Enamel Opacities Research Articles

A comparison of the prevalence of fluorosis in 8‐year‐old children from seven European study sites using a standardized methodology

The objectives of this study were to report on the prevalence of enamel opacities from seven European study sites using a standardized photographic method, and to investigate the importance of variables responsible for enamel fluorosis. The sample comprised a randomly selected group of 300 8-year-old children in each of the study areas. One examiner from each area was trained and calibrated in the use of a standardized photographic technique. Two transparencies were taken of each child's permanent maxillary central incisor teeth; one to represent the teeth 'wet' and one when the teeth had been allowed to dry out naturally for 105 s. The transparencies were viewed 'blind' by the author (JAC) and scored using the DDE and TF indices. Data relating to variables considered to be associated with enamel fluorosis were also collected. The prevalence of diffuse opacities ranged from 61% in fluoridated Cork (Ireland) to 28% in Athens (Greece). The percentage of subjects with a TF score of three or more ranged from 4% in Cork and nonfluoridated Haarlem (the Netherlands) to zero in Oulu (Finland) and Athens. Fluoridated water and the prolonged use of fluoride tablets were found to be significant contributory factors to fluorosis. The prevalence of fluorosis was found to be highest in fluoridated Cork. The prolonged use of fluoride supplements was also found to be a significant risk indicator associated with fluorosis.

A review of fluorosis in the European Union: prevalence, risk factors and aesthetic issues.

Fluoride has played a key role in caries prevention for the past 50 years but excessive ingestion of fluoride during tooth development may lead to dental fluorosis. Throughout Europe many vehicles have been, and are currently, employed for optimal fluoride delivery including drinking water, toothpaste, fluoride supplements, salt and milk. Several indices, both descriptive and aetiological, have been developed and used for measuring fluorosis. This factor, combined with the lack of use of a standardized method for measurement of fluorosis, has made comparison between studies difficult and assessment of trends in fluorosis prevalence unreliable. Overall the evidence would appear to indicate, however, that diffuse enamel opacities are more prevalent in fluoridated than in nonfluoridated communities and that their prevalence at the very mild level may be increasing. In addition to fluoridated drinking water, risk factors for fluorosis include inadvertent ingestion of fluoride toothpaste and the inappropriate use of fluoride supplements. The risk is of aesthetic concern primarily during the period of enamel development of the permanent central incisors, although this largely appears to be a cosmetic rather than a public-health issue. It is concluded that there is a need to co-ordinate studies measuring fluorosis throughout Europe and that development of a standardized photographic method would be useful. Furthermore, the aesthetic importance of fluorosis needs to be determined in more detail in each country in the light of each country's respective risk factors and dental health policies.

Esthetic perception and psychosocial impact of developmental enamel defects among Malaysian adolescents

The aim of this study was to investigate the prevalence and psychosocial impact of enamel defects among 16-year-old school children on the island of Penang. The data were collected through a self-administered questionnaire survey and an oral examination, using the Modified Developmental Defects of Enamel Index (FDI, 1992). In all, 1024 subjects were selected using a multistage random sampling technique. About two-thirds of the sample (67.1%) had at least one tooth affected by enamel defects. Enamel opacities accounted for 85.6% of the total condition. Diffuse-type opacity predominated (63.5%). Among subjects who expressed dissatisfaction, 18.8% reported covering their mouths when smiling, 8.7% avoided going out with friends and 39.1% had consulted their dentists. About 17% of the subjects reported that their parents had complained about the color of their front teeth but only 5.7% had experienced being teased by their friends about the problem. Two-thirds of the subjects were affected by enamel defects involving at least one tooth; however, the esthetic perception and psychosocial impact of those affected were minor.

Oral health and related factors in cystic fibrosis and other chronic respiratory disorders

Aim: To compare the prevalence of dental caries, dental calculus, and enamel defects in children with cystic fibrosis (CF) and children with other chronic respiratory disorders. Methods: A cross sectional...

