Automatic detection and classification of dental fluorosis in vivo using white light and fluorescence imaging.

OBJECTIVES: To assess a novel method of automatic fluorosis detection and classification from white light and fluorescent images. METHODS: Dental images from 1,729 children living in two fluoridated and two non-fluoridated UK cities were utilised. A novel detection and classification algorithm was applied to each image and TF scores were obtained using thresholding criteria. These were compared to clinical reference standard images. Comparisons between reference and automated assessments were undertaken to record correct and incorrect classifications and the ability of the system to separate the fluoridated and non-fluoridated populations. RESULTS: The automated system performed well and was able to differentiate the two populations (P < 0.0001) to the same degree as the reference standard. When using the highest score from the clinical assessment the agreement between automated and clinical assessments was 0.56 (Kappa SE = 0.0160, p < 0.0001). CONCLUSIONS: Assessment of dental fluorosis is typically undertaken by clinical examiners in epidemiological studies. The training and calibration of such examiners is complex and time consuming and the assessments are subject to bias - frequently because of the examiner's awareness of the water fluoridation status of subjects. The use of remote scoring using photographs has been advocated but still requires trained examiners. This study has shown that image-processing methodologies applied to white light and fluorescent images could automatically score fluorosis and statistically separate fluoridated and non-fluoridated areas. The system requires further refinement to manage confounding factors such as the presence of non-fluoride opacities and tooth stain.

Examiner reliability in fluorosis scoring: a comparison of photographic and clinical methods.

OBJECTIVE: To assess examiner reliability when scoring dental fluorosis in Malaysian children using clinical (Dean's Index) and photographic methods. METHOD: The upper central incisors of 111 children were examined both clinically and photographically for fluorosis status using Dean's index. Twenty children were re-examined after a two-week interval for intra-examiner reliability by a single examiner. In addition, two independent examiners and the clinical examiner scored 111 photographic images of the same children in a standardized manner. Fluorosis scores were compared individually between examiners for both clinical and photographic scoring. Examiner reliability was assessed using both simple and weighted kappa statistics at tooth level. Sensitivity, specificity, positive-negative predictive values and a Receiver Operating Characteristic (ROC) curve were also calculated to determine the accuracy of the test. RESULTS: Across the three examiners, the prevalence of fluorosis (Dean's score ≥ 2) using photographs was lower (ranged from 23% to 26%) than the prevalence recorded by clinical examination (30%). The kappa score for intra-examiner reliability for the duplicate clinical examination was excellent (0.89). Inter-examiner reliability between the photographic method and the clinical examination (gold standard) for each examiner was substantial with weighted kappa values ranging from 0.74 to 0.77. The photographic method indicated higher specificity (99%) than sensitivity (79%) and the area under the ROC curve was also high (0.89) which suggests good accuracy of the diagnostic test. CONCLUSION: These results suggest that photographic examination of fluorosis on central incisors can be recorded with good examiner reliability. The recorded fluorosis prevalence was lower using the photographic scores.

Lactotransferrin Gene Polymorphism Associated with Caries Experience.

Dental caries is a common multifactorial disease, resulting from the interaction of biofilm, cariogenic diet and host response over time. Lactotransferrin (LTF) is a main salivary glycoprotein, which modulates the host immune-inflammatory and antibacterial response. Although a genetic component for caries outcome has been identified, little is known over the genetic aspects underlying its susceptibility. Thus, the aim of this study was to investigate the association between LTF polymorphisms and caries susceptibility. Six hundred seventy seven 12-year-old students were selected: 346 with (DMFT ≥ 1) and 331 without caries experience (DMFT = 0). Also, individuals concentrating higher levels of disease (polarization group, DMFT ≥ 2, n = 253) were tested against those with DMFT ≤ 1 (n = 424). Along with clinical parameters, three representative LTF tag SNPs (rs6441989, rs2073495, rs11716497) were genotyped and the results were evaluated using univariate and multivariate analyses. Allele A for tag SNP rs6441989 was found to be significantly less frequent in the polarization group, conferring a protective effect against caries experience [AA + AG × GG (OR: 0.710, 95% CI: 0.514-0.980, p = 0.045)], and remained significantly associated with caries protection in the presence of gingivitis (p = 0.020) and plaque (p = 0.035). These results might contribute to the understanding of the genetic control of caries susceptibility in humans.

