Summation - Perception and Psychological Impact of Dental Fluorosis:

Excessive ingestion of fluoride during the early childhood years may result in a disorder of the enamel known as dental fluorosis.

In the mild forms of fluorosis, the teeth are stained with opaque white spots and specks, while in the more severe forms, the teeth develop extensive brown and black stains.

Recent studies have found that, even in the milder forms of fluorosis, the staining of the teeth can produce significant dissatisfaction over the teeth's appearance. It is now estimated that the occurrence of "esthetically objectionable" dental fluorosis in fluoridated communities ranges from 2 to 12% of the childhood population.

The moderate/severe forms of fluorosis, meanwhile, can result in profound embarrassment and psychological stress for the impacted child, especially during the adolescent years. The resulting impact on self-esteem can have long-lasting effects on an individual's emotional and mental health.

PICTURES - Dental Fluorosis: (back to top)

Very Mild/Mild Fluorosis Photo by Hardy Limeback, DDS	Mild Fluorosis Photo by Jeffrey Hamilton DDS
Moderate Fluorosis Photo by Hardy Limeback, DDS	Severe Fluorosis Photo by Hardy Limeback, DDS

Dental Fluorosis - Incidence of "Esthetically Objectionable" Fluorosis in Fluoridated Areas: (back to top)

"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 and Oral Epidemiology 30:199-209.

"The prevalence of fluorosis at a water fluoride level of 1.0 ppm was estimated to be 48% and for fluorosis of aesthetic concern it was predicted to be 12.5%."
SOURCE: McDonagh, M. et al. (2000). A Systematic Review of Public Water Fluoridation. NHS Center for Reviews and Dissemination, University of York.

Dental Fluorosis - General Issues Surrounding Perception of Fluorosis: (back to top)

"There was a significant correlation between dental fluorosis and level of concern caused by dental appearance (p < 0.05). Children perceptions of dental fluorosis appeared to have an impact on well being, as measured by a culturally appropriate research tool."
SOURCE: Soto-Rojas AE, et al. (2002). Impact of dental fluorosis on well-being in Mexico City children. Fluorides and Fluorosis, IADR/AADR/CADR 80th General Session (March 6-9, 2002), San Diego.

"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 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.

"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.

Dental Fluorosis - Perception of Mild Dental Fluorosis: (back to top)

"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.

"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.

"Mild fluorosis was assessed less favorably than normal/control, midline diastema was less favorable than mild fluorosis, and mild fluorosis was less favorable than isolated opacity."
SOURCE: 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: 18-23.

"Although many dental professionals often state that very mild fluorosis is not a cosmetic problem, these results suggest that it is perceived otherwise. Even parents of children suffering from very mild fluorosis showed an increase in dissatisfaction with their child's apperance."
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.

"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.

"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: 461-4.

"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 (fluorosis) score was 0, but agreement declined as the TF score increased; when the TF score was 3, most people disagreed. Similarly, observers felt that the appearance would increasingly embarrass the child as the TF score increased. Observers, except the dentists, tended to feel that higher TF scores indicated neglect on the part of the child."
SOURCE: Riordan PJ. (1993). Perceptions of dental fluorosis. Journal of Dental Research 72: 1268-74.

Dental Fluorosis - Psychological Impact of Moderate/Severe Dental Fluorosis: (back to top)

"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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