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Objective: Very few studies have examined the relationship between timing of fluoride intake and development of dental fluorosis on late-erupting permanent teeth using period-specific fluoride intake information. This study examined this relationship using longitudinal fluoride intake information from the Iowa Fluoride Study. Methods: Participants' fluoride exposure and intake (birth to 10 years of age) from water, beverages, selected food products, dietary fluoride supplements, and fluoride toothpaste was collected using questionnaires sent to parents at 3- and 4- month intervals from birth to 48 months of age and every 6 months thereafter. Three trained and calibrated examiners used the Fluorosis Risk Index (FRI) categories to assess 16 late-erupting teeth among 465 study participants. A tooth was defined as having definitive fluorosis if any of the zones on that tooth had an FRI score of 2 or 3. Participants with questionable fluorosis were excluded from analyses. Descriptive and logistic regression analyses were performed to assess the importance of fluoride intake during different time periods. Results: Most dental fluorosis in the study population was mild, with only four subjects (1%) having severe fluorosis (FRI Score 3). The overall prevalence of dental fluorosis was 27.8%. Logistic regression analyses showed that fluoride intake from each of the individual years from age 2 to 8 plays an important role in determining the risk of dental fluorosis for most late-erupting permanent teeth. The strongest association for fluorosis on the late-erupting permanent teeth was with fluoride intake during the sixth year of life. Conclusion: Late-erupting teeth may be susceptible to fluorosis for an extended period from about age 2 to 8. Although not as visually prominent as the maxillary central incisors, some of the late-erupting teeth are esthetically important and this should be taken into consideration when making recommendations about dosing of fluoride intake. [ABSTRACT FROM AUTHOR]

Objectives: To compare dental esthetic perceptions of adolescents at age 13 with those of parents and to assess associations with dental fluorosis. Methods: Adolescents aged 13 underwent dental examinations for fluorosis on maxillary anterior teeth using the Fluorosis Risk Index. Adolescents and parents completed questionnaires concerning satisfaction with adolescents' dental appearance. McNemar and Bowker tests of symmetry were used for comparisons of esthetics ratings between parents and adolescents. Comparison of satisfaction between subjects with fluorosis and subjects with no fluorosis was made using Cochran-Armitage Trend and Fisher's Exact tests. Results: From 376 adolescents included in the study, 26 percent had definitive fluorosis, mostly at a mild level. Fifteen percent of adolescents were dissatisfied with dental appearance, and concerns were mainly about color (45 percent) and alignment (35 percent). Adolescents were less satisfied with overall dental appearance ( P < 0.001) and color ( P = 0.048) and more concerned about tooth shape ( P = 0.002) than were their parents. Fluorosis status (yes/no) was not significantly associated with adolescents' perceptions ( P > 0.05). Parents of subjects with fluorosis were more dissatisfied with dental appearance ( P = 0.014) and color ( P < 0.001) than other parents. The number of maxillary anterior zones exhibiting fluorosis was negatively associated with adolescent ( P = 0.03) and parent ( P = 0.002) satisfaction. Conclusion: Adolescents generally had less satisfaction with dental appearance and color, and were more concerned with tooth shape than were parents. For both parents and adolescents, decreased satisfaction was associated with the number of zones with definitive fluorosis. [ABSTRACT FROM AUTHOR]

Objective: To assess and compare examiner reliability of clinical and photographic fluorosis examinations using the Fluorosis Risk Index (FRI) among children in the Iowa Fluoride Study (IFS). Methods: The IFS examined 538 children for fluorosis and dental caries at age 13 and obtained intraoral photographs from nearly all of them. To assess examiner reliability, duplicate clinical examinations were conducted for 40 of the subjects. In addition, 200 of the photographs were scored independently for fluorosis by two examiners in a standardized manner. Fluorosis data were compared between examiners for the clinical exams and separately for the photographic exams, and a comparison was made between clinical and photographic exams. For all three comparisons, examiner reliability was assessed using kappa statistics at the tooth level. Results: Interexaminer reliability for the duplicate clinical exams on the sample of 40 subjects as measured by kappa was 0.59, while the repeat exams of the 200 photographs yielded a kappa of 0.64. For the comparison of photographic and clinical exams, interexaminer reliability, as measured by weighted kappa, was 0.46. FRI scores obtained using the photographs were higher on average than those obtained from the clinical exams. Fluorosis prevalence was higher for photographs (33 percent) than found for clinical exam (18 percent). Conclusion: Results suggest that interexaminer reliability is greater and fluorosis scores are higher when using photographic compared with clinical examinations. [ABSTRACT FROM AUTHOR]

