ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10015-2361
World Journal of Dentistry
Volume 15 | Issue 1 | Year 2024

Assessment of the Impact of Dental Fluorosis on the Oral Health-related Quality of Life in 10–14-year-old Children


Kodali Srija1, Swarna Swathi Silla2, Cheruku S Reddy3, Penmetcha Sarada4, Ziauddin Mohammad5, Prathap C Manivannan6

1–5Department of Pedodontics and Preventive Dentistry, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India

6Department of Orthodontics, Faculty of Dentistry, MAHSA (Malaysian Allied Health Sciences Academy) University, Selangor, Malaysia

Corresponding Author: Kodali Srija, Department of Pedodontics and Preventive Dentistry, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India, Phone: +91 9951037666, e-mail: srijakodali5@gmail.com

Received: 07 December 2023; Accepted: 09 January 2024; Published on: 20 February 2024

ABSTRACT

Aim: To assess the impact of dental fluorosis on the oral health-related quality of life (OHRQoL) in 10–14-year-old children.

Materials and methods: The present study included a total of 545 children aged 10–14 years. All the children were screened to note dean fluorosis indices, decayed, missing, filled teeth (DMFT), and oral hygiene index-simplified (OHI-S) followed by which, children were asked to answer the Child Perception Questionnaire (CPQ) in their local language. Screening at schools ended with an oral healthcare talk. The data collected was compiled, tabulated, and subjected to statistical analysis.

Results: Among the 545 subjects in the study 58.3% were males and 41.7% were females. The mean Dean fluorosis index score was 2.48 ± 0.77. The means of domains oral symptoms, functional limitations, emotional well-being, and social well-being were 2.41 ± 2.56, 2.14 ± 2.70, 3.73 ± 4.58, and 4.38 ± 5.55, respectively. Multiple regression analysis of the data showed that dental fluorosis had a significant impact on OHRQoL in children. A comparison of OHRQoL scores between various Dean’s fluorosis index scores shows that OHRQoL was mostly affected in children with severe fluorosis followed by moderate fluorosis.

Conclusion: Dental fluorosis has a negative impact on the OHRQoL of children. An increase in the degree of fluorosis has a more negative effect on the OHRQoL. Dental fluorosis mainly affects the children’s social and emotional well-being.

Clinical significance: Fluorosis affects the OHRQoL of children, suitable health education and preventive measures can be provided. It is essential to take precautions to lower the danger of fluoride exposure. Parents can be educated about the causes of dental fluorosis, preventive measures, and management.

How to cite this article: Srija K, Silla S Swathi, Reddy CS, et al. Assessment of the Impact of Dental Fluorosis on the Oral Health-related Quality of Life in 10–14-year-old Children. World J Dent 2024;15(1):30–35.

Source of support: Nil

Conflict of interest: None

How to cite this article: Srija K, Silla S Swathi, Reddy CS, et al. Assessment of the Impact of Dental Fluorosis on the Oral Health-related Quality of Life in 10–14-year-old Children. World J Dent 2024;15(1):30–35.

Keywords: Child perception, Dental fluorosis, Oral health-related quality of life

INTRODUCTION

The most popular and effective strategy for the prevention of dental caries is the use of fluoride. The reduction in dental caries prevalence can be widely associated with fluoride-containing products. Fluorides can be delivered to the public in drinking water, mouth rinses, dentifrices, professional products, and dietary supplements.1

Dental fluorosis is a condition brought on by consuming too much fluoride as teeth are developing. Hypomineralization of the tooth structure and changes in the biological enamel matrix being replaced by minerals (calcium and phosphates) are characteristics of dental fluorosis. It is possible to observe changes in the composition and structure of enamel. Enamel that is only slightly and mildly fluorotic is perfectly functional, while the enamel that has been exposed to higher levels of fluoride becomes porous, pitted, and discolored and is more likely to break and wear out. In severe situations, the enamel begins to pit, and the pitted regions unite to form larger areas where the enamel is lost.2

Excessive intake of fluoride affects the teeth and bones. Skeletal fluorosis is a severe form of fluorosis where the long bones of the body are affected. This leads to deformities, stiffness, and pain in the joints. The bones are weak and are more prone to fractures. Fluoride toxicity can lead to abdominal pain, nausea, vomiting, and diarrhea.

