 photographs, displaying four levels of fluorosis, in addition to fluorosis-free, at five different 'distances'. The closest images were shown with and without retractors, while the more distant pictures showed more of the subject's face. Teenage pupils (n = 217) were then asked to grade the acceptability of the appearances and indicate if they would wish treatment for each such appearance.

RESULTS

At any one distance, acceptability fell as fluorosis level increased. When the same degree of fluorosis was compared at different distances, acceptability improved as the teeth were viewed from further away. Pictures taken without retractors had higher acceptability than those taken with retractors in place.

CONCLUSIONS

Teenagers can discriminate between various degrees of fluorosis. However, more distant viewing of fluorosed teeth, within the overall context of the face, improves acceptability of the appearance.

Aesthetically objectionable fluorosis in the United Kingdom

OBJECTIVES

A cross-sectional national survey to explore perceptions of dental fluorosis and to determine the proportion of people regarding fluorosis as aesthetically objectionable at differing levels of defect.

METHODS

A survey using a multistage stratified random probability sample of 6,000 UK adult households. Face-to-face interviews were carried out using a structured questionnaire and photographs of different levels of dental fluorosis. Respondents were interviewed about the parameters of satisfaction, attractiveness and need for treatment for dental fluorosis.

RESULTS

The proportion of respondents perceiving teeth as unattractive, unsatisfactory and requiring treatment increased with increasing severity of dental fluorosis. Using agreement between the three negative perceptions as a measure, 14% of the sample perceived mild dental fluorosis as aesthetically objectionable, 45% at moderate level and 91% at severe levels.

CONCLUSION

Negative perceptions of dental fluorosis were lower than reported previously. Three parameters were included in the approach to estimate aesthetically objectionable fluorosis which may provide a more realistic measure than those used previously. The nature of the index and the sample included suggest that findings of this survey provide a reasonable indicator of the likely impact of water fluoridation. Findings may have important implications for fluoridation policies in the United Kingdom and elsewhere.

The rational use of fluoride toothpaste

Well-formulated fluoride toothpastes are clinically proven to prevent and control dental caries. They may also be a risk factor in the aetiology of dental fluorosis. This review considers the available evidence to support the appropriate use of fluoride toothpaste to maximise the benefit and minimise the risk. Three factors have an important influence on the anticaries efficacy of fluoride toothpaste, namely concentration, frequency of brushing and post brushing rinsing behaviour. The evidence suggests that low-fluoride (<600 ppm F) toothpastes provide less caries protection than standard (1,000 ppm F) or high (1,500 ppm F) concentration formulations. However, low-fluoride toothpastes are appropriate for very young children (under 7 years) at low caries risk, particularly if living in fluoridated areas. For other young children, higher concentrations of fluoride should be used. Brushing should be recommended twice daily, whilst rinsing with large volumes of water should be discouraged. Small amounts of toothpaste are comparable in efficacy to large amounts. The risk of fluorosis is associated with the ingestion of high doses of fluoride during tooth development and consequently only young children are at risk. The variability in the dose of fluoride ingested is mainly a function of the amount used, less so its concentration. To minimise fluorosis risk, parents should be advised to use only a pea-sized amount of toothpaste and encourage spitting out of excess. It is concluded that by using fluoride toothpastes appropriately, the benefits can be maximised and the risks of fluorosis minimised.

Perceptions of desirable tooth color among parents, dentists and children

BACKGROUND

As part of a large-scale fluoridation cessation study, standardized examiners assessed 8,281 school-aged children for dental fluorosis using the Thylstrup Fejerskov index, or TFI, in which scores range from 0 (no fluorosis) to 9 (severe loss of enamel with change of anatomical appearance).

METHODS

Dentists, parents and children were asked to respond to a statement, "The color of these teeth (mine or my child's) is pleasing and looks nice." Agreement or disagreement with the statement was indicated on a five-level scale, with a rating of 1 representing total agreement with the reference statement. The authors used repeated-measures analysis of variance to ascertain differences in satisfaction with the esthetic appearance of the subject's tooth color across dentists', parents' and subjects' perceptions.

RESULTS

Girls were more critical of their tooth color than were boys; however, parents and dentists were more critical of boys' tooth color than of girls'. While younger subjects were more critical than older subjects, parents of younger subjects were less critical than those of older subjects. Dentists' ratings were not significantly associated with subjects' age group. Subjects with a TFI score of 1 or 2 were not significantly more critical than subjects with a TFI score of 0, while those with a TFI score of 3 of higher were. Similarly, only parents of subjects with a TFI score of 3 of higher had significantly different ratings.

