Any condition that can cause children to be embarrassed about their physical appearance can have significant consequences on their self-esteem and confidence.  Researchers have repeatedly found that “physical appearance [is] the best predictor of self-esteem” in adolescents, (Harter 2000) and that facial attractiveness, particularly the appearance of one’s teeth, is a key component of one’s physical appearance. (Williams 2006; Lalumandier 1998).

Dental fluorosis, a condition caused by too much fluoride exposure during childhood, can cause significant discoloration of teeth. This discoloration ranges from white specks, splotches and streaks in the “mild” forms of the condition to extensive brown and black staining in the severe forms. While there is no dispute that severe fluorosis is a highly disfiguring condition that can cause significant embarrassment and distress to the impacted child, the public health community long dismissed the cosmetic significance of “mild” fluorosis.  In the last 20 years, however, research has repeatedly shown that the general public views teeth with “mild” fluorosis (TF score 3) as a significant blemish of the teeth, one that is likely to embarrass the affected child to a degree that cosmetic treatment would be warranted.  The Centers for Disease Control now concedes, therefore, that mild fluorosis is “cosmetically objectionable” when present on the front teeth. (Griffin 2002).

• To see excerpts of studies on the perceptions and psychological impact of mild fluorosis, click here.
• To see excerpts of studies on the perceptions and/or psychological impact of severe fluorosis, click here.

“Mild” Fluorosis — Photograph by David Kennedy, DDS

Incidence of Cosmetically Objectionable Fluorosis in Fluoridated Areas

Since it is undisputed that water fluoridation can cause dental fluorosis, several attempts have been made to estimate the prevalence of cosmetically objectionable fluorosis in fluoridated areas. In 2000, for example, the British Government reviewed fluorosis studies from around the world and estimated that the rate of cosmetically objectionable fluorosis (TF Score 3+) in fluoridated areas is 12.5%. (York Review 2000).

Following the British Government’s report, scientists at the U.S. Centers for Disease Control re-analyzed data from an oral health survey of U.S. school children that was conducted during the years 1986 and 1987. (Griffin 2002). Although the survey found that 30% of children in the fluoridated areas had some form of definitive fluorosis, the CDC focused only on the fluorosis that was visible on the children’s front teeth which the CDC could attribute to fluoridated water. According to CDC’s scientists:

“We found that approximately 2% of US schoolchildren may experience perceived esthetic problems which could be attributed to the currently recommended levels of fluoride in drinking water.”
SOURCE: Griffin SO, et al. (2002). Esthetically objectionable fluorosis attributable to water fluoridation. Community Dentistry & Oral Epidemiology 30:199-209.

Since more recent surveys of fluorosis in the United States have found that fluorosis rates have significantly increased since the 1980s, the CDC’s conclusion under-states the rate of cosmetically objectionable fluorosis caused by fluoridation. However, whether the rate is 2% or 12%, the important fact is that millions of children have developed cosmetically objectionable teeth because of fluoride in the water. Because a child’s self-esteem is “inextricably linked” to their physical appearance, (Harter 2000), causing a child to be embarrassed about their teeth is not a trivial matter.

Despite this fact, the CDC’s cost-benefit analyses of water fluoridation have never considered the increased costs associated with treating the effects of fluorosis. As noted by the CDC, “at present there are no data that define the number or cost of esthetic restorative procedures performed to change the appearance of enamel fluorosis.” (Griffin 2002). This is a significant omission, particularly when considering that fluoridation’s benefit to teeth (i.e., reduced tooth decay) has been found in recent studies to be minimal. This has led some dental researchers, such as the former President of the Canadian Association of Dental Research, Dr. Hardy Limeback, to speculate that “we are now spending more money treating dental fluorosis than we would spend treating new decay if water fluoridation halted.”

General Issues Surrounding Perception of Fluorosis

“The public is generally not aware of dental fluorosis. This is changing; there have been attempts at litigation in several countries. Cosmetic issues related to teeth matter, witness the increasing proportion of dentists’ time devoted to aesthetic care and the many articles in clinical journals about techniques to improve the appearance of moderate and severe fluorosis. It is only a matter of time until a case is brought that gets public attention. The risk is that noticeable fluorosis will be perceived by the public as a toxic consequence of fluoride ingestion – which, arguably, it is.”
SOURCE: Riordan P J. (1999) Fluoride supplements for young children: an analysis of the literature focusing on benefits and risks. Community Dentistry and Oral Epidemiology 27: 72-83.

“The psychosocial consequences of dental staining could be considerable.”
SOURCE: Shulman JD, et al. (2004). Perceptions of desirable tooth color among parents, dentists and children. Journal of the American Dental Association 135:595-604.

