seminar on indices measuring dental fluorosis

1. INDICES USED FOR
DENTAL FLUOROSIS
BY
NITYA SHARMA

2. INTRODUCTION


INDEX : an index has been defined as a numerical
value describing the relative status of a population
on a graduated scale with definite upper and
lower limits which is designed to permit and
facilitate comparison with other populations
classified by same criteria and methods.(Russel)
DENTAL FLUOROSIS : is a hypoplasia or
hypomineralisation of tooth enamel or dentine
produced by the chronic ingestion of excessive
amounts of fluoride during the period when teeth
are developing.

3. HISTORY





1888 : “KUHNS” described teeth of persons in
areas of Mexico that were opaque, discolored and
disfigured. (Kuhns1888; Moller 1982).
1901 Dr. Fredrick Mckay of Colorado USA
discovered permanent stains on teeth of his
patients which were referred as Colorado stains.
Mckay named then “mottled enamel”.
An Assitant surgeon of U.S marine hospital
service reported similar condition in Italians
emigrating from USA from Naples named it denti
di chiaie. ( Eager 1901).
1916 Mckay and Black published a series of
articles in dental cosmos.

4. 


In 1931 this condition of teeth was found to b
correlated to fluoride content of drinking water.
(Churchill 1931; Smith et al 1931)
1931 shoe leather survey by Trendley H. Dean
1934 DEAN‟S FLUOROSIS INDEX was given
by Trendley H.Dean

5. CLASSIFICATION OF
FLUOROSIS MEASURING
INDICES
FLUOROSIS
SPECIFIC
DESCRIPTIVE
DEAN’S INDEX
DEVELOPMENTAL
DEFECTS OF
ENAMEL INDEX
THYLSTRUP AND
FERJESKOV
TOOTH SURFACE
INDEX FOR
FLUOROSIS
FLUOROSIS RISK
INDEX
JACKSON AlALOUSI INDEX
MURRAY SHAW
INDEX

6. DEAN’S FLUOROSIS INDEX

1934; TRENDLEY H.DEAN
devised an index for
assessing the presence and
severity of mottled enamel.

7. The fluorosis index set
criteria for categorisation of
dental fluorosis on a 7point
scale.
Although no numbers were
used it was considered to be
on ordinal scale.
SALIENT
FEATURES
Children who had not lived in
the community continously
or had obtained domestic
water from other than public
supply are eliminated
Under his classification all
those showing hypoplasia
other than mottling of enamel
were placed in normal
category

8. METHOD ( as implied by
DEAN)
Each individual recieves a score
corresponding to clinical appearance of two
most affected teeth.
• Examinations are made in good natural light with the
subject sitting facing the window
No specific information as to whether the
teeth were cleaned or dried before
examination is given
• Mouth mirror and probes were utilised for examination.

9. • Slight
aberrations in
translucency
of normal
enamel
ranging from
few white
flecks to
occasional
white spots,
1-2mm in
diameter.
VERY MILD
• The enamel
represents
the usual
transluceny
semivitriform
type of
structure
• The surface is
smooth,
glossy and
usually of
pale creamy
white color
QUESTIONABLE
NORMAL
CLASSIFICATION AND
CRITERIA
• Small, opaque,
paper white ares
are scatterd
irregularily or
streaked over the
tooth surface
• Observed on labial
and buccal
surfaces ; <25% of
teeth surface
involved.
• Small pitted white
areas are
frequently found
on summits of
cusps
• No brown stain

10. • Smoky white
appearance
• Pitting is
more
frequent and
generally
seen on all
surfaces
• Brown stain if
present has
more hue and
involves all
surfaces
SEVERE
• No change
in form of
tooth but all
surfaces are
involved
• Surfaces
subjected to
attrition are
definitely
marked
• Minute
pitting is
present on
buccal n
labial
surfaces
MODERATELY SEVERE
MODERATE
MILD
• White
opaque
areas
involve half
of tooth
surface.
• Surfaces of
cuspids n
bicuspids
prone to
attrition
show thin
white layers
worn off and
bluish
shades of
normal
enamel
• Faint brown
stains are
apparent
• Form of
teeth are
affected.
• Pits are
deeper and
confluent
• Stains are
widespread
and range
from
choclate
brown to
almost black

11. Based on this index, Dean. Dixon and
Cohen(1935) proposed that their
classification should determine a mottled
enamel index of a community for
epidemiological purpose
negative
boderline
Slight
Medium
Rather
marked
Very
marked

12. 