CONCLUSIONS

The three stakeholders in the esthetic treatment of children-parents, dentists and patients-appear to see the potential outcome of such treatment differently.

CLINICAL IMPLICATIONS

Dentists should ensure that parents and children agree about the course of treatment, the rationale for undertaking it and the results that could reasonably be expected.

Fluoride ingestion from toothpaste: conclusions of European Union-funded multicentre project

An important challenge encountered in this multicentred project was the need to take account of the different cultural and legal differences between the seven sites when agreeing the protocol. Examples such as access to registers of births and subject consent dictated that there were some differences in the methods used in the different sites. The data presented showed that it was possible to train and calibrate a number of examiners in a standardized photographic method for recording enamel fluorosis. This method has a number of important advantages for the objective monitoring of enamel fluorosis over time. There were considerable differences between the seven sites in the formulations of the toothpaste used and in the pattern of their use. The results indicate that it is possible to agree and adopt a standardized method for measuring fluoride ingestion from toothpaste. The aesthetic impact of enamel fluorosis seemed low in the populations included in this project, but further work is required on this issue.

Parental perception of fluorosis among 8-year-old children living in three communities in Iceland, Ireland and England

OBJECTIVES

To assess the impact of enamel fluorosis in three of the communities examined in 'Project FLINT', it was decided to conduct a structured telephone interview with the parents of some of the children who took part in the study.

METHODS

Three communities involved in this project were able to conduct this investigation: Reykjavik (Iceland), Cork (Ireland) and Knowsley (England). The aim was to interview the parents of children with a range of Thylstrup and Fejerskov (TF) index grades selected from each participating centre with respect to the appearance of their child's permanent maxillary central incisors. Interviewers were blinded as to the TF grade of the subject.

RESULTS

Interviews were conducted with parents of 215 children: 69 with TF grade 0; 70 with TF grade 1; 60 with TF grade 2 and 16 with TF grade 3 or greater. There was a trend towards more parents being unhappy with the appearance of their child's teeth with increasing TF grade. However, the main reasons given by parents for being unhappy with the appearance of their child's teeth was tooth alignment followed by the more yellow colour of permanent compared with primary teeth. Only with a TF grade of 3 was any appreciable concern expressed about fluorosis.

CONCLUSION

It would appear that there is a public awareness of both developmental defects and enamel fluorosis although this is not always expressed as dissatisfaction. Further research is required into the clinical impact of both fluorosis and other developmental defects of enamel.

A review of fluorosis in the European Union: prevalence, risk factors and aesthetic issues

Fluoride has played a key role in caries prevention for the past 50 years but excessive ingestion of fluoride during tooth development may lead to dental fluorosis. Throughout Europe many vehicles have been, and are currently, employed for optimal fluoride delivery including drinking water, toothpaste, fluoride supplements, salt and milk. Several indices, both descriptive and aetiological, have been developed and used for measuring fluorosis. This factor, combined with the lack of use of a standardized method for measurement of fluorosis, has made comparison between studies difficult and assessment of trends in fluorosis prevalence unreliable. Overall the evidence would appear to indicate, however, that diffuse enamel opacities are more prevalent in fluoridated than in nonfluoridated communities and that their prevalence at the very mild level may be increasing. In addition to fluoridated drinking water, risk factors for fluorosis include inadvertent ingestion of fluoride toothpaste and the inappropriate use of fluoride supplements. The risk is of aesthetic concern primarily during the period of enamel development of the permanent central incisors, although this largely appears to be a cosmetic rather than a public-health issue. It is concluded that there is a need to co-ordinate studies measuring fluorosis throughout Europe and that development of a standardized photographic method would be useful. Furthermore, the aesthetic importance of fluorosis needs to be determined in more detail in each country in the light of each country's respective risk factors and dental health policies.