Effects of enamel fluorosis and dental caries on quality of life.

The objectives of this study were to determine the impact of enamel fluorosis and dental caries on oral health-related quality of life (OHRQoL) in North Carolina schoolchildren and their families. Students (n = 7,686) enrolled in 398 classrooms in grades K-12 were recruited for a onetime survey. Parents of students in grades K-3 and 4-12 completed the Early Childhood Oral Health Impact Scale (ECOHIS) and Family Impact Scale (FIS), respectively. Students in grades 4-12 completed the Child Perceptions Questionnaire (CPQ8-10 in grades 4-5; CPQ11-14 in grades 6-12). All students were examined for fluorosis (Dean's index) and caries experience (d2-3fs or D2-3MFS indices). OHRQoL scores (sum response codes) were analyzed for their association with fluorosis categories and sum of d2-3fs and D2-3MFS according to ordinary least squares regression with SAS procedures for multiple imputation and analysis of complex survey data. Differences in OHRQoL scores were evaluated against statistical and minimal important difference (MID) thresholds. Of 5,484 examined students, 71.8% had no fluorosis; 24.4%, questionable to very mild fluorosis; and 3.7%, mild, moderate, or severe fluorosis. Caries categories were as follows: none (43.1%), low (28.6%), and moderate to high (28.2%). No associations between fluorosis and any OHRQoL scales met statistical or MID thresholds. The difference (5.8 points) in unadjusted mean ECOHIS scores for the no-caries and moderate-to-high caries groups exceeded the MID estimate (2.7 points) for that scale. The difference in mean FIS scores (1.5 points) for the no-caries and moderate-to-high groups exceeded the MID value (1.2 points). The sum of d2-3fs and D2-3MFS scores was positively associated with CPQ11-14 (B = 0.240, p < .001), ECOHIS (B = 0.252, p ≤ .001), and FIS (B = 0.096, p ≤ .01) scores in ordinary least squares regression models. A child's caries experience negatively affects OHRQoL, while fluorosis has little impact.

Retention of fissure sealants in young permanent molars affected by dental fluorosis: a 12-month clinical study.

AIM: To evaluate and compare retention and caries occurance following placement of Clinpro and FUJI VII fissure sealants, by two different techniques simultaneously in unsealed, contralateral young permanent molars of 7- to 10-year-old children affected by mild to moderate dental fluorosis at various recall intervals of 1 week, 1, 3, 6 and 12 months. STUDY DESIGN: 80 schoolchildren with mild to moderate dental fluorosis were assigned to Group A and Group B with 40 children in each group. In Group A Clinpro fissure sealant and in Group B Fuji VII fissure sealant was used. In both the groups fissure sealants were applied by conventional fissure sealant technique (CST) on one side and enameloplasty sealant technique (EST) on the other side of the same arch. The applied fissure sealants were evaluated clinically for retention and caries incidence. RESULTS: Clinpro fissure sealant showed a retention rate of 95% when compared with Fuji VII (57.5%) at the end of 12 months, which was statistically significant. Regarding techniques, EST showed better results than CST in both the groups. STATISTICS: Comparison of groups with respect to retention and techniques at different time periods was performed using Mann-Whitney U test (p < 0.05). Comparison of different time periods with respect to retention and technique in all the groups was performed using Wilcoxon matched pairs test by ranks (p < 0.05). CONCLUSION: Clinpro fissure sealant showed better retention at all treatment intervals, when compared with Fuji VII. Further follow-up is required to study the efficacy of the fissure sealant placement techniques.

Dental fluorosis: concentration of fluoride in drinking water and consumption of bottled beverages in school children.

