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ORIGINAL ARTICLE
Year : 2009  |  Volume : 27  |  Issue : 4  |  Page : 190-196
 

Prevalence and severity of dental fluorosis among 13- to 15-year-old school children of an area known for endemic fluorosis: Nalgonda district of Andhra Pradesh


1 Department of Preventive and Community Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Community Dentistry, College of Dental Sciences, Davangere, Karnataka, India
3 Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka, India
4 Department of Pedodontics and Preventive Dentistry, V S Dental College and Hospital, Bangalore, Karnataka, India

Date of Web Publication14-Nov-2009

Correspondence Address:
G N Chandu
Department of Community Dentistry, College of Dental Sciences, Davangere - 577 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.57651

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   Abstract 

Objectives: The present study was conducted to assess dental fluorosis and to compare fluorosis in incisor teeth among 13- to 15-year-old school children of Nalgonda district, Andhra Pradesh. Methods: Cross-sectional analytical study was conducted. A total of 1000 school children aged 13 to 15 years were selected by stratified cluster sampling from 4 different areas with different levels of naturally occurring fluoride in drinking water. Fluorosis was recorded using TF index (TFI). Results: Prevalence of fluorosis (TFI score, ≥1) was 100% at all the 4 different fluoride levels. The prevalence and severity increased with increased fluoride levels in drinking water. Prevalence and severity of fluorosis did not show any significant variation between maxillary and mandibular incisor teeth. Conclusion: There is a high prevalence of mild-to-moderate fluorosis in Nalgonda district, even in areas with optimal fluoride levels in water.


Keywords: Dental fluorosis, TF index


How to cite this article:
Sudhir K M, Prashant G M, Subba Reddy V V, Mohandas U, Chandu G N. Prevalence and severity of dental fluorosis among 13- to 15-year-old school children of an area known for endemic fluorosis: Nalgonda district of Andhra Pradesh. J Indian Soc Pedod Prev Dent 2009;27:190-6

How to cite this URL:
Sudhir K M, Prashant G M, Subba Reddy V V, Mohandas U, Chandu G N. Prevalence and severity of dental fluorosis among 13- to 15-year-old school children of an area known for endemic fluorosis: Nalgonda district of Andhra Pradesh. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2019 Jul 22];27:190-6. Available from: http://www.jisppd.com/text.asp?2009/27/4/190/57651



   Introduction Top


Endemic fluorosis continues to remain a challenging national dental health problem. [1] The effect of fluoride on dentition is dose dependent and is not confined to increased caries resistance. Although being a 'late' measure of fluoride exposure, dental fluorosis is the most sensitive sign of prolonged high fluoride exposure. [2]

To fully appreciate how fluoride affects the forming tissues, the gradient of early changes in the enamel, including the biological effect of fluoride, needs to be examined. To do this, a clinical classification system, the Thylstrup and Fejerskov index, has been developed. The classification scale corresponds closely to histological changes that occur in dental fluorosis and fluoride concentrations found in enamel. [3]

Nalgonda district of Andhra Pradesh consists of areas with various levels of fluoride in drinking water, starting from below-optimum to optimum and above-optimum levels. This area is ideal for assessing the prevalence and severity of dental fluorosis. Till today no data is available on the prevalence and severity of fluorosis in this district of Andhra Pradesh.

Objectives

  • To assess dental fluorosis using Thylstrup and Fejerskov index among 13- to 15-year-old school children of Nalgonda district, Andhra Pradesh, where the drinking water supply consists of various levels of fluoride.
  • To compare fluorosis in incisor teeth between areas with different fluoride levels.



   Materials and Methods Top


Study design

A cross-sectional analytical study was conducted among 13- to 15-year-old school children of Nalgonda district, Andhra Pradesh.

Study population/ Source of data

Data was collected from the 13- to 15-year-old school children who were lifelong residents of Nalgonda district, Andhra Pradesh, and who consumed drinking water from the same source in the initial 10 years of their life.