1939 Dean combined the “moderarely severe”
and “severe” into a single category “severe”.
1942 Dean introduced the revised scale for
fluorosis index where now he used the six
point scale.

13. Deans revised index (1942)
NORMAL (0) The
enamel represents the
usual translucent
semivitriform type of
structure. The surface is
smooth , glossy and
usually of a pale, creamy
white colour.

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

15. VERY MILD (1) Small, opaque, paper
white areas scattered irregularly over
the tooth , but not involving as much as
approximately 25% of tooth surface.
Frequently included in this
classification are teeth showing no
more than about 1-2 mm of white
opacity at the tip of the summit of the
cusps of bicuspids or second molars.

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

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

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

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

20. USES







Most widely used index to measure dental
fluorosis.
Helped to indicate prevalence of moderate to
severe fluorosis in many communities as
Sweden by Forsman in 1974
Austria by Binder in 1973
England by Murray et al(1956), Forrest (1965),
Goward (1976)
USA by Galagan and Lamson (1953)
India by Nanda et al (1974)

21. The National Survey of Children‟s Dental
Health in Ireland in 1984 measured fluorosis
using Dean‟s index to provide baseline data for
future refernce.
( Whelton HP;Ketley CE;Mcsweeny
F;O’Mullane DM;2004)
 National Fluorosis Survey in USA in 1986-87
to note baseline values was done using
Dean‟s index.


22. LIMITATIONS
Does not give sufficient information on distribution
of fluorosis withtin the dentition.
 Isolated defects are not recorded.
 The distinction amongst the categories is unclear,
indistinct and lacking sensitivity.
 Even though Dean‟s scale is ordinal , it involves
averaging of the scores which is inappropriate.
(A. Rizan Mohamed,W. Murray Thomson;Timothy
D. Mackay, An epidemiological comparison of
Dean’s index and the Developmental Defects
of Enamel (DDE) index; JPHD ISSN 0022-4006)


23. COMMUNITY FLUOROSIS
INDEX


1942 , based on the revised fluorosis index
scale , he developed a scoring system so as to
derive a COMMUNITY FLUOROSIS INDEX .
On basis of the number and distribution of
individual scores, a community index for dental
fluorosis (Fci) can be calculated by the formula
Fci = sum of( no. of individuals*stastical
weights)/ no. of individuals examined

24. RANGE OF SCORES FOR CFI
SIGNIFICANCE

0.0 – 0.4

0.4 – 0.5

0.5 – 1.0


1.0 – 2.0


2.0 – 3.0


3.0 – 4.0



Negative
Borderline
Slight
Medium
Marked
Very Marked

25. 



It gives an indication of public health significance
of fluorosis.
It was used by Galagan and Lamson (1953) in
their investigation of climate and endemic
fluorosis.
Minoguchi (1970) refined the above analysis to
take into account the total fluoride content from
the diet by a community.
Myers(1978) suggested a graphic method of
abtaining optimal fluoride concentration by
comparing CFI against water fluoride content at
different temperatures.

27. THYLSTRUP – FEJERSKOV
CLASSIFICATION OF
FLUOROSIS

1978 ; Thylstrup and Frejeskov suggested a
10point classification system designed to
categorise the degree of fluorosis affecting
buccal/lingual and occlusal surfaces.

28. Plane mirror n
probes are used
Prior to
examination the
teeth are dried
with cottonwool
rolls
Examination is
done on a
portable chair
out in daylight.
SALIENT
FEATURES

29. THYLSTRUP – FEJERSKOV
CLASSIFICATION OF
FLUOROSIS
Score
Criteria

0
1
.

Normal translucency
of enamel remains
after prolonged air –
drying
Narrow white lines
located
corresponding to the
perikymata.