Esthetic perception and psychosocial impact of developmental enamel defects among Malaysian adolescents

The aim of this study was to investigate the prevalence and psychosocial impact of enamel defects among 16-year-old school children on the island of Penang. The data were collected through a self-administered questionnaire survey and an oral examination, using the Modified Developmental Defects of Enamel Index (FDI, 1992). In all, 1024 subjects were selected using a multistage random sampling technique. About two-thirds of the sample (67.1%) had at least one tooth affected by enamel defects. Enamel opacities accounted for 85.6% of the total condition. Diffuse-type opacity predominated (63.5%). Among subjects who expressed dissatisfaction, 18.8% reported covering their mouths when smiling, 8.7% avoided going out with friends and 39.1% had consulted their dentists. About 17% of the subjects reported that their parents had complained about the color of their front teeth but only 5.7% had experienced being teased by their friends about the problem. Two-thirds of the subjects were affected by enamel defects involving at least one tooth; however, the esthetic perception and psychosocial impact of those affected were minor.

Practitioner's guide to fluoride

The current health care trend is to provide evidence-based recommendations and treatment. Many literature reviews have shown fluoride's effectiveness against caries. The current use of fluoride in the prevention of dental caries is based on community, professional, and individual strategies. Personalized fluoride regimens should include a risk analysis and a review of the patient's current fluoride exposure. The future of fluoride may be found in its slow release and retention in the oral cavity through various modalities. Because of the many uncertainties still associated with fluoride, further research is needed.

Esthetically objectionable fluorosis attributable to water fluoridation

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.

[Neonatal screening for hemoglobinopathies: a pilot study in Porto Alegre, Rio Grande do Sul, Brazil]

This study was conducted to establish the frequency of hemoglobinopathies among newborns undergoing screening tests for metabolic diseases at the University Hospital (Hospital de Clínicas) in Porto Alegre, Rio Grande do Sul, Brazil. Testing for abnormal hemoglobins was performed by isoelectric focusing electrophoresis on agarose gel with blood obtained by heel stick and applied to filter paper. For confirmatory testing of abnormal neonatal screening, a venopuncture blood sample was obtained from the infant and parents and then submitted to hemoglobin electrophoresis on cellulose acetate at pH 8.6 and citrate agar at pH 6.2. A total of 1,615 subjects were studied: 20 samples showed the Hb S pattern and six samples showed Hb C. Thus, frequency of the sickle cell gene was 1.2% and that of the Hb C gene was 0.4%, regardless of race or origin. These data suggest that the inclusion of universal neonatal screening for hemoglobinopathies in the ongoing projects for the detection of phenylketonuria and congenital hypothyroidism has many advantages and should be considered in health programs.

Follow-up study of dental students' esthetic perceptions of mild dental fluorosis

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.

A pilot study of dental students' esthetic perceptions of computer-generated mild dental fluorosis compared to other conditions

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.

Role of fluoride in oral health promotion

Fluoride has played a pivotal role in oral health promotion over the past 50 years. This paper reviews key issues currently impacting on the role of fluoride in preventing dental caries. The understanding of the process of dental caries and the mode of action of fluoride has changed in recent years. Dental caries is a continuous process of demineralisation and remineralization of the enamel and fluoride plays a key role in this process through its action at the plaque enamel interface. It is now accepted that the primary mode of action of fluoride is post-eruptive. The post-eruptive action of fluoride has resulted in new methods of delivering fluoride. The paper discusses the impact of these new methods of delivering fluoride on total fluoride intake in children and on the prevalence of dental fluorosis. The role of different methods of delivering fluoride both on a community and individual basis is presented and recommendations are outlined.

The prevalence and severity of enamel fluorosis in North American children

The question considered in this review is the extent to which changes in the prevalence or severity of enamel fluorosis have occurred over the last half-century. Emphasis is given to a review of those studies in which subjects are drinking water that is fluoride deficient and those in which subjects are drinking optimally fluoridated water, either adjusted or natural. Trends in fluorosis were examined using two definitions of fluorosis (definite and any signs) and three types of comparisons--comparisons of pooled estimates from all available studies that include data from different communities and time periods, comparisons of estimates from the same communities at different times, and comparisons of estimates from selected studies in the early years of fluorosis research with results of the US National Fluorosis Survey done by the National Institute of Dental Research. A clear increase in fluorosis among populations drinking community water that contains less than 0.3 ppm fluoride was found. Results of the comparisons using studies with Dean's Index pooled at different time points, comparisons in the same communities over time, and comparisons of prevalence found in selected communities before fluoride was widely available with the National Fluorosis Survey all support this conclusion. An increase in the prevalence of fluorosis in those drinking optimally fluoridated water likely has occurred as well; however, evidence for such a trend is not as clear as for fluoride deficient communities because of mixed results depending on the type of comparison. The majority of fluorosis cases continue to be mild and seem of little esthetic consequence for most of the public or dental profession. But a few cases of more severe fluorosis can be found now in some communities. Because the prevalence of fluorosis is now higher than 50 years ago, we can conclude that fluoride availability to the developing enamel during critical periods when enamel is at risk of fluorosis has increased in North American children.

