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.

A standardized photographic method for evaluating enamel opacities including fluorosis.

OBJECTIVES: The objective of this study was to demonstrate the reproducibility of a standardized photographic technique for recording fluorosis when used by a group of epidemiologists as part of a large multicentred European study. METHODS: Studies were first carried out to develop the equipment specification and photographic method. The author (JAC) was then trained and calibrated in this method. She was then responsible for the training and calibration of examiners from a further six European study sites. The method involved taking two transparencies of the permanent maxillary central incisors of 8-year-old children, the first after 8 s while the teeth were still wet and the second after 105 s when the teeth had been allowed to dry out naturally. Data were collected at a central location during a training/calibration exercise and subsequently, during the conduct of a large study to measure fluorosis prevalence, at the seven sites. Intra- and interexaminer reproducibility of the photographic method were measured by grading the transparencies produced by all the examiners according to the DDE and TF indices. RESULTS: The time period in which the transparencies were taken was to within 4 s among the examiners. Transparencies scored according to the TF index gave a range of Kappa values of 0.45-0.66 for intraexaminer reliability and 0.32-0.55 for interexaminer reliability. When using the DDE index Kappa values ranged from 0.43 to 0.70 for intraexaminer reliability and from 0.34 to 0.69 for interexaminer reliability. CONCLUSION: The photographic method was mostly robust and reproducible when used by epidemiologists from seven European study sites.

A comparison of the prevalence of fluorosis in 8-year-old children from seven European study sites using a standardized methodology.

OBJECTIVES: The objectives of this study were to report on the prevalence of enamel opacities from seven European study sites using a standardized photographic method, and to investigate the importance of variables responsible for enamel fluorosis. METHODS: The sample comprised a randomly selected group of 300 8-year-old children in each of the study areas. One examiner from each area was trained and calibrated in the use of a standardized photographic technique. Two transparencies were taken of each child's permanent maxillary central incisor teeth; one to represent the teeth 'wet' and one when the teeth had been allowed to dry out naturally for 105 s. The transparencies were viewed 'blind' by the author (JAC) and scored using the DDE and TF indices. Data relating to variables considered to be associated with enamel fluorosis were also collected. RESULTS: The prevalence of diffuse opacities ranged from 61% in fluoridated Cork (Ireland) to 28% in Athens (Greece). The percentage of subjects with a TF score of three or more ranged from 4% in Cork and nonfluoridated Haarlem (the Netherlands) to zero in Oulu (Finland) and Athens. Fluoridated water and the prolonged use of fluoride tablets were found to be significant contributory factors to fluorosis. CONCLUSIONS: The prevalence of fluorosis was found to be highest in fluoridated Cork. The prolonged use of fluoride supplements was also found to be a significant risk indicator associated with fluorosis.

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.

Development of a standardized method for comparing fluoride ingested from toothpaste by 1.5-3.5-year-old children in seven European countries. Part 1: Field work.

OBJECTIVES: To develop a standardized method for measuring the variables affecting fluoride ingestion from toothpaste in young children between the ages of 1.5 and 3.5 years, and to use the method at seven European sites. METHODS: Random samples of children were invited to take part in the study. Parents who gave consent were visited at home. The children brushed their teeth using the toothpaste brand and toothbrush type currently in use. Variables measured were: type of toothpaste used, fluoride concentration of toothpaste used, weight of toothpaste used, frequency of brushing and body weight of the child. RESULTS: It was not possible to follow the agreed protocol in all seven countries and in three countries appropriate alternative methods were employed. There was considerable variation between countries in the variables investigated. Use of children's toothpaste ranged from 69% in Ireland to 98% in Portugal. In the Netherlands up to 60% of the children were using toothpaste containing <400 ppm F and in Finland up to 27% of children were using toothpaste containing >1200 ppm F. Over half of the children used <0.25 g of toothpaste per brushing and the majority of children brushed once or twice per day. CONCLUSION: Although adherence to the agreed protocol was not possible at all study sites there was a clear picture of considerable variation in the oral hygiene practices of young children throughout Europe.

Development of a standardized method for comparing fluoride ingested from toothpaste by 1.5-3.5-year-old children in seven European countries. Part 2: Ingestion results.

OBJECTIVES: To develop a standardized method for measuring the variables affecting fluoride ingestion from toothpaste in young children between the ages of 1.5 and 3.5 years, and to use the method at seven European sites. METHODS: Random samples of children were invited to take part in the study. Parents who gave consent were visited at home. The children brushed their teeth using the toothpaste brand and toothbrush type currently in use. The difference between the fluoride dispensed onto the toothbrush and the fluoride recovered after accounting for losses was deemed to be the fluoride ingested. Details of other oral health-care habits were collected by questionnaire. For each child, the fluoride concentration of the toothpaste used was measured in the laboratory, from which an estimate of total daily fluoride ingestion was made. RESULTS: There was considerable variation between countries in the types of toothpaste used and in the amounts of toothpaste applied and ingested. The amount of fluoride ingested ranged from 0.01 to 0.04 mg fluoride per kg of body weight per day. CONCLUSION: The amount of fluoride ingested that is likely to be a risk factor for the development of dental fluorosis during tooth formation is equivocal and was found to vary widely between European countries. There appears to be a need for clearer health messages regarding the use of fluoridated toothpaste by young children.

Fluoride ingestion from toothpaste: fluoride recovered from the toothbrush, the expectorate and the after-brush rinses.