Effectiveness of microabrasion technique for improvement of dental aesthetics

Objectives To investigate which types of enamel opacity are effectively treated by the microabrasion technique and whether this technique could be used as a diagnostic aid to determine the aetiology of these defects. Materials and method Thirty two patients who had enamel opacities affecting both upper central incisors were selected and the disfigurements were classified into four types: single line, multi-line, patched and diffused. The patient's previous medical history, possible history of fluoride ingestion, presence of taurodontism and family history of similar enamel defects were recorded. Both incisors were treated with Prèma abrasive paste mixed with 18% hydrochloric acid. The aesthetic improvements were assessed by the patients and their parents and their satisfaction level after the treatment was recorded. Results Approximately two-thirds (65.6%) of the patients were satisfied with their appearance after microabrasion. Apart from four patients, the improved appearance was stable and acceptable to the remaining patients at the six month recall. Statistical analysis showed that acceptable improvement was found in patients with single line/patched types of defects but not in multi-line/diffused types (P=0.03). However, the aesthetic improvement was not related to the patient's fluoride history, presence of taurodontism or the family history of enamel defects. Conclusion Microabrasion using Prèma abrasives with 18% HCl is effective in improving the appearance of enamel with single-line or patched opacities, indicating that these defects are a surface phenomenon. For the multi-line and diffused types, the defects appear to extend deeper into the enamel. The technique failed to assist in determining the aetiology of these defects.

Use of microabrasion to improve dental aesthetics

Objectives To investigate which types of enamel opacity are effectively treated by the microabrasion technique and whether this technique could be used as a diagnostic aid to determine the aetiology of these defects. Materials and method Thirty two patients who had enamel opacities affecting both upper central incisors were selected and the disfigurements were classified into four types: single line, multi-line, patched and diffused. The patient's previous medical history, possible history of fluoride ingestion, presence of taurodontism and family history of similar enamel defects were recorded. Both incisors were treated with Prema abrasive paste mixed with 18% hydrochloric acid. The aesthetic improvements were assessed by the patients and their parents and their satisfaction level after the treatment was recorded. Results Approximately two-thirds (65.6%) of the patients were satisfied with their appearance after microabrasion. Apart from four patients, the improved appearance was stable and acceptable to the remaining patients at the six month recall. Statistical analysis showed that acceptable improvement was found in patients with single line/patched types of defects but not in multi-line/diffused types (P=0.03). However, the aesthetic improvement was not related to the patient's fluoride history, presence of taurodontism or the family history of enamel defects. Conclusion Microabrasion using Prema abrasives with 18% HCl is effective in improving the appearance of enamel with single-line or patched opacities, indicating that these defects are a surface phenomenon. For the multi-line and diffused types, the defects appear to extend deeper into the enamel. The technique failed to assist in determining the aetiology of these defects.

Effectiveness of microabrasion technique for improvement of dental aesthetics.

To investigate which types of enamel opacity are effectively treated by the microabrasion technique and whether this technique could be used as a diagnostic aid to determine the aetiology of these defects. Thirty two patients who had enamel opacities affecting both upper central incisors were selected and the disfigurements were classified into four types: single line, multi-line, patched and diffused. The patient's previous medical history, possible history of fluoride ingestion, presence of taurodontism and family history of similar enamel defects were recorded. Both incisors were treated with Prèma abrasive paste mixed with 18% hydrochloric acid. The aesthetic improvements were assessed by the patients and their parents and their satisfaction level after the treatment was recorded. Approximately two-thirds (65.6%) of the patients were satisfied with their appearance after microabrasion. Apart from four patients, the improved appearance was stable and acceptable to the remaining patients at the six month recall. Statistical analysis showed that acceptable improvement was found in patients with single line/patched types of defects but not in multi-line/diffused types (P = 0.03). However, the aesthetic improvement was not related to the patient's fluoride history, presence of taurodontism or the family history of enamel defects. Microabrasion using Prèma abrasives with 1 8% HCI is effective in improving the appearance of enamel with single-line or patched opacities, indicating that these defects are a surface phenomenon. For the multi-line and diffused types, the defects appear to extend deeper into the enamel. The technique failed to assist in determining the aetiology of these defects.

Oral health in liver transplant children administered cyclosporin A or tacrolimus.

