Community Dent Oral Epidemiol 2011; 39: 127–136  2011 John Wiley & Sons A/S

All rights reserved

Deirdre Browne1, Helen Whelton1, Denis

The aesthetic impact of enamel O’Mullane1, Jacqueline Tavener2 and
Edel Flannery3

fluorosis on Irish adolescents

1
Dental School, University of Cork, Cork,
Ireland, 2University of Manchester,
Manchester, UK, 3School of Mathematical
Sciences, University of Cork, Cork, Ireland
Browne D, Whelton H, O’Mullane D, Tavener J, Flannery E. The aesthetic
impact of enamel fluorosis on Irish adolescents. Community Dent Oral
Epidemiol 2011; 39: 127–136.  2011 John Wiley & Sons A ⁄ S

Abstract – Objectives: To assess the impact of differing degrees of enamel

fluorosis on dental aesthetics according to Irish adolescents. The same
participants also aesthetically rated other variations in dental appearances
including a carious lesion, bleached teeth and a demarcated
opacity. Methods: One hundred and fifty adolescents examined seven identical
template photographs of an attractive dental smile displaying varying levels of
enamel fluorosis (TF1, TF2, TF3), a demarcated opacity, no fluorosis (TF0),
anterior caries and very white or bleached teeth. By indicating their level of
agreement or disagreement with five statements on a five-point Likert scale, the
participants rated the aesthetic acceptability of each of the
photographs. Results: Using paired t-tests with the Bonferroni correction, it
was found that the photographs depicting the very white teeth and anterior
caries were rated as the most and least aesthetically pleasing images,
respectively. There was no significant difference in the ratings of the
Key words: adolescents; aesthetics; fluoride;
photographs displaying TF0, TF1 and TF2 levels of fluorosis indicating that fluorosis; photographic images
these photographs were viewed similarly (P > 0.002). The remaining two
photographs (TF3 and the demarcated opacity) were rated similarly and Deirdre Browne, Dental School, University of
Cork, Cork, Ireland
significantly worse (P < 0.002) than the photographs showing no or low Tel.: +353 21 4901210
grades of fluorosis (TF0, TF1 and TF2). Conclusions: TF3 level of fluorosis Fax: +353 21 4545391
represented the break point at which enamel fluorosis became aesthetically e-mail: dm.browne@ucc.ie
objectionable to these participants. Low grades of fluorosis (TF1 and TF2) Submitted 6 August 2009;
were rated similarly to the photograph depicting no fluorosis (TF0). accepted 29 July 2010

Several international studies have addressed the
issue of whether or not enamel fluorosis is per-
ceived to be an aesthetic problem by those children
and adolescents affected, and by their parents
(1–10). There is some agreement that when using
the fluorosis-specific TF index (9), only cases with
scores of TF3 or more may be of aesthetic concern.
Although data from Ireland indicate a prevalence
of Dean’s very mild fluorosis (equivalent to a TF
score of 2 or 3) of 10.6% among 15-year-olds living
in areas with water fluoridated at 1 ppm (71%
coverage of the population of the Republic of
Ireland) (11), the impact of enamel fluorosis on
those adolescents currently affected in Ireland is
unknown. Perception of aesthetics and body image
is multidimensional and influenced by behaviour-
al, social and cultural factors (12, 13). With glob-
alization and the availability of mass media, lay
people and dental professionals from different
countries are tending to have very similar percep-
tions of aesthetics. However, across cultures, there
can be subtle ethnic differences in ratings of
aesthetics (14). Currently, 23% of 8-year-olds and
38% of 15-year-olds in fluoridated communities in
the Republic of Ireland have signs of enamel
fluorosis (11). These levels have increased since
1984 when 6% of 8-year-olds and 5% of 15-year-
olds had some signs of fluorosis (15). Therefore,
assessment of the aesthetic impact of enamel
fluorosis among an Irish population needs to be
investigated. This study aimed to (i) assess the
impact of varying levels of enamel fluorosis on
dental aesthetics according to a sample of Irish
adolescents using template photographs of an
attractive smile and (ii) compare the aesthetic
ratings of the photographs depicting enamel