Fluoride supplements for young children: an analysis of the literature focusing on benefits and risks

The use of fluoride supplements to prevent caries has been advised for more than 100 years, but serious promotion of this strategy occurred only after the effectiveness of water fluoridation was established, in the late 1950s and 1960s. Although the effectiveness of fluoride supplements was apparently endorsed by many small clinical studies, closer examination of the experimental conditions of these, their methods and the analysis of their results undermined confidence in their findings. It is likely that confounding resulted in spurious conclusions in many of them. More modern, well-conducted clinical trials of supplements suggest that today, in children also exposed to fluoride from other sources such as toothpaste, the marginal effect of fluoride supplements is very small. There is evidence that fluoride lozenges, designed to maximise any local effect, may have a small caries preventive effect, particularly in deciduous teeth. Overall, poor compliance makes fluoride supplements a poor public health measure. Supplement use by young children is associated with a substantial risk of dental fluorosis. Fluorosis is an issue about which the public is becoming concerned in several countries and this concern, if translated into opposition to all fluoride use, could jeopardise the most successful caries preventive aid we have. The potential for dental fluorosis, concern about the public's reaction to this, the poor effectiveness of supplements and the public's poor compliance with their use are persuasive arguments for a radical reduction in the use of supplements by young children. Recent changes in fluoride dosage schedules and deferment of the age of commencing the use of supplements, implemented in many countries, have followed from these concerns. Supplements formulated as lozenges maximise topical exposure of enamel to fluoride and such products may offer older children and some adults a way of maintaining an elevated fluoride level in saliva at times when toothbrushing is not practical.

Parents' satisfaction with children's tooth color: fluorosis as a contributing factor

The authors surveyed parents of 708 patients in a pediatric dental practice about their satisfaction with the color of their children's teeth and factors associated with their level of satisfaction. Overall, 43 percent of parents were dissatisfied with their children's tooth color, and 78 percent of children had a Tooth Surface Index of Fluorosis, or TSIF, score greater than 0. The worst TSIF score was the only factor associated with parent satisfaction.

The influence of various fluoride exposures on the prevalence of esthetic problems resulting from dental fluorosis

OBJECTIVES

This study sought to determine the prevalence of esthetic problems due to dental fluorosis, and determine the relationship of different fluoride exposure histories to the occurrence of these problems.

METHODS

In 1993-94 2,715 children in grades 2 and 3 and 3,297 adolescents in grades 8 and 9 were examined by four dentists. Questionnaires detailing exposures to various fluoride technologies were collected from 3,022 of these study participants. Esthetic ratings of the participants' maxillary anterior teeth were made by the examiners, the participants themselves, and their parents using questionnaires designed for this purpose.

RESULTS

Data indicate that 46 percent of the participants had dental fluorosis. Only 40 percent had fluorosis on anterior maxillary teeth. The prevalence of esthetic problems ranged from about 1 percent to 4 percent, depending on how an esthetic problem was defined. Esthetic problems as defined by the participant were more prevalent for the "over 11" age group. Logistic regression results demonstrated significant associations between several of the classifications of esthetic problems and the use of fluoride supplements and dentifrices, and exposure to fluoridated water during the third year of life.

CONCLUSIONS

Results suggest that the prevalence of esthetic problems is low in the communities surveyed, and that exposure to any number of fluoride technologies in the third year of life can increase a child's risk for this problem.

Risk factors associated with fluorosis in a non-fluoridated population in Norway

In Norway, there is no water fluoridation and little naturally occurring fluoride in drinking water. Fluoride toothpaste is used by 95% of the population and there is a long tradition of fluoride supplement use. The purpose of this study was to record the prevalence and severity of dental fluorosis in 8-year-old children and relate this to systemic fluoride exposure (supplements and toothpaste). All children (n = 551, born 1988) in a municipality in Norway were invited to participate. Dental fluorosis on the buccal surface of the upper permanent incisors was recorded according to the Thylstrup-Fejerskov index (TF). Parents provided data on use of supplements and toothpaste. Complete data were obtained from 383 children. Sixty-seven percent of the children had used fluoride supplements regularly during childhood. At 8 months or earlier, the teeth of 26% of the children, and at age 14 months or earlier the teeth of 82%, were being brushed. Among children who used fluoride supplements regularly, periodically, seldom and not at all, 45%, 21%, 10% and 0%, respectively, had dental fluorosis. The dental fluorosis was mild (TF = 1) in 87% of the cases. Bivariate and multivariate analyses showed that, in addition to use of fluoride supplements, starting toothbrushing at an early age was associated with higher prevalence of dental fluorosis. The child's birth weight and liking for or swallowing of toothpaste did not influence the prevalence of fluorosis. Risk factors for fluorosis were use of toothpaste before the age of 14 months and regular use of fluoride supplements during childhood.