Due to the time when permanent dentition is developing, children aged between 3 and 6 are more prone to dental fluorosis. The benefits of reducing dental caries outweigh the hazards of dental fluorosis; hence, the suggestion for fluoridating public water supplies is generally supported. Children’s esthetic discomfort brought on by the rising prevalence of dental fluorosis worldwide has complicated their psychological and behavioral development.3

Quality of life (QoL) helps evaluate individuals’ emotional reactions to life occurrences, sense of life fulfillment and satisfaction, satisfaction with work and personal relationships, and disposition.4 Oral health-related QoL (OHRQoL) is a self-report about oral health capturing the social, functional, psychological, and emotional impacts of oral disease. The subjective assessment of OHRQoL considers a person’s contentment with their oral health and their level of comfort when eating, sleeping, and interacting with others.

Children’s OHRQoL is probably affected due to the discoloration of the enamel and the altered shape of the teeth, although milder versions of this ailment may have a favorable effect on QoL. Dental enamel appears whiter and teeth look better with little or mild dental fluorosis. Mild fluorosis increases a child’s or adolescent’s likelihood of thinking their teeth are attractive or very appealing.

Few studies on the connection between dental fluorosis and QoL have been done, although there has recently been an increase in the prevalence of dental fluorosis.2

Based on this background, the present study aimed to determine the impact of dental fluorosis on the OHRQoL in 10–14-year-old children. This study was conducted in Vikarabad which is a fluorosis endemic area due to larger amounts of fluoride in groundwater. Since groundwater is their primary source, children in these regions are susceptible to fluorosis.5 Although fluorosis is endemic in Vikarabad, limited data is available on the impact of dental fluorosis on the OHRQoL of children in Vikarabad. Children between the ages of 10–14 were chosen for the study because these are transitional years for kids, during which they also tend to be more self-conscious.

MATERIALS AND METHODS

The study was conducted in high schools in various regions in the Vikarabad. The present study was conducted in the Department of Pedodontics and Preventive Dentistry, Sri Sai College of Dental Surgery. The study was conducted to assess the OHRQoL in 10–14-year-old children with dental fluorosis using a Child Perception Questionnaire (CPQ 11–14) (Fig. 1).

Fig. 1: Child with dental fluorosis

Ethical clearance was obtained from the Institutional Ethics Committee (IEC No: 734/SSCDS/IRB-E/2020). From the district school officer, a list of public schools in the Vikarabad district was acquired. The study was conducted over a duration of 6 months (June to November 2022).

The study population consisted of 10–14-year-old children with dental fluorosis.

Inclusion Criteria

  • Children aged 10–14 years.
  • Children with dental fluorosis.

Exclusion Criteria

  • Children with physical or mental disabilities.
  • Children with long-standing systemic illness and skeletal fluorosis.
  • Children with a history of professional topical fluoride therapy.
  • Children with fixed orthodontic treatment.

Sample

A pilot study was carried out on 30 participants and sample size was calculated. The sample size was calculated using the standard formula:n = 4(Z1-α/2 + Z1-β)2 (Sp)2/d2

where, n = size of the sample

Z1-α/2 = confidence interval = 95% = 1.96

Z1-β = Power = 80% = 0.84

Sp = pooled standard deviation = 8.34

d = clinical meaningful difference = 2

Using the equation the sample size was calculated to be 545. The sample was collected using a simple random sampling technique. The sampling technique is shown in Flowchart 1.

Flowchart 1: Sampling technique flowchart

The children from various schools located in Vikarabad were screened for dental fluorosis. A total of 545 children with dental fluorosis were identified and included in the study. The study procedure, the importance of the study, and how to fill out the questionnaire was explained to the children. The parental consent form was given to the children. Parental consent was taken and the children were subjected to a clinical oral examination by a single calibrated examiner using a mouth mirror and double-ended explorer under natural light to record dental caries and oral hygiene status using decayed, missing, filled teeth/decayed, extracted, filled teeth (DMFT/deft) and oral hygiene index-simplified (OHI-S) indices, respectively and the fluorosis scores were recorded using the modified Dean’s fluorosis index. Modified Dean fluorosis index was recorded based on the two most affected teeth. If the teeth were not equally affected the lesser score was taken. When in doubt the lower score was taken. The grades of fluorosis were recorded as 0 = normal, 0.5 = questionable, 1 = very mild, 2 = mild, 3 = moderate, and 4 = severe.6 After examination, the children were given the CPQ in the language of their choice and were asked to fill out the questionnaires in the presence of the examiner.

