GOOD MORNING

BYAKSHAY THAKUR

Dr. Harvansh Singh judge Institute Of Dental Sciences And Hospital, Panjab university, Chandigarh.

INDICES USED FOR DENTAL FLUOROSIS

Contents• Introduction• History• Classification of indices• Dean’s index • Modified Dean’s index• Community fluorosis Index• Thylstrup and Fejerskov Index• Tooth Surface index of fluorosis• Fluorosis Risk Index• Young’s Classification Of Enamel Fluorosis• Murray and Shaw’s Classification of Enamel

Fluorosis• Simplified Fluoride Mottling Index• Summary• References

INTRODUCTION• INDEX : a numerical value describing the relative

status of a population on a graduated scale with definite upper and lower limits which is designed to permit and facilitate comparison with other populations classified by same criteria and methods.(Russel)

• DENTAL FLUOROSIS : a hypoplasia or hypomineralisation of tooth enamel or dentine produced by the chronic ingestion of excessive amounts of fluoride during the period when teeth are developing.

HISTORY• 1888 : “KUHNS” described teeth of persons in areas of

Mexico that were opaque, discolored and disfigured. (Kuhns1888; Moller 1982).

• 1901 Dr. Fredrick Mckay of Colorado USA discovered permanent stains on teeth of his patients which were referred as Colorado stains.

• Mckay named then “mottled enamel”.• An Assitant surgeon of U.S marine hospital service reported

similar condition in Italians emigrating from USA from Naples named it denti di chiaie. ( Eager 1901).

• 1916 Mckay and Black published a series of articles in dental cosmos.

• In 1931 this condition of teeth was found to b correlated to fluoride content of drinking water. (Churchill 1931; Smith et al 1931)

• 1931 shoe leather survey by Trendley H. Dean• 1934 DEAN’S FLUOROSIS INDEX was given by Trendley

H.Dean

CLASSIFICATION OF FLUOROSIS MEASURING INDICES

FLUOROSIS SPECIFIC

THYLSTRUP AND FERJESKOV

DEAN’S INDEX

TOOTH SURFACE INDEX FOR FLUOROSIS

FLUOROSIS RISK INDEX

DESCRIPTIVE

DEVELOPMENTAL DEFECTS OF

ENAMEL INDEX

JACKSON Al- ALOUSI INDEX

MURRAY SHAW INDEX

DEAN’S FLUOROSIS INDEX• 1934; TRENDLEY H.DEAN devised

an index for assessing the presence and severity of mottled enamel.

SALIENT FEATURES

METHOD ( as implied by DEAN)Each individual recieves a score corresponding to clinical appearance of two most affected teeth.

• Examinations are made in good natural light with the subject sitting facing the window

No specific information as to whether the teeth were cleaned or dried before examination is given

• Mouth mirror and probes were utilised for examination.

CLASSIFICATION AND CRITERIANORMAL

• The enamel represents the usual transluceny semivitriform type of structure• The surface is smooth, glossy and usually of pale creamy white color

QUESTIONABLE

• Slight aberrations in translucency of normal enamel ranging from few white flecks to occasional white spots, 1-2mm in diameter.

VERY MILD• Small, opaque, paper white ares are scatterd irregularily or streaked over

the tooth surface• Observed on labial and buccal surfaces ; <25% of teeth surface involved.• Small pitted white areas are frequently found on summits of cusps• No brown stain

MILD• White opaque areas involve half of tooth surface.• Surfaces of cuspids n bicuspids prone to attrition show thin white layers worn

off and bluish shades of normal enamel• Faint brown stains are apparent

MODERATE • No change in form of tooth but all surfaces are involved• Surfaces subjected to attrition are definitely marked• Minute pitting is present on buccal n labial surfaces

MODERATELY SEVERE• Smoky white appearance• Pitting is more frequent and generally seen on all surfaces• Brown stain if present has more hue and involves all surfaces

SEVERE• Form of teeth are affected.• Pits are deeper and confluent• Stains are widespread and range from choclate brown to almost black

•1939 Dean combined the “moderately severe” and “severe” into a single category “severe”.

•1942 Dean introduced the revised scale for fluorosis index where now he used the six point scale.

Deans revised index (1942)

NORMAL (0) The enamel represents the usual translucent semivitriform type of structure. The surface is smooth , glossy and usually of a pale, creamy white colour.

QUESTIONABLE(0.5) The enamel discloses slight aberrations from the

translucency of normal enamel, ranging from a few white fleck to occasional

white spots. This classification is used in those instances where a definite

diagnosis of the mildest form of fluorosis is not warranted and a classification of

“normal” not justified.

VERY MILD (1) Small, opaque, paper white areas scattered irregularly over the tooth , but not involving as much as approximately 25% of 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 bicuspids or second molars.

MILD (2)The white opaque areas in the

enamel of teeth are more extensive but do not

involves as much as 50% of tooth.

MODERATE (3) All enamel surfaces of the teeth are affected and surfaces subject to attrition show wear. Brown stain is frequently a disfiguring feature.

