Summation - Moderate to Severe Dental Fluorosis:

Excessive ingestion of fluoride during the early childhood years may result in a disorder of the enamel known as dental fluorosis. In its "moderate" and severe forms, fluoride causes a marked increase in the porosity of the enamel.

After eruption into mouth, the porous enamel of moderate to severe fluorosis readily takes up stain, creating permanent brown and black discolorations of the teeth.

In addition to extensive staining, teeth with moderate to severe fluorosis are more prone to attrition and wear - leading to pitting, chipping, and decay.

As a result of the staining and crumbling of enamel, children with moderate to severe dental fluorosis can suffer a great deal of social embarrassment and pyschological stress - with a corresponding loss in self-esteem.

Recent studies in the United States have found that some cases of moderate to severe dental fluorosis can now be found in fluoridated (1 ppm) and, even, unfluoridated areas.

However, despite the obvious impact on tooth quality - and the evidence showing that teeth are not the only affected tissue - the US Environmental Protection still classifies severe dental fluorosis as a "cosmetic" effect. As a result, the federal government is not required by law to protect people from developing this condition.

EPA readily acknowledges that between 30 and 40% of children drinking water with 4 ppm fluoride (the EPA's current Maximum Contaminant Level) will develop moderate to severe fluorosis.

PICTURES - Moderae/Severe Dental Fluorosis: (back to top)

Moderate/Severe Fluorosis Photo by David Kennedy, DDS	Moderate/Severe Fluorosis Photo by David Kennedy, DDS
Severe Fluorosis Photo by Hardy Limeback, DDS	Severe Fluorosis Photo by Hardy Limeback, DDS
Severe Fluorosis Photo by John Colquhoun, DDS	Severe Fluorosis Source of photo unknown

Classification Criteria - Moderate to Severe Dental Fluorosis: (back to top)

Coming to a Town Near You - Moderate to Severe Dental Fluorosis: (back to top)

"Moderate to severe fluorosis, where teeth are discolored and sometimes pitted, was found in less than 4 percent of children and adolescents."
SOURCE: Centers for Disease Control. (2005). "New Report Finds Improvements in Oral Health of Americans", Press Release, August 25.

"At a national level, the prevalence of moderate-to-severe fluorosis amounts to only 1.3 percent of the total US child population... While the prevalence of fluorosis at this level of severity affects a small percentage of the US population, its occurrence in both optimally fluoridated and fluoride-deficient communities should be taken as a warning sign that overall exposures to fluoride may be exceeding a desirable level."
SOURCE: Rozier RG. (1999). The prevalence and severity of enamel fluorosis in North American children. Journal of Public Health Dentistry 59:239-46.

"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.

Impact on Tooth Quality - Moderate to Severe Dental Fluorosis: (back to top)

Note: For more information on the relationship between dental fluorosis & tooth decay, click here

"Severe enamel fluorosis is characterized by dark yellow to brown staining and discrete and confluent pitting, which constitutes enamel loss... One of the functions of tooth enamel is to protect the dentin and, ultimately, the pulp from decay and infection. Severe enamel fluorosis compromises that health-protective function by causing structural damage to the tooth. The damage to teeth caused by severe enamel fluorosis is a toxic effect that is consistent with prevailing risk assessment definitions of adverse health effects."
SOURCE: National Research Council. (2006). Fluoride in Drinking Water: A Scientific Review of EPA's Standards. National Academies Press, Washington D.C.

"In more severely fluorosed teeth, the enamel is pitted and discolored and is prone to fracture and wear. Several studies have found significant increases in the number of decayed, missing, or filled tooth surfaces in children with severe dental fluorosis."
SOURCE: Agency for Toxic Substances and Disease Registry. (2003). Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine. Department of Health & Human Services, Atlanta, Georgia.

"With more severe forms of fluorosis, caries risk increases because of pitting and loss of the outer enamel."
SOURCE: Levy SM. (2003). An update on fluorides and fluorosis. Journal of the Canadian Dental Association 69: 286-91.

"fluoride affects the forming enamel by causing porosity, e.g., widening gaps between the enamel rods and enlarging intercrystalline spaces in parts of the rod. With increasing severity, the subsurface enamel all along the tooth becomes increasingly porous... [T]he more severe forms are subject to extensive mechanical breakdown of the surface."
SOURCE: Aoba T, Fejerskov O. (2002). Dental fluorosis: chemistry and biology. Critical Reviews of Oral Biology and Medicine 13: 155-70.

"Dental fluorosis is characterized by an increasing porosity (hypomineralization) of the subsurface enamel, causing the enamel to appear opaque... In advanced stages, the enamel may become so porous that the outer layers break down and the exposed porous subsurface becomes discolored."
SOURCE: Fomon SJ, et al. (2000). Fluoride intake and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants. Journal of Public Health Dentistry 60: 131-9.

"the most severe forms of fluorosis manifest as heavily stained, pitted, and friable enamel that can result in loss of dental function."
SOURCE: Burt BA ; Eklund SA. (1999). Dentistry, Dental Practice, and the Community (5th Ed). WB Saunders Co; Philadelphia.

"In the more severe forms of dental fluorosis, the tooth erupts into the oral cavity entirely chalky white. The degree of porosity (hypomineralization) of such teeth results in a diminished physical strength of the enamel, and parts of the superficial enamel may break away... Such loss of outermost enamel is particularly frequent along incisal edges and cusp tips. In the latter case, this will also involve the occlusal surfaces which become rapidly worn. In the most severe forms of dental fluorosis, the extent and degree of porosity within the enamel are so severe that most of the outermost enamel will be chipped off immediately following eruption."
SOURCE: Fejerskov O, et al. (1990). The nature and mechanisms of dental fluorosis in man. Journal of Dental Research 69(Spec Iss): 692-700.