Immunosuppression by cyclosporin A (CsA) is associated with adverse side-effects, including nephrotoxicity, neurotoxicity and gingival overgrowth. Tacrolimus (TAC/FK506) is a new immunosuppressive agent, recently approved for use in solid-organ transplants. The mode of action of TAC is similar to that of CsA and the toxicity profile of CsA is duplicated by TAC. The effect of TAC on the gingival tissue is not yet conclusive. Gingival overgrowth was assessed in 30 liver transplant children, 20 boys and 10 girls, aged 2-19 years. Seventeen children (10 boys, seven girls) were on a CsA-based immunosuppressive regimen whereas 13 children (10 boys, three girls) were on TAC for at least 1 year (mean 4.3 +/- 2.7). In the CsA group, 35% of children exhibited gingival overgrowth characterized by one or more units with increased sulcus probing depth (> or = 4 mm), i.e. pseudopockets. In contrast to the CsA group, none of the children in the TAC group exhibited gingival overgrowth. The occurrence of enamel hypoplasia was observed in 11 children (36%) and enamel opacities were found in 23 children (76%). Six of the 12 children (50%) with hyperbilirubinaemia biliary atresia exhibited a marked greenish discoloration of the teeth. Caries experience (dmft/DMFT) among these children was 2.0 +/- 2.8. No difference in caries experience or enamel defect was observed between the CsA and TAC group.

A quantitative study of the effect of pumicing and etching on the remineralisation of enamel opacities.

The aim of this study was to investigate the effects of pumicing and acid etching on the remineralisation of enamel opacities using quantitative measurement methods. Teeth with diffuse opacities were subjected to a treatment sequence of: (a) pumicing for 30-35 seconds (b) etch with 37.5% phosphoric acid for 2 minutes, (c) pumicing for 30-35 seconds and (d) etch for 1 minute, or served as controls. Both groups were then placed in a remineralising solution containing 1.5 mmol/L Ca2+ for 3 weeks. Mineral content changes were measured using contact microradiography and x-ray microtomography. In addition, the reflectivity of the opacities was monitored with infrared reflectance. The treatment sequence removed 34 +/- 4 microns of the surface enamel but no mineral loss was observed in the subsurface layer. The treatment sequence enhanced the formation of a new remineralised surface layer with a mean thickness of 22 +/- 3 microns. This new surface layer was less reflective. Pumicing and acid etching can be used as a simple technique for the conservative treatment of enamel opacities.

Dental fluorosis in upper permanent incisors of public schoolchildren in Rio de Janeiro, Brazil

To assess the prevalence and severity of dental fluorosis in children aged 7 to 12. The study population comprised 266 children aged 7 to 12 years, enrolled in a public school in the city of Rio de Janeiro, Brazil, selected using a simple random sample method. All examinations were carried out between August and December 1999 by a single trained and calibrated examiner (Kappa = 0.92). After obtaining their parents' consent the children had their upper permanent incisors examined under natural light. Their teeth were previously cleaned and dried with cotton rolls. The differential diagnosis between milder forms of dental fluorosis and nonfluoride enamel opacities was made according to Russel's diagnostic criteria. The severity of fluorosis was assessed by the Thylstrup and Fejerskov Index (TF). The prevalence of dental fluorosis was 7.9% (CI 95%, 5.0-11.8). The severity ranged from 1 to 3 and 77% of the affected teeth had a TF score of 1. These results suggest that dental fluorosis does not represent a public health problem in this population.

Dental Health Indices and Caries Associated Microflora in Children With Unilateral Cleft Lip and Palate

Abstract Objective: To investigate the dental health and caries related microflora of children with unilateral cleft lip and palate. Study Group: Sixty children with unilateral cleft lip and palate and matched controls. Outcome Measures: The decayed, missing, and filled teeth and surfaces in both the deciduous and permanent dentitions. The presence of developmental defects and plaque and gingivitis scores were also recorded. Plaque was collected from 25 of the children and their matched controls from three different sites, which were (1) the first approximal site distal to the cleft, (2) a contralateral anterior site, and (3) a remote site. It was cultured for Streptococcus mutans and lactobacilli. Plaque was collected from two sites in the matched controls. Results: There was no significant difference in the caries, plaque, and gingivitis scores between the children with cleft palate and the controls. A greater number of enamel opacities were recorded in the control group, and there was a higher prevalen...

Dental health indices and caries associated microflora in children with unilateral cleft lip and palate.

To investigate the dental health and caries related microflora of children with unilateral cleft lip and palate. Sixty children with unilateral cleft lip and palate and matched controls. The decayed, missing, and filled teeth and surfaces in both the deciduous and permanent dentitions. The presence of developmental defects and plaque and gingivitis scores were also recorded. Plaque was collected from 25 of the children and their matched controls from three different sites, which were (1) the first approximal site distal to the cleft, (2) a contralateral anterior site, and (3) a remote site. It was cultured for Streptococcus mutans and lactobacilli. Plaque was collected from two sites in the matched controls. There was no significant difference in the caries, plaque, and gingivitis scores between the children with cleft palate and the controls. A greater number of enamel opacities were recorded in the control group, and there was a higher prevalence of enamel discoloration in the children with cleft lip and palate. There was no significant difference in the proportion of S. mutans or lactobacilli at the cleft site, compared with the unaffected site in the study group, although there was an anterior-posterior gradient in the proportion of S. mutans. There was no significant association between the stagnation area at the cleft site and the bacteria associated with dental caries.