SEVERE (4) All enamel surfaces of the tooth 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.

COMMUNITY FLUOROSIS INDEX•1942 , based on the revised fluorosis

index scale , H. Dean developed a scoring system so as

to derive a COMMUNITY FLUOROSIS INDEX .

•On basis of the number and distribution of individual scores, a community index for dental fluorosis (Fci) can be calculated by the formula

Fci = sum of( no. of individuals*stastical weights)/ no.

of individuals examined

RANGE OF SCORES FOR CFISIGNIFICANCE

0.0 – 0.4 0.4 – 0.5 0.5 – 1.0 1.0 – 2.0 2.0 – 3.0 3.0 – 4.0

• Negative

• Borderline

• Slight

• Medium

• Marked

• Very Marked

THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS• 1978 ; Thylstrup and Frejeskov suggested a

10point classification system designed to categorise the degree of fluorosis affecting buccal/lingual and occlusal surfaces.

SALIENT FEATURES

Examination is done on a portable

chair out in daylight.

Plane mirror n probes are

used

Prior to examination the

teeth are dried with cottonwool rolls

THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS

Score Criteria 0

1

2

• Normal translucency of enamel remains after prolonged air – drying

• Narrow white lines located corresponding

to the perikymata.• Smooth surfaces;

More pronounced lines of opacity which follow the perikymata. Occasionally, confluence of adjacent lines.

Occlusal surfaces: Scattered areas of opacity of 2mm in diameter and pronounced opacity of cuspal ridges.

Score Criteria • 3

• 4

• Smooth surfaces: Merging and irregular cloudy areas of opacity. Accentuated drawing of perikymata often visible between opacities.

• Occlusal surfaces : Confluent areas of marked opacity. Worn areas appear almost normal but usually circumscribed by a rim of opaque enamel.

• Smooth surfaces: The entire surface exhibits marked opacities or appears chalky white. Parts of surface exposed to attrition appear less affected.

Occlusal surfaces : Entire surface exhibits marked opacity. Attrition is often pronounced shortly after eruption.

Score Criteria

• 5

• 6

• 7

• Smooth and Occlusal surfaces: Entire surface displays marked opacity with focal loss of outermost enamel (pits) 2mm in diameter.

• Smooth surfaces: Pits are regularlyarranged in horizontal bands 2mm in vertical extension.Occlusal surfaces: Confluent areas 3mm in diameter exhibit loss of enamel. Marked attrition

• Smooth surfaces: Loss of outermost enamel in irregular areas involving half of the entire surface.Occlusal surfaces: Changes in the morphology caused by the merging pits and marked attrition.

Score Criteria

• 8

• 9

• Smooth and Occlusal surfaces: Loss of outermost enamel involving half of the surface.

• Smooth and Occlusal surfaces: Loss of main part of enamel with change in anatomic appearance of surfaces. Cervical rim of almost unaffected enamel is often noted

ACHIEVEMENT : Cleaton-Jones and Hargreaves (1990) compared the three fluorosis indexes (DEAN, T-F and TSIF) in deciduous dentition, reporting that the prevalence of fluorosis in individual teeth was more frequently diagnosed with the T-F index. They concluded that the T-F index is the most indicated for work where detailed information about the problem is required. 

DISADVANTAGES : Clarkson (1989) reported that in TF index drying of teeth creates an unnatural situation due to which changes in score 1 and 2 are very minor.

The aesthetic significance of these changes are questionable

TOOTH SURFACE FLUOROSIS INDEX•It was developed by HOROWITZ et al.,

DRISCOLL, MEYERS , HEIFETZ & ALBERT KINGMAN in 1984 at National Institute of Dental Research U.S.A

AIM : Overcome the shortcomings

of Dean’s index and assess the prevalence of fluorosis from a tooth

surface prospective.

Numerical score Descriptive Criteria

•0

•1

•Enamel shows no evidence of fluorosis

•Enamel shows definite evidence of fluorosis namely areas with parchment-white colour that total less than one third of the visible enamel surface. Includes fluorosis confined only to incisal edges of anterior teeth and cusp tips of posterior teeth (Snow capping)

Numerical score Descriptive Criteria

• 2

• 3

• 4

• Parchment – white fluorosis totals at least 1/3 of the visible enamel surface, but less than 2/3

• Parchment – white fluorosis totals at least 2/3 of visible enamel surface.

• 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.

Numerical score Descriptive Criteria

• 5

• 6

• 7

• Discrete pitting of 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 intact enamel. The pitted area is usually stained or differs in colour from the surrounding enamel.

• Both discrete pitting and staining of the intact enamel exist.

• Confluent pitting of the enamel surface exist. Large areas of enamel may be missing and anatomy of tooth altered. Dark brown stain is usually present.

