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INDICES USED FOR
DENTAL FLUOROSIS
BY
NITYA SHARMA
INTRODUCTION




INDEX : an index has been defined as a numerical
value describing the relative status of a population
o...
HISTORY









1888 : “KUHNS” described teeth of persons in
areas of Mexico that were opaque, discolored and
disfig...





In 1931 this condition of teeth was found to b
correlated to fluoride content of drinking water.
(Churchill 1931; ...
CLASSIFICATION OF
FLUOROSIS MEASURING
INDICES
FLUOROSIS
SPECIFIC

DESCRIPTIVE

DEAN’S INDEX

DEVELOPMENTAL
DEFECTS OF
ENAM...
DEAN’S FLUOROSIS INDEX


1934; TRENDLEY H.DEAN
devised an index for
assessing the presence and
severity of mottled enamel...
The fluorosis index set
criteria for categorisation of
dental fluorosis on a 7point
scale.

Although no numbers were
used ...
METHOD ( as implied by
DEAN)
Each individual recieves a score
corresponding to clinical appearance of two
most affected te...
• Slight
aberrations in
translucency
of normal
enamel
ranging from
few white
flecks to
occasional
white spots,
1-2mm in
di...
• Smoky white
appearance
• Pitting is
more
frequent and
generally
seen on all
surfaces
• Brown stain if
present has
more h...
Based on this index, Dean. Dixon and
Cohen(1935) proposed that their
classification should determine a mottled
enamel inde...




1939 Dean combined the “moderarely severe”
and “severe” into a single category “severe”.
1942 Dean introduced the re...
Deans revised index (1942)

NORMAL (0) The
enamel represents the
usual translucent
semivitriform type of
structure. The su...
QUESTIONABLE(0.5) The enamel
discloses slight aberrations from the
translucency of normal enamel,
ranging from a few white...
VERY MILD (1) Small, opaque, paper
white areas scattered irregularly over
the tooth , but not involving as much as
approxi...
MILD (2)The white opaque
areas in the enamel of
teeth are more extensive
but do not involves as
much as 50% of tooth.
MODERATE (3) All enamel
surfaces of the teeth are
affected and surfaces subject
to attrition show wear. Brown
stain is fre...
SEVERE (4) All enamel surfaces
of the tooth are affected and
hypoplasia is so marked that the
general form of the tooth ma...
MODIFICATIONS


Moller (1965) in Denmark introduced three
intermediate classifications and variations in
the weightings t...
USES












Most widely used index to measure dental
fluorosis.
Helped to indicate prevalence of moderate to
s...
The National Survey of Children‟s Dental
Health in Ireland in 1984 measured fluorosis
using Dean‟s index to provide baseli...
LIMITATIONS
Does not give sufficient information on distribution
of fluorosis withtin the dentition.
 Isolated defects ar...
COMMUNITY FLUOROSIS
INDEX




1942 , based on the revised fluorosis index
scale , he developed a scoring system so as to...
RANGE OF SCORES FOR CFI

SIGNIFICANCE



0.0 – 0.4



0.4 – 0.5



0.5 – 1.0





1.0 – 2.0





2.0 – 3.0





3...








It gives an indication of public health significance
of fluorosis.
It was used by Galagan and Lamson (1953) in...
THYLSTRUP – FEJERSKOV
CLASSIFICATION OF
FLUOROSIS


1978 ; Thylstrup and Frejeskov suggested a
10point classification sys...
Plane mirror n
probes are used
Prior to
examination the
teeth are dried
with cottonwool
rolls

Examination is
done on a
po...
THYLSTRUP – FEJERSKOV
CLASSIFICATION OF
FLUOROSIS
Score

Criteria


0
1

.



Normal translucency
of enamel remains
afte...
Score


2

Criteria

Smooth surfaces;
More pronounced lines
of opacity which follow
the perikymata.
Occasionally,
conflue...
Score


3

Criteria

Smooth surfaces:
Merging and irregular
cloudy areas of opacity.
Accentuated drawing of
perikymata of...
Score


4

Criteria

Smooth surfaces:
The entire surface exhibits
marked opacities or
appears chalky white.
Parts of surf...
Score


5

Criteria


Smooth and
Occlusal surfaces:
Entire surface
displays marked
opacity with focal
loss of outermost
...
Score


6



7

Criteria
Smooth surfaces: Pits are
regularlyarranged in
horizontal bands 2mm in
vertical extension.
Occl...
Score


8



9

Criteria

Smooth and Occlusal
surfaces: Loss of
outermost enamel
involving half of the
surface.
Smooth a...
Advantages






It attempts to validate the visual appearance
against the histological defect.
Most sensitive of all f...