Chankanka O, Levy SM, Warren JJ, Chalmers JM. A literature review of aesthetic perceptions of dental fluorosis and relationships with psychosocial aspects/oral health-related quality of life. Community Dent Oral Epidemiol 2010. © 2009 John Wiley & Sons A/S Aesthetic perceptions and oral health-related quality of life concerning dental fluorosis have been assessed in several studies during the past two decades. However, no comprehensive review article summarizing the studies investigating this issue has been published. Objective: To assess the relationships between perceptions of dental appearance/oral health-related quality of life (OHRQoL) and dental fluorosis. Methods: The PubMed database was searched using the Medical Subject Headings (MeSH) for English-language studies from 1985 to March 2009. Thirty-five articles qualified for inclusion and then were classified into three categories based on the type of study approach: (i) respondent review of photographs and assessment concerning satisfaction/acceptance, (ii) respondent assessment of study subject’s teeth concerning satisfaction/acceptance, and (iii) respondent assessments of the psychosocial/OHRQoL impact. Results: There were varied results from earlier studies focused on satisfaction/acceptance of very mild to mild fluorosis. More recent studies with methodological improvements to assess impact on quality of life clearly showed that mild fluorosis was not a concern. Furthermore, mild fluorosis was sometimes associated with improved OHRQoL. Severe fluorosis was consistently reported to have negative effects on OHRQoL. Conclusion: Because dental fluorosis in the United States and other nations without high levels of naturally-occurring fluoride is mild or very mild, with little impact on OHRQoL, dental professionals should emphasize the appropriate use of fluorides for caries prevention and preventing moderate/severe fluorosis. [ABSTRACT FROM AUTHOR]

The 'optimal' intake of fluoride has been widely accepted for decades as between 0.05 and 0.07 mg fluoride per kilogram of body weight (mg F/kg bw) but is based on limited scientific evidence. The purpose of this paper is to present longitudinal fluoride intake data for children free of dental fluorosis in the early-erupting permanent dentition and free of dental caries in both the primary and early-erupting permanent teeth as an estimate of optimal fluoride intake. Data on fluoride ingestion were obtained from parents of 602 Iowa Fluoride Study children through periodic questionnaires at the ages of 6 weeks; 3, 6, 9, 12, 16, 20, 24, 28, 32, and 36 months; and then at 6-month intervals thereafter. Estimates of total fluoride intake at each time point were made by summing amounts from water, dentifrice, and supplements, as well as other foods and beverages made with, or containing, water. Caries data were obtained from examinations of children at ages 5 and 9 years, whereas fluorosis data were obtained from examinations of children only at age 9 years. The estimated mean daily fluoride intake for those children with no caries history and no fluorosis at age 9 years was at, or below, 0.05 mg F/kg bw for nearly all time points through the first 48 months of life, and this level declined thereafter. Children with caries had generally slightly less intakes, whereas those with fluorosis generally had slightly higher intakes. Given the overlap among caries/fluorosis groups in mean fluoride intake and extreme variability in individual fluoride intakes, firmly recommending an 'optimal' fluoride intake is problematic. [ABSTRACT FROM AUTHOR]

Objective: To assess the relative importance of an orthodontic esthetic index, dental fluorosis and nonfluoride opacities, with respect to parents' satisfaction with their children's dental esthetics. Materials and Methods: Dental examinations of Iowa Fluoride Study participants assessed fluorosis and nonfluoride opacities in the mixed dentition. Dental casts of 200 randomly selected subjects were scored using the Dental Aesthetic Index (DAI) criteria. Parent satisfaction was assessed via multiple items on a questionnaire. Associations were evaluated using logistic regression. Results: Nineteen percent of parents were somewhat or very dissatisfied with their children's dental esthetics. Overall DAI score was positively associated with dissatisfaction (P < .001), as was fluorosis (P = .003). Conclusions: In addition to changes related to DAI scores, parent esthetic satisfaction decreased with the presence of fluorosis. Dental professionals should address both the issues of tooth positioning and color aberration with respect to dental esthetics. [ABSTRACT FROM AUTHOR]

