Fluoride Action Network

Diagnostic Criteria for Dental Fluorosis: The TSIF (“Total Surface Index of Fluorosis”)

By Michael Connett | July 2012

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 researchers have developed more finely tuned diagnostic scales. These include the “Thylstrup-Fejerskov Index” (“TF Index“) and the “Tooth Surface Index of Fluorosis” (“TSIF”). Whereas the Dean Index identifies four types of fluorosis (very mild, mild, moderate, and severe), the TSIF Index identifies nine types and — as shown below — the TSIF identifies seven.


Score = 0: Enamel shows no evidence of fluorosis.

Score = 1: Enamel shows definite evidence of fluorosis, namely areas with parchment-white color that total less than one-third of the visible enamel surface. This category includes fluorosis confined only to incisal edges of anterior teeth and cusp tips of posterior teeth (“snowcapping”).

Score = 2: Parchment-white fluorosis totals at least one-third of the visible surface, but less than two-thirds.

Score = 3: Parchment-white fluorosis totals at least two-thirds of the visible surface.

Score = 4: Enamel shows staining in conjunction with any of the preceding levels of fluorosis. Staining is defined as an area of definite discoloration that may range from light to very dark brown.

Score = 5: Discrete pitting of the enamel exists, unaccompanied by evidence of staining of intact enamel. A pit is defined as a definite physical defect in the enamel surface with a rough floor that is surrounded by a wall of intact enamel. The pitted area is usually stained or differs in color from the surrounding enamel.

Score = 6: Both discrete pitting and staining of the intact enamel exist.

Score = 7: Confluent pitting of the enamel surface exists. Large areas of enamel may be missing and the anatomy of the tooth may be altered. Dark-brown stain is usually present.

SOURCE: Horowitz HS, et al. (1984). A new method for assessing the prevalence of dental fluorosis–the Tooth Surface Index of Fluorosis. Journal of the American Dental Association 109(1):37-41.

RESULTS FROM Studies Using TSIF Index:

A) Esthetic Concerns:

“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 dissatisfied with the color of their children’s teeth.”
SOURCE: Lalumandier JA, Rozier G.  (1998). Parents’ satisfaction with children’s tooth color: Fluorosis as a contributing factor. Journal of the American Dental Association 129:1000-1006.

“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” to “6” 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: 461-64.

B) Prevalence of Dental Fluorosis:

“Of the 62.5 percent of the White children [from Indianapolis, Indiana] who presented with dental fluorosis upon examination, 41.3 percent had a maximum score of 1 and only 21.2 percent of the children had a maximum score of 2. Of the 80.1 percent of African American children who had dental fluorosis, a maximum score of 1 was assigned to 50.5 percent of the children, 15.4 percent were assigned a maximum score of 2, 1.5 percent had a maximum score of 3, and 12.7 percent were assigned the highest score of 5. Differences in severity were also statistically significant (P < 0.001).”
SOURCE: Martinez-Mier EA, Soto-Rojas AE. (2010). Differences in exposure and biological markers of fluoride among White and African American children. Journal of Public Health Dentistry 70:234-40.

FIGURE 1: Martinez-Mier EA, Soto-Rojas AE. (2010). Differences in exposure and biological markers of fluoride among White and African American children. Journal of Public Health Dentistry 70:234-40.

Dental Fluorosis Rates in Augusta & Richmond County, Georgia 
Residence/Race No Fluorosis
(TSIF Score = 0)
Very Mild/Mild Fluorosis
(TSIF Score = 1 – 3)
Moderate/Severe Fluorosis
(TSIF Score = 4 – 7)
City/Black 19.6% 63.7% 16.7%
City/White 18.2% 72.7% 9.1%
County/Black 47.8% 48.9% 3.3%
County/White 44.9% 55.1% 0%
SOURCE: Williams JE, Zwemer JD. (1990). Community water fluoride levels, preschool dietary patterns, and the occurrence of fluoride enamel opacities. Journal of Public Health Dentistry 50:276-81.