doi: 10.1111/j.1600-0528.2010.00577.x 127

Browne et al.
fluorosis with other photographs showing a
carious lesion, bleached teeth and a demarcated
opacity, among the same participants.
Materials and methods
Images depicting seven different appearances of
upper anterior incisors were computer generated
using a ‘template smile’ and were assessed for
aesthetic impact by 150 adolescents. The template
facilitated control of the size, shape and arrange-
ment of the teeth as well as the lips and smile line.
The only differences among the images were those
created for the assessment; the differences included
varying levels of fluorosis, (TF1, TF2, TF3), ‘Very
White’ (or bleached) teeth, dental caries, a demar-
cated opacity and no opacities (TF0), to provide
respondents with a realistic range of dental appear-
ances from which to compare and contrast (Fig. 1).
An image with caries was added to enable com-
parison between the aesthetic impact of enamel
fluorosis and dental caries, as the trade-off for
prevention of dental caries with fluorides is that a
proportion of the population will have enamel
fluorosis. A photograph depicting a demarcated
opacity was also added to compare the aesthetic
impact of fluorosis with that of another type of
enamel opacity. The photographs also included
lips to make the images appear more realistic (8).
The images were presented as printed photo-
graphs to the study participants to assess their
opinions on the appearance of the teeth depicted.
Photographic images are stable and less susceptible
to variations, which may arise when using com-
puter screens (4, 8, 16, 17). The photographs were
JPEG digital images and printed on photo paper
with no labels ⁄ titles attached. Their dimensions
were 3040 · 2016 (twice life size to allow partici-
pants to clearly view the defects but without
excessive magnification that could accentuate small
opacities). The adolescents viewed the images
individually, whilst being supervised by one of
the authors and a research assistant. The images
were scored by the adolescents, one at a time,
without viewing the remaining images. Photo-
graphs were randomized and presented to each
participant in the same order: ‘No defects’, ‘TF1’,
‘Demarcated’, ‘TF3’, ‘Caries’, ‘TF2’ and ‘Very
White’.
A questionnaire was developed in consultation
with psychologists to assess participants’ opinions
of the photographs. The questionnaire contained
128
five statements and was drafted based on questions
asked previously by Riordan (1) regarding the
impact of enamel fluorosis on dental aesthetics. The
study received ethical approval from the Clinical
Research Ethics Committee of the Cork Teaching
Hospitals, reference OHSRC00705. The question-
naire was piloted on 52 participants. Following the
pilot study, slight modifications were made to the
wording of the questionnaire to reduce ambiguity.
For each photograph, five observations were
made by each participant (Fig. 2). The participants
were asked to focus on the appearance of the upper
anterior teeth in each photograph. For each photo-
graph, participants were asked to indicate whether
or not they agreed with the statement ‘The appear-
ance of these teeth is pleasing and looks nice’,
based on a five-point Likert scale (from Agree
Strongly, Agree, Neutral, Disagree to Disagree
Strongly). Individual assessments were then made
of the upper anterior teeth using the same scale,
including whether or not someone with teeth like
those shown in the photograph would be embar-
rassed by their appearance, whether or not the
appearance of the teeth was indicative of neglect or
would be a disadvantage in life.
The study population
Four schools were selected in Cork city and county,
primarily for convenience. These schools were
selected to provide a sample balanced for gender.
Their mean age was 14.5 (0.5 SD) years. Of the
sample, 76.5% resided in a full-fluoridated area all
of their lives, 16.1% resided in a full-fluoridated
area some, but not all, of their lives, and 7.4% had
always resided in a nonfluoridated area.
Three hundred and eighty-five adolescents were
invited to participate, 188 consented (consent rate
48.8%). However, 30 were not included in the final
sample because they were wearing fixed orthodon-
tic appliances or had one or more demarcated
opacities on their maxillary incisors. These partic-
ipants were excluded to eliminate ‘noise’ in the
data and to obtain a ‘pure’ sample with either
normal enamel or enamel fluorosis affecting at least
one of the permanent maxillary incisors. Eight
participants were also absent on the day of the
screening. Of the remaining 150 participants, 52.7%
were female (n = 79) and 47.3% (n = 71) were male.
The participants’ upper permanent incisors were
examined in natural light and classified according
to the Thylstrup and Fejerskov (TF) Index (9) after
drying with cotton wool rolls for one minute. The
single highest TF score of the central and lateral
 The aesthetic impact of enamel fluorosis on Irish adolescents

