Fluoride Action Network

“Mild” Dental Fluorosis: Perceptions & Psychological Impact

By Michael Connett | July 2012

Due to widespread exposure to fluorides, millions of children now have some form of “mild” or “very mild” dental fluorosis. Teeth with “mild” fluorosis are marked by cloudy white specks, splotches, and streaks on the teeth. For years, the public health community dismissed the cosmetic significance of mild fluorosis, with some fluoridation advocates even arguing that fluorosed teeth are more attractive than normal teeth.

“Mild” Fluorosis — Photograph from BMC Public Health (2012)

Beginning in the early 1990s, however, dental researchers began conducting studies to assess the general public’s perception of mild fluorosis stains. (Riordan 1993). To the surprise of some in the dental community, the vast majority of research has found that patients, parents, and the general public alike view 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. One recent study, for example, found that teenagers viewed front teeth with mild or very mild fluorosis as less attractive than a chipped front tooth, (McGrady 2012), while other studies have found that mild fluorosis is viewed as less attractive than misaligned teeth and tetracycline staining. (McKnight 1998). In 2002, the Centers for Disease Control conceded that mild fluorosis is “cosmetically objectionable” when present on the front teeth. (Griffin 2002).

Since conditions which cause a child to be embarrassed about their physical appearance can have significant impacts on their self-esteem, (Harter 2000), researchers have begun to assess whether mild fluorosis may impact the well-being of children with mild fluorosis. Although the research to date is conflicting, two recent studies provide strong evidence that mild and very mild fluorosis, when present on the front teeth, can significantly effect a child’s self-image and bring about a “reluctance to smile or a lack of confidence.” (Rodd 2011; Marshman 2008).

“Mild” Fluorosis — Photograph by Hardy Limeback, DDS, PhD

Results of U.K. National Survey on Aesthetic Perceptions of Dental Fluorosis 
TF Score % of people who find the tooth unattractive % of people who would not be satisfied with appearance % of people who think treatment is needed
(Very Mild/Mild)
34% 36.1% 28.9%
63.1% 58.8% 68.5%
99.5% 99.5% 90.6%
SOURCE: Alkhatib MN, et al. (2004). Aesthetically objectionable fluorosis in the United Kingdom. British Dental Journal 197:325-28.


Many of the studies in this list categorized the fluorosis based on TF ranking. Since most teeth with a TF score of 3 are “mild” fluorosis under the Dean Index (Mabelya 1994; Griffin 2002), studies addressing the perceptions of teeth with TF 3 fluorosis are included in this list.  

“For both parents and adolescents, decreased satisfaction was associated with the number of zones of definitive fluorosis.”
SOURCE: Kavand G, et al. (2012). Comparison of dental esthetic perceptions of young adolescents and their parents. Journal of Public Health Dentistry 72:164-71.

“The perceived opinion that dental fluorosis is only and properly diagnosed by trained examiners was not supported in this study as children not only detected the presence of something abnormal in their teeth but also reported feeling embarrassed (“a lot of embarrassment” to “a little bit”: 64%), worried (“very worried” to “somewhat worried”: 70%), and avoided smiling (“a lot” to “somewhat”: 59%) due to their dental fluorosis stains.”
SOURCE: Tellez M, et al. (2012). Dental fluorosis, dental caries, and quality of life factors among schoolchildren in a Colombian fluorotic area. Community Dental Health 29(1):95-99.

“It is clear from the results of this study that participants have a preference for white, blemish-free teeth . . . . As fluorosis severity increases (TF 2 or greater), the rating of images (and perhaps the level of acceptance) declines which is in agreement with earlier work.”
SOURCE: McGrady MG, et al. (2012). Adolescents’ perceptions of the aesthetic impact of dental fluorosis vs. other dental conditions in areas with and without water fluoridation. BMC Oral Health 12:4.

“Mild and moderate dental fluorosis had a negative aesthetic effect on the studied population, leading to a strong desire to seek dental treatment to change the appearance of affected teeth.”
SOURCE: Gleber-Netto FO, et al. (2011). Assessment of aesthetic perception of mild and moderate dental fluorosis levels among students from the Federal University of Minas Gerais-UFMG, Brazil. Oral Health & Preventive Dentistry 9(4):339-45.