Gaps remain in our knowledge about the levels of fluoride intake that cause dental fluorosis. The purpose of this study was to report the fluorosis prevalence by levels of estimated fluoride intake in an effort to understand the importance of different levels of daily fluoride intake. As part of the longitudinal Iowa Fluoride Study, subjects were followed from birth to 36 months with questionnaires every 3–4 months to gather information on fluoride intake from various sources. Daily fluoride intake in mg per kg body weight (BW) was estimated from water, beverages and selected foods, fluoride supplements and dentifrice. Six hundred and twenty-eight subjects were examined for fluorosis on permanent incisors and first molars at about age 9 by two calibrated examiners using the Fluorosis Risk Index categories. Fluorosis prevalence rates were determined separately for maxillary central incisors and first molars by levels of estimated fluoride intake. There were significant positive associations between fluorosis prevalence and levels of fluoride intake. Cumulatively from birth to 36 months, average daily intake of 0.04 mg F/kg BW or less carried relatively low risk for fluorosis (12.9% for maxillary central incisors, 6.8% for first molars). Average daily intake of 0.04–0.06 mg F/kg BW showed a significantly elevated risk for fluorosis (23.0% for maxillary central incisors, 14.5% for first molars), while fluorosis risk was even higher for average intake above 0.06 mg F/kg BW (38.0% for maxillary central incisors, 32.4% for first molars). The study suggests that fluorosis prevalence is related to elevated fluoride intake when averaged over the first 3 years of life, but is even more strongly related to fluoride intake that is elevated for all of the first 3 years of life. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives: Relatively little is known about associations between primary and permanent tooth fluorosis. In this study, associations between dental fluorosis of the permanent and primary dentitions were assessed. Methods: Subjects (n=601) are in the Iowa Fluoride Study, which included fluorosis examinations of the primary and early-erupting permanent dentitions by trained dentist examiners. Relative risks, correlations, and logistic regression assessed associations between permanent tooth fluorosis and primary molar fluorosis. Results: Ten percent had primary molar fluorosis at age 5; 36% had definitive (mostly mild), 28% questionable, and 36% no permanent incisor fluorosis at age 9. Those with primary molar fluorosis were significantly more likely to have definitive permanent incisor fluorosis (76% vs. 32%), and permanent molar fluorosis (59% vs. 16%). The strong association between primary and permanent tooth fluorosis is independent of level of fluoride intake. Conclusions: Detection of primary tooth fluorosis in pre-school children should alert clinicians and parents to the high likelihood of subsequent fluorosis in the permanent dentition. [ABSTRACT FROM AUTHOR]

Objectives: Several studies have focused on the timing of fluoride intake relative to the development of dental fluorosis. This study reports the relationships of fluoride intake during the first 48 months of life with fluorosis on early-erupting permanent teeth. Methods: Subjects were followed from birth to 48 months with questionnaires every 3-4 months. Questionnaires gathered data on intakes from water, diet, supplements, and dentifrice to estimate total fluoride intake. Early-erupting permanent teeth of 579 subjects were assessed for fluorosis using the Fluorosis Risk Index (FRI) at approximately age 9. Fluorosis cases were defined as having FRI definitive or severe fluorosis on both maxillary central incisors. Individuals with FRI questionable fluorosis were excluded. The importance of fluoride intake during different time periods was assessed using t-tests and logistic regression. Results: One hundred and thirty-nine (24%) subjects had fluorosis on both maxillary central incisors. Mean fluoride intake per unit body weight (bw) ranged from 0.040 to 0.057 mg/kg bw, with higher intake during earlier time periods and relative stability after 16 months. In bivariate analyses, fluoride intakes during each of the first 4 years were individually significantly related to fluorosis on maxillary central incisors, with the first year most important (P < 0.01), followed by the second (P < 0.01), third (P < 0.01), and fourth year (P = 0.03). Multivariable logistic regression analyses showed that, after controlling only for the first year, the later years individually were still statistically significant. When all four time periods were in the model, the first (P < 0.01) and second years (P = 0.04) were still significant, but the third (P = 0.32) and fourth (P = 0.82) were not. Conclusions: The first two years of life were most important to fluorosis development in permanent maxillary central incisors; however, this study also suggests the importance of other individual years. [ABSTRACT FROM AUTHOR]