Very white No opacity

TF1 TF2

TF3 Demarcated opacity

Dental caries

Fig. 1. Template dental photographs

examined by adolescents in the study
on the aesthetic impact of enamel
fluorosis.

maxillary incisors was recorded. Among the sam- an exercise, principal components (PC) analysis, as
ple, 79.3% had no enamel fluorosis (TF0), 10.7%, recommended by Jolliffe (18) and Browne (19). The
8.0% and 2.0% had TF scores of 1, 2 and 3, weights were applied to the mean score for each
respectively. No subjects had a TF score of ‡4. subject for each of the seven photographs.

Data analyses PC Analysis

The data set consisted of five responses to each of
seven photographs for 150 participants. As the
responses to the statements were based on the
same 5-point Likert scale (agree strongly, agree,
neutral, disagree to disagree strongly), mean scores
were derived from the responses to show the
variation in responses for all participants to the
different statements for each of the seven photo-
graphs. It was recognized that, in data of this
nature, the weights assigned to each statement
should differ. A weighting was adopted based on
On the basis of PC Analysis, the weights assigned
to the mean score for each photograph were 0.47,
)0.48, )0.46, )0.43 and 0.39 for Statements 1, 2, 3, 4
and 5, respectively. The weights were derived from
an algorithm as part of the PC procedure. The
negative weights are applied to the negatively
phrased questions; statements 2, 3 and 4 were
negative i.e. ‘embarrassed’, ‘neglect’ and ‘disad-
vantage in life’. The fact that all the weights for PC
are of similar magnitude means PC can be inter-
preted as an average desirability. More detail on

129
Browne et al.

For each of the photographs you are about to be shown, please consider the following

statements. Answer by circling the option that is closest to your own opinion.

You will be given a separate questionnaire for each of the photographs:

Photograph 1

1. The appearance of these teeth is agree agree neutral disagree disagree

pleasing and they look nice: strongly strongly

2. Someone with teeth like these agree agree neutral disagree disagree
would be embarrassed by their strongly strongly
appearance:

3. Teeth like these indicate that the agree agree neutral disagree disagree
person has neglected his/her teeth in strongly strongly
the past:

4. To have front teeth like this would agree agree neutral disagree disagree
be a disadvantage in life: strongly strongly

5. To have front teeth like this would agree agree neutral disagree disagree
Fig. 2. Questionnaire to assess
be an advantage in life: strongly strongly aesthetic impact of enamel fluorosis.

PC Analysis can be obtained in Browne (2008) PhD
thesis (19).
Pair-wise comparisons between the desirability
of the seven different photographs were evaluated
using paired t-tests (Table 1). The weighted mean
scores of each pair of photographs for each partic-
ipant derived using the weights from PC, were
compared using t-tests and P-values. Twenty-one
comparisons were made. Bonferroni correction was
used to correct for the increasing chance of Type 1
error. With Bonferroni correction, all P-values
<0.002 (0.05 ⁄ 21) were significant at the 0.05 level.
The weighted mean responses to the photographs
according to PC Analysis (irrespective of what
photograph) according to gender, age (in years),
fluoridation status, medical card ownership and
one’s own TF score for all participants were
compared using box-plots. Medical card ownership
is a surrogate for disadvantage.
Results
Reading the first line of Table 1 horizontally, the
comparison between the photographs depicting
‘Very White’ teeth is obviously redundant (‘x’) as
like is being compared with like. However, the
comparison between the photographs depicting
‘Very White’ teeth and ‘TF0’ is significantly differ-
ent (‘*’), as is the comparison between the ‘Very
White’ photograph and each of the remaining five
photographs. In the second line, the ‘Very White’
and ‘TF0’ photographs have previously been com-
pared (and found to be significantly different), so

Table 1. Pair-wise comparisons using paired t-tests between the desirability of the seven photographs according to
principal components analysis
(1) (2) (3) (4) (5) (6) (7)
Photographs Very white TF0 TF1 TF2 TF3 Demarcated Caries
(1) Very white x * * * * * *
(2) TF0 x x 0.396 0.007 * * *
(3) TF1 x x x 0.015 * * *
(4) TF2 x x x x * * *
(5) TF3 x x x x x 0.219 *
(6) Demarcated x x x x x x *
(7) Caries x x x x x x x
*Means P-value <0.002.
x, comparison meaningless (diagonal) or already given above the diagonal.

