Fluorosis

Definition

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 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 often is 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 only be detected 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, 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.

ClassificationDescriptive criteriaNormalEnamel shows no evidence of fluorosis. The surface of the tooth is smooth, glossy, and typically has a pale, creamy white color.Very mildEvidence 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").MildParchment-white fluorosis can be seen on more than 25% but less than 50% of the tooth surface.ModerateLight to very dark brown staining occurs on the enamel, along with the parchment-white coloration of fluorosis.SevereAll 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.

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.