The differential diagnosis of fluorosis.

Following the introduction of the first fluorosis index by Dean, a series of fluorosis indexes were introduced. While they may differ in the specific way fluorosis is categorized, they all nevertheless use the same underlying diagnostic signs--originally described by Dean, Black, and McKay--that were causally linked to the development of enamel in areas with above-optimum fluoride in the drinking water. Underlying the various fluorosis indexes is the belief that specific clinical diagnostic criteria, based upon established clinical signs, can be utilized to differentiate fluorotic from nonfluorotic enamel opacities. These criteria repeatedly have been substantiated in studies in which the presence of enamel fluorosis, identified by clinical differential diagnosis, has been associated with fluoride exposure history. Further, to whatever extent nonfluorotic opacities have been misdiagnosed as fluorosis, observed estimates of association derived from analytical studies will have been underestimated.

A Pilot Study of Dental Students' Esthetic Perceptions of Computer‐generated Mild Dental Fluorosis Compared to Other Conditions

Few studies have considered people's opinions about the esthetics of dental fluorosis. Assessments of fluorosis esthetics can be confounded by differences in a number of clinical factors, including tooth shape, color, contour, and gingival status. This pilot study compared esthetic perceptions of mild fluorosis and other conditions using computer-generated images made from a base set of normal appearing teeth. Entering dental students (n = 61) completed questionnaires about four sets of paired photographs. Three sets consisted of fluorotic teeth (very mild to mild) versus other conditions (diastema, isolated enamel opacity, "normal"/control) and the other pair compared two presentations of mild fluorosis (generalized versus limited to incisal one-third). Six questions, both qualitative and quantitative, were asked about each pair of photographs. 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. This approach allows fluorosis to be better compared with other oral conditions because the images are standardized. Additional research with this method is warranted, including more variations in conditions, more comparisons, and other study populations.

Amelogenesis imperfecta with enamel opacities and taurodontism: an alternative diagnosis for 'idiopathic dental fluorosis'.

A retrospective study of 32 children (mean age 10.3 years) attending the Children's Department, Eastman Dental Hospital with enamel opacities resembling dental fluorosis in the majority showed that these changes were probably genetically determined and had a close association with taurodontism of permanent molar teeth. It seems likely that these enamel defects should be classified as hypomaturation types of amelogenesis imperfecta (AI) conveyed by mutant auto-somal genes. The clinical expression (phenotype) of these mutant genes has a greater heterogeneity than previously described.

Dental health of aboriginal pre-school children in Brisbane, Australia.

This investigation studied the dental health status of a group of 184 Australian Aboriginal children with a mean age of 4.4 +/- 0.8 years, who were attending pre-schools in metropolitan Brisbane, a non-fluoridated state capital city. The DDE (Developmental Defects of Enamel) Index was used to chart enamel hypoplasia and enamel opacities. WHO criteria was used to diagnose dental caries. The results showed that 98% of children had at least one tooth showing developmental enamel defects. Each child had a mean of 3.8 +/- 1.7 teeth affected by enamel hypoplasia and another 1.1 +/- 0.8 teeth affected by enamel opacity. Seventy-eight percent of the children had dental caries. The mean number of decayed, missing, filled teeth (dmft) per child was 3.8 +/- 3.7. The decayed component constituted 3.5 (95%) of the mean dmft, indicating a high unmet restorative need in this group. The mean dmfs (decayed, missing, filled, surfaces) was 5.9 +/- 7.3. Maxillary anterior labial decay of at least one tooth affected 43 (23%) of the children. In this sub-group, the dmft and dmfs was 9.1 +/- 2.8 and 15.4 +/- 7.7 respectively. Oral debris was found in 98% of the children. It is hypothesized that the high levels of underlying developmental enamel defects, compounded by low fluoride exposure, poor oral hygiene and a diet high in refined sugars pose an important caries risk factor in this group of children.