130
 The aesthetic impact of enamel fluorosis on Irish adolescents
any further comparison is not required (‘x’).
However, the photograph depicting ‘TF0’ is not
significantly different from the ‘TF1’ photograph
(P = 0.396). The difference between the photo-
graphs depicting ‘TF0’ and ‘TF2’, although close,
also did not reach significance (P = 0.007). There-
fore, there was no significant difference in level of
desirability between these photographs (P > 0.002)
meaning that the photographs depicting ‘TF0’,
‘TF1’ and ‘TF2’ were considered aesthetically sim-
ilarly. Looking at the pattern of these preferences
(and lack of preferences), the photographs can be
placed into four distinct groups (P < 0.002);
• Group 1: Photograph 1 (‘Very White’ teeth)
• Group 2: Photographs 2, 3 and 4 depicting ‘TF0’,
‘TF1’ and ‘TF2’ levels of fluorosis, respectively
• Group 3: Photographs 5 and 6 depicting ‘TF3’
fluorosis and the ‘Demarcated’ opacity, respec-
tively
• Group 4: Photograph 7 (dental ‘Caries’)
The range of mean responses weighted accord-
ing to PC Analysis for all participants to the seven
photographs is shown as box-plots in Fig. 3. The
range of possible weights applied (PC) were 0.47
(statement 1), )0.48 (statement 2), )0.46 (statement
3), )0.43 (statement 4) and 0.39 (statement 5). The
PC was constructed as follows; 0.47 multiplied by
the response to statement 1 (score 1–5), minus 0.48
multiplied by the response to statement 2, minus
0.46 multiplied by the response to statement 3,
minus 0.43 multiplied by the response to statement
4, plus 0.39 multiplied by response to statement 5.
Fig. 3. Ratings of photographs 1–7: 1 ‘Very White’, 2 ‘No
Defects’, 3 ‘TF1’, 4 ‘TF2’, 5 ‘TF3’, 6 ‘Demarcated’ and 7
‘Caries’ according to principal components analysis.
Each box in Fig. 3 indicates the interquartile
range with the horizontal line in the box indicating
the median (i.e. 50% of responses lying above and
50% of responses lying below the median). The
upper edge of the box indicates the 75th percentile
of the data set and the lower edge indicates the 25th
percentile. The outer limits of the vertical dotted
lines indicate the maximum and minimum values.
The whiskers (the vertical lines extending out from
the boxes) extend out for a maximum distance of
1.5 times the interquartile range [IQR = the
distance between the top (75th percentile) and
bottom (25th percentile) of the box] on either side
of the box. If the upper (or lower) value was
<1.5 · IQR away from the box, the whisker only
extended out to the maximum value. If the upper
(or lower) value was further than 1.5 · IQR away
from the box, then the whisker stopped at the dis-
tance of 1.5 · IQR away from the box and any
outliers (values outside the whisker) are marked
with a circle as in slides 2, 4 and 6.
The box-plot for the ‘Very White’ photograph
(Photograph 1) is heavily skewed in the negative
direction. In this case, 50% of participants have a
weighted median response score of approximately
‡4. The ‘Very White’ photograph was rated signif-
icantly better than all of the other six photographs
(P < 0.002). Photographs 2, 3 and 4 refer to the
following photographs: 2, ‘No Defects’ (TF0), 3,
‘TF1’ and 4, ‘TF2’, respectively. The box-plots for
these photographs were more symmetrically
distributed. As can be seen from Fig. 3 and Table 1,
these three photographs were rated similarly to
each other (P > 0.002) and significantly different to
the other photographs. Photographs 5 and 6
represent ‘TF3’ level of fluorosis and the ‘Demar-
cated’ opacity (‘Spot’), respectively; these two
photographs were also rated similarly (P > 0.002)
and significantly worse than the photographs
depicting ‘Very White’ teeth, ‘No Defects’, ‘TF1’
and ‘TF2’ levels of fluorosis (P < 0.002). The ‘Car-
ies’ photograph was rated as the least favourable of
all the photographs (Photograph 7) (P < 0.002). The
box-plot for this photograph is heavily skewed in
the positive direction.
The effects of the following variables; gender,
age (in years), fluoridation status, medical card
ownership by parent and one’s own TF score on
the responses to Statements 1–5 were also exam-
ined. Gender did not have an effect on the adoles-
cents’ rating of the photographs (P > 0.05). Older
adolescents (16-year-olds) rated the photographs
significantly better than younger adolescents
131
Browne et al.
(15-year-olds) (P = 0.025). Fluoridation status and
medical card ownership did not have any impact
on the ratings of the photographs (both P > 0.05).
Those with fluorosis tended to rate the photo-
graphs worse. However, this relationship was not
statistically significant (P > 0.05).
To summarize the results, the photograph