Cleaton-Jones and Hargreaves (1990)
compared the three fluorosis indexes (DEAN,
T-F and TSIF) in deciduous dentition,
r...
USES






To assess the impact of enamel fluorosis in three
communities examined in project FLINT.(
Sigourjon’s H et a...
Disadvantages


Clarkson (1989) reported that in TF index
drying of teeth creates an unnatural situation
due to which cha...
TOOTH SURFACE FLUOROSIS
INDEX
It was developed by HOROWITZ et al. in 1984
at National Institute of Dental Research U.S.A
A...
Numerical score

Descriptive Criteria

0



1



Enamel shows no evidence of
fluorosis
Enamel shows definite
evidence of...


2



3



4

Parchment – white fluorosis
totals at least 1/3 of the
visible enamel surface, but
less than 2/3
Parchme...


5



6



7

Discrete pitting of enamel exists,
unaccompanied
by
evidence of staining of
intact enamel. A pit is
defi...
Intent to use






TSIF index - studies in which an aesthetic basis is
desired for defining case and it may be used
wh...
FLUOROSIS RISK INDEX
Introduced by DAVID G. PENDRYS in 1990
AIM
To improve researcher‟s ability to relate the risk
of fluo...
Incisal edges of 11
21 32 31 41 42 and
occlusal tables of 16
26 36 46.

FR1- those begin
to form in first year
of life

Su...
FR 1

112

FR 2

UNASSIGN
ED

•1O

•48
•54
SCORING CRITERIA

NEGATIVE
FINDING

SCORE =0

Complete
absence of any
white spots or
striations.
SCORE = 1

White
spots, striations
or fluorotic
defects that
cover 50% or
less surface zone

SCORE = 7

Any surface
that h...
SCORE = 2

A surface
zone with
greater than
50% of zone
displaying
parchment
white
striations.

SCORE =
3

Surface
zone wi...
SURFACE ZONE
EXCLUDED

SCORE = 9

Incomplete
eruption ,
orthodontic
appliances and
bands, surface
crowned or
restored, gro...
CASES

Subject who has a
positive score on 2 or
more enamel surface
zones

CONTROLS

Subject who has no
positive or
questi...


To obtain the FRI score for each individual the
scores of classification 1 and 2 are combined
into one summary score.
USES
Risk factors for enamel fluorosis in a
fluoridated population. (Pendrys DG, Katz RV,
Morse DE. 1994)
 Risk factors f...
DEVELOPMENTAL DEFECTS OF
INDEX


The developmental defects of enamel was
developed by “ FDI – Commission on Oral
Health, ...
PROCEDURE

Tooth surface is
inspected visually
and defective areas
are tactilely
explored with a
probe.

Natural or artifi...
CODING AND CRITERIA









Unerupted, missing, heavily restored , bacle
decayed , fractured teeth and teeth or toot...
TYPE OF DEFECT
• OPACITY
• HYPOPLASIA
• DISCOLORATION

NUMBER
• SINGLE
• MULTIPLE

DEMARCATION
• DEMARCATED
• DIFFUSE

LOC...
MODIFICATIONS





Clarkson J.J and O‟Mullane D.M in 1989
modified the DDE to be used in one of the two
manners
General...
General purpose
epidemiological studies












NORMAL
DEMARCATED OPACITY
White/cream
Yellow/brown
DIFFUSE OP...






HYPOPLASIA
Pits
Missing enamel
ANY OTHER
DEFECTS





Code 7
Code 8
Code 9
Extent of defect






Normal
< 1/3rd
At least 1/3rd < 2/3rd
At least 2/3rd







Code 0
Code 1
Code 2
Code 3
Screening surveys









NORMAL
DEMARCATED
OPACITY
DIFFUSE OPACITY
HYPOPLASIA PITS
OTHER DEFECTS









CODE...