OBJECTIVE: The purpose of the study was to identify dental fluorosis prevalence and to analyze its association with tap water fluoride concentration and beverage consumption in school children from the city of Oaxaca, who were receiving fluoridated salt. STUDY DESIGN: A cross-sectional study was performed on elementary public school children. Dean's Index was applied to assess dental fluorosis. The parents of the children who were studied completed a questionnaire about socio-demographic characteristics and type of beverages consumed by their children. A total of 917 school children participated in this study. RESULTS: Dental fluorosis prevalence was 80.8%. The most frequent fluorosis category was very mild (41.0%), and 16.4% of the children were in the mild category. The mean water fluoride concentration was 0.43 ppm (±0.12). No association was detected between tap water fluoride concentration and fluorosis severity. The multinomial regression model showed an association among the mild fluorosis category and age (OR = 1.25, [95% CI 1.04, 1.50]) and better socio-economic status (OR = 1.78, [95% CI 1.21, 2.60]), controlling for fluoride concentration in water. Moderate and severe fluorosis were associated with soft drink consumption (OR = 2.26, [95% IC 1.01, 5.09]), controlling for age, socio-economic status, and water fluoride concentration. CONCLUSIONS: The prevalence of fluorosis was high. Mild fluorosis was associated with higher socio-economic status, while higher fluorosis severity was associated with soft drink consumption.

The impact of oral health status on the oral health-related quality of life (OHRQoL) of 12-year-olds from children's and parents' perspectives.

OBJECTIVES: To assess the effect of dental caries, periodontal status and dental fluorosis on the oral health-related quality life (OHRQoL) of 12-year-olds and to assess the agreement between parents and children on the children's OHRQoL relative to the children's oral health status. METHODS: A two-stage sampling method was used to select a sample of 12-year-olds from Binzhou, China. Their oral health status was recorded using the DMFT, CPI and Dean's Index. The Child Perception Questionnaire 11-14 (CPQ(11-14)) and the Parental Perception Questionnaire (PPQ) were administered to the children and their parents, respectively, to assess the children's oral health-related quality of life. RESULTS: The data used in the analysis were collected from 1,120 children. The prevalence of tooth decay was 31.6% and that of dental fluorosis was 29.7%; 4.1% of the children had healthy gums and 52.4% had dental calculus. There was a moderate to good correlation between the CPQ and PPQ (ICC = 0.51-0.68). Having dental fluorosis and brushing teeth less than twice a day negatively influenced the emotional well-being domain of the CPQ, but was not related to this domain of the PPQ. Having calculus, dental fluorosis, brushing teeth less than twice a day and having dental visits negatively influenced the social well-being domain of the CPQ, but only tooth brushing was related to this domain of the PPQ. CONCLUSIONS: Children's self-reported CPQ(11-14) scores were more strongly associated with their oral health status and OHRQoL than their parents' PPQ scores were, especially in the social and emotional well-being domains. Having caries, dental fluorosis or dental calculus negatively affected children's oral health-related quality of life.

Use of clinical bleaching with 35% hydrogen peroxide in esthetic improvement of fluorotic human incisors in vivo.

AIM: The aim of the study was to evaluate esthetic improvement with the use of 35% hydrogen peroxide clinical bleaching as related to the different grades of enamel fluorosis in vivo and to study adverse effect of clinical bleaching with 35% hydrogen peroxide on teeth and gingiva. MATERIALS AND METHODS: A total of 60 children of different grades of fluorosis were included in the study. With 35% hydrogen peroxide-based dual activated bleaching system, in-office vital teeth bleaching was carried out for each subject. Clinical evaluation for improvement in esthetics, effect on teeth and gingiva were performed for each child during preoperative, immediate postoperative and later 6 months postoperative period. For evaluation and comparison, all the collected data were subjected to statistical analysis. RESULTS: Although in all the subjects, partial shade relapse was seen over a period of time, good homogeneous and esthetic results were seen in very mild and mild cases. A total of 35% hydrogen peroxide in-office bleaching has no adverse effect on teeth and gingiva. CONCLUSION: Comparing all the three groups who participated in the study, 35% hydrogen peroxide in-office bleaching seems to be very effective in very mild and mild forms of fluorosis. CLINICAL SIGNIFICANCE: In very mild and mild forms of fluorosis, in-office vital tooth bleaching with 35% hydrogen peroxide is the most conservative and effective approach in esthetic improvement.

Evaluating oral health promotion activity within a general dental practice.

The prevention of the common dental diseases is fundamental to modern day general dental practice. Oral health promotion (OHP) is therefore key to facilitating health outcomes within organisations. The literature surrounding OHP stresses the importance of evaluation in order to assess the effectiveness of OHP activities. This paper describes the evaluation of OHP within a general dental practice setting. Early attendance, the use of adult toothpastes during childhood and consequential fluorosis are investigated. A small service evaluation study of 100 consecutive patients was undertaken. The results support the ongoing promotion of early attendance and the use of toothpastes with adequate fluoride levels. There was no evidence of unsightly fluorosis in the sample studied.