Enamel defects in the deciduous dentition as a potential predictor of defects in the permanent dentition of 8- and 9-year-old children in fluoridated Cheshire, England.

It is claimed that dental fluorosis in both deciduous and permanent teeth is increasing in fluoridated and non-fluoridated communities. What is unclear is whether fluoride-induced enamel opacities in the deciduous dentition are associated with the subsequent appearance of enamel defects in the permanent dentition. The aim of this study was to establish whether a relationship existed between the presence of diffuse enamel defects on the deciduous molars and permanent incisors of schoolchildren who were lifetime residents in an optimally fluoridated community in Cheshire, England. The dentitions of eight-and nine-year-old children were examined by two examiners, each unaware of the findings of the other. There was a significant increased risk of diffuse enamel defects in the permanent incisors for those children who presented with diffuse defects on their first deciduous molars (Relative Risk, 1.45; 95% confidence interval, 1.05 to 2.0) or second deciduous molars (Relative Risk, 1.86; 95% confidence interval, 1.36 to 2.54). In light of these findings, it is worth considering the potential of the presence of enamel defects in deciduous molars in children aged 1 to 3 years as a predictor of the future appearance of similar lesions in their permanent incisors.

The association between developmental enamel defects and caries in populations with and without fluoride in their drinking water.

The purpose of this study was to consider the association between developmental enamel defects and dental caries in children from areas with different levels of fluoride in their drinking water. children (mean age = 14.1 +/- 0.3 years) were examined from areas with less than 0.1 ppm (n = 267) and 0.7 ppm (n = 196) in their drinking water. These areas were chosen to contain subjects with a similar social profile. Two types of enamel defect were considered: those consistent with the diagnostic criteria of the Thylstrup Fejerskov (TF) index and demarcated opacities. Dental caries was recorded for surfaces at the level of the dentinal lesion. Subjects with one or more demarcated opacities had more dental caries than those without these opacities present. Children with enamel defects scored with the TF index tended to have less dental caries than those without these defects present. However, the difference was only statistically significant in the area without fluoride in the drinking water. Developmental enamel defects may be useful markers of caries susceptibility, which should be considered in the risk-benefit assessment for use of fluoride. Further studies are required to clarify the relationship between developmental enamel opacities and dental caries and the reasons for any associations.

A scanning electron microscopic study of early enamel caries formed in vivo beneath orthodontic bands.

A clinical trial was conducted to investigate the development of caries lesions associated with fixed orthodontic appliance therapy. To introduce a cariogenic challenge on sound buccal enamel surfaces in vivo, specially designed orthodontic bands were attached to premolars scheduled for extraction for orthodontic reasons. The bands were modified by having two metal wires (0.8 mm in diameter) welded to the inner surface of the band to produce a space for plaque accumulation similar to that occurring under loose orthodontic bands. The bands were cemented with a zinc phosphate cement (Tenet) and left in situ for 4 weeks. Of 22 premolar teeth banded in eight different patients, eight showed definite white spot lesions, eight showed definite faint enamel opacities, and six showed no discernible lesions. Examination of definite white spot lesions by scanning electron microscopy revealed characteristic patterns of initial tissue destruction. Focal holes and an accentuation of the perikymata were observed affecting the enamel surface zone, an area previously considered to remain relatively intact during the development of a caries lesion. The superficial nature of the caries lesions observed and the rapidity of their formation is significant in the clinical management of decalcified areas forming beneath orthodontic bands.

Enamel opacities and dental esthetics.

The purpose of this study was to determine the esthetic importance of different types of developmental enamel defect. In the first method used, individual subjects from three different populations with less than 0.1, 0.7, and 0.9 ppm fluoride in their drinking water, were asked about the appearance of their teeth and results compared to assessments of clinical photographs made by a single examiner. In the second method used, dentist and lay observers were asked to assess the appearance of the dentition of selected individuals who had a range of enamel defects. According to the first method, both the size of demarcated opacities and the degree of enamel hypomineralization (TF index) were related to satisfaction with appearance. However, there was no difference in satisfaction with the appearance of the teeth among the three areas included in this study. In the second method, similar types of enamel defects were found to be esthetic stimuli as with the first study, but the dentists responded more strongly to the stimulus of enamel hypomineralization than the lay examiners. Both demarcated opacities and enamel hypomineralization may be important when assessing differences between populations. Further, esthetic ratings by dentists may not be a suitable means of assessing the esthetic importance of different types of enamel defects.