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Dental fluorosis: Exposure, prevention and management

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J Clin Exp Dent. 2009;1(1):e14-18. Dental fluorosis: Exposure, prevention and management

Dental fluorosis: Exposure, prevention and management

Jenny Abanto Alvarez 1, Karla Mayra P. C. Rezende 2, Susana María Salazar Marocho 3, Fabiana B. T. Alves 4,
Paula Celiberti 5, Ana Lidia Ciamponi 6

1
DDS, Specialist in Pediatric Dentistry, MSc student, Department of Pediatric Dentistry, Dental School, University of São
Paulo-USP, São Paulo, SP, Brazil
2
DDS. Department of Pediatric Dentistry, Dental School, University of São Paulo-USP, São Paulo, SP, Brazil
3
DDS, MSc. Department of Dental Materials and Prosthodontics, Dental School of São José dos Campos, São Paulo State
University-UNESP, SP, Brazil
4
DDS, Specialist in Pediatric Dentistry, MSc, Add PhD student. Department of Pediatric Dentistry, Dental School, University
of São Paulo-USP, São Paulo, SP, Brazil
5
DDS, Specialist in Pediatric Dentistry, Add MSc, PhD student, Department of Pediatric Dentistry, Dental School, University
of São Paulo-USP, São Paulo, SP, Brazil
6
DDS, PhD, Assistant Professor of Pediatric Dentistry and Orthodontics Department, Dental School, University of São Paulo-
USP, São Paulo, SP, Brazil

Correspondence:
Dr. Jenny Abanto Alvarez
Faculdade de Odontologia de São Paulo,
Departamento de Odontopediatria -
Avenida Professor Lineu Prestes, 2227
Cidade Universitária.
CEP: 05508-000. São Paulo
SP, Brazil. Abanto JA, Rezende KMPC, Marocho SMS, Alves FBT, Celiberti P,
jennyaa@usp.br Ciamponi AL. Dental fluorosis: Exposure, prevention and management.
J Clin Exp Dent. 2009;1(1):e14-18.

Abstract
Dental fluorosis is a developmental disturbance of dental enamel, caused by successive exposures to high con-
centrations of fluoride during tooth development, leading to enamel with lower mineral content and increased
porosity. The severity of dental fluorosis depends on when and for how long the overexposure to fluoride occurs,
the individual response, weight, degree of physical activity, nutritional factors and bone growth. The risk period
for esthetic changes in permanent teeth is between 20 and 30 months of age. The recommended level for daily
fluoride intake is 0.05 - 0.07 mg F/Kg/day, which is considered of great help in preventing dental caries, acting
in remineralization. A daily intake above this safe level leads to an increased risk of dental fluorosis. Currently
recommended procedures for diagnosis of fluorosis should discriminate between symmetrical and asymmetrical
and/or discrete patterns of opaque defects. Fluorosis can be prevented by having an adequate knowledge of the
fluoride sources, knowing how to manage this issue and therefore, avoid overexposure.

Key words: Dental fluorosis, fluoride sources, prevention, dentistry management.

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J Clin Exp Dent. 2009;1(1):e14-18. Dental fluorosis: Exposure, prevention and management