In UK, DDE has been the most frequently used
index
However since it is not fluorosis specific , it is
difficult to a...
YOUNG’S CLASSIFICATION OF
ENAMEL FLUOROSIS





Developed by YOUNG M.A in 1973.
Similar classification was developed by...
TYPE A

TYPE B

• White areas less than 2mm in diameter
• White areas of > 2mm diameter

TYPE C

• Colored areas <2mm in d...
TYPE E

TYPE F

• Horizontal white lines irrespective of
there being any non linear lines

• Colored or white lines or are...
MURRAY AND SHAW’S
CLASSIFICATION OF ENAMEL
FLUOROSIS



Developed by Murray J.J and Shaw L in 1979.
Based on young‟s cla...
REFERENCES








Whelton HP;Ketley CE;Mcsweeny F;O’Mullane
DM; A review on fluorosis in European
Union:prevelance ri...




R.G Rosier, Epidemiologic Indices for
Measuring the Clinical Manifestations of
Dental Fluorosis: Overview and Critiq...






Steven M. Levy; Liang Hong; John J.
Warren;Barbara Broffitt; Use of the Fluorosis
Risk Index in a Cohort Study:Th...


R. Gary Rozier; The Prevalence and Severity
of Enamel Fluorosis in North American
Children; Vol. 59, No. 4, Fall 1999
indices measuring dental fluorosis
indices measuring dental fluorosis
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  1. 1. INDICES USED FOR DENTAL FLUOROSIS BY NITYA SHARMA
  2. 2. INTRODUCTION   INDEX : an index has been defined as a numerical value describing the relative status of a population on a graduated scale with definite upper and lower limits which is designed to permit and facilitate comparison with other populations classified by same criteria and methods.(Russel) DENTAL FLUOROSIS : is a hypoplasia or hypomineralisation of tooth enamel or dentine produced by the chronic ingestion of excessive amounts of fluoride during the period when teeth are developing.
  3. 3. HISTORY      1888 : “KUHNS” described teeth of persons in areas of Mexico that were opaque, discolored and disfigured. (Kuhns1888; Moller 1982). 1901 Dr. Fredrick Mckay of Colorado USA discovered permanent stains on teeth of his patients which were referred as Colorado stains. Mckay named then “mottled enamel”. An Assitant surgeon of U.S marine hospital service reported similar condition in Italians emigrating from USA from Naples named it denti di chiaie. ( Eager 1901). 1916 Mckay and Black published a series of articles in dental cosmos.
  4. 4.    In 1931 this condition of teeth was found to b correlated to fluoride content of drinking water. (Churchill 1931; Smith et al 1931) 1931 shoe leather survey by Trendley H. Dean 1934 DEAN‟S FLUOROSIS INDEX was given by Trendley H.Dean
  5. 5. CLASSIFICATION OF FLUOROSIS MEASURING INDICES FLUOROSIS SPECIFIC DESCRIPTIVE DEAN’S INDEX DEVELOPMENTAL DEFECTS OF ENAMEL INDEX THYLSTRUP AND FERJESKOV TOOTH SURFACE INDEX FOR FLUOROSIS FLUOROSIS RISK INDEX JACKSON AlALOUSI INDEX MURRAY SHAW INDEX
  6. 6. DEAN’S FLUOROSIS INDEX  1934; TRENDLEY H.DEAN devised an index for assessing the presence and severity of mottled enamel.
  7. 7. The fluorosis index set criteria for categorisation of dental fluorosis on a 7point scale. Although no numbers were used it was considered to be on ordinal scale. SALIENT FEATURES Children who had not lived in the community continously or had obtained domestic water from other than public supply are eliminated Under his classification all those showing hypoplasia other than mottling of enamel were placed in normal category
  8. 8. METHOD ( as implied by DEAN) Each individual recieves a score corresponding to clinical appearance of two most affected teeth. • Examinations are made in good natural light with the subject sitting facing the window No specific information as to whether the teeth were cleaned or dried before examination is given • Mouth mirror and probes were utilised for examination.
  9. 9. • Slight aberrations in translucency of normal enamel ranging from few white flecks to occasional white spots, 1-2mm in diameter. VERY MILD • The enamel represents the usual transluceny semivitriform type of structure • The surface is smooth, glossy and usually of pale creamy white color QUESTIONABLE NORMAL CLASSIFICATION AND CRITERIA • Small, opaque, paper white ares are scatterd irregularily or streaked over the tooth surface • Observed on labial and buccal surfaces ; <25% of teeth surface involved. • Small pitted white areas are frequently found on summits of cusps • No brown stain