30. Score

2
Criteria
Smooth surfaces;
More pronounced lines
of opacity which follow
the perikymata.
Occasionally,
confluence of adjacent
lines.
Occlusal surfaces:
Scattered areas of
opacity of 2mm in
diameter and
pronounced opacity of
cuspal ridges.

31. Score

3
Criteria
Smooth surfaces:
Merging and irregular
cloudy areas of opacity.
Accentuated drawing of
perikymata often visible
between opacities.
Occlusal surfaces :
Confluent areas of marked
opacity. Worn areas appear
almost normal but usually
circumscribed by a rim of

32. Score

4
Criteria
Smooth surfaces:
The entire surface exhibits
marked opacities or
appears chalky white.
Parts of surface exposed
to attrition appear less
affected.
Occlusal surfaces :
Entire surface exhibits
marked opacity. Attrition is
often pronounced shortly
after eruption.

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

34. Score

6

7
Criteria
Smooth surfaces: Pits are
regularlyarranged in
horizontal bands 2mm in
vertical extension.
Occlusal surfaces:
Confluent areas 3mm
in diameter exhibit loss
of enamel. Marked attrition
Smooth surfaces: Loss of
outermost enamel in irregular
areas involving half of the
entire surface.
Occlusal surfaces: Changes
in the morphology caused by
the merging pits
and
marked attrition.

35. Score

8

9
Criteria
Smooth and Occlusal
surfaces: Loss of
outermost enamel
involving half of the
surface.
Smooth and Occlusal
surfaces: Loss of main
part of enamel with
change in anatomic
appearance of
surfaces. Cervical rim
of almost unaffected
enamel is often noted

37. Advantages



It attempts to validate the visual appearance
against the histological defect.
Most sensitive of all fluorosis measuring
indices.
Granath et al. (1985), comparing the DEAN
and T-F indexes, concluded that the latter was
more detailed and sensitive because it was
based on biological aspects where there is an
increase in hypo mineralization with a
simultaneous increase in the depth of the
enamel surface in direction of the amelodentin junction.

38. 
Cleaton-Jones and Hargreaves (1990)
compared the three fluorosis indexes (DEAN,
T-F and TSIF) in deciduous dentition,
reporting that the prevalence of fluorosis in
individual teeth was more frequently
diagnosed with the T-F index. They concluded
that the T-F index is the most indicated for
work where detailed information about the
problem is required.

39. USES



To assess the impact of enamel fluorosis in three
communities examined in project FLINT.(
Sigourjon’s H et al 2004)
Clark et al 1993 showed an increasing level of
dissatisfaction by both parents and children with
appearance as the child‟s TSIF index grade rose.
Burger et al. (1987), recommended the T-F index
for future field studies, due to the facility of use
and better defined criteria.

40. Disadvantages

Clarkson (1989) reported that in TF index
drying of teeth creates an unnatural situation
due to which changes in score 1 and 2 are
very minor.
The aesthetic significance of these changes
are questionable.

41. TOOTH SURFACE FLUOROSIS
INDEX
It was developed by HOROWITZ et al. in 1984
at National Institute of Dental Research U.S.A
AIM


42. Numerical score
Descriptive Criteria
0

1

Enamel shows no evidence of
fluorosis
Enamel shows definite
evidence of fluorosis namely
areas with parchment-white
colour that total less than one
third of the visible enamel
surface. Includes fluorosis
confined only to incisal edges
of anterior teeth and cusp tips
of posterior teeth (Snow

43. 
2

3

4
Parchment – white fluorosis
totals at least 1/3 of the
visible enamel surface, but
less than 2/3
Parchment – white fluorosis
totals at least 2/3 of visible
enamel surface.
Enamel shows staining in
conjunction with any of the
preceding
levels
of
fluorosis.
Staining
is
defined as an area of
definite discoloration that
may range from light to
very dark brown.

