Fluoride Action Network

Severe Dental Fluorosis & “Psychosocial Suffering”

EXCERPTS from: de Castilho, et al. (2009). Perceptions of adolescents and young people regarding endemic dental fluorosis in a rural area of Brazil: Psychosocial suffering. Health and Social Care in the Community 17:557-63.

SUMMARY: Severe dental fluorosis is endemic in some rural areas of Brazil. This paper describes the psychosocial consequences of this condition and how it has affected the self-esteem of adolescents and young people in a rural area in Brazil. Semi-structured, face-to-face interviews were carried out with 23 adolescents and young people affected by severe dental fluorosis and 14 of their teachers. The study revealed the affected individuals were embarrassed to smile at strangers due to a presumed association between fluorosis and a lack of dental hygiene. Further findings include conflicts between affected and non-affected students at school, problems in pursuing a romantic relationship and uncertainties regarding a professional future. Disbelief and scepticism were observed regarding the ethical position that science can offer a solution to the problems stemming from the disease. Lesions from severe dental fluorosis appear to be a stigmatising factor and have contributed toward suffering and self-exclusion among an entire generation of adolescents and young people.


Regardless of gender, the affected individuals expressed awareness of yellow, black and stained teeth as unhealthy and weak. The individuals perceive severe dental fluorosis as a process in which the tooth becomes weakened. The direct consequences that most worry the interviewees regard the progression of the disease rotting the teeth and, as with caries, future pain and tooth loss:

My teeth were fragile… Later they were starting to break. They were made weak because of the water… (Girl, 12 years old, TF 6)

Inferring that severe dental fluorosis will progress in a manner similar to dental caries is a conclusion stemming from the similarity between the two types of lesions. Nonetheless, there is an understanding that the causes are different. Stopping the degradation of the tooth is therefore an ever-present hope, as the evolution of the lesions is perceptible and felt:

I would like to restore this upper part, because there are some spots that look like they are penetrating the inner part of the tooth more and more. (Boy and field hand, 22 years, TF 8 )

. . . . Regardless of whether fluorosis is considered a disease or a problem, older individuals (AGE 3) exhibit complexes stemming from the severe lesions and the impact caused on the daily living of each individual over time:

When I didn’t have this problem [period of deciduous dentition], I smiled more openly. Today I have a more closed smile. The smile comes from inside me… I can’t expose this smile to everyone’s view. (Boy and field hand, 22 years, TF 8 )

Embarrassment and guilt

Dental fluorosis causes feelings of embarrassment among these young people with respect to smiling at someone who comes from far away. This is a situation that is mainly related to the impression on the part of others of a lack of hygiene. It is a strong feeling not only with regard to those coming from other places, but also involves the experience of early romantic relationships, which is a particular mark of adolescence:

They think that it’s a lack of care you have with your teeth. I guess they think: this guy doesn’t brush; he’s a pig! We become embarrassed, especially the girls. (Boy, 19 years, TF 6)

Among the teachers, these social representations are reinforced when they explain action strategies for conflict resolutions or when they relate their initial impressions upon seeing fluorotic lesions:

We arrive in the classroom and there is that same discussion: filthy teeth! So we explain it: This is not his fault. Do you think it’s because he doesn’t brush his teeth? Sometimes, that’s not the case… (Teacher)

The individuals feel embarrassment and guilt at the same time. They produce reactions of disgust among whoever sees them and they feel unfairly judged. When placed in an emotional situation of this nature, they either react or resign themselves to the stigma:

Oh! I feel down… because whenever we stand out. We smile and the person notices our teeth right away and says it’s that one with the yellow teeth. They think we don’t brush. (Girl, 15 years old, TF 5)

The lack of spontaneity in their actions makes these young people believe that they have lost something important in their lives:

I didn’t smile right because of shame. I was happy and everything. I smiled a lot, but I smiled untrustingly. I put my hand over my mouth. I think I missed out on moments of happiness because I couldn’t smile more joyfully. (Boy, 19 years, TF 6)

According to most of the teachers, boys and girls affected by fluorosis are shy, inhibited, quiet, sad and embarrassed. They avoid smiling, cover their faces with their hands, smile with their lips closed, do not get their pictures taken, do not participate in theatre activities at school and avoid conversing with classmates:

Sometimes we are talking to them and looking into their eyes. I try not to look at their mouths. Otherwise, they don’t want to talk anymore. They lower their heads and try to foil the conversation. (Teacher)

Faced with problems of self-esteem and difficulties in relationships in social environments that are different from their place of origin, these individuals tend to isolate themselves in the interior of the country and are overwhelmed with doubts regarding the future. Most of the statements reveal the belief that the stains will cause harm in procuring a place in the job market:

I think with a firm, yes… there are some business owners that despise it… They think the person is sick… and they kick him out… (Boy, 16 years, TF 6)

The images these young people have of themselves have been altered by the constant situations they have gone through in relation to feelings of inferiority and have become rooted in their personalities. An individual without stains would use his ? her smile as a means to attenuate tension, but affected individuals do not smile and do not alleviate such tensions. Actually, they avoid such situations:

I only want to reach the point of having some free treatment for everyone to get their teeth cleaned; to no longer stay at home, without wanting to smile; to have the opportunity to achieve something better. (Girl, 12 years, TF 7)