  10. 10. • Smoky white appearance • Pitting is more frequent and generally seen on all surfaces • Brown stain if present has more hue and involves all surfaces SEVERE • No change in form of tooth but all surfaces are involved • Surfaces subjected to attrition are definitely marked • Minute pitting is present on buccal n labial surfaces MODERATELY SEVERE MODERATE MILD • White opaque areas involve half of tooth surface. • Surfaces of cuspids n bicuspids prone to attrition show thin white layers worn off and bluish shades of normal enamel • Faint brown stains are apparent • Form of teeth are affected. • Pits are deeper and confluent • Stains are widespread and range from choclate brown to almost black
  11. 11. Based on this index, Dean. Dixon and Cohen(1935) proposed that their classification should determine a mottled enamel index of a community for epidemiological purpose negative boderline Slight Medium Rather marked Very marked
  12. 12.   1939 Dean combined the “moderarely severe” and “severe” into a single category “severe”. 1942 Dean introduced the revised scale for fluorosis index where now he used the six point scale.
  13. 13. Deans revised index (1942) NORMAL (0) The enamel represents the usual translucent semivitriform type of structure. The surface is smooth , glossy and usually of a pale, creamy white colour.
  14. 14. QUESTIONABLE(0.5) The enamel discloses slight aberrations from the translucency of normal enamel, ranging from a few white fleck to occasional white spots. This classification is used in those instances where a definite diagnosis of the mildest form of fluorosis is not warranted and a classification of “normal” not justified.
  15. 15. VERY MILD (1) Small, opaque, paper white areas scattered irregularly over the tooth , but not involving as much as approximately 25% of tooth surface. Frequently included in this classification are teeth showing no more than about 1-2 mm of white opacity at the tip of the summit of the cusps of bicuspids or second molars.
  16. 16. MILD (2)The white opaque areas in the enamel of teeth are more extensive but do not involves as much as 50% of tooth.
  17. 17. MODERATE (3) All enamel surfaces of the teeth are affected and surfaces subject to attrition show wear. Brown stain is frequently a disfiguring feature.
  18. 18. SEVERE (4) All enamel surfaces of the tooth are affected and hypoplasia is so marked that the general form of the tooth may be affected. The major diagnostic sign of this classification is discrete or confluent pitting. Brown stains are widespread and teeth often present a corroded-like appearance.
  19. 19. MODIFICATIONS  Moller (1965) in Denmark introduced three intermediate classifications and variations in the weightings to be ascribed to each category.
  20. 20. USES        Most widely used index to measure dental fluorosis. Helped to indicate prevalence of moderate to severe fluorosis in many communities as Sweden by Forsman in 1974 Austria by Binder in 1973 England by Murray et al(1956), Forrest (1965), Goward (1976) USA by Galagan and Lamson (1953) India by Nanda et al (1974)
  21. 21. The National Survey of Children‟s Dental Health in Ireland in 1984 measured fluorosis using Dean‟s index to provide baseline data for future refernce. ( Whelton HP;Ketley CE;Mcsweeny F;O’Mullane DM;2004)  National Fluorosis Survey in USA in 1986-87 to note baseline values was done using Dean‟s index. 
  22. 22. LIMITATIONS Does not give sufficient information on distribution of fluorosis withtin the dentition.  Isolated defects are not recorded.  The distinction amongst the categories is unclear, indistinct and lacking sensitivity.  Even though Dean‟s scale is ordinal , it involves averaging of the scores which is inappropriate. (A. Rizan Mohamed,W. Murray Thomson;Timothy D. Mackay, An epidemiological comparison of Dean’s index and the Developmental Defects of Enamel (DDE) index; JPHD ISSN 0022-4006) 
  23. 23. COMMUNITY FLUOROSIS INDEX   1942 , based on the revised fluorosis index scale , he developed a scoring system so as to derive a COMMUNITY FLUOROSIS INDEX . On basis of the number and distribution of individual scores, a community index for dental fluorosis (Fci) can be calculated by the formula Fci = sum of( no. of individuals*stastical weights)/ no. of individuals examined