depicting ‘TF3’ level of fluorosis and the ‘Demar-
cated’ opacity was rated similarly (P > 0.002).
Participants also rated lower levels of fluorosis
(‘TF0’, ‘TF1’ and ‘TF2’) similarly (P > 0.002) and
significantly better than the photographs depicting
‘TF3’ level of fluorosis and the ‘Demarcated’
opacity (P < 0.002). Age was the only individual
factor (subject effect) that significantly affected the
participants’ ratings of the photographs; older
adolescents rated the photographs more favour-
ably than younger ones (P = 0.025). Medical card
ownership, gender, fluoridation status or TF score
did not significantly affect the participants’ ratings
of the photographs.
Discussion
The photographs depicting ‘TF3’ and the ‘Demar-
cated’ opacity were rated more negatively than the
photographs depicting no fluorosis (‘No Defects’)
or low levels of fluorosis (‘TF1’ and ‘TF2’)
(P < 0.002). Therefore, the photograph depicting
fluorosis level ‘TF3’ represented the level at which
fluorosis became aesthetically objectionable to
these participants. The photograph depicting ‘Very
White’ teeth was rated significantly better than the
other photographs, and ‘Caries’ was rated signif-
icantly worse (all P-values <0.002).
Identifying ‘TF3’ as the break point for the level
at which fluorosis becomes aesthetically objection-
able is consistent with the findings of other
researchers. Riordan (1) asked a group of 110
observers in Australia, including lay people (par-
ents, university students, public servants) and
dentists to rate the appearance of 28 children’s
teeth with varying degrees of enamel fluorosis
(TF0–TF3) from a normal ‘conversational’ distance.
The majority of participants felt that children with
TF3 level of fluorosis would be a source of
embarrassment for the child. Sigurjons et al. (20)
conducted a telephone interview among 215
parents of 8-year-old children in Cork (Ireland),
Reykjavik (Iceland) and Knowsley (England) and
found that children with TF grade of ‡3 were
associated with a higher percentage of parents
132
displeased with the colour of their children’s teeth
than those with TF score of 0 (P = 0.005). Children
aged 7–13 and adolescents aged 14–19 (n = 2495)
with TF ‡ 3 level of fluorosis who participated in a
study by Shulman et al. (7) in British Columbia,
Canada, were also more critical of the appearance
of their teeth than participants with no fluorosis
(P = 0.009).
In the examples just described, participants were
asked to rate the appearance of children’s teeth or
children were asked to rate the appearance of their
own teeth. In this study, participants were asked to
rate photographs and were not asked to consider
the appearance of their own teeth. The results of
this study are compared with the findings of other
authors who also used photographs in their assess-
ment of the aesthetic impact of fluorosis in Table 2.
Hawley et al. (4) identified ‘TF3’ as the most
objectionable level of fluorosis. Edwards et al. (8)
reported that ‘TF3’ and ‘TF4’ had the lowest
acceptability scores.
When comparing the aesthetic acceptability of
demarcated opacities with fluorosis, the results of
this study are similar to other results cited in the
literature. Tavener (21) conducted a similar study
in the U.K. among 205 16–19-year-olds using some
of the same images as featured in this study
(Fig. 2). The participants were asked to arrange
the images in order of aesthetic preference, with
the most pleasing ranked first. A photograph
depicting fluorosis at grade ‘TF4’ was also included
and was ranked less aesthetically pleasing than
fluorosis levels ‘TF1’–’TF3’. The photograph depict-
ing the ‘Demarcated’ opacity was rated less
favourably than the photographs depicting fluoro-
sis, according to the participants in the study by
Tavener (21). In line with the results of the study
described here, the photographs depicting dental
‘Caries’ and the photograph depicting ‘Very White’
teeth were rated as the least and most attractive,
respectively (P < 0.05).
In the study described in this publication, older
participants (16-year-olds) rated the photographs
more favourably than younger participants (15-
year-olds) (P = 0.025). This finding suggests that
older adolescents are less critical of deviations from
an ideal dental appearance than younger partici-
pants. It could be argued that participants who
have enamel defects on their own teeth may be
influenced to rate teeth differently. It is interesting
to note that participants with fluorosis tended
to rate the photographs worse. However, this
relationship was not statistically significant
 The aesthetic impact of enamel fluorosis on Irish adolescents