OBJECTIVES: The aim of this study was to determine the effects of rinsing and spitting on fluoride ingestion from toothpaste during normal oral-hygiene procedures of younger children, and hence to make recommendations on rinsing during toothbrushing. METHODS: The brushing habits of 166 Dutch and 185 Irish children between 1.5 and 3.5 years were observed during home visits. The weight of the toothpaste tube was determined before and after use. After brushing, the toothbrush and any associated expectorate and rinses, combined with any toothpaste spilled during the brushing procedures, were collected. The amounts of fluoride retained on the toothbrush and in the associated expectorate and rinses were measured. RESULTS: Over 90% of the Dutch children used a special toddlers' toothpaste with < or =500 ppm F. Eleven per cent of the younger (<2.5 years) Dutch children and 22% of the older children rinsed after brushing. Of the Irish children approximately 52% used a children's toothpaste containing around 500 ppm F. Of the younger Irish children 31% spat without rinsing, while another 31% rinsed during or after brushing. For the older Irish children, these percentages were 14 and 70%, respectively. On average, 22% of the fluoride dispensed on the toothbrush was retained on the brush after brushing irrespective of the rinsing and spitting behaviour of the children. The maximum ingestible amount of fluoride from toothpaste assuming no rinsing or spitting was calculated. CONCLUSIONS: Fluoride ingestion from toothpaste is significantly reduced by rinsing and/or spitting during toothbrushing. Recommendations that younger children use small amounts of toothpaste (< 0.5 g) and that children using toothpaste with > or = 1000 ppm F rinse their mouths after brushing continue to be valid.

Urinary fluoride excretion by preschool children in six European countries.

OBJECTIVE: To measure and compare 24-h urinary fluoride excretion in children aged 1.5-3.5 years from European study sites and to use these data to estimate the 24-h fluoride intake. METHOD: Twenty-four-hour urine samples were collected from 3-year-old children (n = 86) who were already participating in a European multicentre study. Samples were collected from Cork, Ireland (n = 19) where the water is fluoridated to a concentration between 0.8 and 1.0 ppm and from five sites with a water fluoride concentration <0.15 ppm: Knowsley, England (n = 18); Oulu, Finland (n = 18); Reykjavik, Iceland (n = 4); Haarlem, the Netherlands (n = 6); Almada/Setubal, Portugal (n = 21). The volume of the samples was measured; they were analysed for fluoride concentration and the 24-h urinary fluoride excretion was calculated. From this an estimate of the daily fluoride intake was made. RESULTS: It was found that the mean fluoride excretion in response to the usual conditions of fluoride intake in the children in the nonfluoridated areas ranged from 0.16 mg (+/-0.08) in Oulu to 0.33 mg (+/-0.27) in Almada/Setubal with an overall mean of 0.23 mg (+/-0.19). The mean 24-h fluoride excretion in fluoridated Cork was 0.37 mg (+/-0.11). There was a significant difference between the fluoride excretion in the nonfluoridated areas and that in the fluoridated areas, and the data were broadly in agreement with WHO standards. CONCLUSIONS: The daily urinary fluoride excretion and estimated fluoride intake in these children appeared to be within acceptable limits.

A European perspective on fluoride use in seven countries.

OBJECTIVES: The aim of this study was to collate data on national policies for the use of fluoride in the seven European countries participating in the FLINT project. METHODS: Policies on the use of fluoride were obtained for each of the study areas. Data collected included the presence of water fluoridation and regulations governing fluoride toothpaste and fluoride supplements. RESULTS: In Ireland 74% of the population had a fluoridated water supply but in all the other countries fluoride toothpaste was the principal form of delivering fluoride, usually recommended as a dose of a pea-sized amount. Fluoride supplement use varied considerably between countries. The Netherlands had the clearest regulations covering the use of fluoride supplements and definition of at-risk individuals. Most countries, even if they recognized particular caries-risk did not define the term clearly. In Iceland all children were regarded as being at high risk of developing caries. CONCLUSION: Considerable variation exists between European countries in their policies for fluoride use and no clear definitions of high-caries-risk individuals were found. The results show that there is even a lack of coherent thought and planning within the different countries, let alone between them.

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.

Urinary fluoride excretion of young children exposed to different fluoride regimes.

AIMS: To compare 24-hour urinary fluoride excretion in young children exposed to different fluoride regimes. DESIGN: Twenty-four-hour urine samples were collected from children aged between 1.8 and 5.2 years. Samples were collected from Cork, Ireland (n=19) where the water is fluoridated to a concentration between 0.8 and 1.0 mg/l; Knowsley, UK, where the water fluoride concentration is <0.1 mg/l (n=22); and from children in Knowsley drinking milk containing 0.5 mg fluoride in nursery school each day (n=16). The volume of the samples was measured, they were analysed for fluoride concentration and the 24-hour urinary fluoride excretion was calculated. RESULTS: It was found that the mean fluoride excretion in response to usual conditions of fluoride intake in these children was 0.21 mg (SD=0.14) in non-fluoridated Knowsley; 0.36 mg (SD=0.11) in fluoridated Cork and 0.30 mg (SD=0.10) in the children drinking fluoridated school milk. CONCLUSIONS: The daily fluoride excretion in these children, corrected for age and fluoride ingested from toothpaste, appeared to indicate that the fluoride intake in the children drinking fluoridated school milk was somewhere between those living in an optimally fluoridated area and those in a low fluoride area.