  24. 24. RANGE OF SCORES FOR CFI SIGNIFICANCE  0.0 – 0.4  0.4 – 0.5  0.5 – 1.0   1.0 – 2.0   2.0 – 3.0   3.0 – 4.0    Negative Borderline Slight Medium Marked Very Marked
  25. 25.     It gives an indication of public health significance of fluorosis. It was used by Galagan and Lamson (1953) in their investigation of climate and endemic fluorosis. Minoguchi (1970) refined the above analysis to take into account the total fluoride content from the diet by a community. Myers(1978) suggested a graphic method of abtaining optimal fluoride concentration by comparing CFI against water fluoride content at different temperatures.
  26. 26. THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS  1978 ; Thylstrup and Frejeskov suggested a 10point classification system designed to categorise the degree of fluorosis affecting buccal/lingual and occlusal surfaces.
  27. 27. Plane mirror n probes are used Prior to examination the teeth are dried with cottonwool rolls Examination is done on a portable chair out in daylight. SALIENT FEATURES
  28. 28. THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS Score Criteria  0 1 .  Normal translucency of enamel remains after prolonged air – drying Narrow white lines located corresponding to the perikymata.
  29. 29. Score  2 Criteria Smooth surfaces; More pronounced lines of opacity which follow the perikymata. Occasionally, confluence of adjacent lines. Occlusal surfaces: Scattered areas of opacity of 2mm in diameter and pronounced opacity of cuspal ridges.
  30. 30. Score  3 Criteria Smooth surfaces: Merging and irregular cloudy areas of opacity. Accentuated drawing of perikymata often visible between opacities. Occlusal surfaces : Confluent areas of marked opacity. Worn areas appear almost normal but usually circumscribed by a rim of
  31. 31. Score  4 Criteria Smooth surfaces: The entire surface exhibits marked opacities or appears chalky white. Parts of surface exposed to attrition appear less affected. Occlusal surfaces : Entire surface exhibits marked opacity. Attrition is often pronounced shortly after eruption.
  32. 32. Score  5 Criteria  Smooth and Occlusal surfaces: Entire surface displays marked opacity with focal loss of outermost enamel (pits) 2mm in diameter.
  33. 33. Score  6  7 Criteria Smooth surfaces: Pits are regularlyarranged in horizontal bands 2mm in vertical extension. Occlusal surfaces: Confluent areas 3mm in diameter exhibit loss of enamel. Marked attrition Smooth surfaces: Loss of outermost enamel in irregular areas involving half of the entire surface. Occlusal surfaces: Changes in the morphology caused by the merging pits and marked attrition.
  34. 34. Score  8  9 Criteria Smooth and Occlusal surfaces: Loss of outermost enamel involving half of the surface. Smooth and Occlusal surfaces: Loss of main part of enamel with change in anatomic appearance of surfaces. Cervical rim of almost unaffected enamel is often noted
  35. 35. Advantages    It attempts to validate the visual appearance against the histological defect. Most sensitive of all fluorosis measuring indices. Granath et al. (1985), comparing the DEAN and T-F indexes, concluded that the latter was more detailed and sensitive because it was based on biological aspects where there is an increase in hypo mineralization with a simultaneous increase in the depth of the enamel surface in direction of the amelodentin junction.
  36. 36.  Cleaton-Jones and Hargreaves (1990) compared the three fluorosis indexes (DEAN, T-F and TSIF) in deciduous dentition, reporting that the prevalence of fluorosis in individual teeth was more frequently diagnosed with the T-F index. They concluded that the T-F index is the most indicated for work where detailed information about the problem is required.
  37. 37. USES    To assess the impact of enamel fluorosis in three communities examined in project FLINT.( Sigourjon’s H et al 2004) Clark et al 1993 showed an increasing level of dissatisfaction by both parents and children with appearance as the child‟s TSIF index grade rose. Burger et al. (1987), recommended the T-F index for future field studies, due to the facility of use and better defined criteria.
  38. 38. Disadvantages  Clarkson (1989) reported that in TF index drying of teeth creates an unnatural situation due to which changes in score 1 and 2 are very minor. The aesthetic significance of these changes are questionable.