Prevalence of dental fluorosis among primary school children in rural areas of Karera Block, Madhya Pradesh.

OBJECTIVE: To determine prevalence and severity of dental fluorosis in school going children of ten villages of Karera block of Shivpuri District, Madhya Pradesh. METHODS: Fluoride ion concentration was measured in ten hand pump and two wells waters with a fluoride meter (ORION model 720). For the study total 750 school children were selected from ten government primary schools of ten rural villages. The survey was conducted during the period of November 2007 through December 2009. The dental and oral examination was done by two trained dentists. The occurrence and severity of dental fluorosis was recorded using Dean's index. RESULTS: Drinking water sources considered for study were hand pumps, and wells. Out of 750 children surveyed, 341 were found affected with dental fluorosis. The boys had greater prevalence (46.75%) as compared to girls (42.18%). Dental fluorosis, as assessed by Dean's Index shows that 20.8% children had grade I, 19.47% grade II, 5.2% grade III. Overall, 45.46% of the sample showed some grades of dental fluorosis. CONCLUSIONS: In all the 144 water samples from ten villages fluoride level was higher than permissible limits. The boys had greater prevalence of dental fluorosis over the girls.

The impact of a dental program for maternal and infant health on the prevalence of dental fluorosis.

PURPOSE: This study's purpose was to investigate the prevalence of dental fluorosis in children, whose parents had participated in an oral health program when the children were between zero and three years old, residing in a city with fluoridated water. METHODS: Group 1 consisted of 128 eight- to 12-year-olds whose parents had visited a program on at least five occasions when the children were zero to three years old and received education about tooth-brushing and the proper use of fluoridated toothpaste in this young age group. The prevalence of dental fluorosis in the permanent maxillary incisors, using the Thylstrup-Fejerskov index, in Group 1 was compared to that of an age-matched group of children (n=128) whose parents had not participated in the program (Group 2). RESULTS: Group 1 mothers reported higher education levels (P<.05). Group 1 children had a significantly lower prevalence (∼42 percent) and severity (P<.05) of dental fluorosis than those in the control group (∼61 percent). CONCLUSION: Children whose parents participated in a dental program that included counselling on the proper amount of fluoridated toothpaste when their children were between zero and three years old presented less frequently with dental fluorosis than a control group when examined at eight to 12 years old.

Dental fluorosis in populations from Chiang Mai, Thailand with different fluoride exposures - paper 2: the ability of fluorescence imaging to detect differences in fluorosis prevalence and severity for different fluoride intakes from water.

BACKGROUND: To assess the ability of fluorescence imaging to detect a dose response relationship between fluorosis severity and different levels of fluoride in water supplies compared to remote photographic scoring in selected populations participating in an observational, epidemiological survey in Chiang Mai, Thailand. METHODS: Subjects were male and female lifetime residents aged 8-13 years. For each child the fluoride content of cooking water samples (CWS) was assessed to create categorical intervals of water fluoride concentration. Fluorescence images were taken of the maxillary central incisors and analyzed for dental fluorosis using two different software techniques. Output metrics for the fluorescence imaging techniques were compared to TF scores from blinded photographic scores obtained from the survey. RESULTS: Data from 553 subjects were available. Both software analysis techniques demonstrated significant correlations with the photographic scores. The metrics for area effected by fluorosis and the overall fluorescence loss had the strongest association with the photographic TF score (Spearman's rho 0.664 and 0.652 respectively). Both software techniques performed well for comparison of repeat fluorescence images with ICC values of 0.95 and 0.85 respectively. CONCLUSIONS: This study supports the potential use of fluorescence imaging for the objective quantification of dental fluorosis. Fluorescence imaging was able to discriminate between populations with different fluoride exposures on a comparable level to remote photographic scoring with acceptable levels of repeatability.

Validation of fingernail fluoride concentration as a predictor of risk for dental fluorosis.