Introduction optimal fluoride concentration in the public water supply

Dental fluorosis is a developmental disturbance of dental of these different municipalities.
enamel, caused by successive exposures to high concen- Fluorosis can be prevented by monitoring the amount
trations of fluoride during tooth development, leading to of fluoride that children up to 6 years old are exposed,
enamel with lower mineral content and increased poro- therefore, the dentist must be aware of the main sources
sity. The severity of dental fluorosis depends on when of fluoride to prevent fluorosis and instruct parents or
and for how long the overexposure to fluoride occurs, the caregivers on how daily dose should be managed in order
individual response, weight, degree of physical activity, to achieve success in prevention. The fluoride sources
nutritional factors and bone growth, suggesting that are described as follows:
similar dose of fluoride may lead to different levels of - Water fluoridation
dental fluorosis (1). Other factors that may increase the The important role of fluoride in the prevention of dental
individual susceptibility to dental fluorosis are altitude caries is evident and turns the water fluoridation into a
(2), malnutrition (3) and renal insufficiency (4). public health measure. The fluoride level supplied in
Esthetics changes in permanent dentition are the greatest water can vary from 0.7 to 1.0 ppm, depending on the
concern in dental fluorosis, which are more prone to oc- seasons of the year (11). Thus, as the ambient temperature
cur in children who are excessively exposed to fluoride gets warmer, the water intake increases, requiring lower
between 20 and 30 months of age. It is also important to levels of fluoride in drinking water. Fluoridated water
remind that the critical period to fluoride overexposure is, directly or indirectly, responsible for 40% of dental
is between 1 and 4 years old, and the child would not be fluorosis, through water intake or children’s formula and
at risk around 8 years old (5). food prepared with drinking water. The other 60% are
The safe level for daily fluoride intake is 0.05 to 0.07 attributed to other sources of fluoride (12).
mg F/Kg/day. Above this level, the risk of developing In a systematic review, where 214 studies were analyzed,
fluorosis due to chronic fluoride consumption will be McDonagh et al. (13) observed a decrease in the number
evident (6). of caries-affected teeth and an increase in dental fluoro-
Researches in areas with or without the addition of fluo- sis, depending on the fluoride intake. They also stated
ride (F) in drinking water have identified 4 sources that that the prevalence of dental fluorosis indicates that
increase the risk for dental fluorosis, which are: fluorida- children are ingesting other sources of fluoride besides
ted drinking water, fluoride supplements, topical fluoride drinking water. In areas where drinking water is obtained
(especially fluoride toothpastes), and formula prescribed directly from deep wells, dental fluorosis is often ende-
for children. Furthermore, some children’s industrialized mic and in many cases, the deeper the wells, the higher
food can also have an important contribution to daily the fluoride concentration in drinking water.
consumption of fluoride. In order to prevent fluorosis, the pediatric dentist has to
The use of fluoride is considered an important factor in instruct parents about the fluoride content in the drinking
the prevention and management of dental caries, inhibi- water and when it is not known, look for this information
ting demineralization and stimulating remineralization. in the local water supply service. If a child drinks well
Due to the widespread of other fluoride sources a decline water or bottled water, the pediatric dentist may assist the
in dental caries and an increase in the prevalence of dental parents or caregivers in getting an analysis of its fluoride
fluorosis have been documented in communities with and content, and afterwards decide together whether the child
without fluoridated drinking water (7,8). In populations needs a fluoride supplement or not. Dentists also should
supplied with fluoridated drinking water, the prevalence educate parents about diet, such as children’s formula,
of dental fluorosis will depend on the duration of time food or sodas that need water to be manufactured and
that a certain fluoride concentration is kept constant in can indirectly participate in the development of dental
the body during tooth development. Epidemiological data fluorosis. Therefore, parents should also limit the amount
on this matter are, however, scarce in the literature. of fluoride in bottled beverages.
The prevalence of fluorosis in permanent incisors of - Fluoride supplements
8-9 years-old-children, living in communities supplied Fluoride supplements are recommended for children li-
with fluoridated and non-fluoridated water was 54% ving in fluoride deficient areas. The recommended daily
and 23%, respectively (8). Catani et al. (9) described that dose is based on children’s age and on the concentration
the prevalence of fluorosis in areas with oscillating and of fluoride in drinking water. Studies have identified
homogenous fluoride content in water was 31.4%, and fluoride supplements as a risk factor for dental fluorosis,
79.9%, respectively. These values are within the variation both in fluoridated (14) and non-fluoridated areas (7). In
from 35% to 60% reported from fluoridated communities fluoridated areas, the risk of dental fluorosis from use
in the United States (10). The reasons for these variations of fluoride supplements is almost 4 times higher than in
have not been, however, explored. Catani (9) suggests non-fluoridated areas (15).
that the variations might be related to controlling for the The risk of dental fluorosis originated from the use of

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J Clin Exp Dent. 2009;1(1):e14-18. Dental fluorosis: Exposure, prevention and management

