UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL
Fluorosis Dental fluorosis is a development anomaly that occurs by prolonged fluoride intake during the period of tooth formation and enamel maturation. CapĂtulos
Atualizado e Ilustrado
1. Conceptual and Epidemiological Aspects
2. Main Risk Factors Page 2
Page 1
3. Collective Approach a. Organization of Surveillance Actions in Health emphasizing Prevention and Fluorosis Detection b. Health Promotion Actions
4. Individual Approach a. Diagnosis b. Treatment
5. Clinical Cases
6. References and Credits
Page 3 Page 4
Page 3
Page 2
!
1. Conceptual and Epidemiological Aspects
intake
also
around 15 to 25%.
the period of tooth formation and Figure 1. Mild dental fluorosis. Note the whitish lines along the enamel.
is
characterized by an increase in enamel porosity making it seem opaque.
fluoride
the
has access to fluoridated water is
by prolonged fluoride intake during It
topical
and
mild fluorosis in the population that
Dental fluorosis is a development anomaly that occurs
maturation.
of
forms
contribute to fluorosis. According to various authors, the prevalence of
!
enamel
Systemic
!
In 12 year-old children, the
highest rates were seen in the
! In the most severe forms the enamel is completely whitish and it is possible to lose structure. Dark spots are frequent, resulting from food pigments and they are not
necessarily related to the degree of In some regions in Brazil, Southeast and South regions severity. Severe fluorosis is generally there is an increased number in (around 12%) and the lowest in the seen in places where the residual diagnosis of dental fluorosis. Results Central West and Northeast (about fluoride contents (in natura) are from the Survey of the Oral Health 4%). present in high concentrations in Conditions of the Brazilian ! The mild forms of fluorosis consumption water, mainly the rural Population – SB Brasil, finished in are characterized by thin lines or areas supplied by artesian wells. The 2003 showed around 9% prevalence white chalky spots that appear in the concomitant fluoride intake from of dental fluorosis in 12 year-old dental enamel or tips of cusps. They various sources may also result in children and 5% in adolescents from are common in places where public severe fluorosis. 15 to 19 years of age. water supply is fluoridated. !
UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health
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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL •
2. Main Risk Factors •
products containing fluoride.
Presence of fluoride in contents above the
the fluoridation process or naturally existing in
Include dental fluorosis in the routine epidemiological trials: oral health services should
springs (fluoride residual content).
carry on longitudinal epidemiological trials in the
recommended in public water supply, derived from
•
•
population exposed to fluoride sources following
Concomitant use of two or more forms of fluoride
the trend of damage prevalence and severity.
intake (systemic). Example: fluoridated water and •
fluoride-containing drugs. •
Frequent intake of fluoridated toothpaste in the
objective of identifying social, environment, cultural and individual factors that favored the incidence and proposing integral prevention actions.
Absence of a surveillance system to monitor fluoride content in public water supply and
•
packaged mineral water. Preparation of child’s food with fluoridated water, for example, powdered milk.
•
Abusive
of
Creation of protocols with recommendations about the individual and collective use of fluoridated
•
use
Epidemiological surveillance of dental fluorosis cases: perform epidemiological investigation of fluorosis cases diagnosed in its range with the
period of dental formation (up to 6 years of age) in areas with fluoridated water. •
Check fluoride content in dentifrices and dental
topical
fluoride
applications
(causing swallowing) in places where there is systemic fluoride.
substances in dental care.
Health Promotion Actions (interdepartmental and educational) !
The Oral Health Team should pay attention to
the causes of dental fluorosis in the region in order to plan prevention actions according to the existing
3. Collective Approach Organization
of
Health
Surveillance
Actions
Emphasizing Prevention and Fluorosis Detection •
Surveillance,
control
and
education
to
swallowing fluoride dentifrice, mainly children in cities the
preventive procedures.
as a necessary measure to control the acute and
! In the regions where room temperature is high, water intake is greater and the risk of excessive fluoride
ages at risk of dental fluorosis (children up to 6 years of age).
ingestion through the water is also high. The ideal
Implementation of surveillance systems to control
where the average room temperature is around 30!C
fluoride contents in public water supply to improve the quality of water fluoridation, systematic control of contents applied and process continuity. •
supplied with fluoridated water, as well as other
population about the several ways of using fluoride chronic forms of fluoride intoxication mainly in the
•
problems, including broad communication and information to the population about the risks of
fluoride concentration in drinking water in places is 0.7 ppm (mg/L). The fluoride concentration in drinking water should increase according to the drop in room temperature. In regions where the climate is mild (< 25!C) and where water consumption is less, the
Surveillance of fluoride content in food: mineral
ideal fluoride concentration is 1 ppm (mg/L) and
water, canned drinks, soft drinks, juices and teas
should not exceed 1.2 ppm.
should have their maximum allowed fluoride content regulated and exhibited in labels and packaging and be systematically analyzed by the sanitary surveillance.
UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health
!
There should be a joint search for alternative
sources of water supply when it is identified the presence of elevated fluoride contents in the water for human consumption. If dental fluorosis is proven in a 2
UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL
community,
it
is
recommended
to
investigate the degree of esthetic satisfaction
5. Clinical Cases
and perception of the problem in the region.
4. Individual Approach
Diagnosis Clinically, dental fluorosis presents fine white lines that may become yellowish or brown due to food !
dye impregnation, as well as various forms of erosion.
Figure 2. Mild dental fluorosis. See the whitish lines along enamel.
The severity of fluorosis depends on dosage (contents and amounts), age when ingestion occurred, exposure time. It may lead to loss of enamel parts with anatomic deformity in teeth. !
The individual diagnosis should be done after
prophylaxis and drying for 30 seconds (with gauze or air spray) to disclose the enamel pores. ! Fluorosis is always symmetrical; homologous teeth show fluorosis in the same levels. The most important differential diagnosis is the white spot due to caries and other opacities. When evaluating, consider fluoride exposure, its origin and content in water consumption.
Treatment !
Figure 3. Severe dental fluorosis. See dental enamel loss in the buccal aspect of incisors.
Severe forms of dental fluorosis may sometimes
be considered an esthetic discomfort to the patient and the indication is to treat the spots. This treatment consists of pumicing the external porous enamel until the spot, caused by the impregnation of food pigments, is removed. After micro abrasion, fluoride application (gel or varnish) is indicated. Enamel with fluorosis stains is more porous and not necessarily richer in fluoride. Among the products used in the micro abrasion technique there are hydrochloric acid, hydrogen peroxide and phosphoric acid. In severe cases, it is necessary to fabricate crowns or veneers. UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health
Figure 4. Severe dental fluorosis with great enamel loss and staining
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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL
6. Credits Updating of Primary Health Care Notebook on Oral Health and images – 2012: Prof. Fábio Correia Sampaio – Universidade Federal da Paraíba Layout: Profa. Mary Caroline Skelton-Macedo Translation: Flávia Egner
UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health
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