Children’s OHRQoL was measured using the CPQ 11–14.7 The questionnaire comprises 18 items distributed among four domains—oral symptoms, functional limitations, emotional well-being, and social well-being. The participants were instructed to read carefully and choose the answer that best describes them in the past 3 months regarding their teeth, mouth, or face. The responses were recorded as 0 = never; 1 = once or twice; 2 = sometimes; 3 = often; 4 = every day or almost every day. Questionnaires were given in English, Telugu, and Hindi languages for the convenience of the children and parents. A higher score indicates more negative OHRQoL and a lower score indicates more positive OHRQoL.

Statistical Analysis

Statistical analysis was done using Statistical Packages for the Social Sciences version 20.0. The confidence interval was set at 95%. The p-value < 0.05 was considered statistically significant. Frequency and percentages were reported for discrete data. Mean and standard deviation (SD) were reported for continuous data. Normality tests were conducted and all the variables were found to be normally distributed so parametric tests were done. Student t-test, one-way analysis of variance (ANOVA) with repeated measures, Pearson’s correlation, and multiple regression analysis were performed.

RESULTS

The mean age and class are 12.86 ± 1.28 and 7.84 ± 1.34, respectively. The mean OHI-S score is 1.11 ± 0.18, and the mean DMFT score is 1.07 ± 1.01. The mean Dean’s fluorosis index is 2.48 ± 0.77. The means of four domains, oral symptoms, functional limitations, emotional well-being, and social well-being are 2.41 ± 2.56, 2.14 ± 2.70, 3.73 ± 4.58, and 4.38 ± 5.55, respectively (Table 1). Of all the scores, the mean score of the social well-being domain 4 was statistically significantly higher than all the other scores, and the lowest score was noted in the functional limitations domain 2. It can be deduced that social well-being was the most affected, followed by emotional well-being followed by oral symptoms, and functional limitations (Table 2). Multiple regression analysis with OHRQoL as a dependent variable was done, and a significant value (p-value < 0.0001) was noted for Dean’s fluorosis index (Table 3). This indicates that fluorosis affects the OHRQoL of children. OHRQoL was mainly affected in children with severe fluorosis followed by moderate fluorosis. Very mild fluorosis has a negligible effect on the OHRQoL. Severe fluorosis has the most effect on the OHRQoL compared to questionable, very mild, mild, and moderate fluorosis (Table 4).

Table 1: Descriptive statistics for continuous study variables
N Minimum Maximum Mean Standard deviation (SD)
Age 545 9.00 16.00 12.86 1.28
Class 545 5.00 10.00 7.84 1.34
Developmental index-simplified 545 0.30 1.00 0.57 0.13
Cavity index-simplified 545 0.30 1.00 0.54 0.12
OHI-S 545 0.80 2.00 1.11 0.18
D 545 0.00 3.00 0.55 0.69
M 545 0.00 0.00 0.00 0.00
F 545 0.00 3.00 0.51 0.76
DMFT score 545 0.00 4.00 1.07 1.01
Dean’s fluorosis index 545 0.50 4.00 2.48 0.77
Oral symptoms score 545 0.00 13.00 2.41 2.56
Functional limitations score 545 0.00 16.00 2.14 2.70
Emotional well-being score 545 0.00 16.00 3.73 4.58
Social well-being score 545 0.00 20.00 4.38 5.55
Total score 545 0.00 48.00 12.66 11.63
Table 2: Comparison among four domain scores of the study subjects (one way ANOVA with repeated measures and Bonferroni’s post hoc analysis)
Domain Mean SD N p-value Post hoc analysis
Oral symptoms score 1 2.41 2.56 545 <0.001* 2 < 1< 3 < 4
Functional limitations score 2 2.14 2.70 545
Emotional well-being score 3 3.73 4.58 545
Social well-being score 4 4.38 5.55 545
Table 3: Multiple regression analysis with OHRQoL score as dependent variable
Unstandardized coefficients Standardized coefficients T p-value 95.0% confidence interval for B
B Standard error β Lower bound Upper bound
Constant 5.586 5.238 1.066 0.287 −4.703 15.876
Age −0.574 0.329 −0.063 −1.748 0.081 −1.220 0.071
Gender −0.203 0.869 −0.009 −0.233 0.816 −1.910 1.505
OHI-S −5.448 2.309 −0.086 −2.359 0.019* −9.985 −0.912
DMFT score 0.385 0.415 0.034 0.927 0.354 −0.430 1.199
Dean’s fluorosis index 8.193 0.545 0.543 15.033 <0.001* 7.123 9.264