Sample size determination

A pilot study was carried out on 100 school children to determine the feasibility of the study. The time required for examination of each subject and the practicability of the Thylstrup and Fejerskov index were assessed during the examination. Prevalence of severe dental fluorosis was found to be 35%. Depending on this prevalence determined in the pilot study, the sample size was determined.

Sample size

After conducting a pilot study, the size of the sample was estimated at 1000.

Sampling technique/ Selection of sample

A stratified random sampling technique was used. The entire geographical area of Nalgonda district was divided into 4 strata based on different levels of naturally occurring fluoride in drinking water supply. Fluoride levels in drinking water for the purpose of stratifying the district were obtained from the documented records of District Rural Water Works Department, Nalgonda. So in each stratum, or for each level, several villages were involved. Sample size was divided equally among all the 4 strata, and representation from both the sex was included in the sampling.



Inclusion criteria

  • School children aged 13-15 years who were lifelong residents of that particular region and who were using the same source of drinking water from birth to 10 years of age.
  • Children with permanent teeth with at least more than 50% of the crown erupted and no fillings on facial surface.


Exclusion criteria

  • Children who had migrated from some other place or who were not permanent residents of that particular area and had change of source of drinking water.
  • Children who obtained their drinking water from more than one source.
  • Children with orthodontic brackets and children with severe extrinsic stains on their teeth.


Collection and analysis of water sample

Collection of water samples was done based on the methodology followed in National Oral Health Survey and Fluoride Mapping 2002-2003.

The water samples collected were subjected to water fluoride analysis using Orion 720A ion-specific electrometer at the District Water Works, Nalgonda, to confirm the fluoride levels in the water samples before commencement of clinical examination.

Ethical clearance and informed consent

Before starting the study, ethical clearance was obtained from the Ethical Committee of College of Dental Sciences, Davangere. An official permission was obtained from the District Educational Officer (DEO), Nalgonda.

Informed consent was obtained from the respective school headmasters before commencement of the study.

Scheduling

The study was conducted over a period of 1 year (1 st June 2006 to 31 May 2007).

Study tools

Data was collected through individual interview followed by clinical examination. The questionnaire consisted of information in 2 parts: The first part consisted of information on demographic data, permanent residential address, source of drinking water, duration of use of present source of drinking water, staple food, liquids routinely consumed, aids used for oral hygiene maintenance (fluoridated or nonfluoridated); and the second part consisted of a table for recording fluorosis using Thylstrup and Fejerskov index.

Russell's criteria were used for the differential diagnosis of nonfluorotic, opaque lesions on enamel and lesions due to mild fluorosis. [4]

Method of calibration of examiner

All examinations were carried out by a single examiner. Calibration of the examiner was done before the study was conducted and in the middle of the study by conducting duplicate examination of 5% (1 in 20) of the total population; and intra-examiner agreement was assessed with Kappa statistics for dental fluorosis with Kappa levels above 75%.

Clinical assessment

The study population was selected after interviewing depending on the inclusion criteria, and clinical examination was done among those who were eligible for the study.

Clinical examination was carried out under adequate natural light in the school premises. For assessment of dental fluorosis as per the recommendations for using the index, the teeth were dried with gauze and then the facial/ buccal surface of all the permanent teeth was scored for fluorosis using Thylstrup and Fejerskov index. [5]

Statistical analysis

Data were computerized and analyzed using the statistical package for social sciences (SPSS version 13.0).

Since the data were in scores, nonparametric tests were used for analysis. Kruskal-Wallis ANOVA test was used for multiple group comparisons; and Mann-Whitney U test, for group-wise comparisons.


   Results Top


This cross-sectional analytical study was conducted in the Nalgonda district of Andhra Pradesh. A total of 1000 school children from 4 different strata were included in the study. Their ages ranged from 13 to 15 years, with a mean age of 14.1 ±7.3 years.