Intent to use• TSIF index - studies in which an aesthetic basis is

desired for defining case and it may be used where risk factors are identified or when the teeth may not be cleaned and dried. (Antonio Carlos PEREIRA Ben-Hur Wey MOREIRA 1999)

• It doesnot have questionable category as in Dean’s index and is based on the premise that any sign of fluorosis regardless of extent is positive for a case

• The TSIF described by Horowitz et al. makes a useful contribution because it provides clearer diagnostic criteria and provides for an analysis based on esthetic concerns. .( R.Gary Rozier 1999)

FLUOROSIS RISK INDEX•Introduced by DAVID G. PENDRYS in

1990AIMTo improve researcher’s ability to relate

the risk of fluorosis to developmental stage of permanent dentition at the time of exposure to fluorosis.

FR1- those begin to form in first year of

life

FR2- those who donot

begin to form until 2nd year

of life

Surface zones which donot come under

above groups are left

unassigned

ENAMEL ZONESIncisal edges of 11 21 32 31 41 42 and occlusal tables of 16 26 36 46.

Cervical third of incisors,middle third of canines, occlusal table,incisal third and middle third of bicuspid and 2nd molars

FR 1

•1OFR 2

•48UNASSIGNED

•54112

SCORING CRITERIANEGATIVE FINDI

NG

SCORE =0

Complete absence of any white

spots or striations.

QUESTIONABLE

SCORE

= 1

White spots,

striations or

fluorotic defects

that cover

50% or less

surface zone

SCORE = 7

Any surface that has an opacity that

appears to be a non

fluoride opacity

POSITIVE FINDING

SCORE = 2

A surface zone with

greater than

50% of zone

displaying

parchment white striation

s.

Incisal edges and

occlusal tables with

greater than

50% of surface marked

by snowcap

ping

SCORE = 3

Surface zone with greater than 50% of zone that displays

pitting, staining and deformity

SURFACE ZONE EXCLUD

ED

SCORE =

9

Incomplete eruption ,

orthodontic appliances and bands, surface

crowned or restored, gross

plaque and debris

CLASSIFICATION 1

CASES

Subject who has a positive score on 2 or more enamel surface zones

CONTROLS

Subject who has no positive or questionable scores on any enamel surface zones

• To obtain the FRI score for each individual the scores of classification 1 and 2 are combined into one summary score.

YOUNG’S CLASSIFICATION OF ENAMEL FLUOROSIS•Developed by YOUNG M.A in 1973.•Similar classification was developed by Al-

Lousi et al in 1975.•Principle

Recording of any condition once defined

must be made on basis of that definition

and not on basis of presumed etiology.

TYPE A •White areas less than 2mm in diameter

TYPE B •White areas of > 2mm diameter

TYPE C •Colored areas <2mm in diameter irrespective of white areas.

TYPE D •Colored areas of <2mm diameter irrespective of area covered

TYPE E• Horizontal white lines

irrespective of there being any non linear lines

TYPE F• Colored or white lines or

areas associated with pits or hypoplastic areas

MURRAY AND SHAW’S CLASSIFICATION OF ENAMEL FLUOROSIS•Developed by Murray J.J and Shaw L in

1979.•Based on young’s classification with two

modifications

Colored flecks and patches

were combined into

one group

Occlusal and lingual/palatal surfaces were also included

1 White opaque spots (or flecks) less than 2mm in dia

2 Greater than 2mm measured in any direction. Well demarcated from surroundings.

3 Coloured spots, flecks or patches

4 Horizontal white lines, not associated with hypoplasia

5 Hypoplasia + Category 1 to 4 (any)

6 Possible early carious lesions

7 Missing

SCORE CRITERIA

SIMPLIFIED FLUORIDE MOTTLING INDEX (FMI)

• Introduced by RAHMATULLA. M. And RAJASEKHAR. A. In 1984.• It is based on enamel opacities/lesions present on facial

surfaces of six upper and lower ant. Teeth which are asthetically important. SCORE CRITERIA 0 No involvement of facial

surface. Enamel : translucent, smooth and glossy.

1 Less than 1/3rd of facial surface involved

2 Above 1/3rd but less than 2/3rd

3 Over 2/3rd facial surface involved

4 Brownish Black discolouration of entire facial surface.

SUMMARY• Tooth surface index of fluorosis (TSIF), permits a specific

assessment of fluorosis and because of this, it is especially useful for determining the public effect of fluorosis in a population.

• Thylstrup and Fejerskov index for fluorosis (TFI), is thought to be most sensitive since it calls for drying of teeth which accentuates the appearance of fluorosis , making the diagnosis easier in questionable cases.

• Even though the Fluorosis risk Index (FRI) is thought to be complex from biological perspective and in application, it is reliable and valid when identifying risk factors for enamel fluorosis.

• Dean’s index has been used most frequently over the years, till today. But, modified dean’s index is one still recommended by WHO in its basic survey manual.

REFERENCES•Essentials of Preventive and Community

Dentistry by Soben Peter.•ncib.nih.gov US National Library of

MedicineNational Institutes of Health•publichealth.med.miami.edu , official site

of university of miami health system.

THANK YOU