Dependent variable: total score *;factors have significant effect on the OHRQoL

Table 4: Comparison of OHRQoL scores between various Dean’s fluorosis index scores. One-way ANOVA and Tukey’s post hoc test
Dean’s fluorosis index N OHRQoL mean SD p-value Post hoc analysis
Questionable (a) 4 4.50 5.196 <0.001* a < e
b < c, d, e
b < c < e
b < d < e
a, b, c, d < e
Very mild (b) 14 2.00 3.464
Mild (c) 315 9.57 9.913
Moderate (d) 140 11.78 8.799
Severe (e) 72 30.42 7.498
Total 545 12.66 11.626

*degree of fluorosis has more effect on OHRQoL

DISCUSSION

Fluorosis is an endemic disease that affects 22 Indian states.8 At least 50% of India’s 6 lakh villages have drinking water with fluoride levels above 1.0 ppm.9 The prevalence of dental fluorosis has been the subject of numerous epidemiological research, although it is still unclear how it affects OHRQoL.

Children between the ages of 10 and 14 were chosen for the study sample because these are transitional years for kids, during which they also tend to be more self-conscious.

Patton and Viner 200710 stated that transitions, menarche, hormonal changes, the occurrence of stressful life events, and particular coping techniques can all affect teenagers’ psychological well-being.

Michel et al.11 stated that puberty causes physical and social changes in teenagers, and they must adjust to their changing bodies and gender identities. These changes may have an impact on QoL.

The present study’s findings revealed that the study population included more males than females; most subjects, that is, 26.4%, belonged to IX, and most were 14 years old.

Most of the study population had mild fluorosis followed by moderate fluorosis. This is similar to the study conducted by Singh et al.,1 where most of their study population had mild fluorosis. Prabu and Saravanan12 and Honarmand et al.13 According to the Dean’s index and Thylstrup–Fejerskov index, the most common forms of dental fluorosis are very mild and severe, respectively. Their findings conflict with ours due to variations in geography, dietary habits, drinking water fluoride levels, age-groups, and indices.

Fluoride is frequently referred to as a “double-edged sword” since it can prevent cavities when used optimally and wisely and cause chronic fluoride toxicity, manifesting as dental and skeletal fluorosis. In contrast to optimal fluoride areas and high fluoride areas, where the teeth will have both topical and systemic benefits from repeated exposure to fluoridated water, the high caries experience may be seen in below optimum fluoride areas due to the absence of preventive use of fluoride (both topical and systemic). People in high-fluoride locations will exhibit confluent pitting because of severe fluorosis. The teeth’s morphological change may make it easier for food to stay in them, making the tooth surface more vulnerable to caries.14

In our study, the DMFT community score was found to be low. This finding could be because most of the study population had mild fluorosis and were residents of optimum fluoride areas.

Wondwossen et al.,15 from their study, concluded that both in areas with moderate and high levels of fluoride, dental caries increased as the severity of dental fluorosis increased. As a result, a link between dental caries and dental fluorosis was found in both regions and among different tooth types.

Most of the children answered never or once/twice for all the questions in the four domains. This could be because most of the study population had mild fluorosis, indicating that mild fluorosis has no or minimal effect on the OHRQoL.

Chankanka et al.16 and Michel-Crosato et al.3 reported that OHRQoL was not affected either by mild or very mild fluorosis. However, higher fluorosis scores may have a more significant negative effect, similar to the present study’s findings.

When asked if the children were teased/called names, argued with children/family, avoided smiling/laughing, were asked questions, and did not want to speak/read loud in the class, children with severe fluorosis answered it as often, sometimes, everyday/almost every day indicating that severe fluorosis affected the social well-being of the children.