“Fluorosis may also trigger stereotypes associated with poor health, similar to those associated with both visible conditions such as psoriasis or conditions with no obvious pathology such as temporomandibular pain. Such negative effects may be compounded as a consequence of perceived blame for the condition.”
SOURCE: Bennett P, et al. (2008). A reaction-time study of social, health, and personal attributions in relation to fluorosed teeth. Psychology, Health & Medicine 13:75-86.

“If the public becomes concerned about dental fluorosis as an aesthetic problem, all fluoride use may be put at risk.”
SOURCE: Riordan PJ. (1996). The place of fluoride supplements in caries prevention today. Australian Dental Journal 41: 335-42.

“There is a growing body of evidence which indicates that the prevalence and, in some cases, the severity of dental fluorosis is increasing in both fluoridated and non-fluoridated regions in the U.S… This trend is undesirable for several reasons: (1) It increases the risk of esthetically objectionable enamel defects; (2) in more severe cases, it increases the risk of harmful effects to dental function; (3) it places dental professionals at an increased risk of litigation; and (4) it jeopardizes the perception of the safety and, therefore, the public acceptance of the use of fluorides.”
SOURCE: Whitford GM. (1990). The physiological and toxicological characteristics of fluoride. Journal of Dental Research 69(Special Issue):539-49.

The Psychological Importance of Physical Appearance

“Among U.S. youth, self-perceptions of appearance are inextricably linked to one’s level of self-esteem. . . . That is, there is a robust relationship between how one evaluates one’s physical appearance (how one judges his or her outer self) and one’s level of self-esteem (how one evaluates one’s inner self). . . . [A]t every developmental level, the evaluation of one’s looks takes precedence over other domains as the Number 1 predictor of self-esteem.”
SOURCE: Harter S. (2000). Is self-esteem only skin deep? The inextricable link between physical appearance and self-esteem. Reclaiming Children and Youth 9(3):133-38.

“Studies show physical attractiveness to be important psychologically, especially in children and young adults. . . . Facial attractiveness, in particular, is important, and several studies have indicated that the oral region has a primary importance in determining overall facial attractiveness. When asked about their satisfaction with 25 of their physical features in a Psychology Today body-image questionnaire, the majority of the 62,000 respondents were more unhappy with their teeth than with any other feature and nearly one-third were dissatisfied, feelings that reduced both self-esteem and confidence.”
SOURCE: Lalumandier JA, Rozier G.  (1998). Parents’ satisfaction with children’s tooth color: Fluorosis as a contributing factor. Journal of the American Dental Association 129:1000-06.

“The attention given to the appearance of the teeth, especially the incisors, is linked to an image of personal care, education, responsibility and higher status in the social hierarchy.”
SOURCE: Silva de Castilho L, 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 Vol. 17, p. 557.

To read excerpts from studies that have investigated public perceptions of dental fluorosis, click here.

Fluorosis Is Not “Just” a Cosmetic Effect

“It is a toxic effect and a cosmetic effect. These are not mutually exclusive. It’s toxic and it’s cosmetic.”
SOURCE: Dr. Arvid Carlsson, Nobel Prize Laureate in Medicine/Physiology (2000)

“it is illogical to assume that tooth enamel is the only tissue affected by low daily doses of fluoride ingestion.”
SOURCE: Dr. Hardy Limeback, Head of Preventive Dentistry, University of Toronto. (2000). Why I am now Officially Opposed to Adding Fluoride to Drinking Water.

“Common sense should tell us that if a poison circulating in a child’s body can damage the tooth-forming cells, then other harm also is likely.”
SOURCE: Colquhoun J. (1997). Why I changed my mind about Fluoridation. Perspectives in Biology and Medicine 41:29-44.

“Like bones, a child’s teeth are alive and growing. Fluorosis is the result of fluoride rearranging the crystalline structure of a tooth’s enamel as it is still growing. It is evidence of fluoride’s potency and ability to cause physiologic changes within the body, and raises concerns about similar damage that may be occurring in the bones.”
SOURCE: Environmental Working Group, “National Academy Calls for Lowering Fluoride Limits in Tap Water”, March 22, 2006.

“It seems prudent at present to assume that the ameloblasts are not the only cells in the body whose function may be disturbed by the physiological concentrations of fluoride which result from drinking water containing 1 ppm”
SOURCE: Groth, E. (1973), Two Issues of Science and Public Policy: Air Pollution Control in the San Francisco Bay Area, and Fluoridation of Community Water Supplies. Ph.D. Dissertation, Department of Biological Sciences, Stanford University, May 1973.

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