fluoride supplements is well established. Therefore, cli- using a fluoride-containing toothpaste or not, depends on
nicians must be aware of the optimum concentration of caries activity and risk, on children’s age and the ability
fluoride needed in water, before prescribing them. Fluo- to spit the dentifrice during oral hygiene.
rosis can be prevented if pediatricians, as well as dentists, Studies considering the relative toxicity of the profes-
follow the new guidelines for fluoride supplements, and sional topical fluoride application in children are scarce
be aware that these supplements are not recommended in the literature; however, it is important to prevent the
for children who are exposed to water supplies with an toxicity risks that can occur, mainly in little children.
adequate amount of fluoride. Whenever topical fluoride is applied, such as acidulated
- Topical fluoride phosphate fluoride (APF) at 1, 23% and sodium fluoride
The excessive fluoride intake, in consequence to the at 2.0% in gel, some recommendations and suggestions
inadequate use or swallowing of fluoride-containing too- should be followed in order to prevent or reduce the
thpastes, is also responsible for the development of dental potential ingestion of fluoride. These are: to reduce the
fluorosis. Children up to 5 years old swallow around 30% concentration of fluoride in the product and decrease
of the amount of toothpaste used every time they brush the application time; to confection individuals trays
their teeth. If fluoridated water is consumed at the same recovered with foam and trimmed; to maintain the seat
time, a potential risk of dental fluorosis occurs (16). in a vertical position so that the patient remain seated;
Two alternatives have been suggested to reduce the con- to always use a saliva ejector; to remove the excess of
sumption of fluoride: fluoride with a gauze; and to request the patient to spit
Firstly, a reduction in the amount of toothpaste used as much as possible after the fluoride application. This
should be achieved by educating parents to offer small, method is, however, appropriate for children above 3
and therefore safe, amounts of toothpaste. For children years old.
between 4 and 6 years old, parents can be taught to use an Based on the risks of the overexposure to fluoride and
amount equivalent to “a pea size”, dispending toothpaste the prevention of dental fluorosis, another presentation of
over the toothbrush with the “transverse technique”. For acidulated phosphate fluoride was developed, the fluoride
children in a more tender age, parents should simply dental foam. According to manufacturers’ instructions,
touch the toothbrush inside the toothpaste cover or tube, the product is safer because of its lower ability to flow
instead of squeezing it on the toothbrush (16). It has to and the smaller amounts requires for application, when
be always reminded that children under six years old compared to the gel. Indeed, the use of fluoride dental
should be monitored during tooth brushing, encouraged foam is considered a safe method with respect to toxi-
not to swallow toothpaste, and not to use fluoridated city, due to its quick adhesion to the dental surface and
mouth rinses. slow dissolution, making it feasible to be used specially
The second alternative is the development of dentifri- in the young children. It is important to clarify that the
ces with low fluoride concentration, which are already properties offered by the fluoride dental foam goes be-
available in many countries. Some studies did not found yond prevention of fluorosis and includes effectiveness
significant differences in the anticaries effectiveness in the prevention of caries (23, 24). Four-minute fluoride
between the fluoride toothpastes with low (500-550 ppm) foam applications, every six months, would be effective
and standard concentration of fluoride (1.000-1.1000 reducing the increment of dental caries in the primary
ppm) (17,18). Nevertheless, some other researches are still dentition and newly erupted permanent first molars
controversial when considering the effectiveness of low (23,24). However, there are few clinical studies in the
fluoride toothpastes (19, 20). However, several studies literature considering the effectiveness of this foam,
assessed children older than 6 years old, which are not and it needs to be more investigated to support the foam
in risk of dental fluorosis anymore. We cannot assume advantages.
that similar results would be seen in primary teeth as in
permanent teeth since the literature indicates that there Diagnostic and Treatment
may be differences between primary and permanent The adequate diagnosis of fluorosis requires inspection of
enamel in reactivity to cariogenic challenges (21). In dry and clean dental surfaces, under a good light source.
addition, the oral cavity of young children (2–6 years The clinical appearance of mild dental fluorosis is cha-
old) is much smaller than that of children aged 12 or racterized by bilateral, diffuse (not sharply demarcated),
more, so the amount of F necessary for caries preventive opaque, and white striations that run horizontally across
effects may not be the same in these age groups. Without the enamel. The opacities may coalesce to form white
the confirmation of studies that show their anticaries patches. In the more severe forms, enamel may become
effectiveness, it seems that the best balance between discolored and/or pitted. Upon eruption into the mouth,
the prevention of caries and dental fluorosis is obtained fluorosed enamel is not discolored, the stains develop
with low concentrations, approximately 400-550 ppm over time due to the diffusion of exogenous ions (ex, iron
of fluoride, in preschool children (17, 22). The choice of and copper) into the abnormally porous enamel.