The aim of this study was to validate the use of fingernail fluoride concentrations at ages 2-7 years as predictors of the risk for developing dental fluorosis in the permanent dentition. Fifty-six children of both genders (10-15 years of age) had their incisors and premolars examined for dental fluorosis using the Thylstrup-Fejerskov index. Fingernail fluoride concentrations were obtained from previous studies when children were 2-7 years of age. Data were analyzed by unpaired t test, ANOVA, and Fisher's exact test when the fingernail fluoride concentrations were dichotomized (≤ 2 or >2 µg/g). Children with dental fluorosis had significantly higher fingernail fluoride concentrations than those without the condition, and the concentrations tended to increase with the severity of fluorosis (r(2) = 0.47, p < 0.0001). Using a fingernail fluoride concentration of 2 µg/g at ages 2-7 years as a threshold, this biomarker had high sensitivity (0.84) and moderate specificity (0.53) as a predictor for dental fluorosis. The high positive predictive value indicates that fingernail fluoride concentrations should be useful in public health research, since it has the potential to identify around 80% of children at risk of developing dental fluorosis.

Prevalence of dental fluorosis in relation with different fluoride levels in drinking water among school going children in Sarada tehsil of Udaipur district, Rajasthan.

AIM: To estimate the prevalence of dental fluorosis in relation with different fluoride levels in drinking water among school going children of 6-12 years age group. MATERIALS AND METHODS: Dental fluorosis was recorded using Dean's index in school children of selected villages. The drinking water samples of all the selected villages were collected in polyethylene bottles and the fluoride content of these samples was determined by fluoride ion selective method using Orion microprocessor analyser. RESULTS: The overall prevalence of dental fluorosis was found to be 69.84%. An increase in the community fluorosis index (CFI) with corresponding increase in water fluoride content was found. CONCLUSION: There was an increase in prevalence of dental fluorosis with a corresponding increase in water fluoride content from 0.8 ppm to 4.1 ppm. A significantly strong positive correlation was found between CFI and fluoride concentration in drinking water.

Assessment of periodontal status among dental fluorosis subjects using community periodontal index of treatment needs.

AIM: To determine the periodontal status and treatment needs among dental fluorosis subjects residing in Ennore, Chennai, using Community Periodontal Index of Treatment Needs (CPITN). MATERIALS AND METHODS: All the subjects with dental fluorosis above 15 years of age, permanent residents of Ennore, were included in the study. Subjects with known systemic diseases and subjects with other intrinsic dental stains were excluded from the study. Periodontal status was estimated using CPITN and Dental fluorosis was recorded using Dean's Dental Fluorosis Index. RESULTS: The total number of study subjects was 1075, of which 489 were males and 586 were females. Males were predominantly affected with periodontal disease than females. This was found to be statistically significant (P=0.000). The association between Degree of Fluorosis and Periodontal Status is statistically significant (P=0.000). There was statistically significant difference in mean number of sextants between the degree of fluorosis in each of the periodontal status (P=0.000). CONCLUSION: The finding that the lower prevalence of shallow pockets in the study area, where the fluoride level in the drinking water ranges from 1.83 to 2.01 ppm, indicates that the use of fluoride in water is beneficial to the periodontal tissues.

Relation between dental fluorosis and intelligence quotient in school children of Bagalkot district.

This study was conducted on 160 children, in the Bagalkot district of Karnataka state between August and October 2010, with the aim of finding out if there is a relation between dental fluorosis status and Intelligence Quotient (IQ). Children were categorized as, those suffering from dental fluorosis and those not suffering from dental fluorosis and for all children in both categories, Intelligence testing was done using the Raven's Coloured Progressive Matrices. The following observations were made from the data gathered: The mean IQ score of children without dental fluorosis was significantly higher than those children who had dental fluorosis. The mean IQ scores did not vary with the severity of dental fluorosis as classified by Dean's fluorosis index. Also it was noticed that the percentage of children with dental fluorosis was more in Extremely Low and Low IQ categories whereas the percentage of children without dental fluorosis was more in Average and High Average IQ categories. Previous studies had indicated toward decreased Intelligence in children exposed to high levels of fluoride and our study also confirmed such an effect.

Nanostructure evaluation of healthy and fluorotic dentin by atomic force microscopy before and after phosphoric acid etching.

