Clinically, it ranges from diffuse white opacities to brown stains, pitting, and enamel loss in severe cases.
Risk depends on dose, duration, timing of exposure, and individual susceptibility.
Major fluoride sources in childhood include drinking water, fluoridated salt, inappropriate use of supplements, toothpaste ingestion, and professional fluoride products (varnishes, gels).
Public health policies recommend maintaining a balance between caries prevention and fluorosis risk, with 0.7 mg/L as the optimal fluoride concentration in community water.
The WHO sets 1.5 mg/L as the upper safety limit for potable water.
Clinical Diagnosis and Differential Considerations
★ History Taking
- Residence history during the first 6–8 years.
- Water source (tap, well, bottled), use of fluoridated salt, or supplements.
- Oral hygiene habits: toothpaste amount, swallowing behavior.
★ Clinical Features
- Symmetrical, diffuse enamel opacities, often on incisors and cusps.
- In moderate/severe cases: brown discoloration, porosity, pitting.
★ Severity Indices
- Dean Index: widely used in epidemiology.
- Thylstrup-Fejerskov (TF) Index: 0–9 scale to assess depth/extent; highly relevant in clinical practice.
★ Differential Diagnosis
- Molar-Incisor Hypomineralization (MIH): demarcated opacities, post-eruptive breakdown.
- Amelogenesis imperfecta, developmental hypoplasia, trauma- or fever-related enamel defects.
Practical Classification in Clinical Settings
✔ Mild (Dean “very mild/mild”; TF 1–2): diffuse striations or white patches without structural loss.
✔ Moderate (TF 3–4): yellow/brown stains, surface porosity.
✔ Severe (TF ≥5): pitting, structural loss, esthetic/functional compromise.
Prevention Strategies in Children and Adolescents
★ Water and Environmental Monitoring
- Maintain ~0.7 mg/L fluoride in water; avoid >1.5 mg/L (implement defluoridation/alternative sources if necessary).
★ Toothpaste Guidelines
- 0-3 years: smear/rice grain size (≈0.1 g, 1,000–1,100 ppm).
- 3–6 years: pea-size (≈0.25 g, 1,000–1,450 ppm).
- Parents must supervise and encourage spitting without swallowing.
★ Fluoride Supplements
- Prescribe only when caries risk is high and local water fluoride is 0.3 mg/L.
★ Professional Products
- Fluoride varnishes/gels: for high caries risk patients; record all fluoride exposures.
★ Parental Education
- Avoid excessive flavored toothpaste use.
- Monitor tea consumption and local water sources.
Treatment by Severity
A) Mild Cases
- Bleaching (carbamide or hydrogen peroxide) in adolescents.
- Microabrasion (acid + pumice) for superficial opacities.
- Resin infiltration (RI) to mask hypomineralized areas.
- Evidence: bleaching + RI provides superior masking compared to bleaching alone; microabrasion + bleaching also shows high effectiveness.
B) Moderate Cases
- Stepwise approach: microabrasion → bleaching → RI.
- Clinical trials show RI offers significant esthetic improvement for mild-moderate fluorosis.
C) Severe Cases
- Direct adhesive restorations for localized defects.
- Veneers (porcelain, ceramic) for widespread enamel compromise.
- Full crowns in cases with extensive breakdown and esthetic/functional needs.
Clinical Notes: Bleaching protocols should be conservative to avoid increased enamel porosity or sensitivity.
Practical Protocol for Dentists
1. Assess fluoride exposure history.
2. Document severity using Dean or TF Index + photographs.
3. Educate caregivers: proper toothpaste dosing, supervision, and water monitoring.
4. TF 1–2: bleaching ± microabrasion ± RI.
5. TF 3–4: staged approach (microabrasion → bleaching → RI).
6. TF ≥5: restorative/esthetic management (veneers, crowns).
7. Schedule annual follow-ups to monitor color stability and enamel integrity.
Public Health and Community Measures
- Regular water monitoring and reporting.
- Defluoridation programs in high-fluoride regions.
- Health education campaigns to promote correct use of fluoride toothpaste and safe supplementation.
References
1. StatPearls Publishing. Dental Fluorosis. Updated 2023.
2. Saldarriaga A, et al. Clinical changes in the severity of dental fluorosis. J Dent Child. 2021.
3. Wittich G, et al. Masking efficacy of bleaching and resin infiltration for fluorotic lesions. J Dent. 2024.
4. Zhou J, et al. Comparison of three whitening protocols for mild dental fluorosis. 2025 (PMC).
5. U.S. NIH ODS. Fluoride – Health Professional Fact Sheet. Updated April 2025.