The place of fluoride supplements in caries prevention today

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.

Risk factors for dental fluorosis in pediatric dental patients

OBJECTIVES

Concerns have been raised recently about whether a substantial amount of dental fluorosis is resulting from the increased use of fluoride from various sources. The purposes of this study were to determine the prevalence and severity of dental fluorosis in a sample of pediatric patients seeking dental treatment in a university pediatric dental clinic and to evaluate sources of fluoride as risk factors for dental fluorosis.

METHODS

A convenience sample of 157 children aged 8 to 17 years were examined for dental fluorosis using the Tooth Surface Index of Fluorosis (TSIF). Fluoride history questionnaires assessing previous exposure to fluoride during the first eight years of life were completed by the children's parents. Fluoride exposures were compared among 54 cases and 54 matched controls using a case-control retrospective design.

RESULTS

Fluorosis was found in 72 percent of the children, but was generally quite mild. The risk of fluorosis was significantly greater for children who had greater exposure to fluoridated water and who used larger amounts of fluoridated toothpaste up to age eight.

CONCLUSIONS

This study provided evidence that increased use of fluoride toothpaste may be a risk factor for dental fluorosis. The results suggest prudent use of dentifrice by young children to minimize the risk of fluorosis.

Enamel opacities and dental esthetics

OBJECTIVES

The purpose of this study was to determine the esthetic importance of different types of developmental enamel defect.

METHODS

In the first method used, individual subjects from three different populations with less than 0.1, 0.7, and 0.9 ppm fluoride in their drinking water, were asked about the appearance of their teeth and results compared to assessments of clinical photographs made by a single examiner. In the second method used, dentist and lay observers were asked to assess the appearance of the dentition of selected individuals who had a range of enamel defects.

RESULTS

According to the first method, both the size of demarcated opacities and the degree of enamel hypomineralization (TF index) were related to satisfaction with appearance. However, there was no difference in satisfaction with the appearance of the teeth among the three areas included in this study. In the second method, similar types of enamel defects were found to be esthetic stimuli as with the first study, but the dentists responded more strongly to the stimulus of enamel hypomineralization than the lay examiners.

CONCLUSIONS

Both demarcated opacities and enamel hypomineralization may be important when assessing differences between populations. Further, esthetic ratings by dentists may not be a suitable means of assessing the esthetic importance of different types of enamel defects.

Evaluation of aesthetics for the different classifications of the Tooth Surface Index of Fluorosis

The prevalence of dental fluorosis for children both from fluoridated and non-fluoridated communities has increased dramatically in some regions of North America. This study evaluated the aesthetics of dental fluorosis for school-aged children from a reference population of 1131 children. The methodology from the Social Acceptability Scale of Occlusal Conditions (SASOC), part of the Dental Aesthetics Index (DAI), was used to assess fluorosis-related aesthetics. 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.

Influence of exposure to various fluoride technologies on the prevalence of dental fluorosis

An increase in the prevalence of dental fluorosis among children in North America is well documented. Published reports of the relationship between the occurrence of dental fluorosis and early exposure to various fluorides and the use of different types of infant feeding practices have begun to provide insights into possible causes for this increase. This study was designed to investigate this issue for children living in a non-fluoridated and a fluoridated community in British Columbia, Canada. Parents or guardians completed a questionnaire which detailed exposure to different types of fluorides and infant feeding practices during the first 6 yr of life. Completed questionnaires were returned and examinations were performed on 1131 children. 60% of children had dental fluorosis, and only 8% presented with scores of 2 or greater. Logistic regression analyses showed that the use of infant formula and parental educational attainment were significantly associated with the occurrence of dental fluorosis in the range of scores from 2 to 6. Despite these statistically significant findings, these variables actually had little additional predictive value beyond a chance occurrence in determining which children would have dental fluorosis.