Objectives: Several studies have used the Fluorosis Risk Index (FRI) to assess risk factors for dental fluorosis. This study reports fluorosis prevalence estimates in a birth cohort using the FRI in different ways.Methods: Subjects (n=443) were participants in the Iowa Fluoride Study, a birth cohort study of fluoride exposures and intake, fluorosis, and caries. Early-erupting permanent teeth were assessed for fluorosis using the FRI at approximately age 9. Fluorosis prevalence rates were calculated separately for specific teeth and different combinations of teeth, with varied FRI zones included and using different thresholds. Mean numbers of teeth with fluorosis were calculated.Results: Tooth-specific fluorosis prevalence varied, with maxillary central incisor fluorosis most prevalent and mandibular incisors least affected. Considering three zones of each tooth (cervical zones excluded), 40.6% overall had at least one tooth with mild or more involved fluorosis, 30.2% were questionable fluorosis, and 29.1% had no fluorosis. When only FRI zone I areas were considered, the corresponding percentages were 33.2%, 29.3%, and 37.5%, respectively. When different combinations of teeth were used to define fluorosis cases, the prevalences estimated using three zones were generally 1 to 9 percentage points higher than those estimated from FRI zone 1 only. Most fluorosis was mild, with only 7 individuals (1.6%) having FRI severe fluorosis.Conclusions: The FRI has advantages for use in analytical epidemiologic studies of dental fluorosis. However, the population prevalence estimates vary, depending on the index and case definition used. Therefore, it is recommended that consideration be given to concurrent use of another index (i.e., TSIF, TF, Dean's) if prevalence estimates are an important study outcome. [ABSTRACT FROM AUTHOR]

Purpose: With the increasing prevalence of dental fluorosis, improved understanding about esthetic perceptions of dental fluorosis is warranted. The purpose of this report was to present results concerning parents' overall satisfaction with the appearance of their children's teeth and factors related to dissatisfaction, comparing subjects with and without fluorosis and demarcated opacities. Methods: Data were obtained from 577 parents in the Iowa Fluoride Study who answered a questionnaire concerning their satisfaction with the appearance of their children's teeth at age 9 years, as well as several components of dissatisfaction. Concurrent assessment of the mixed dentition was made by 1 of 2 trained dentist examiners. Results: Overall, 31% of parents were very satisfied, 51% somewhat satisfied, 16% somewhat dissatisfied, and 3% very dissatisfied with appearance. Parents of children without fluorosis were more likely to be very satisfied (46%) than were parents of children with questionable fluorosis (31%) or definitive fluorosis (22%). Among the 401 nor "very satisfied," 50% of those with fluorosis vs 40% with no fluorosis were concerned about color, 60% of both groups were concerned about alignment, 44% and 51%, respectively, were concerned about crowding, and 44% and 9%, respectively, were concerned about blotchiness. Conclusions: Fluorosis was associated with increased parental dissatisfaction with overall appearance, color, and blotchiness of their children's teeth. [ABSTRACT FROM AUTHOR]