[Table 1] represents the distribution of the study population according to age and gender. Among the total population of 1000 children, 227 (22.7%) belonged to the age group '13 years,' 453 (45.3%) belonged to the age group '14 years' and 320 (32.0%) of them belonged to the age group '15 years.' Out of the total population, 586 (58.6%) were boys and 414 (41.4%) were girls.

Graph 1-[Additional file 1] illustrates the percentage distribution of subjects at different fluoride levels; the subjects were almost equally distributed. Graph 2-[Additional file 2] displays the distribution of subjects according to source of water supply. Majority of them [900 (90%)] were using bore well/ hand pump as their source of drinking water.

The main staple food of the entire sample population was rice (100%). Apart from drinking water, tea was the most frequently consumed beverage (87.4%).

The comparison of prevalence and severity of fluorosis using TF index (TFI) scores in areas with different fluoride levels in drinking water is presented in [Table 2]. The prevalence of fluorosis (TFI score, ≥1) was 100% at all the fluoride levels. The corresponding mean score for fluoride level 1 was 1.3 ±0.9, with a range of 0-4; on the other hand, the mean score for fluoride level 4 was 4.8 ±1.4, with a greater range, viz., 1-9. This association was found to be significant using Kruskal-Wallis ANOVA test [χ2 , 556.4; P<0.001(HS)] for multiple group comparisons. The results of Mann-Whitney U test for group-wise comparison were also highly significant [P<0.001(HS)]. The TFI scores increased with increased fluoride levels in drinking water.

The comparison of prevalence and severity of fluorosis using TFI scores in incisor teeth between areas with different fluoride levels is presented in [Table 3]. The mean TFI score at fluoride level 1 for maxillary incisors was 1.1 ±0.7; and severity of fluorosis was found to be higher at fluoride level 4, with a mean score of 4.4 ±1.6. Kruskal-Wallis ANOVA test [χ2 , 504.6; P≤0.001(HS)] showed statistically significant variation in severity of fluorosis at different fluoride levels. The mean TFI score at fluoride level 1 for mandibular incisors was 1.1 ±0.7. TFI scores were found to be higher at fluoride level 4, with mean score being 3.9 ±1.4. Kruskal-Wallis ANOVA test [χ2 , 470.4; P≤0.001(HS)] showed statistically significant variation in severity of fluorosis at different fluoride levels. The results of Mann-Whitney U test for group-wise comparison were highly significant [P<0.001]. The comparison of prevalence and severity of fluorosis using TFI scores in incisor teeth between maxillary and mandibular teeth in areas with different fluoride levels did not show any significant variation in the prevalence and severity.

The frequency distribution of TFI scores at water fluoride level 1 is shown in Graph 3A-[Additional file 3]; 70.8% of the teeth were affected with mild fluorosis (TFI score, 1). The frequency of teeth affected by severe dental fluorosis (TFI score, ≥5) was 1.6%. The frequency distribution of TFI scores at water fluoride level 4 is shown in Graph 3B-[Additional file 4]; 4.6% of the teeth were affected with mild fluorosis (TFI score, 1). The frequency of teeth affected by severe dental fluorosis (TFI score, ≥5) was 40.0%.

[Table 4] depicts the prevalence and severity of fluorosis with different sources of drinking water. The mean TFI score was higher (3.0 ±1.8) for children consuming water from bore well, with a range of 0-8. Children consuming water from draw well had a mean TFI score of 1.3 ±1.0, with a low range, viz., 0-4. River water had the lowest mean score (1.0 ±1.0, with a range of 0-5). This difference was highly significant [Kruskal-Wallis ANOVA test: χ2 , 100.5; P<0.001(HS)]. Group-wise comparison using Mann-Whitney U test showed statistically significant association between different sources of drinking water and severity of fluorosis.

Severity of fluorosis showed a weak negative correlation with age. Prevalence and severity of fluorosis with respect to gender showed no statistically significant differences.

