indices used for dental fluorosis including all the indices and their modifications

1. GOOD
MORNING

2. INDICES USED
FOR DENTAL
FLUOROSIS

3. Contents
• Introduction
• History
• Classification of indices
• Dean’s index
• Modified Dean’s index
• Community fluorosis Index
• Thylstrup and Fejerskov Index
• Tooth Surface index of fluorosis
• Fluorosis Risk Index
• Young’s Classification Of Enamel Fluorosis
• Murray and Shaw’s Classification of Enamel Fluorosis
• Simplified Fluoride Mottling Index
• Summary
• References

4. INTRODUCTION
• INDEX : 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 : 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.

5. 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.
• 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

6. CLASSIFICATION OF FLUOROSIS
MEASURING INDICES
FLUOROSIS
SPECIFIC
THYLSTRUP AND
FERJESKOV
DEAN’S INDEX
TOOTH SURFACE
INDEX FOR
FLUOROSIS
FLUOROSIS RISK
INDEX
DESCRIPTIVE
DEVELOPMENTAL
DEFECTS OF
ENAMEL INDEX
JACKSON Al-
ALOUSI INDEX
MURRAY SHAW
INDEX

7. DEAN’S FLUOROSIS INDEX
• 1934; TRENDLEY H.DEAN devised an
index for assessing the presence and
severity of mottled enamel.
Although no numbers were
used it was considered to be
on ordinal scale.
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
The fluorosis index set
criteria for categorisation of
dental fluorosis on a 7point
scale.
SALIENT
FEATURES

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. CLASSIFICATION AND CRITERIA
• The enamel represents the usual transluceny semivitriform type of
structure
• The surface is smooth, glossy and usually of pale creamy white color
NORMAL
• Slight aberrations in translucency of normal enamel ranging from
few white flecks to occasional white spots, 1-2mm in diameter.
QUESTIONABLE
• 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
VERY MILD

10. • 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
MILD
• 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
MODERATE
• Smoky white appearance
• Pitting is more frequent and generally seen on all surfaces
• Brown stain if present has more hue and involves all surfaces
MODERATELY SEVERE
• Form of teeth are affected.
• Pits are deeper and confluent
• Stains are widespread and range from choclate brown to almost black
SEVERE

11. • 1939 Dean combined the “moderately 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.

12. 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.
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.

13. 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.
MILD (2)The white
opaque areas in the
enamel of teeth are
more extensive but do
not involves as much as
50% of tooth.

14. MODERATE (3)
All enamel surfaces
of the teeth are
affected and surfaces
subject to attrition
show wear. Brown
stain is frequently a
disfiguring feature.
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.

15. COMMUNITY FLUOROSIS INDEX
• 1942 , based on the revised fluorosis index scale ,
H. Dean 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

16. 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

17. 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.
SALIENT
FEATURES
Examination is
done on a
portable chair
out in daylight.
Plane mirror n
probes are used
Prior to
examination
the teeth are
dried with
cottonwool
rolls

18. THYLSTRUP – FEJERSKOV
CLASSIFICATION OF FLUOROSIS
Score Criteria
0
1
2
• Normal translucency of
enamel remains after
prolonged air – drying
• Narrow white lines located
corresponding to the
perikymata.
• 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.

19. Score Criteria
• 3
• 4
• 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
opaque enamel.
• 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.

20. Score Criteria
• 5
• 6
• 7
• Smooth and Occlusal surfaces:
Entire surface displays marked
opacity with focal loss of
outermost enamel (pits) 2mm in
diameter.
• 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.

21. Score Criteria
• 8
• 9
• 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

23. ACHIEVEMENT : 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.
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

24. TOOTH SURFACE FLUOROSIS INDEX
• It was developed by HOROWITZ et al.,
DRISCOLL, MEYERS , HEIFETZ & ALBERT
KINGMAN in 1984 at National Institute of
Dental Research U.S.A
AIM :

25. 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
capping)

26. Numerical score Descriptive Criteria
• 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.

27. Numerical score Descriptive Criteria
• 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
altered. Dark brown stain is
usually present.