  39. 39. TOOTH SURFACE FLUOROSIS INDEX It was developed by HOROWITZ et al. in 1984 at National Institute of Dental Research U.S.A AIM 
  40. 40. Numerical score Descriptive Criteria 0  1  Enamel shows no evidence of fluorosis Enamel shows definite evidence of fluorosis namely areas with parchment-white colour that total less than one third of the visible enamel surface. Includes fluorosis confined only to incisal edges of anterior teeth and cusp tips of posterior teeth (Snow
  41. 41.  2  3  4 Parchment – white fluorosis totals at least 1/3 of the visible enamel surface, but less than 2/3 Parchment – white fluorosis totals at least 2/3 of visible enamel surface. Enamel shows staining in conjunction with any of the preceding levels of fluorosis. Staining is defined as an area of definite discoloration that may range from light to very dark brown.
  42. 42.  5  6  7 Discrete pitting of enamel exists, unaccompanied by evidence of staining of intact enamel. A pit is defined as a definite physical defect in the enamel surface with a rough floor that is surrounded by intact enamel. The pitted area is usually stained or differs in colour from the surrounding enamel. Both discrete pitting and staining of the intact enamel exist. Confluent pitting of the enamel surface exist. Large areas of enamel may be missing and anatomy of tooth
  43. 43. Intent to use    TSIF index - studies in which an aesthetic basis is desired for defining case and it may be used where risk factors are identified or when the teeth may not be cleaned and dried. (Antonio Carlos PEREIRA Ben-Hur Wey MOREIRA 1999) It doesnot have questionable category as in Dean‟s index and is based on the premise that any sign of fluorosis regardless of extent is positive for a case The TSIF described by Horowitz et al. makes a useful contribution because it provides clearer diagnostic criteria and provides for an analysis based on esthetic concerns. .( R.Gary Rozier 1999)
  44. 44. FLUOROSIS RISK INDEX Introduced by DAVID G. PENDRYS in 1990 AIM To improve researcher‟s ability to relate the risk of fluorosis to developmental stage of permanent dentition at the time of exposure to fluorosis. 
  45. 45. Incisal edges of 11 21 32 31 41 42 and occlusal tables of 16 26 36 46. FR1- those begin to form in first year of life Surface zones which donot come under above groups are left unassigned FR2- those who donot begin to form until 2nd year of life Cervical third of incisors,mi ddle third of canines, occlusal table,incisal third and middle third of bicuspid and 2nd molars
  46. 46. FR 1 112 FR 2 UNASSIGN ED •1O •48 •54
  47. 47. SCORING CRITERIA NEGATIVE FINDING SCORE =0 Complete absence of any white spots or striations.
  48. 48. SCORE = 1 White spots, striations or fluorotic defects that cover 50% or less surface zone SCORE = 7 Any surface that has an opacity that appears to be a non fluoride opacity QUESTIONABLE
  49. 49. SCORE = 2 A surface zone with greater than 50% of zone displaying parchment white striations. SCORE = 3 Surface zone with greater than 50% of zone that displays pitting, staining and deformity POSITIVE FINDING Incisal edges and occlusal tables with greater than 50% of surface marked by snowcapping
  50. 50. SURFACE ZONE EXCLUDED SCORE = 9 Incomplete eruption , orthodontic appliances and bands, surface crowned or restored, gross plaque and debris
  51. 51. CASES Subject who has a positive score on 2 or more enamel surface zones CONTROLS Subject who has no positive or questionable scores on any enamel surface zones CLASSIFICATION 1
  52. 52.  To obtain the FRI score for each individual the scores of classification 1 and 2 are combined into one summary score.
  53. 53. USES Risk factors for enamel fluorosis in a fluoridated population. (Pendrys DG, Katz RV, Morse DE. 1994)  Risk factors for enamel fluorosis in a nonfluoridated population. (Pendrys DG, Katz RV, Morse DE1999)  The Iowa Fluoride Study(2005) (Steven M. Levy; Liang Hong,; John J. Warren, Barbara Broffitt,) 
  54. 54. DEVELOPMENTAL DEFECTS OF INDEX  The developmental defects of enamel was developed by “ FDI – Commission on Oral Health, Research and Epidemiology” in 1982 to avoid need for diagnosing fluorosis before recording enamel opacities.