The prevalence and severity of dental fluorosis did not significantly vary among children who had different patterns of liquid consumption and among children who used different oral hygiene aids and different fluoridated products.


   Discussion Top


Children who lived in the same place where they were born and who obtained drinking water from the same source throughout their life were included in the study. As the ground water table is constantly receding and some communities have started getting piped water from surface water in recent times, it was decided to include those children who obtained drinking water from the same source, at least in the first 10 years of their life. This amendment was done keeping in mind the fact that mineralization of all permanent teeth, except third molars is completed by 10 years. [6],[7]

Information regarding source of drinking water; liquids they routinely consumed, other than water; oral hygiene aids used and their fluoridation status was collected, since these are important confounding factors for dental fluorosis.

To measure dental fluorosis, Thylstrup and Fejerskov index was used. The histological and clinical bases for the criteria used for scoring fluorosis with this index have clarified the way in which fluorosis is distributed over the tooth surface in case of continuous exposure to constant levels of fluoride during tooth development, as well as the role of enamel loss in fluorosis. The approach used in formulating scoring criteria has had the effect of reducing some of the subjectivity in scoring. Further cleaning and drying of teeth accentuates the appearance of fluorosis, making diagnosis easier in questionable cases. [5]

The prevalence of dental fluorosis reported by Akpata et al.[8] in Saudi Arabia (0.5-2.8 ppm) and by Na'ang'a, Valderhaug [9] in Nairobi, Kenya, was 90% and 76%, respectively, which indicates a lower fluorosis prevalence compared to our study, which showed 100% prevalence in all the areas with different fluoride levels in drinking water. However, similar prevalence of 100% was found in a study conducted by Manji et al.[10] in Kenya (2 ppm) and Fantaye Wondwossen et al.[11] in high-fluoride areas of Ethiopia. The possible explanation for these observations may be, first, as originally suggested by Galagan and Lamson, that there is a positive association between mean annual temperature and total fluoride intake. [12] The most detailed studies concerting climatic factors were done by in Uganda [13] and in USA. [14] In Nalgonda district, the mean annual temperature is, in fact, higher, i.e., 37°C, [15] which might be one of the possible explanations for high prevalence of more severe forms of dental fluorosis.

In the present study, 100% of the children, who resided in areas with water fluoride levels of 0.0-0.6 ppm, had dental fluorosis. This high prevalence in the areas with low water fluoride levels could be explained by A. K. Susheela's explanation, [16] that in an endemic fluorosis area, a great amount of fluoride is incorporated into food materials and ingested into the body. High temperature of Nalgonda, which necessitates greater intake of water, could also be one reason.

The fluorotic changes showed high degree of bilateral symmetry in the homologous pairs of buccal surfaces of teeth in our study, which is similar to the findings from the study conducted by Manji et al.[17] in Kenya. This is indicative of a systemic origin and characteristic of dental fluorosis.

The present study revealed 2 patterns of fluorotic enamel changes in dentition: one, in the communities with low-to-moderate fluoride levels; and the other, in the communities with high fluoride levels. In communities with high fluoride levels, the intraoral distribution of fluorotic enamel was different. The incisors exhibited lower TFI values than canines, premolars and molars. These findings are similar to the findings from the studies conducted by Van Palenstein Helderman et al.[18] in west Tanzania and Fantaye Wondwossen et al.[19] in Ethiopia. With high fluoride exposure, pitting of the enamel is known to occur post-eruptively; the severity of pitting is determined by both the degree of porosity of enamel at the time of eruption and the extent of exposure of the tooth surface to masticatory forces.

Manji et al.[17] in Kenya and Akpata et al.[8] in Saudi Arabia reported that in low-fluoride areas, incisors and first molars were most commonly affected by dental fluorosis, followed by second molars and premolars. In the present study, the effect of waterborne fluoride in low-fluoride areas was reflected in the form of a steeper profile of dental fluorosis, from incisors and first molars through canine and premolars to second molars; so the teeth formed early in the life showed less prevalence of fluorosis than the late-formed teeth.