This is similar to the study by Singh et al.1 wherein the increasing severity of dental fluorosis leads to a rise in the overall scores as well as the mean scores for a number of other categories, including “oral symptoms,” “self-assessment,” “social and well-being,” “functional restrictions,” and “free time.” and the studies carried out by Do and Spencer,17 and Vargas-Ferreira and Ardenghi18 agreed with the results of the present study.

In this study, social well-being was the most affected domain, followed by emotional well-being. Functional limitations were the least affected domain in the study population.

de Castilho et al.19 stated that the clinical features of fluorosis cause shy, depressed, and quiet youngsters who hide their faces with their hands to show happiness and grin with their lips closed. These kids also avoid participating in school social activities and talking to their classmates out of shame about their dental health. This was in accordance with our study.

The present study’s findings showed that dental fluorosis influenced research participants’ QoL in a quantifiable way. This was clear from the findings of the study population, which were consistent with other studies by Do and Spencer17 Vargas-Ferreira and Ardenghi18 and Tellez et al.20

The results of the present study were contrary to the survey conducted by Robinson et al.21 in Uganda, who discovered that fluorosis with strong social manifestations has negative effects on QoL. Fluorosis has been shown to improve OHRQoL in several studies. According to a study conducted in Brazil, the majority of parents of children who had fluorosis thought their children’s teeth looked as attractive as or even more so than healthy enamel.

Amaral et al.22 found no relationship between fluorosis and eight oral impacts on daily performance fields, as most of the study population had questionable fluorosis. Dental fluorosis did not affect the QOL in elementary school students.

Williams et al.23 reported that dental fluorosis had no discernible adverse effects on appearance or emotional state. These findings do not match what we found. These results are inconsistent with ours, which could be due to their study’s very low severity of dental fluorosis.

A study by Menezes et al.24 conducted a survey in which the majority of the respondents (59.9%) did not express any self-perception of any dental lesions, including fluorosis lesions. This confirms that the disease did not worsen the subjects’ QoL. Also, one theory for interpreting these findings is that teenagers who live in a setting where their classmates’ dental appearance is similar to their own develop a sense of identity distinct from other groups, which may affect how they perceive their OHRQoL.

None of the studies reported adverse effects of mild dental fluorosis but, several studies involving severe fluorosis consistently said it harmed the OHRQoL.

The present study also found a connection between the degree of dental fluorosis and the OHRQoL. It was found that severe fluorosis has a negative impact on the OHRQoL of children.

Chankanka et al.16 conducted a literature review and concluded that severe fluorosis had consistently been reported to affect OHRQoL, negatively. For instance, Indian children perceived dental fluorosis as an adverse or disadvantageous condition.

Studies have shown that higher disease severity levels promoted social and psychological discomfort. Few children in this study who believed they had fluorosis in their teeth expressed a desire to alter their dental appearance. These results are in accordance with the findings of Bhagyajyothi and Pushpanjali.25

Since fluorosis affects the OHRQoL of children, suitable health education and preventive measures are needed. It is essential to take precautions to lower the danger of fluoride exposure. Parents should be educated about the causes of dental fluorosis, preventive measures, and management. Esthetic treatments cannot be performed as the child is still developing. But still, they can be informed about the appropriate age and treatment modalities for esthetic corrections. The state government also should be encouraged to conduct surveys regarding the levels of fluoride in the groundwater, and defluoridation protocols should be implemented. Dental professionals can interact with children in a mutually beneficial manner. The children can be explained that oral hygiene is more important than appearance and should be encouraged to maintain good oral hygiene. The children should be also made to understand that dental fluorosis is a common natural phenomenon, and there is no reason to be concerned about it.

The limitations of the study were that the study population was restricted to a smaller geographic area. The study did not include a population with skeletal fluorosis. Although the current study evaluated OHRQoL in children with dental fluorosis in the endemic fluoride region of Vikarabad, there is a need for additional epidemiological research, including a diverse group of study participants.

CONCLUSION

The results showed that dental fluorosis had a measurable impact on the QoL of affected study participants. A correlation existed between the degree of dental fluorosis and the OHRQoL. It was found that severe fluorosis has a negative impact on the OHRQoL of children. Dental fluorosis mainly affects the children’s social and emotional well-being.

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