“”The key finding to emerge from this study was the negative psychosocial impact reported by some children with untreated enamel defects . . . . Over half of the children stated that they had been subject to unkind remarks about their teeth by their peers. A number of children described a reluctance to smile or a lack of confidence. . . . . [Enamel defects] had an impact on individuals’ whose sense of self was defined by appearance and who depended on approval from others about their appearance. These young people saw the appearance of their teeth as a threat to their sense of self although, in some cases, the defects on the teeth were normatively assessed as being of mild severity. . . . The variation between individuals and lack of relationship with severity found in this study has implications for discussions on the impact of fluorosis. In the York Review, fluorosis was considered an adverse effect of fluoridation and fluorosis of TFI greater than or equal to 3 was classified as being of ‘aesthetic concern.’ This study provides some evidence that for some young people with TFI greater than or equal to 3, fluorosis is of no concern but may be for others with lower TFI scores.”
SOURCE: Marshman Z, et al. (2008). The impact of developmental defects of enamel on young people in the UK. Community Dentistry & Oral Epidemiology 37:45-57.

“In this study, when viewing viewing intra-oral photographs of mild fluorosis, participants’ endorsements of a number of characteristics were more similar to their ratings of severe fluorosis than to their ratings of moderate or non-fluorosed enamel. This may reflect a preference for the more uniform whitening associated with moderate fluorosis (where the whole tooth appears white), than the diffuse striations that represented mild fluorosis (where the degree of whiteness varies across the tooth.”
SOURCE:  Williams DM, et al. (2006). Characteristics attributed to individuals with dental fluorosis. Community Dental Health 23:209-16.

“Fluorosis was associated with increased parental dissatisfaction with overall appearance, color, and blotchiness of their children’s teeth. . . . The associations between fluorosis and concerns about color are generally consistent with findings of previous studies, which is not surprising given that fluorosis (as well as opacities) alter tooth color.”
SOURCE: Levy SM, et al. (2005). Factors associated with parents’ esthetic perceptions of children’s mixed dentition fluorosis and demarcated opacities. Pediatric Dentistry 27(6):486-92.

“As found in previous studies, it is clear that the present lay observers were able to distinguish different levels of fluorosis when shown photographs of teeth. . . . Acceptability fell as fluorosis increased for the ‘teeth’ images, especially when fluorosis became more severe (TF3 and TF4). . . . The pupils’ feedback was extremely useful, revealing that they believed the ‘marks’ on the teeth to be due to poor oral hygiene, despite a preliminary tutorial which indicated this was not the case.”
SOURCE: Edwards M, et al. (2005). An assessment of teenagers’ perceptions of dental fluorosis using digital stimulation and web-based testing. Community Dentistry & Oral Epidemiology 33:298-306.

“At mild levels of dental fluorosis where pictures of teeth with TF scores of 1 and 2 were shown, 34% perceived them as unattractive. . . . Twenty-nine per cent of the study population perceived a definite need for treating mild levels of fluorosis, this percentage increased to over two thirds (69%) when pictures of moderate fluorosis were presented, and the majority (91%) perceived a need for treatment for severe levels of fluorosis.”
SOURCE: Alkhatib MN, et al. (2004). Aesthetically objectionable fluorosis in the United Kingdom. British Dental Journal 197:325-28.

“Many participants reported that they were at least occasionally distressed or worried over the appearance of the children’s teeth, that it hindered children from smiling freely, and that it was an unsatisfactory appearance.”
SOURCE: Martinez-Mier EA, et al. (2004). Development of a questionnaire to measure perceptions of, and concerns derived from, dental fluorosis. Community Dental Health 21:299-305.

“Subjects with a TFI score of 1 or 2 [very mild fluorosis] were not significantly more critical than subjects with a TFI score of 0 [no fluorosis], while those with a TFI score of 3 [mild fluorosis] or higher were. Similarly, only parents of subjects with a TFI score of 3 or higher had significantly different ratings.”
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.

“There is some evidence that members of the public can be aware of even mild changes due to fluorosis and may display a preference for ‘normal’ over mildly fluorotic teeth. Our studies of esthetic perceptions of dental fluorosis found that members of the public had strong preferences about variations from normal tooth appearance. For example, all respondents had a preference for teeth with normal colour over teeth with mild fluorosis, whereas about two-thirds preferred the appearance of an open bite to that of moderate fluorosis..”
SOURCE: Levy SM. (2003). An update on fluorides and fluorosis. Journal of the Canadian Dental Association 69: 286-91.

