fluoride indices in dentistry

indices used for dental fluorosis including all the indices and their modifications

1. GOOD MORNING

2. BY AKSHAY THAKUR Dr. Harvansh Singh judge Institute Of Dental Sciences And Hospital, Panjab university, Chandigarh . INDICES USED FOR DENTAL FLUOROSIS

3. Contents Introduction History Classification of indices Dean’s index Modified Dean’s index Community fluorosis Index Thylstrup and Fejerskov Index Tooth Surface index of fluorosis Fluorosis Risk Index Young’s Classification Of Enamel Fluorosis Murray and Shaw’s Classification of Enamel Fluorosis Simplified Fluoride Mottling Index Summary References

4. INTRODUCTION INDEX : 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 : 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.

5. 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. 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

6. CLASSIFICATION OF FLUOROSIS MEASURING INDICES

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

8. METHOD ( as implied by DEAN)

9. CLASSIFICATION AND CRITERIA

10. 1939 Dean combined the “moderately 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.

11. Deans revised index (1942)

12. COMMUNITY FLUOROSIS INDEX 1942 , based on the revised fluorosis index scale , H. Dean 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

13. 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

14. 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.

15. THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS Score Criteria 1 2 Normal translucency of enamel remains after prolonged air – drying Narrow white lines located corresponding to the perikymata . 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.

16. Score Criteria 3 4 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 opaque enamel. 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.

17. Score Criteria 5 6 7 Smooth and Occlusal surfaces: Entire surface displays marked opacity with focal loss of outermost enamel (pits) 2mm in diameter. 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.

18. Score Criteria 8 9 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

19. ACHIEVEMENT : 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.  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

20. TOOTH SURFACE FLUOROSIS INDEX It was developed by HOROWITZ et al., DRISCOLL, MEYERS , HEIFETZ & ALBERT KINGMAN in 1984 at National Institute of Dental Research U.S.A AIM : Overcome the shortcomings of Dean’s index and assess the prevalence of fluorosis from a tooth surface prospective.

21. Numerical score Descriptive Criteria 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 capping)

22. Numerical score Descriptive Criteria 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.

23. Numerical score Descriptive Criteria 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 altered. Dark brown stain is usually present.

24. 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 )

25. 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.

26. ENAMEL ZONES Incisal edges of 11 21 32 31 41 42 and occlusal tables of 16 26 36 46. Cervical third of incisors,middle third of canines, occlusal table,incisal third and middle third of bicuspid and 2 nd molars

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28. SCORING CRITERIA SCORE = 7 Any surface that has an opacity that appears to be a non fluoride opacity

29. SCORE = 3 Surface zone with greater than 50% of zone that displays pitting, staining and deformity

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

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

32. 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

33. 1 White opaque spots (or flecks) less than 2mm in dia 2 Greater than 2mm measured in any direction. Well demarcated from surroundings. 3 Coloured spots, flecks or patches 4 Horizontal white lines, not associated with hypoplasia 5 Hypoplasia + Category 1 to 4 (any) 6 Possible early carious lesions 7 Missing SCORE CRITERIA

34. SIM PLIFIED FLUORIDE MOTTLING INDEX (FMI) Introduced by RAHMATULLA. M. And RAJASEKHAR. A. In 1984. It is based on enamel opacities/lesions present on facial surfaces of six upper and lower ant. Teeth which are asthetically important. SCORE CRITERIA No involvement of facial surface. Enamel : translucent , smooth and glossy. 1 Less than 1/3 rd of facial surface involved 2 Above 1/3 rd but less than 2/3 rd 3 Over 2/3 rd facial surface involved 4 Brownish Black discolouration of entire facial surface.

35. SUMMARY Tooth surface index of fluorosis (TSIF), permits a specific assessment of fluorosis and because of this, it is especially useful for determining the public effect of fluorosis in a population. Thylstrup and Fejerskov index for fluorosis (TFI), is thought to be most sensitive since it calls for drying of teeth which accentuates the appearance of fluorosis , making the diagnosis easier in questionable cases. Even though the Fluorosis risk Index (FRI) is thought to be complex from biological perspective and in application, it is reliable and valid when identifying risk factors for enamel fluorosis . Dean’s index has been used most frequently over the years, till today. But, modified dean’s index is one still recommended by WHO in its basic survey manual.

36. REFERENCES Essentials of Preventive and Community Dentistry by Soben Peter. ncib.nih.gov US National Library of Medicine National Institutes of Health publichealth.med.miami.edu , official site of university of miami health system.

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