29. 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)

30. 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.

31. FR1- those begin
to form in first
year of life
FR2- those
who donot
begin to form
until 2nd year
of life
Surface zones
which donot
come under
above groups
are left
unassigned
Incisal edges of 11
21 32 31 41 42 and
occlusal tables of
16 26 36 46.
Cervical
third of
incisors,m
iddle third
of canines,
occlusal
table,incis
al third
and
middle
third of
bicuspid
and 2nd
molars

32. FR 1 •1O
FR 2 •48
UNASSIGN
ED
•54
112

33. SCORING CRITERIA
NEGATIVE
FINDING
SCORE =0
Complete
absence of any
white spots or
striations.
QUESTIONABLE
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

34. POSITIVE
FINDING
SCORE = 2
A surface
zone with
greater than
50% of zone
displaying
parchment
white
striations.
Incisal edges
and occlusal
tables with
greater than 50%
of surface
marked by
snowcapping
SCORE =
3
Surface zone with greater
than 50% of zone that
displays pitting, staining
and deformity
SURFACE ZONE
EXCLUDED
SCORE = 9
Incomplete eruption
, orthodontic
appliances and
bands, surface
crowned or restored,
gross plaque and
debris

35. CLASSIFICATION 1
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
• To obtain the FRI score for each individual
the scores of classification 1 and 2 are
combined into one summary score.

36. YOUNG’S CLASSIFICATION OF ENAMEL
FLUOROSIS
• Developed by YOUNG M.A in 1973.
• Similar classification was developed by Al-Lousi
et al in 1975.
• Principle
Recording of any
condition once defined
must be made on basis
of that definition and
not on basis of
presumed etiology.

37. TYPE A
• White areas less than 2mm in diameter
TYPE B
• 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
TYPE E
• Horizontal white lines irrespective of there being
any non linear lines
TYPE F
• Colored or white lines or areas associated with
pits or hypoplastic areas

38. 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

39. 1 White opaque spots (or flecks)
less than 2mm in dia
2 Greater than 2mm measured in
any direction. Well demarcated
from surroundings.
3 Coloured spots, flecks or patches
4 Horizontal white lines, not
associated with hypoplasia
5 Hypoplasia + Category 1 to 4
(any)
6 Possible early carious lesions
7 Missing
SCORE CRITERIA

40. SIMPLIFIED FLUORIDE MOTTLING INDEX
(FMI)
• Introduced by RAHMATULLA. M. And RAJASEKHAR. A. In 1984.
• It is based on enamel opacities/lesions present on facial
surfaces of six upper and lower ant. Teeth which are
asthetically important.
SCORE CRITERIA
0 No involvement of facial
surface. Enamel : translucent,
smooth and glossy.
1 Less than 1/3rd of facial
surface involved
2 Above 1/3rd but less than 2/3rd
3 Over 2/3rd facial surface
involved
4 Brownish Black discolouration
of entire facial surface.

41. SUMMARY
• Tooth surface index of fluorosis (TSIF), permits a specific
assessment of fluorosis and because of this, it is especially
useful for determining the public effect of fluorosis in a
population.
• Thylstrup and Fejerskov index for fluorosis (TFI), is thought
to be most sensitive since it calls for drying of teeth which
accentuates the appearance of fluorosis , making the diagnosis
easier in questionable cases.
• Even though the Fluorosis risk Index (FRI) is thought to be
complex from biological perspective and in application, it is
reliable and valid when identifying risk factors for enamel
fluorosis.
• Dean’s index has been used most frequently over the years, till
today. But, modified dean’s index is one still recommended by
WHO in its basic survey manual.

42. REFERENCES
• Essentials of Preventive and Community
Dentistry by Soben Peter.
• ncib.nih.gov US National Library of
MedicineNational Institutes of Health
• publichealth.med.miami.edu , official site of
university of miami health system.

43. THANK
YOU