Dental fluorosis comes in various stages of severity. The severity of fluorosis increases with the dose of fluoride the child consumes, and can be exacerbated by nutritional deficiencies and kidney impairment. Dentists generally use the “Dean Index” to diagnose the severity of a child’s fluorosis. Developed in the 1930s and 1940s by the “Father of Fluoridation” (H. Trendley Dean), the Dean Index classifies fluorosis into five types: “questionable,” “very mild,” “mild,” “moderate,” and “severe.”
Dean’s use of the descriptors “very mild” and “mild” to characterize the first definitive stages of fluorosis is problematic. A tooth with “mild” fluorosis is defined as one which has cloudy white staining (e.g., specks, streaks, splotches) on up to 50% of the tooth’s surface. While dentists have long dismissed the esthetic implications of “mild” fluorosis, research over the past two decades has consistently shown that the general public finds “mild” fluorosis highly objectionable when present on the front two teeth.
Another problem with the Dean Index is that it’s five broad categories of fluorosis fail to distinguish significant variations that can occur within each stage. Researchers have thus developed more finely tuned diagnostic guides. One such guide is the “Thylstrup-Fejerskov Index,” (TF Index), and another is the “Total Surface Index of Fluorosis” (TSIF).
The following is Dean’s criteria for diagnosing dental fluorosis:
Questionable: “The enamel discloses slight aberrations from the translucency of normal enamel, ranging from a few white flecks to occasional white spots. This classification is utilized in those instances where a definite diagnosis of the mildest form of fluorosis is not warranted and a classification of ‘normal’ is not justified.”
“Very Mild” Fluorosis
Very Mild: “Small opaque, paper white areas scattered irregularly over the tooth but not involving as much as 25% of the 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 the bicuspids or second molars.” (Photo by the Center for Natural Dentistry)
Mild: “The white opaque areas in the enamel of the teeth are more extensive but do not involve as much as 50% of the tooth.” (Photograph by Hardy Limeback DDS, PhD)
Moderate: “All enamel surfaces of the teeth are affected, and the surfaces subject to attrition show wear. Brown stain is frequently a disfiguring feature.”(Photograph by Hardy Limeback, DDS, PhD)
Severe: “All enamel surfaces 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.” (Photograph by Hardy Limeback, DDS, PhD)
Source for dean index criteria:
Dean, 1942. As Reproduced in “Health Effects of Ingested Fluoride” National Academy of Sciences, 1993. pp. 169.
Fluoride, Arthritis, and the Specter of Misdiagnosed Skeletal Fluorosis in the US
It has been known since the 1930s that ingesting too much fluoride can cause stiff and painful joints. According to scientists who have studied this condition (commonly referred to as skeletal fluorosis), the joint damage caused by fluoride may mimic other, more common, forms of “arthritis,” making it easy to
X-Ray Diagnosis of Skeletal Fluorosis
In 1937, Kaj Roholm published his seminal study Fluorine Intoxication in which he described three phases of bone changes that occur in skeletal fluorosis. (See below). These three phases, which are detectable by x-ray, have been widely used as a diagnostic guide for detecting the disease. They describe an osteosclerotic bone disease that develops first in the axial skeleton (the spine, pelvis, and ribs), and ultimately results in extensive calcification of ligaments and cartilage, as well as bony outgrowths such as osteophytes and exostoses. Subsequent research has found, however, that x-rays provide a very crude measure for diagnosing fluorosis since the disease can cause symptoms and effects (e.g., osteoarthritis) before, and in the absence of, radiologicaly detectable osteosclerosis in the spine.
Variability in Radiographic Appearance of Skeletal Fluorosis
Osteosclerosis (dense bone) is the bone change typically associated with skeletal fluorosis, particularly in the axial skeleton (spine, pelvis, and ribs). Research shows, however, that skeletal fluorosis produces a spectrum of bone changes, including osteomalacia, osteoporosis, exostoses, changes resulting from secondary hyperparathyroidism, and combinations thereof. Although the reason for this radiographic variability is not yet fully understood, it is believed to relate to the dose of fluoride consumed, the individual's nutritional status, exposure to aluminum, genetic susceptibility, presence of kidney disease, and area of the skeleton examined.
Diagnostic Criteria for Dental Fluorosis: The Thylstrup-Fejerskov (TF) Index
The traditional criteria (the "Dean Index") for diagnosing dental fluorosis was developed in the first half of the 20th century by H. Trendley Dean. While the Dean Index is still widely used in surveys of fluorosis -- including the CDC's national surveys of fluorosis in the United States -- dental
Email Exchange with FDA re: Fluoride Supplements
Email exchange regarding FDA's reasons for not approving fluoride supplements.
Harvard's Statement on Chester Douglass/Scientific Misconduct
Statement Concerning the Outcome of the Review into Allegations of Research Misconduct Involving Fluoride Research BOSTON-August 15, 2006-The Harvard Medical School and School of Dental Medicine (HSDM) review of Chester Douglass, DMD, PhD, professor of oral health policy and epidemiology at HSDM, has concluded that Douglass did not intentionally omit, misrepresent,
The 'Altered Recommendations' of the 1983 Surgeon General's Panel
"We believe that EPA staff and managers should be called to testify, along with members of the 1983 Surgeon Generals panel and officials of the Department of Human Services, to explain how the original recommendations of the Surgeon Generals panel were altered to allow EPA to set otherwise unjustifiable drinking water standards for fluoride."
Related Miscellaneous Content: