Flourides and oral health

FLOURIDES AND ORAL HEALTH: IN
PRESENT SCENARIO IN DEVELOPED
AND DEVELOPING COUNTRIES
PRESENTED BY- DR. ILA VERMA (JR III)
MODERATED BY- DR. SHREYA SINGH
2

CONTENTS
1. Introduction
2. Present Scenario Of Oral Disease Burden In Developing And
Developed Countries
3. Historical Evolution of Fluoride
4. Fluoride & Oral Health: Brief
5. Fluoride and Dental Caries
6. Fluoride and Periodontal Health
7. Fluoride and Orthodontic Anomalies
3

7. Delivery Method of Fluoride
8. Global Scenario of Water Fluoridation
9. Global scenario of the intensity and severity of excess ﬂuoride
in drinking water
10. Water Fluoridation in India
11. Salt Fluoridation in Developed and Developing Countries
12. Fluoridated Toothpaste In Developed And Developing
Countries
4
CONTENTS

13. Present Scenario Of Use Of Professionally Applied Topical
Fluoride In Developing & Developed Countries
14. Oral Health through Fluoride
15. Significance Of Fluoride In Public Health
16. Conclusion
17. References
CONTENTS
5

PRESENT SCENARIO OF ORAL DISEASE BURDEN IN
DEVELOPING AND DEVELOPED COUNTRIES
6
Changing levels of dental caries experience (Decayed, Missing and Filled Teeth
(DMFT) index) among 12-years old in developed and developing countries
Peterson P E et al.The global burden of oral diseases and risks to oral health. Bulletin of the World Health Organization.2005 ;83: 661-689.

7
National Oral HealthSurvey& Fluoride Mapping-2003

HISTORICAL EVOLUTION OF FLUORIDE
• In 1901 Dr. Federick Mckay- “Colorodo Stains” minute white flecks,
yellow or brown spots scattered..
• In 1902 Dr. J.M. Eager noticed in Italian emigrants -“denti di chiaie”
• 1916, Dr. Green supported Mckay work with histologic evidence “ an
endemic imperfection of the enamel of the tooth
• In 1918 Dr. O. E. Martin and Mckay- Britton (1898) changed water
supply from shallow wells to deep drilled artesian wells….
• 1931 Mr. H. V. Churchill- spectrographic analysis of rare element present
in Bauxite water at a level of 13.7ppm
1. Tewari A. Fluorides and Dental Caries. A Compendium. Journal of Indian Dental Association.1986.
8

• In 1933, Dr. H. Trendley Dean- conducted “Shoe Leather Survey” in 97
localities, with an aim to find out minimal threshold level.
• In 1934, Dean developed a standard classification of mottling- mottling index.
• In 1939 came out with ‘domestic water is primary cause of human mottled
enamel (dental fluorosis).
• In the same year- hypothesis showing ‘inverse relationship between endemic
fluorosis and dental caries’
• In 1942, milestone discovery was made that 1ppm of fluoride in drinking water
results in maximal reduction(60%) of caries experience.
1. Tewari A. Fluorides and Dental Caries. A Compendium. Journal of Indian Dental Association.1986.9

Fluoride & Oral Health: Brief
• The discovery during the first half of the 20th century of the link
between natural fluoride, adjusted fluoride levels in drinking water and
reduced dental caries prevalence proved to be a stimulus for worldwide
on-going research into the role of fluoride in improving oral health.
• The use of fluorides, whether through community programmes,
professionally applied or self-applied, have been shown to be effective in
reducing dental caries in children and adolescents, it is not unreasonable
to speculate that this public health measure have a positive impact on the
oral health.
O'Mullane DM, Baez RJ, Jones S, et al. Fluoride and Oral Health. Community Dent
Health. 2016;33(2):69-99 10

• The major reasons for the burden of dental caries in countries relate to
the high consumption of sugars and inadequate exposure to fluoride.
• The use of fluoride is a major breakthrough in public health. Controlled
addition of fluoride to drinking water supplies in communities where
fluoride concentration is below optimal levels to have a cariostatic effect
began in the 1940s and since then extensive research has confirmed the
successful reduction in dental caries in many countries.
• The prevalence of dental caries is inversely related to the concentration
of fluoride in drinking water; while there is a dose-response relationship
between the concentration of fluoride in drinking water and the
prevalence of dental fluorosis
Fluoride & DENTAL CARIES
6. Petersen P E ,Ogawa H. Prevention of dental caries through the use of ﬂuoride – the WHO
approach. Community Dental Health. 2016; 33: 66–68.
11

• The mechanisms by which fluoride increases caries resistance may arise
from both systemic and topical applications of fluoride. A number of
proposed mechanisms are as follows-
1. Increase enamel resistance (or) Reduction in enamel solubility
2. Increased rate of posteruptive maturation
3. Remineralization of incipient lesions
4. Interference with plaque microorganisms
5. Modification in tooth morphology
mechanism of action of Fluoride
12

1. Burt BA, Eklund. Community, dentistry and the dental practice. 13

1. Burt BA, Eklund. Community, dentistry and the dental practice. 14

Fluoride interferes with oral bacteria
in two ways
Fluoride helps in retarding
acid formation
It helps control the growth of bacteria
without destroying them.
1. Fejerskov O, Ekstrand J, Burt BA. Fluoride in Dentistry. Second ed. Copenhagen: Munksgaard, 1996.
15

MODIFICATION IN TOOTH
MORPHOLOGY
• There is a direct relationship between the amount of fluoride ingested
during tooth development and the incidence of dental caries.
1. Fejerskov O, Ekstrand J, Burt BA. Fluoride in Dentistry. Second ed. Copenhagen: Munksgaard, 1996.
16

• Fluoridated drinking water may affect periodontal disease through direct
or indirect mechanisms.
• Direct effects may occur if fluoridation decreases the amount of
adherence of plaque or if fluorosed teeth inhibit plaque.
• Fluoridation may also affect indirectly on the periodontal tissue by
reducing caries and the amount of restorative treatment. If fluoridation
reduces interproximal caries, fewer restorations may be placed on
smooth tooth surfaces, resulting in less subgingival calculus.
Fluoride & PERIODONTAL HEALTH
6. Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Fluoride - an adjunctive therapeutic agent for periodontal disease?
Evidence from a cross-sectional study. Med Oral Patol Oral Cir Bucal. 2009 Oct 1;14 (10):e547-53. 17

• Similarly, if fluoridation decreases interproximal restorations, fewer
overhangs may occur, this may reduce attachment loss, pocket depth and
the number of interproximal bleeding sites.
• Study conducted by Jiraskova (1961) in Czechoslovakia, as well as
Englander & White (1963) in the USA, found the periodontium to be in
better condition among teenagers living in fluoride rich districts than
among those in fluoride-poor districts, in regard to the no. of teeth
affected per person and the percentage of subjects with periodontal
pockets.
Fluoride & PRIODONTAL HEALTH
6. Fluorides and Human Health. WHO Geneva 1994. 18

• Study conducted by Kumar S (2009) to assess the influence of the water
fluoride level on periodontal status, by determining the periodontal health
status of subjects residing in low, optimum and high fluoride areas
showed the subjects had a higher risk of having periodontal attachment
loss of more than 8mm if they lived in low fluoride area.
• It was evident from the results of this study that as the fluoride level in
drinking water increased the periodontal status improved.

• When fluoride ingestion from water is adequate, there is less undesirable
migration and tilting in the remaining teeth after loss of individual milk
teeth and permanent teeth than there is when fluoride poor water is
consumed. As a result anomalies of occlusion are also rarer.
• The effect of fluoride on orthodontic tooth movement was previously
investigated by Hellsing and Hammarstrom (1991) who reported that
fluoride, delivered via a subcutaneous osmotic pump in rats, reduced the
rate of tooth movement. In addition, it was found that the number of
osteoclasts on the pressure side of the PDL decreased significantly.
Fluoride & Orthodontic Anomalies

• Thus, in Evanston, the frequency of malocclusion among 6-8
years old children fell after 8 years of fluoridation from
37.51% to 29.54% and among 12-14 years old children, after
10 years of fluoridation, from 55.83% to 46.32%.

DIFFERENT FLUORIDE DELIVERY METHODS
Community water
fluoridation
Salt fluoridation
Milk fluoridation
Fluoride tablets /
lozenges / drops
SYSTEMIC FLUORIDES
PROFESSIONALLY APPLIED
Aqueous solutions & gels
Fluoride varnishes
Fluoridated prophylactic
pastes
SELF APPLIED
Fluoride rinse
Fluoride dentrifices
Fluoride gels
TOPICAL FLUORIDES
1. Norman O Harris. Primary preventive dentistry. Prentice hill. 6th edition. 22

WATER FLUORIDATION
• Water fluoridation is defined as
23

• Currently about 372 million people (around 5.7% of the world
population) receive artificially-fluoridated water in about 24 countries,
including Australia(D), Brazil, Canada(D), Chile, Republic of Ireland(D),
Malaysia, the U.S.(D), and Vietnam. With 57.4 million people who
receive naturally occurring fluoridated water at or above optimal levels in
countries such as Sweden(D), China, Sri Lanka, Finland(D), Zimbabwe
and Gabon. Community water fluoridation is rare in Continental Europe
with 97–98% choosing not to fluoridate drinking water
Global scenario of water FLUORIDATION
24

• Countries practicing artificial water fluoridation vary in their
recommended fluoride levels according to what health authorities in each
have determined to be most effective for its citizens.
• The US recently reset the recommended optimal level of fluoride[0.7
milligrams per liter of water (mg/L)] in drinking water, lowering it
slightly, because of observed increased Fluorosis levels, likely due to
additional fluoride sources like toothpaste and mouthwash which were
not present when this level was originally set.
25

• Nine developed (industrialized) countries showed apparent substantial
reduction (30-50 per cent) in the prevalence of dental caries in 5 and 12
year old children during the past decade.
• The countries are: Australia, Denmark, Finland, Netherlands, New
Zealand, Norway, Sweden, United Kingdom and the USA. Caries in
Thailand and Nigeria and other developing countries appear to have
increased considerably.
Renson CE. Changing patterns of dental caries: a survey of 20 countries. Ann Acad Med Singap. 1986;15(3):284-298
26

• The most probable reasons for the decrease in dental caries in children in
the developed countries were considered to be associated with: the
widespread exposure to fluoridated water, fluoride supplements,
especially the regular use of fluoridated toothpaste; the provision of
preventive oral health services; the increased dental awareness through
organised health education programmes; the ready availability of dental
resources.
27

• A review of studies conducted in ten countries between 1990 and 2000
on individuals ranging from 3 to 44 years of age reported average caries
reductions of between 30% and 59% in primary teeth and between 40%
and 49% in permanent teeth (Rugg-Gunn and Do, 2012) through
artificial water fluoridation.
• The pre-eruptive effect of ingested fluoride is also confirmed as being
important; findings from Australia and the Netherlands(D) for example
support the pre-eruptive effect of fluoride in reducing caries levels in pit
and fissure surfaces of permanent teeth (Groeneveld et al, 1990; Singh et
al, 2007).
O'Mullane DM, Baez RJ, Jones S, et al. Fluoride and Oral Health. Community Dent Health. 2016;33(2):69-99
28

Global scenario of the intensity and severity of excess ﬂuoride in drinking
water
Neha Mumtaz, Govind Pandey & Pawan Kumar Labhasetwar . Global Fluoride Occurrence, Available Technologies for Fluoride Removal,
and Electrolytic Defluoridation: A Review, Critical Reviews in Environmental Science and Technology 2015; 45(21) 2357-2389 29
(D)

Neha Mumtaz, Govind Pandey & Pawan Kumar Labhasetwar . Global Fluoride Occurrence, Available Technologies for Fluoride
Removal, and Electrolytic Defluoridation: A Review, Critical Reviews in Environmental Science and Technology 2015; 45(21) 2357-2389
30
(D)
(D)

31
(D)

32
(D)

33
(D)
(D)
(D)

34

Neha Mumtaz, Govind Pandey & Pawan Kumar Labhasetwar . Global Fluoride Occurrence, Available Technologies for Fluoride Removal,
and Electrolytic Defluoridation: A Review, Critical Reviews in Environmental Science and Technology 2015; 45(21) 2357-2389 35

• Water fluoridation is not practiced in India. Due to naturally-occurring
fluoride, both skeletal and dental fluorosis have been endemic in India in
at least 20 states, including Uttarakhand, Jharkhand and Chhattisgarh.
The maximum permissible limit of fluoride in drinking water in India is
1.2 mg/L, and the government has been obligated to install fluoride
removal plants of various technologies to reduce fluoride levels from
industrial waste and mineral deposits. Now reverse osmosis plants are
widely used.
water FLUORIDATION IN INDIA
36

• Household and public system reverse osmosis plants are common in the
market. Alleppey in Kerala is most affected with over-fluoridated
water. Government-installed reverse osmosis plants supply free filtered
water. Rotary International Club, Saratoga USA, helped to install 3 RO
Plants in rural Alleppey.
• As of 2014, there are 14,132 habitations in 19 States still containing
fluoride above the permissible levels in drinking water. Rajasthan has the
highest number of habitations (7,670) with high amount of fluoride in
drinking water. Telangana has 1174, Karnataka has 1122 and Madhya
Pradesh has 1055 habitation. Assam, Andhra Pradesh, Bihar,
Chhattisgarh, Maharashtra, Odisha, West Bengal and Uttar Pradesh also
has such habitations.
37

• The government of India launched the National Programme for
Prevention and Control of Fluorosis in 2008–2009. In 2013–2014, the
programme was brought under the National Rural Health Mission, which
has so far covered 111 districts.
• The programme includes surveillance of fluorosis in the community,
training and manpower support, establishment of diagnostic facilities,
treatment and health education. The Indian Council of Medical Research
has formed a task force on fluorosis to address issues related to
prevention and control.
38

BRAZIL
• The success of water fluoridation method in relation to reduction of
dental caries prevalence was also proved in developing countries. DMFT
of 12-year-old children in Brazilian cities as a function of time after
water fluoridation shows reduction.
• Many other studies show that the prevalence of dental caries in Brazil
was very high before water fluoridation and decreased reaching a
moderate prevalence in the nineties. This fact shows the strength of the
method alone leading to a reduction of 50% in caries prevalence.
Cury Jaime Aparecido, Tabchoury Cínthia Pereira Machado. Determination of appropriate exposure to
fluoride in non-EME countries in the future. J. Appl. Oral Sci. 2021; 11( 2 ): 83-95. 39

• The capacity of this method to reduce dental caries has been proved in
other developing countries, such as Cuba, where very high caries
prevalence was reduced to moderate.
Cury Jaime Aparecido, Tabchoury Cínthia Pereira Machado. Determination of appropriate exposure to fluoride in non-EME
countries in the future. J. Appl. Oral Sci. 2021; 11( 2 ): 83-95. 40

• Salt fluoridation has cariostatic potential like water fluoridation (caries
reductions up to 50%).
• Salt fluoridation is by far the cheapest method of caries prevention, and
billions of people throughout the world could benefit from this method
• In Switzerland 85% of domestic salt consumed is fluoridated and 67% in
Germany. Salt fluoridation schemes are reaching more than one hundred
million in Mexico, Colombia, Peru and Cuba.
Marthaler TM. Salt fluoridation and oral health. Acta Med Acad. 2013;42(2):140-155.
SALT FLUORIDATION IN DEVELOPED AND
DEVELOPING COUNTRIES
41

• In Latin America, there are more than 100 million users, and several
countries have arrived at coverage of 90 to 99%.
• In 1990, there was an attempt to implement a program of salt fluoridation
in Brazil, arguing that it would be efficient and would reach more areas
such as north-northeast region, which are not favored by water
fluoridation.

• The program of salt fluoridation was successfully implemented in some
countries. Results of significant caries reduction have been reported in
Costa Rica.
• However, the concentration of fluoride in salt produced by 3 companies
in Costa Rica is in accordance with what is expected, in Mexico it is
below the value established by law.
• Additionally, recent publication has suggested that the caries decline
found in Jamaica may not be attributed to the program of salt fluoridation
implemented in that country.

Zurich T M, Petersen P E. Salt fluoridation – an alternative in automatic prevention of dental
caries. International Dental Journal (2005) 55, 351-358.
44

Fluoridated toothpaste
• Based on global estimates, about 500 million people utilize fluoride
toothpaste, 210 million have access to fluoridated water, 40 million have
access to fluoridated salt, and 60 million benefit from fluoride mouth
rinses, tablets and clinically applied fluoride.
• Taking into account the global population for 2007 is estimated to be 6.6
billion it can be assumed that only about 12.5% of the world's population
benefit from the caries preventive possibilities of fluoride toothpaste.
FLUORIDATED TOOTHPASTE IN DEVELOPED AND
45
Goldman, A.S., Yee, R., Holmgren, C.J. et al. Global affordability of
fluoride toothpaste. Global Health 2008;4(7):1-8

• The price of fluoride toothpaste is believed to be too high in some
developing countries and this might impede equitable access
• In a survey conducted at a hospital dental clinic in Lagos, Nigeria 32.5%
of the respondents reported that the cost of toothpaste influenced their
choice of brands and 54% also reported that the availability of dentifrices
influenced their choice.
Goldman, A.S., Yee, R., Holmgren, C.J. et al. Global affordability of
fluoride toothpaste. Global Health 2008;4(7):1-8 46

• In Brazil there was sharp caries decline:
1) Before September 1998 approximately 25% of toothpaste sold contained
fluoride, which increased to 90% because the most popular Brazilian
dentifrice was fluoridated.
• Now all toothpastes sold in Brazil are fluoridated;
2) Implementation of educational and preventive programs in several
public schools with distribution of toothpaste and toothbrush every three
months.

• A survey indicated that 83% of children in Singapore used toothpaste
containing fluoride. Thus, Ministry of Health decided to lower the
concentration of fluoride in water from 0.7 to 0.6 mg F/L in 1992 and
further to 0.5 mg F/L in 2008. Other vehicles of fluoride are also
available to the population of Singapore.
Rathore B, Pallavi HN, Pushpanjali K. Community Water Fluoridation: Revisiting a Cost
Effective Measure. Int J Sci Stud 2015;3(4):154-158. 48

PRESENT SCENARIO OF USE OF PROFESSIONALLY
APPLIED TOPICAL FLUORIDE IN DEVELOPING &
DEVELOPED COUNTRIES
• Professionally applied topical fluoride varnish, gel, and solution have
been shown to be effective in preventing and in arresting dental caries.
Their use in different countries varies greatly and may not correlate with
the dental caries situation of the populations in the countries.
• In the higher-income countries, use of fluoride varnish and gel is
common among dental professionals.
• In contrast, the use of professionally administered topical fluorides is not
common in the lower-income countries.
Lo EC, Tenuta LM, Fox CH. Use of professionally administered topical fluorides in Asia. Adv Dent Res. 2012;24(1):11-15.
49

50

51

• Numerous studies report that water fluoridation reduces caries in children,
but little current evidence exists about fluoridation's effects on the
periodontal health of adults.
54

Authors Date Population/ Fluoride
Concentration
Fluoridation
effect on
periodontal
Disease
Kumar S,
Sharma J,
Duraiswamy P,
Kulkarni S
2009 All the panchayat samitis in
the Udaipur district were
stratified as Low (<0.6 ppm),
optimum
(0.6 - 1.2 ppm) and high
fluoride (>3ppm) based on
the
fluoride concentrations in
drinking water.
(Age group- 35 to 44 years)
Sample size- 967
The fluoride
level in drinking
water increased
the periodontal
status improved.
55
6. Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Fluoride - an adjunctive therapeutic agent for periodontal disease?
Evidence from a cross-sectional study. Med Oral Patol Oral Cir Bucal. 2009 Oct 1;14 (10):e547-53.

56
Chandra Shekar BR, Suma S, Kumar S, Sukhabogi JR, Manjunath BC. Malocclusion status among 15 years
old adolescents in relation to fluoride concentration and area of residence. Indian J Dent Res 2013;24:1-7.
Authors Date Population/ Fluoride
Concentration
Fluoridation effect on
Malocclusion
Chandra Shekar
BR, Suma S,
Kumar S,
Sukhabogi JR,
Manjunath BC.
2013 The study population in relation
to the area of residence and
fluoride concentration in the
drinking water was taken as
below optimal, optimal and
above optimal.
(Age group- 15 years)
Sample size- 1268
The prevalence and
severity of malocclusion
was more in urban than
rural areas, more among
females than males, and it
decreased with increasing
concentration of fluoride in
drinking water.

• The WHO Oral Health Programme, jointly with the FDI World Dental
Federation (FDI) and the International Association for Dental Research
(IADR), have embarked on an action plan for the promotion of using
fluoride, particularly focusing on the disadvantaged and under-served
population groups.
• The Global Consultation on "Oral Health through Fluoride" is an
essential component of this joint project.
Oral Health through Fluoride
57

• The aim and objectives of the Consultation were to:
1. Review and highlight successes in promoting oral health through the use
of fluoride.
2. Identify barriers for making fluoride available to all;
3. Explore effective strategies for making fluoride available and affordable
to all;
4. Develop an action plan for fluoride promotion and advocacy.
58

59
• As increasing prevalence of oral diseases in developed and developing
countries and lack of preventive awareness of oral diseases, communal
water fluoridation appears to be the most effective, practical and
economical public health measure for prevention of dental caries and
directly and indirectly prevention of periodontal health and maloclussion
as this measure extends its benefit to all the resident of the community
with out necessitating any conscious effort in the part of the residents.
1. Norman O Harris. Primary preventive dentistry. Prentice hill. 6th edition.
Significance Of Fluoride In Public Health

• A certain level of fluoride consumption- especially when this is
continuous from earliest childhood- affords considerable protection for
both permanent and milk teeth against caries, without exerting any
unfavourable influence on the appearance of the teeth or on the
periodontium.
• Hence the best way to ensure adequate fluoride consumption is by
fluoridation of drinking water, which is a collective measure of benefit to
all those drawing water for drinking and cooking purposes from a central
water supply system.
conclusion
60

1. Fejerskov O, Ekstrand J, Burt BA. Fluoride in Dentistry. Second ed.
Copenhagen: Munksgaard, 1996.
2. Tewari A. Fluorides and Dental Caries. A Compendium. Journal of Indian
Dental Association.1986.
3. Peterson P E et al.The global burden of oral diseases and risks to oral
health. Bulletin of the World Health Organization.2005 ;83: 661-689.
4. Murray JJ, Rugg-Gunn AJ, Jenkins GN. Fluorides in caries prevention.
Third ed. Varghese Publishing House, 1999.
5. Norman O Harris. Primary preventive dentistry. Prentice hill. 6th edition.
6. Burt BA, Eklund. Community, dentistry and the dental practice.7th edition.
2020.
bibliography
61

6. Mullane DM, Baez RJ, Jones S, et al. Fluoride and Oral
Health. Community Dent Health. 2016;33(2):69-99.
7. Petersen P E ,Ogawa H. Prevention of dental caries through the use of
ﬂuoride – the WHO approach. Community Dental Health. 2016; 33: 66–
68.
8. Fluorides and Human Health. WHO Geneva 1994.
9. Renson CE. Changing patterns of dental caries: a survey of 20
countries. Ann Acad Med Singap. 1986;15(3):284-298
10. Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Fluoride - an adjunctive
therapeutic agent for periodontal disease? Evidence from a cross-
sectional study. Med Oral Patol Oral Cir Bucal. 2009 Oct 1;14
(10):e547-53. 62

11. Cury Jaime Aparecido, Tabchoury Cínthia Pereira Machado.
Determination of appropriate exposure to fluoride in non-EME
countries in the future. J. Appl. Oral Sci. 2021; 11( 2 ): 83-95.
12. Neha Mumtaz, Govind Pandey & Pawan Kumar Labhasetwar . Global
Fluoride Occurrence, Available Technologies for Fluoride Removal,
and Electrolytic Defluoridation: A Review, Critical Reviews in
Environmental Science and Technology 2015; 45(21) 2357-2389
13. Marthaler TM. Salt fluoridation and oral health. Acta Med Acad.
2013;42(2):140-155.
63

14. Zurich T M, Petersen P E. Salt fluoridation – an alternative in automatic
prevention of dental caries. International Dental Journal 2005; 55:351-358.
15. Goldman, A.S., Yee, R., Holmgren, C.J. et al. Global affordability of
fluoride toothpaste. Global Health 2008;4(7):1-8
16. Rathore B, Pallavi HN, Pushpanjali K. Community Water Fluoridation:
Revisiting a Cost Effective Measure. Int J Sci Stud 2015;3(4):154-158.
17. Lo EC, Tenuta LM, Fox CH. Use of professionally administered topical
fluorides in Asia. Adv Dent Res. 2012;24(1):11-15.
18. Chandra Shekar BR, Suma S, Kumar S, Sukhabogi JR, Manjunath BC.
Malocclusion status among 15 years old adolescents in relation to fluoride
concentration and area of residence. Indian J Dent Res 2013;24:1-7.
64

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