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J Clin Exp Dent. 2009;1(1):e14-18. Dental fluorosis: Exposure, prevention and management

Nowadays, the differential diagnosis between fluorosis also used for treating discolored areas(TFI = 1-3). Com-
and non-fluoride-induced opacities needs to establish posite restorations can be associated to microabrasion
differences between symmetrical and asymmetrical or to esthetic veneers in cases of type TFI≥ 5. For TFI =
and/or discrete patterns of opaque defects (25). These 8-9, the use of prosthetic crowns might be needed (27).
criteria imply that all symmetrically distributed and
non-discrete opaque conditions of enamel are fluorosis. Conclusions
Diagnostic difficulties occur mostly with mild forms of To identify the different ways of intake fluoride by chil-
fluorosis, or when a mix of fluorotic and non-fluorotic dren is important to evaluate which sources represent
conditions is evident. It’s important to emphasize that some risk for the development of dental fluorosis. The
non-fluoride enamel opacities include all categories of dentist has to consider the recommendations for profes-
opacities not defined as fluorosis, i.e. dental hypoplasia sional topical fluoride application, as well as instruct the
lesions that are commonly characterized as discrete, parents or caregivers in what refers to the age for too-
demarcated white or discolored opacities often affecting thpaste introduction, and the amount and concentration to
a single tooth and, less frequently, multiple teeth, with be used in each age, in order to diminish the prevalence
a symmetrical distribution (25), and result from a wide of dental fluorosis.
variety of systemic or local factors.
Controlling the fluoride intake is the best preventive References
measure for dental fluorosis, however when this is 1. Den Besten PK. Dental fluorosis: its use as a biomarker. Adv Dent
already installed and causing esthetic problems to the Res. 1994;8:105-10.
2. Akosu TJ, Zoakah AI. Risk factors associated with dental fluorosis
patient, some treatment techniques are described in the in Central Plateau State, Nigeria. Community Dent Oral Epidemiol.
literature and will depend on the severity of the condition. 2008;36:144-8.
The dental fluorosis classification criteria developed 3. Yoder KM, Mabelya L, Robison VA, Dunipace AJ, Brizendine
by Thylstrup and Fejerskov Index (TFI) (26) is very EJ, Stookey GK. Severe dental fluorosis in a Tanzanian population
consuming water with negligible fluoride concentration. Community
appropriate to determine the kind of treatment, based Dent Oral Epidemiol. 1998;26:382-93.
on biological aspects of dental fluorosis, and classifying 4. Porcar C, Bronsoms J, Lopez-Bonet E, Valles M. Fluorosis, osteo-
individuals into categories: mild (TFI = 1-3), moderate malacia and pseudohyperparathyroidism in a patient with renal failure.
(TFI = 4-5) and severe (TFI = 6-9). Nephron. 1998;79:234-5.
5. Rodrigues CRMD, Ramires-Romito ACD, Zardetto CGDC. Abor-
Bleaching and enamel microabrasion techniques are dagem educative-preventiva em odontopediatria. In: Cardoso RJA,
conservative, and provide highly satisfactory results, Gonçalves EAN. Odontopediatria. São Paulo: Arte Ciência; 2002.
without excessive wear of sound dental. They may be p. 113-36.
used in cases of TFI = 1-2 and TFI = 1-4, respectively 6. Burt BA. The changing patterns of systemic fluoride intake. J Dent
Res. 1992;71:1228-37.
(27). Some authors (28,29) described the association of 7. Jackson RD, Kelly SA, Katz B, Brizendine E, Stookey GK. Dental
both techniques (microabrasion and bleaching) in cases fluorosis in children residing in communities with different water
of TFI = 1-4. Firstly, microabrasion is carried out, and in fluoride levels: 33-month follow-up. Pediatr Dent. 1999;21:248-54.
the next appointment, the bleaching. Those authors con- 8. Tabari ED, Ellwood R, Rugg-Gunn AJ, Evans DJ, Davies RM.
Dental fluorosis in permanent incisor teeth in relation to water fluo-
cluded that the whole technique provides regularization, ridation, social deprivation and toothpaste use in infancy. Br Dent J.
planning and recovery of the standard color. 2000;189:216-20.
According to Loyola-Rodriguez et al. (30), microabra- 9. Catani DB, Hugo FN, Cypriano S, Sousa Mda L, Cury JA. Rela-
sion is carried out by rubbing an abrasive paste prepared tionship between fluoride levels in the public water supply and dental
fluorosis. Rev Saude Publica. 2007;41:732-9.
with pumice stone and 37% phosphoric acid gel over the 10. Clark DC, Hann HJ, Williamson MF, Berkowitz J. Influence of
pigmented enamel surface, during 10 seconds, and then exposure to various fluoride technologies on the prevalence of dental
washing it during 20 seconds. A 10% chloridic acid so- fluorosis. Community Dent Oral Epidemiol. 1994;22:461-4.
lution can be also used associated with different abrasive 11. Richards LF, Westmoreland WW, Tashiro M, McKay CH, Morrison
JT. Determining optimum fluoride levels for community water su-
particles. Some sessions can be done, with breaks of 15 pplies in relation to temperature. J Am Dent Assoc. 1967;74:389-97.
days, until good results are obtained (30). 12. Fernandes CM, Tabchoury CM, Cury JA. Fluoride concentration
Some studies have shown that bleaching is enough to in infant foods and risk of dental fluorosis. [Abstract 1505]. J Dent
improve esthetics results. Active agents of carbamide Res. 2001; 80:224.
13. McDonagh MS, Whiting PF, Wilson PM, Sutton AJ, Chestnutt
peroxide (10-20%) and hydrogen peroxide (1-10%) can I, Cooper J, et al. Systematic review of water fluoridation. BMJ.
be used on vital teeth (30). The association of home and 2000;321:855-9.
in-office bleaching is interesting in more resistant cases 14. Pendrys DG, Katz RV. Risk factors for enamel fluorosis in optima-
or when the time of treatment has to be shortened. In lly fluoridated children born after the US manufacturers’ decision to
reduce the fluoride concentration of infant formula. Am J Epidemiol.
these cases, the treatment must begin with 35% hydrogen 1998;148:967-74.
peroxide, and be followed by home teeth bleaching under 15. Mascarenhas AK. Risk factors for dental fluorosis: a review of the
professional supervision. recent literature. Pediatr Dent. 2000;22:269-77.
Composite resin and resin-modified glass ionomer are 16. Villena RS. An investigation of the transverse technique of denti-