In studies conducted by Akpata et al.[8] in Hail (0.50-0.79 ppm) region of Saudi Arabia, it was found that 24% of children had severe fluorosis (TFI score, ≥5) with pitting; and in another study conducted by Manji et al.[10] in Kenya (2.14 ppm), the distribution was more severe, with 92% of all teeth having severe fluorosis without pitting (TFI score, ≥4). In the present study, the percentage of teeth affected by severe dental fluorosis with pitting (TFI score, ≥5) at fluoride level 1 (0.1-0.7 ppm) was just 1.6%; and it was the highest at fluoride level 4 (≥4 ppm), with 40% of the teeth affected by severe fluorosis.

Akpata et al.[8] in Hail region of Saudi Arabia, Asgeir Bardsen et al., [20] and Hamdan [21] in Jordan reported that dental fluorosis was generally more severe in maxillary teeth than in homogenous mandibular teeth. In contrast, in the present study there was no significant difference in the prevalence and severity of fluorosis between maxillary and mandibular incisor teeth; both were equally affected.

In the present study, children who obtained drinking water from tube wells or hand pumps showed greater severity of dental fluorosis when compared to children who obtained drinking water from draw wells or rivers. These findings were similar to the findings from the study conducted by Na'ang'a, Valderhaug [9] in Nairobi, Kenya; and Asgeir Bardsen et al.[20] in western Norway. So, the surface water is known to contain less fluoride than ground water, and this was again proved in this study.

A study conducted by Baelum et al.[22] in Nairobi, Kenya, fluorosis was significantly more prevalent and widespread in children aged 13-15 years compared to children aged 10-12 years; in contrast, the present study showed a weak negative correlation with age.

There was no significant difference in the prevalence and severity of dental fluorosis between boys and girls. These findings are similar to the findings from the study conducted by Gladys et al.[23] in Kenya; Na'ang'a, Valderhaug [9] in Nairobi, Kenya; Rwenyonyi et al.[24] and Hamdan [25] in Jordan.

Liquids consumed, like tea, coffee and milk, did not show any influence on fluorosis. Tea is a rich source of fluoride, [2] and its intake is supposed to cause fluorosis. The contrary observation in the present study can be attributed to the changing habits of beverage consumption with age.

Prevalence and severity of fluorosis did not show significant variation among fluoridated and nonfluoridated dentifrices users. The observation in the present study may be attributed to frequent changes of toothpaste used; and what they may be using now may not be the same as what they may have used in the past 10 years.


   Conclusion Top


It can be concluded that there is a high prevalence of mild-to-moderate fluorosis in Nalgonda district, even in areas with optimal fluoride levels in water.

