Fluorosis is an abnormal condition of the tooth enamel caused by excessive exposure to fluoride (a nutrient used to prevent tooth decay) while a child's teeth are forming under the gums. Excessive fluoride affects the formation of tooth enamel (the hard outer surface of a
Classification and descriptive criteria for dental fluorosis
Classification
Descriptive criteria
Normal
Enamel shows no evidence of fluorosis. The surface
of the tooth is smooth, glossy, and typically has a
pale, creamy white color.
Very mild
Evidence of fluorosis in the enamal is shown by
areas with parchment-white color that total up to
25% of the tooth surface. This includes fluorosis
seen only on the incisal edges of anterior teeth and
cusp tips of bicuspids or molars ("snowcapping").
Mild
Parchment-white fluorosis can be seen on more than
25% but less than 50% of the tooth surface.
Moderate
Light to very dark brown staining occurs on the
enamel, along with the parchment-white coloration
of fluorosis.
Severe
All enamel surfaces are affected, and the anatomy of
the tooth may be altered. Discrete or confluent pitting
of the enamel surface exists. Dark-brown stain is
usually present and may be widespread, presenting a
corroded appearance of the teeth.
tooth). Fluorosis can be very mild, as a few white spots on a tooth; or severe, showing etching, pitting, and brown discoloration on many teeth.
Description
Fluoridated community water systems and toothpaste with fluoride have significantly contributed to the prevention and mitigation of dental caries (tooth decay) in developed countries, reducing the number of cavities by 70%. Even at the safe level of 1 ppm of fluoride in drinking water, 22% of the people drinking that water have reported some form of fluorosis. In some areas, the rate of incidence is 50%.
Though fluorosis is mainly a cosmetic problem, it has become a marker for overexposure to fluoride in a child's environment.
Causes and symptoms
Fluorosis does not affect the permanent teeth once they have fully appeared. Fluorosis may occur in primary (baby) teeth as well as permanent teeth. Most often, the condition appears on the front incisors (front teeth) and less frequently on the molars. This characteristic poses a high cosmetic problem because the front teeth are most exposed when children speak or smile.
Symptoms can range from mild to severe. Very mild fluorosis is seen as tiny white spots on 25% of a tooth surface. Mild fluorosis covers 26% to 50% of a tooth surface. Moderate fluorosis compromises all of a tooth's surface and is most characterized by brown discoloration of the tooth. Severe fluorosis involves pitting of the enamel and more serious brown staining. Approximately 94% of dental fluorosis is very mild to mild.
Excess fluoride exposure is often accidental. Naturally occurring fluoride in well water can sometimes be much higher than water from artificially fluoridated, community or municipal systems that are kept at strict levels. Drought conditions can also concentrate fluoride levels.
According to the ADA, young children under six often use too much toothpaste that contains fluoride, and they consistently swallow it. This alone has been the biggest cause of excess fluoride ingestion.
Some children drink fluoridated water and also drink large amounts of bottled beverages that have fluoride in them. Carbonated drinks and juices have fluoride in varying amounts. Often, the fluoride in these products is not printed on the labels. Still other children are offered foods high in fluoride (fish with bones, tea, poultry products, cereals, or infant formula made with fluoridated water) in addition to fluoridated water.
Finally, fluorosis may be caused by some pediatricians who prescribe fluoride supplements without determining the amount of fluoride exposure the child has in his or her environment.
Topical applications of fluoride gels applied by dentists to the surfaces of a child's teeth and fluoride mouth rinses available through dentists or over the counter (OTC) are other ways that a child can add to her fluoride quota. These methods are extremely helpful for older children and adults, but they often add to the cumulative fluoride exposure a young child can have, especially if she swallows fluoride residues.
Diagnosis
Fluorosis can be identified through examination by a dentist or dental hygienist. Very mild fluorosis sometimes can be detected only through x rays. Often the dentist uses the Fluorosis Index to classify the severity of the condition from very mild to severe. (See Causes & Symptoms for details of each classification.)
Treatment
There is no treatment for fluorosis except cosmetic restoration.
Prognosis
There are many more ways to deliver fluoride than through drinking water and toothpaste. These methods,
KEY TERMS
Deciduous teeth—The teeth a child has before permanent ones; baby teeth.
Dental caries—Tooth decay.
Enamel—The hard outer surface of a tooth.
Fluoride—A fluorine compound used to treat water or apply directly to tooth surfaces to prevent dental caries.
Incisors—Front teeth used for biting.
however, remain the most effective ways to discourage dental caries (tooth decay). With more awareness of the amount of fluoride in a child's environment, pediatricians and dentists are becoming more accurate in prescribing fluoride supplements to infants and young children. Parents are becoming educated about the risks of their children swallowing fluoride toothpaste and fluoride mouth rinses.
Health care team roles
The pediatrician has an important role in a child's oral health because the pediatrician is usually the first health-care professional a child sees about his or her dental needs. The pediatrician can monitor a child's oral hygiene, determine when to make referrals, and regulate fluoride therapy in relation to a child's specific fluoride needs. The pediatrician can also educate parents about fluoride excess and safety issues.
The dentist regulates the amount and frequency of fluoride therapy, monitors a child's oral hygiene, and also assesses the amount of fluoride in a child's environment. The dentist also suggests and implements therapeutic plans for the child's dental health. Parent education is also a part of the dentist's role.
Dental hygienists, nurses, and teachers participate in parent education about fluoride usage and good dental habits, teach children about proper tooth brushing—especially the amount of toothpaste to use—and encourage periodic testing of the water for fluoride levels in the community or at a child's home, where filters that may lower fluoride concentrations in tap water may be used.
Prevention
Fluorosis can be prevented by monitoring the amount of fluoride children are exposed to before the age of six. Professionals can educate parents about diet, fluoridated water, proper tooth brushing, and safe amounts of toothpaste to use. Children under six should be monitored during tooth brushing, shown to use only a pea-sized drop of toothpaste, and encouraged to not swallow toothpaste. Children under six should also not use fluoridated mouth rinses. Parents should limit the amount of fluoride in bottled beverages, and substitute milk for between-meal snacks. Pediatricians and dentists should adhere to the new guidelines for fluoride supplements. These supplements are not recommended for children who are exposed to adequate amounts of fluoridated water.
Author unspecified. "Position of the American Dietetic Association: The Impact of Fluoride on Health." Journal of the American Dietetic Association 101, no. 1 (January 2001):126.
Hale, K.J., and K. Heller. "Fluorides: Getting the Benefits, Avoiding the Risks." Contemporary Pediatrics 17, no. 2 (February 2000): 121.
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000. <http://www.aap.org>.
American Dental Association. 211 East Chicago Ave., Chicago, IL 60611. (800)947-4746, (312)440-2500. <http://www.ada.org>.
National Association of Pediatric Nurse Associates & Practitioners. 1101 Kings Highway, N., Suite 206, Cherry Hill, NJ 08034-1912. <http://www.napnap.org>.