e17
 J Clin Exp Dent. 2009;1(1):e14-18. Dental fluorosis: Exposure, prevention and management

frice application to reduce the amount of fluoride dentifrice for young

children. Pediatr Dent. 2000;22:312-7.
17. Negri HM, Cury JA. Dose-response effect of a dentifrice for-
mulation with low fluoride concentration - an in vitro study. Pesqui
Odontol Bras. 2002;16:361-5.
18. Stookey GK, Mau MS, Isaacs RL, Gonzalez-Gierbolini C,
Bartizek RD, Biesbrock AR. The relative anticaries effectiveness
of three fluoride-containing dentifrices in Puerto Rico. Caries Res.
2004;38:542-50.
19. Steiner M, Helfenstein U, Menghini G. Effect of 1000 ppm re-
lative to 250 ppm fluoride toothpaste. A meta-analysis. Am J Dent.
2004;17:85-8.
20. Nagpal DI, Damle SG. Comparison of salivary fluoride levels
following use of dentifrices containing different concentrations of
fluoride. J Indian Soc Pedod Prev Dent. 2007;25:20-2.
21. Sønju Clasen AB, Ogaard B, Duschner H, Ruben J, Arends J, Sönju
T. Caries development in fluoridated and non-fluoridated deciduous
and permanent enamel in situ examined by microradiography and
confocal laser scanning microscopy. Adv Dent Res. 1997;11:442-7.
22. Do LG, Spencer AJ. Risk-benefit balance in the use of fluoride
among young children. J Dent Res. 2007;86:723-8.
23. Evans D. APF foam does reduce caries in primary teeth. Evid
Based Dent. 2007;8:7.
24. Jiang H, Tai B, Du M, Peng B. Effect of professional application of
APF foam on caries reduction in permanent first molars in 6-7-year-old
children: 24-month clinical trial. J Dent. 2005;33:469-73.
25. An epidemiological index of developmental defects of dental
enamel (DDE Index). Commission on Oral Health, Research and
Epidemiology. Int Dent J. 1982;32:159-67.
26. Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis
in permanent teeth in relation to histologic changes. Community Dent
Oral Epidemiol. 1978;6:315-28.
27. Akpata ES. Occurrence and management of dental fluorosis. Int
Dent J. 2001;51:325-33.
28. Bertassoni LE, Martin JM, Torno V, Vieira S, Rached RN, Mazur
RF. In-office dental bleaching and enamel microabrasion for fluorosis
treatment. J Clin Pediatr Dent. 2008;32:185-7.
29. Ardu S, Stavridakis M, Krejci I. A minimally invasive treatment
of severe dental fluorosis. Quintessence Int. 2007;38:455-8.
30. Loyola-Rodriguez JP, Pozos-Guillen Ade J, Hernandez-Hernandez
F, Berumen-Maldonado R, Patiño-Marin N. Effectiveness of treatment
with carbamide peroxide and hydrogen peroxide in subjects affected by
dental fluorosis: a clinical trial. J Clin Pediatr Dent. 2003;28:63-7.

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