44. 
5

6

7
Discrete pitting of enamel exists,
unaccompanied
by
evidence of staining of
intact enamel. A pit is
defined as a definite
physical defect in the
enamel surface with a
rough
floor
that
is
surrounded
by
intact
enamel. The pitted area is
usually stained or differs in
colour from the surrounding
enamel.
Both discrete pitting and staining
of the intact enamel exist.
Confluent pitting of the enamel
surface exist. Large areas
of enamel may be missing
and anatomy of tooth

45. Intent to use



TSIF index - studies in which an aesthetic basis is
desired for defining case and it may be used
where risk factors are identified or when the teeth
may not be cleaned and dried. (Antonio Carlos
PEREIRA
Ben-Hur Wey MOREIRA 1999)
It doesnot have questionable category as in
Dean‟s index and is based on the premise that
any sign of fluorosis regardless of extent is
positive for a case
The TSIF described by Horowitz et al. makes a
useful contribution because it provides clearer
diagnostic criteria and provides for an analysis
based on esthetic concerns. .( R.Gary Rozier
1999)

46. FLUOROSIS RISK INDEX
Introduced by DAVID G. PENDRYS in 1990
AIM
To improve researcher‟s ability to relate the risk
of fluorosis to developmental stage of
permanent dentition at the time of exposure to
fluorosis.


47. Incisal edges of 11
21 32 31 41 42 and
occlusal tables of 16
26 36 46.
FR1- those begin
to form in first year
of life
Surface zones
which donot
come under
above groups
are left
unassigned
FR2- those
who donot
begin to form
until 2nd year of
life
Cervical
third of
incisors,mi
ddle third
of canines,
occlusal
table,incisal
third and
middle third
of bicuspid
and 2nd
molars

48. FR 1
112
FR 2
UNASSIGN
ED
•1O
•48
•54

49. SCORING CRITERIA
NEGATIVE
FINDING
SCORE =0
Complete
absence of any
white spots or
striations.

50. SCORE = 1
White
spots, striations
or fluorotic
defects that
cover 50% or
less surface zone
SCORE = 7
Any surface
that has an
opacity that
appears to be a
non fluoride
opacity
QUESTIONABLE

51. SCORE = 2
A surface
zone with
greater than
50% of zone
displaying
parchment
white
striations.
SCORE =
3
Surface
zone with
greater than
50% of zone
that
displays
pitting,
staining and
deformity
POSITIVE
FINDING
Incisal edges
and occlusal
tables with
greater than
50% of
surface
marked by
snowcapping

52. SURFACE ZONE
EXCLUDED
SCORE = 9
Incomplete
eruption ,
orthodontic
appliances and
bands, surface
crowned or
restored, gross
plaque and
debris

53. CASES
Subject who has a
positive score on 2 or
more enamel surface
zones
CONTROLS
Subject who has no
positive or
questionable scores
on any enamel surface
zones
CLASSIFICATION 1

54. 
To obtain the FRI score for each individual the
scores of classification 1 and 2 are combined
into one summary score.

55. USES
Risk factors for enamel fluorosis in a
fluoridated population. (Pendrys DG, Katz RV,
Morse DE. 1994)
 Risk factors for enamel fluorosis in a
nonfluoridated population. (Pendrys DG, Katz
RV, Morse DE1999)
 The Iowa Fluoride Study(2005)
(Steven M. Levy; Liang Hong,; John J. Warren,
Barbara Broffitt,)


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

57. PROCEDURE
Tooth surface is
inspected visually
and defective areas
are tactilely
explored with a
probe.
Natural or artificial
light
Teeth should
receive a
prophylaxis and be
dried at time of
examination

58. CODING AND CRITERIA





Unerupted, missing, heavily restored , bacle
decayed , fractured teeth and teeth or tooth
surfaces which for any other reason cannot be
classified with defects must be coded ‘X‟.
Permanent teeth are number coded.
Primary teeth are letter coded.
When in doubt the tooth surface should be scored
„normal’.
when an abnormality is present but cannot be
classified into listed categories, it should be
scored as „other defects’.

59. TYPE OF DEFECT
• OPACITY
• HYPOPLASIA
• DISCOLORATION
NUMBER
• SINGLE
• MULTIPLE
DEMARCATION
• DEMARCATED
• DIFFUSE
LOCATION OF
DEFECTS
• GINGIVAL OR
INCISAL HALF
• OCCLUSAL
• CUSPAL
• WHOLE
SURFACE

60. MODIFICATIONS



Clarkson J.J and O‟Mullane D.M in 1989
modified the DDE to be used in one of the two
manners
General purpose epidemiology studies
Screening surveys

61. General purpose
epidemiological studies









NORMAL
DEMARCATED OPACITY
White/cream
Yellow/brown
DIFFUSE OPACITY
Diffuse lines
Diffuse patchy
Diffuse confluent
Confluent +Staining+loss Of
Enamel

Code 0

Code 1
Code 2


Code 3
Code 4
Code 5

Code 6



62. 