Background It has been speculated that amoxicillin use could be associated with dental enamel defects. Objective To assess the association between dental fluorosis, one of the most common developmental tooth enamel defects, and amoxicillin use during early childhood. Design, Setting, and Participants As participants in the Iowa Fluoride Study, subjects were followed up from birth to 32 months using questionnaires every 3 to 4 months to gather information on fluoride intake and amoxicillin use. Methods Early-erupting permanent teeth of 579 subjects were assessed for fluorosis using the Fluorosis Risk Index at approximately the age of 9 years. Relationships between fluorosis and amoxicillin use were assessed using relative risk (RR), Mantel-Haenszel stratified analyses, and multivariable logistic regression. Results Amoxicillin use was reported by 75% of subjects by 12 months and 91% by 32 months. Overall, 24% had fluorosis on both maxillary central incisors. Amoxicillin use from 3 to 6 months significantly increased the risk of fluorosis on the maxillary central incisors (RR = 2.04; 95% confidence interval [CI], 1.49-2.78). After adjusting for fluoride intake and otitis media, the risk of fluorosis on the maxillary central incisors from amoxicillin use during 3 to 6 months (Mantel-Haenszel RR = 1.85; 95% CI, 1.20-2.78) was still statistically significant. Multivariable logistic regression analyses confirmed the increased risk of fluorosis from amoxicillin use during 3 to 6 months (odds ratio = 2.50; 95% CI, 1.21-5.15); fluoride intake was also statistically significant. Conclusion The findings from this study suggest a link between amoxicillin use during infancy and developmental enamel defects of permanent teeth; however, further research is needed. [ABSTRACT FROM AUTHOR]

Objectives: This paper reports on estimated daily fluoride intake from water by itself, beverages, selected foods, dentifrice, and dietary supplements, both individually and combined (mg and mg F/kg bw), among 785 children in the Iowa Fluoride Study from 36 to 72 months of age.Methods: Children were recruited in 1992-95, with questionnaires sent at four- to six-month intervals. Dietary fluoride intake estimates used community and individual water fluoride levels and average fluoride levels of beverages and foods prepared with water. Descriptive statistics and generalized linear models (GLM) assessed levels and associations with demographic factors.Results: There was substantial variation in fluoride intake, with some individuals' intakes greatly exceeding the means. Daily water fluoride intake estimates (in mg) increased with age, fluoride intake from other beverages and dentifrice both decreased slightly, and combined intake was quite consistent. For combined intake per unit body weight (mg F/kg bw), there was a steady decline with age. Therefore, the percentages with estimated intake exceeding possible thresholds for dental fluorosis also declined with age.Conclusions: Daily mean fluoride intakes from single and combined sources are relatively stable from 36-72 months of age among these children. [ABSTRACT FROM AUTHOR]

Objectives: Few studies in North America have assessed dental fluorosis of the primary dentition and few, if any, anywhere have assessed the relative importance in fluorosis etiology of fluoride intake during different time periods or from multiple sources. The purpose of this paper is to report on analyses relating estimated prenatal fluoride intake and fluoride intake during different parts of the first year of life to primary tooth fluorosis. Methods: As part of The Iowa Fluoride Study, subjects were recruited at birth and studied longitudinally. Trained examiners assessed dental fluorosis for children aged 4--7 years using the Tooth Surface Index of Fluorosis (TSIF) adapted for the primary denfition. Detailed parent questionnaires at childbirth were used to estimate prenatal fluoride intake and questionnaires sent at 6 weeks and 3, 6, 9, and 12 months were used to estimate fluoride intake during the first year of life (combined fluoride intake from water, food and beverage, supplements, and dentifrice). There were 504 children with prenatal and at least four of the tive postnatal responses with complete data. Results: Fluorosis prevalence was 12.1%, occurring primarily on the second primary mojars. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the importance of different time periods' fluoride intake. In bivariate analyses, fluoride intake during each time interval was individually significantly related to fluorosis occurrence. For multivariate analyses, the period from 6 to 9 months was most important individually (P = 0.0001), and no other period was jointly statistically significant. Conclusions: Results suggest that the middle of the first year of life is most important in fluorosis etiology for the primary dentition in this setting. [ABSTRACT FROM AUTHOR]