"It is difficult to conclude a priori that teeth which spontaneously pit are stronger teeth. Further, data suggest that the effects of fluorosis are not merely discoloration and pitting, but fracturing, caries and tooth loss as well."
SOURCE: Kimm VJ. (1984). The adverse health effects of fluorosis. Letter from Victor J. Kimm, Director, US EPA Office of Drinking Water, to William D. Ruckelshaus, EPA Administrator. July 26.

"Microhardness of fluorosed enamel is markedly decreased."
SOURCE: DenBesten PK, Crenshaw MA. (1984). The effects of chronic high fluoride levels on forming enamel in the rat. Archives of Oral Biology 29:675-9.

" more severe degrees of enamel fluorosis are associated with an abnormally high incidence of caries... There is thus no doubt that a high degree of enamel fluorosis causes an increased tendency to caries."
SOURCE: Carlsson A. (1978). Current problems relating to the pharmacology and toxicology of fluorides. Journal of the Swedish Medical Association 14: 1388-1392.

"Severe mottling is as destructive to teeth as is dental caries."
SOURCE: Gruebbel AO. (1952). Summarization of the subject. Journal of the American Dental Association 44: 151-155.

"there is ample evidence that mottled teeth, though they be somewhat more resistant to the onset of decay, are structurally weak, and that unfortunately when decay does set in, the result is often disastrous... Caries once started evidently spreads rapidly. Steps taken to repair the cavities in many cases were unsuccessful, the tooth breaking away when attempts were made to anchor the fillings, so that extraction was the only course."
SOURCE: Smith MC, Smith HV. (1940). Observations on the Durability of Mottled Teeth. American Journal of Public Health 30: 1050-1052.

Impact on Total Health - Moderate to Severe Dental Fluorosis: (back to top)

Bone fractures vs Dean dental fluorosis index

SOURCE: Alarcon-Herrera MT, et al. (2001). Well Water Fluoride, Dental fluorosis, Bone Fractures in the Guadiana Valley of Mexico. Fluoride 34(2): 139-149. (See paper)

"A linear correlation between the Dean index of dental fluorosis and the frequency of bone fractures was observed among both children and adults."
SOURCE: Alarcon-Herrera MT, et al. (2001). Well Water Fluoride, Dental fluorosis, Bone Fractures in the Guadiana Valley of Mexico. Fluoride 34(2): 139-149.

"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.

"The safety of the use of fluorides ultimately rests on the assumption that the developing enamel organ is most sensitive to the toxic effects of fluoride. The results from this study suggest that the pinealocytes may be as susceptible to fluoride as the developing enamel organ."
SOURCE: Luke J. (1997). The Effect of Fluoride on the Physiology of the Pineal Gland. Ph.D. Thesis. University of Surrey, Guildford. p. 176.

"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.

Perception/Psychological Effects - Moderate to Severe Dental Fluorosis: (back to top)

Note: For information on the perception of very-mild to mild fluorosis, click here

"the more severe forms can cause great psychological distress to the affected individual."
SOURCE: Rodd HD, Davidson LE. (1997). The aesthetic management of severe dental fluorosis in the young patient. Dental Update 24: 408-11.

"Dental fluorosis was viewed as an important problem because of its unfavourable effects on an individual's personality by between 60.4 and 84.3% of the respondents."
SOURCE: Mwaniki DL, et al. (1994). Endemic fluorosis: an analysis of needs and possibilities based on case studies in Kenya. Social Science and Medicine 39: 807-13.

"Mottling of teeth can have significant psychological impact on patients -- particularly on adolescents, who may be subjected to much unkind teasing."
SOURCE: Welbury RR, Shaw L. (1990). A simple technique for removal of mottling, opacities and pigmentation from enamel. Dental Update 17: 161-3.

"An independent panel, convened at EPA's request to study the question of psychological and behavioral effects, concluded that persons with dental fluorosis could be at risk of 'behavioral problems' as a result of an 'impaired self-image' or 'loss of self-esteem.' In particular, the panel believed that dental fluorosis would effect the perception of physical attractiveness. The panel noted that facially attractive persons are viewed as more self-confident and are thought to be more socially skilled. Persons who are not perceived as physically attractive are believed to avoid social behaviors requiring responsiveness, be less academically successful and be more dissatified with their physical appearance. In some cases, the panel believed that this could result in psychological distress or anxiety. In addition to the panel report several persons have informed the Agency that they suffered embarrassment and an impared self-image from dental fluorosis and that they did not want mottled or pitted teeth."
SOURCE: Environmental Protection Agency. (1985). National Primary Drinking Water Regulations; Fluoride. Final Rule. Federal Register November 14; 50(220): 47142-47155.

"The stains of endemic dental fluorosis can have a tremendous psychological impact on the patient."
SOURCE: Colon PG. (1972). Removal of Tooth Stains in Prisoner Rehabilitation. Dental Survey 48: 30.

"A matter which should not be overlooked in this, is the mental attitude of these persons. I have found it very difficult to obtain a good opportunity to examine these teeth in the mouth because the persons have been so sensitive to such observation. One of them told me that he had almost completely retired from society because people stared at him as though there was something about this countenance that was uncanny."
SOURCE: Black GV, McKay FS. (1916). Mottled teeth. Dental Cosmos 58: 129.

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