HYPOPLASIA
Pits
Missing enamel
ANY OTHER
DEFECTS



Code 7
Code 8
Code 9

63. Extent of defect




Normal
< 1/3rd
At least 1/3rd < 2/3rd
At least 2/3rd




Code 0
Code 1
Code 2
Code 3

64. Screening surveys





NORMAL
DEMARCATED
OPACITY
DIFFUSE OPACITY
HYPOPLASIA PITS
OTHER DEFECTS





CODE 0
CODE 1
CODE 2
CODE 3
CODE 4

65. 

In UK, DDE has been the most frequently used
index
However since it is not fluorosis specific , it is
difficult to analyze prevalence of fluorosis from
this index.

66. YOUNG’S CLASSIFICATION OF
ENAMEL FLUOROSIS



Developed by YOUNG M.A in 1973.
Similar classification was developed by AlLousi et al in 1975.
Recording of any
Principle
condition once
defined must be
made on baisi of that
definition and not on
basis of presumed
etiology.

67. TYPE A
TYPE B
• White areas less than 2mm in diameter
• White areas of > 2mm diameter
TYPE C
• Colored areas <2mm in diameter irrespective
of white areas.
TYPE D
• Colored areas of <2mm diameter irrespective
of area covered

68. TYPE E
TYPE F
• Horizontal white lines irrespective of
there being any non linear lines
• Colored or white lines or areas
associated with pits or hypoplastic
areas

69. MURRAY AND SHAW’S
CLASSIFICATION OF ENAMEL
FLUOROSIS


Developed by Murray J.J and Shaw L in 1979.
Based on young‟s classification with two
modifications
Colored
flecks and
patches were
combined
into one
group
Occlusal and
lingual/palatal
surfaces
were also
included

70. REFERENCES




Whelton HP;Ketley CE;Mcsweeny F;O’Mullane
DM; A review on fluorosis in European
Union:prevelance risk factors and aesthetic
issues,CDOE2004,32;9-18.
Antonio Carlos PEREIRA ;Ben-Hur Wey
MOREIRA; Analysis of Three Dental Fluorosis
Indexes Used in Epidemiologic Trials, Braz Dent
J (1999) 10(1): 1-60
Pendrys DG, Katz RV, Morse DE. Risk factors
for enamel fluorosis in a fluoridated population.
Am J Epidemiol 1994;140:461-71.
Pendrys DG, Katz RV, Morse DE. Risk factors
for enamel fluorosis in a nonfluoridated
population. Am J Epidemiol1996;143:808-15.

71. 

R.G Rosier, Epidemiologic Indices for
Measuring the Clinical Manifestations of
Dental Fluorosis: Overview and Critique;
ADR June 1994 vol. 8 no. 1 39-55.
A. Rizan Mohamed;W. Murray Thomson,
;Timothy D. Mackay; An epidemiological
comparison of Dean‟s index and the
Developmental Defects of Enamel (DDE)
index; doi: 10.1111/j.1752-7325.2010.00186.x

72. 


Steven M. Levy; Liang Hong; John J.
Warren;Barbara Broffitt; Use of the Fluorosis
Risk Index in a Cohort Study:The Iowa Fluoride
Study;JPHD Vol. 66, No. 2, Spring2006.
David G. Pendrys; Analytical Studies of Enamel
Fluorosis: Methodological Considerations.oxford
journals Vol. 21, No. 2.
Chankanka O, Levy SM, Warren JJ, Chalmers
JM. A literature review ofaesthetic perceptions of
dental fluorosis and relationships with
psychosocialaspects ⁄ oral health-related quality of
life.CDOE 2010. 38: 97–109

73. 
R. Gary Rozier; The Prevalence and Severity
of Enamel Fluorosis in North American
Children; Vol. 59, No. 4, Fall 1999