Objectives: Several studies have assessed people's esthetic perceptions of dental fluorosis, suggesting that concerns may be greater than believed previously. Few studies have assessed dental students' perceptions and none has done so over time. The purpose of this paper is to report on changes in dental students' esthetic perceptions of dental fluorosis and other conditions. Methods: Fourth-year dental students (n=45) completed questionnaires about computergenerated photographs of fluorosis and other conditions, using the same protocol as when they were entering dental students. Results were compared for each of the eight images at the individual level using paired statistical tests. Results: Although many patterns were generally consistent, there were a substantial number of differences in results over time, concerning both the mild fluorosis and non-fluorosis images. In general, students tended to score both fluorosis and non-fluorosis images more favorably as fourth-year students. When rating images from very pleased (1) to very embarrassed (10), fourth-year students rated the images significantly more favorably than they had done as first-year students for normal/control, incisal third only dental fluorosis, and a more generalized, mild fluorosis. Similarly, with a visual analog scale from satisfactory (0) to unsatisfactory (69), fourth-year students reported significantly lower (more favorable) scores than they had done as first-year students for the normal/control, diastema/no fluorosis, more involved mild fluorosis, and incisal third only mild fluorosis. There were no obvious changes in the relative levels of favorable evaluation of fluorosis vs. the other conditions. Conclusions: Fourth-year dental studens generally had more favorable esthetic perceptions of mild dental fluorosis and other conditions than they had reported as entering students. [ABSTRACT FROM AUTHOR]

Sugar-sweetened beverages (SSBs) have been associated with childhood caries; however, associations among lifelong beverage intakes and adolescent caries have received less attention. To investigate associations between beverage intakes during childhood and adolescence and caries experience at 17 years of age, while adjusting for fluoride intakes and toothbrushing. Descriptive model analyses were conducted on data collected from a longitudinal birth cohort study. Participants included Iowa Fluoride Study members (n = 318) recruited at birth between 1992 and 1995 with at least 6 beverage questionnaires completed from ages 1 to 17 years and a caries examination at age 17. Predictors included mean daily milk, juice (100% juice and juice drinks before age 9), SSB (including juice drinks after age 9), and water/sugar-free beverage (SFB) intakes; daily fluoride intakes; and daily toothbrushing frequencies for ages 1 to 17. The outcome was dental caries count at age 17, adjusted for the number of scored tooth surfaces (decayed and filled surfaces attack rate [DFSAR]). Univariable generalized linear models were fit for each predictor and the outcome DFSAR. Multivariable models assessed combined effects of beverage types, fluoride variables, toothbrushing, sex, and baseline socioeconomic status. Based on multivariable models, each 8 oz of additional daily juice and water/SFB decreased expected DFSAR by 53% (95% confidence interval [CI]: 17%-73%) and 29% (95% CI: 7%-46%), respectively, and 8 additional oz SSBs increased expected DFSAR by 42% (95% CI: 5%-92%), after adjustment for other beverage intakes, toothbrushing, total fluoride intake excluding SSB fluoride (non-SSB total fluoride), sex, and baseline socioeconomic status. Each additional daily toothbrushing event decreased expected DFSAR by 43% (95% CI: 14%-62%) after adjustment for beverage intakes, non-SSB total fluoride intake, sex, and baseline SES. Higher juice and water/SFB intakes and more toothbrushing were associated with lower caries at age 17, while higher SSB intakes were associated with higher caries. [ABSTRACT FROM AUTHOR]

Purpose: This study's purpose was to report on parents' esthetic perceptions of their children's mixed dentition and parental satisfaction changes over time. Methods: A total of 376 parents completed esthetic questionnaires concerning satisfaction with their children's teeth at 9- and 11-years-old. Changes in esthetic perceptions were compared based on fluorosis, nonfluoride opacity status (evaluated at 9-years-old), and other factors. Results: A total of 36% had definitive fluorosis on permanent maxillary incisors. Fluorosis (P=.003) and opacity (P=.02) status were significantly related to reduced likelihood of parental satisfaction at 11-years-old. Parents were less satisfied with overall tooth color at 11 vs 9-years-old (P=.045), but revealed no significant change in satisfaction with overall appearance (P=.17). Shape and color concerns increased (both P=.003), while spacing concerns decreased (P=.004). Parental satisfaction increases were associated with higher socioeconomic status (P=.03) and starting orthodontic treatment (P=.002), but changes were not significantly associated with fluorosis (P=.38) or opacities (P=.81). Conclusions: Parents were generally less satisfied with overall tooth color at 11 (vs 9) years old and had greater concerns about tooth shape and color, but fewer concerns with spacing. Improvement in parental satisfaction with overall appearance was related to higher socioeconomic status and having begun orthodontic treatment. [ABSTRACT FROM AUTHOR]