 
   References Top

1.National Oral Health survey and Fluoride Mapping 2002-2003 India. New Delhi: Dental Council of India; 2004.  Back to cited text no. 1      
2.Riordan PJ. Perceptions of dental fluorosis. J Dent Res 1993;72:1268-74.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Fejerskov O, Ekstrand J, Burt BA. Fluorides in dentistry. 2nd ed. Munksgaard Text Book; 1996.  Back to cited text no. 3      
4.Horowitz HS. Indexes for measuring dental fluorosis. J Public Health Dent 1986;46:179-83.  Back to cited text no. 4  [PUBMED]    
5.Rozier RG. Epidemiologic indices for measuring the clinical manifestations of dental fluorosis: Overview and critique. Adv Dent Res 1994;8:39-55.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Villa AE, Guerrero S. Caries experience and fluorosis prevalence in Chilean children from different socio-economic status. Community Dent Oral Epidemiol 1996;24:225-7.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Manji F, Fejerskov O. Dental caries in developing countries in relation to the appropriate use of fluoride. J Dent Res 1990;69:733-41;820-3.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Akpata ES, Fakiha Z, Khan N. Dental fluorosis in 12-15 year old rural children exposed to fluorides from well drinking water in the Hail region of Saudi Arabia. Community Dent Oral Epidemiol 1997;25:324-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Na'ang'a PM, Valderhaug J. Prevalence and severity of dental fluorosis in primary schoolchildren in Nairobi, Kenya. Community Dent Oral Epidemiol 1993;21:15-8.   Back to cited text no. 9      
10.Manji F, Baelum V, Fejerskov O. Dental Fluorosis in an area of Kenya with 2ppm fluoride in the drinking water. J Dent Res 1986;65:659-62.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Wondwossen F, Astrom AN, Bjorvatn K, Bardsen A. The relationship between dental caries and dental fluorosis in areas with moderate and high-fluoride drinking water in Ethiopia. Community Dent Oral Epidemiol 2004;32:337-44.  Back to cited text no. 11      
12.Galgan DJ, Lamsan GG. Climate and dental fluorosis. Publ Health Rep 1953;68:497-508.  Back to cited text no. 12      
13.Moller IJ, Pindborg JJ, Gedalia J. The prevalence of dental fluorosis in the people of Uganda. Archs Oral Biol 1970;15:213-25.  Back to cited text no. 13      
14.Richards LF, Wesmoreland WW. Determining optimum fluoride levels for community water supplies in relation to temperature. J Am Dent Assoc 1967;74:389-97.  Back to cited text no. 14      
15.Available from: http://nalgonda.ap.nic.in/climate_rainfall.htm.2007.   Back to cited text no. 15      
16.Susheela AK. Epidemiology and control of fluorosis in India. J of Nutrition foundation of India, April 1984. Available from: http://nutritionfoundationofindia.res.in/pdfs/jun2007-pdf.   Back to cited text no. 16      
17.Manji F, Baelum V, Fejerskov O. Dental Fluorosis in an area of Kenya with 2ppm fluoride in the drinking water. J Dent Res 1986;65:659-62.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Van Palenstein Helderman WH, Mobelya L, Van't Hof MA, Kong KG. Two types of intraoral distribution of fluorotic enamel. Community Dent Oral Epidemiol 1997;25:251-5.  Back to cited text no. 18      
19.Wondwossen F, Astrom AN, Bjorvatn K, Bardsen A. The relationship between dental caries and dental fluorosis in areas with moderate and high-fluoride drinking water in Ethiopia. Community Dent Oral Epidemiol 2004;32:337-44.  Back to cited text no. 19      
20.Bardsen A, Klock KS, Bjorvatn K. Dental fluorosis among persons exposed to high-and-low-fluoride drinking water in western Norway. Community Dent Oral Epidemiol 1999;27:259-67.  Back to cited text no. 20      
21.Hamdan MA. The prevalence and severity of dental fluorosis among 12year old schoolchildren in Jordan. Int J Paediatr Dent 2003;13:85-92.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.Baelum V, Manji F, Fejerskov O. Posteruptive tooth age and severity of dental fluorosis in Kenya. Scand J Dent Res 1986;94:405-10.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]  
23.Gladys NO, Valderhaug J, Birkeland JM, Lokken P. Fluorosis of deciduous teeth and first permanent molars in rural Kenya community. Acta Odontol Scand 1991;49:197-202.  Back to cited text no. 23      
24.Rwenyonyi CM, Bjorvatn K, Birkeland JM, Haugejorden O. Altitude as a risk indicator of dental fluorosis in children resideng in areas with 0.5 and 2.5 mg fluoride per liter in drinking water. Caries Res 1999;33:267-74.  Back to cited text no. 24      
25.Hamdan MA. The prevalence and severity of dental fluorosis among 12year old schoolchildren in Jordan. Int J Paediatr Dent 2003;13:85-92.  Back to cited text no. 25  [PUBMED]  [FULLTEXT]  



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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