  55. 55. PROCEDURE Tooth surface is inspected visually and defective areas are tactilely explored with a probe. Natural or artificial light Teeth should receive a prophylaxis and be dried at time of examination
  56. 56. CODING AND CRITERIA      Unerupted, missing, heavily restored , bacle decayed , fractured teeth and teeth or tooth surfaces which for any other reason cannot be classified with defects must be coded ‘X‟. Permanent teeth are number coded. Primary teeth are letter coded. When in doubt the tooth surface should be scored „normal’. when an abnormality is present but cannot be classified into listed categories, it should be scored as „other defects’.
  57. 57. TYPE OF DEFECT • OPACITY • HYPOPLASIA • DISCOLORATION NUMBER • SINGLE • MULTIPLE DEMARCATION • DEMARCATED • DIFFUSE LOCATION OF DEFECTS • GINGIVAL OR INCISAL HALF • OCCLUSAL • CUSPAL • WHOLE SURFACE
  58. 58. MODIFICATIONS    Clarkson J.J and O‟Mullane D.M in 1989 modified the DDE to be used in one of the two manners General purpose epidemiology studies Screening surveys
  59. 59. General purpose epidemiological studies          NORMAL DEMARCATED OPACITY White/cream Yellow/brown DIFFUSE OPACITY Diffuse lines Diffuse patchy Diffuse confluent Confluent +Staining+loss Of Enamel  Code 0  Code 1 Code 2   Code 3 Code 4 Code 5  Code 6  
  60. 60.     HYPOPLASIA Pits Missing enamel ANY OTHER DEFECTS    Code 7 Code 8 Code 9
  61. 61. Extent of defect     Normal < 1/3rd At least 1/3rd < 2/3rd At least 2/3rd     Code 0 Code 1 Code 2 Code 3
  62. 62. Screening surveys      NORMAL DEMARCATED OPACITY DIFFUSE OPACITY HYPOPLASIA PITS OTHER DEFECTS      CODE 0 CODE 1 CODE 2 CODE 3 CODE 4
  63. 63.   In UK, DDE has been the most frequently used index However since it is not fluorosis specific , it is difficult to analyze prevalence of fluorosis from this index.
  64. 64. YOUNG’S CLASSIFICATION OF ENAMEL FLUOROSIS    Developed by YOUNG M.A in 1973. Similar classification was developed by AlLousi et al in 1975. Recording of any Principle condition once defined must be made on baisi of that definition and not on basis of presumed etiology.
  65. 65. TYPE A TYPE B • White areas less than 2mm in diameter • White areas of > 2mm diameter TYPE C • Colored areas <2mm in diameter irrespective of white areas. TYPE D • Colored areas of <2mm diameter irrespective of area covered
  66. 66. TYPE E TYPE F • Horizontal white lines irrespective of there being any non linear lines • Colored or white lines or areas associated with pits or hypoplastic areas
  67. 67. MURRAY AND SHAW’S CLASSIFICATION OF ENAMEL FLUOROSIS   Developed by Murray J.J and Shaw L in 1979. Based on young‟s classification with two modifications Colored flecks and patches were combined into one group Occlusal and lingual/palatal surfaces were also included
  68. 68. REFERENCES     Whelton HP;Ketley CE;Mcsweeny F;O’Mullane DM; A review on fluorosis in European Union:prevelance risk factors and aesthetic issues,CDOE2004,32;9-18. Antonio Carlos PEREIRA ;Ben-Hur Wey MOREIRA; Analysis of Three Dental Fluorosis Indexes Used in Epidemiologic Trials, Braz Dent J (1999) 10(1): 1-60 Pendrys DG, Katz RV, Morse DE. Risk factors for enamel fluorosis in a fluoridated population. Am J Epidemiol 1994;140:461-71. Pendrys DG, Katz RV, Morse DE. Risk factors for enamel fluorosis in a nonfluoridated population. Am J Epidemiol1996;143:808-15.
  69. 69.   R.G Rosier, Epidemiologic Indices for Measuring the Clinical Manifestations of Dental Fluorosis: Overview and Critique; ADR June 1994 vol. 8 no. 1 39-55. A. Rizan Mohamed;W. Murray Thomson, ;Timothy D. Mackay; An epidemiological comparison of Dean‟s index and the Developmental Defects of Enamel (DDE) index; doi: 10.1111/j.1752-7325.2010.00186.x
  70. 70.    Steven M. Levy; Liang Hong; John J. Warren;Barbara Broffitt; Use of the Fluorosis Risk Index in a Cohort Study:The Iowa Fluoride Study;JPHD Vol. 66, No. 2, Spring2006. David G. Pendrys; Analytical Studies of Enamel Fluorosis: Methodological Considerations.oxford journals Vol. 21, No. 2. Chankanka O, Levy SM, Warren JJ, Chalmers JM. A literature review ofaesthetic perceptions of dental fluorosis and relationships with psychosocialaspects ⁄ oral health-related quality of life.CDOE 2010. 38: 97–109
  71. 71.  R. Gary Rozier; The Prevalence and Severity of Enamel Fluorosis in North American Children; Vol. 59, No. 4, Fall 1999

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