The aim was to characterize by atomic force microscopy (AFM) the nanostructure of human dentin surfaces affected by dental fluorosis (DF) before and after phosphoric acid etching. This study included 240 human dentin samples classified according to the severity of DF, which were divided into four groups using the Thylstrup-Fejerskov Index (TFI). Samples were analyzed by AFM before and after acid etching for 15, 30, and 60 s. The roughness (R(a)) for healthy dentin, and dentin with mild, moderate, and severe fluorosis were 440 nm, 442 nm, 445 nm, and 449 nm, respectively. After 15, 30, and 60 s of acid etching, all healthy and fluorotic dentin samples increased in roughness (p<0.05). The diameter of dentinal tubule orifices (D(t)) in healthy human dentin increased after acid etching for 60 s. We conclude that effective etching times are 15 s for healthy and mild dentin fluorosis, 30-s for moderately fluorosed dentin, and 45-60 s for severe fluorotic dentin.

Fluoride concentration in dentine as a biomarker of fluoride intake in European roe deer (Capreolus capreolus) - an electron-microprobe study.

OBJECTIVE: Fluoride concentration in dentine has been recommended as the best marker for the level of chronic fluoride intake and the most suitable indicator of an individual's total body burden of fluoride. We analysed fluoride concentrations in the dentine of cheek teeth of European roe deer from fluoride-polluted habitats to retrospectively assess the level of fluoride uptake into the tissue. Thereby, we tested the hypothesis of the existence of mechanisms that limit fluoride intake of individuals and fluoride exposure of forming dental hard tissues during the late foetal and early postnatal periods in the species. DESIGN: Using electron-microprobe analysis, fluoride profiles were obtained on sectioned P(4)s, M(1)s, and M(3)s from individuals exhibiting pronounced dental fluorosis. Fluoride concentrations were compared between early formed (peripheral) and late-formed (juxtapulpal) dentine both within single teeth and amongst the three different teeth studied. RESULTS: Peripheral dentine of the M(1), which is formed during the late foetal and early postnatal periods, exhibited markedly lower fluoride concentrations than juxtapulpal dentine of the same tooth and both, peripheral and juxtapulpal dentine of P(4) and M(3) that are formed post-weaning. CONCLUSIONS: Our study provides strong support for the hypothesis that in the European roe deer the prenatal and early postnatal (pre-weaning) stages of dental development are (largely) protected against exposure to excess fluoride. This is attributed to the operation of certain protective mechanisms during these periods.

Exposure to lead exacerbates dental fluorosis.

AIM: Our aim was to test the hypothesis that co-exposure to lead and fluoride alter the severity of enamel fluorosis. MATERIALS AND METHODS: Wistar rats were allocated in four groups: control, and 3 groups that received water containing 100 ppm of fluoride (F), 30 ppm of lead (Pb), or 100 ppm of F and 30 ppm of Pb (F+Pb) from the beginning of gestation. Enamel analysis and F and Pb determinations in enamel, dentine, and bone were performed in 81-day-old animals. Fluorosis was quantified using a new fluorosis index based on the identification of incisor enamel defects (white bands and white islets, representing hypomineralization, and cavities) weighted according to their severity and quantity. Hypomineralization was validated histopathologically by polarizing microscopy and microradiography. Scores were given by two blinded calibrated examiners (intra and interexaminer kappa values were 0.8 and 0.86, respectively). RESULTS: The control and the Pb groups presented normal enamel. The F+Pb group presented more severe enamel defects compared with the F group (P<0.0001). CONCLUSIONS: This study shows that lead exacerbates dental fluorosis in rodents, suggesting that co-exposure to lead may affect the degree of fluorosis.

Prevalence of dental caries among 13 and 15-year-old school children in an endemic fluorosis area: a cross-sectional study.

AIM: To assess the prevalence of dental caries and dental fluorosis among 13- to 15-year-old school children in Panyam, Andhra Pradesh, India. MATERIALS AND METHODS: The cross-sectional study was conducted among 202 school children and were examined for dental fluorosis and dental caries. RESULTS: This study shows that male students have a decrease in DMFT (Decayed, missing, filled, teeth) index and increase in Dean's index when compared with females. Among students with 13 to 15 years of age, 13-year-old student has increase in DMFT score when compared with other age groups and 14-year-old students has increase in Dean's score when compared with other age group students. CONCLUSION: The prevalence of dental caries decreased with the increase of fluorosis among the students examined. CLINICAL SIGNIFICANCE: Patients with dental fluorosis show a decreased prevalence of dental caries.