“results revealed that respondents generally found the [mild] fluorotic teeth less esthetic. A majority would seek professional dental treatment to change the appearance of the teeth; however, no costs of treatment were considered with this decision, and if faced with time, economics, and costs of treatment, respondents may have deferred treatment.”
McKnight CB, et al. (1999). A pilot study of dental students’ esthetic perceptions of computer-generated mild dental fluorosis compared to other conditions. Journal of Public Health Dentistry 59(1):18-23.

“The prevalence of fluorosis has increased over the past fifty years, and with this increase, esthetic concerns pertaining to fluorosis should also be taken into consideration… Results show that not only is fluorosis noticeable, but it may be more of an esthetic concern than the other conditions (e.g. isolated opacities, tetracycline staining, or various types of malocclusion).”
SOURCE: McKnight CB, et al. (1998). A pilot study of esthetic perceptions of dental fluorosis vs. selected other dental conditions. ASDC J Dent Child 65: 233-8, 229.

“A strong association between fluorosis and parental satisfaction was evident, even at a low level of severity. A significantly greater proportion of parents with children having very mild fluorosis (TSIF score 1) were dissatisfied with their children’s appearance when compared with parents whose children had no fluorosis (37 vs. 26 percent). . . . At a TSIF score of 2, nearly 50 percent of parents were disatisfied with the color of their children’s teeth.”
SOURCE: Lalumandier JA, Rozier RG. (1998). Parents’ satisfaction with children’s tooth color: fluorosis as a contributing factor. Journal of the American Dental Association 129: 1000-6.

“The higher estimate for an esthetic problem of 4 percent represents about one out of every 11 subjects that presented with dental fluorosis, given that the prevalence in this study population was 46 percent. It is difficult to believe that the public would consider this estimate as an acceptable level of risk from the use of fluorides. Even with a more conservative estimate of 1 percent, it is difficult to label the prevalence of esthetic problems as insignificant.”
SOURCE: Clark DC, Berkowitz J. (1997). The influence of various fluoride exposures on the prevalence of esthetic problems resulting from dental fluorosis. Journal of Public Health Dentistry 57(3):144-9.

“South Australian children 10- to 17-years-old were able to recognize very mild and mild fluorosis and register changes in satisfaction with the colour and appearance of teeth. Even mild changes were associated with psycho-behavioural impacts. Hoskin and Spencer asked eight questions on psycho-behavioural impact, such as embarrassment of teeth or self consciousness because of the appearance of the teeth… The most dramatic finding was the strength of the association of TISF score with psycho-behavioural impact was similar to that of crowding and overbite, both considered key occlusal traits driving the demand for orthodontic care. ”
SOURCE: Spencer AJ, et al. (1996). Water fluoridation in Australia. Community Dental Health 13(Suppl 2): 27-37.

“A parent of a child with a TSIF score of two [mild fluorosis] or more was half as likely to be satisfied with the appearance of the child’s teeth than a parent of a child with no or [very] mild fluorosis (TSIF 0, 1).”
SOURCE: Woodward GL, et al. (1996). Clinical determinants of a parent’s satisfaction with the appearance of a child’s teeth. Community Dentistry & Oral Epidemiology 24:416-18.

“Not unexpectedly, children with fluorosis on anterior teeth ranging between TSIF scores of ‘2’ [very mild/mild] to ‘6’ [severe] appear to have increased concerns about tooth color.”
SOURCE: Clark DC, et al. (1994). Aesthetic concerns of children and parents in relation to different classifications of the Tooth Surface Index of Fluorosis. Community Dentistry and Oral Epidemiology 22: 461-4.

“The results, based on just over 3000 responses, showed that lay and dental observers could distinguish between different fluorosis levels. In response to a statement that the teeth appeared pleasing, a large majority agreed when the TF score was 0, but agreement declined as the TF score increased; when the TF score was 3 [very mild/mild], most people disagreed. Similarly, observers felt that the appearance would increasingly embarrass the child as the TF score increased. . . . The dentists responded that most fluorosis did not require any treatment, but when the TF score was 3 [very mild/mild], a majority of them felt that esthetic treatment would be warranted. The results suggest that, for these observers, fluorosis score TF = 2 or greater was easily noticed, and when the TF score was 3, fluorosis aroused concern in most observers.”
SOURCE: Riordan PJ. (1993). Perceptions of dental fluorosis. Journal of Dental Research 72:1268-74.