Table 2. Comparison of the aesthetic rating of images of enamel opacities, including fluorosis, according to type of
opacity as reported in the current and other published studies where photographs were rated
Sample
Authors Country Participants size Age Methods used Findings
Hawley et al. UK Students 534 14-year-olds Case photos ⁄ rating The photos of TF score 1
1996 (4) acceptability of eachhad lower percentage
photo and indicating rated as poor or very
treatment need poor (15%) than TF
score 0 (29%); 92%
rated TF score 3 as
poor or very poor
McKnight USA First year 61 20–24-year-olds Pairs of computer- Mild fluorosis (TF1 ⁄ 2)
et al. 1999 (5) dental generated images ⁄ was assessed less
students questionnaire favourably than normal
enamel. TF3 was rated
less favourably than
isolated opacity.
Diastema was less
favourable than
fluorosis (TF1 ⁄ 2)
Levy et al. USA Fourth year 45 24 years or older Pairs of computer- Fourth year students
2002 (6) dental generated images ⁄ generally had more
students questionnaire favourable aesthetic
perceptions of mild
enamel fluorosis than
they had 4 years earlier
Edwards Scotland Adolescents 239 14–15-year-olds Digitally manipulated Less acceptable with
et al. 2005 (8) images ⁄ using severe fluorosis.
questionnaire to rate Photos that involved
the appearance eyes and chin and
and treatment need all face photos had
similar acceptability
scores among TF0–TF4.
Closer photos of TF3
and 4 had lower
acceptability scores
Tavener UK Students 205 16–19-year-olds Template images, Images of TF1–4 were
2006 (21) adolescents ranked more favourably
asked to rank images than those depicting
based on aesthetics demarcated opacities
The present Ireland Adolescents 150 14–15-year-olds Template images, Photographs depicting
study 2008 adolescents ‘No Defects’, ‘TF1’
asked to rate the and ‘TF2’ were rated
aesthetics of each similarly. Photographs
photograph depicting ‘TF3’ and
based on a ‘Demarcated’ opacity
questionnaire were rated similarly
and less favourably
than the photographs
depicting ‘‘No Defects’,
‘TF1’ and ‘TF2’
(P < 0.002)

(P > 0.05).With a larger sample size, this relation-
ship may have reached statistical significance and
could reflect participants’ inherent dislike for small
deviations from the ‘normal’ appearance of their
own teeth. The four schools selected in the study
were chosen for convenience. The majority of
participants (76.5%) resided in a full-fluoridated
area all of their lives. As these adolescents lived in
a predominately fluoridated area, they may have
been accustomed to seeing fluorosis, and therefore,
their opinions may not be representative of the
general population.
The study design using computer-generated
photographs appears to have been effective as
the results of the study described in this publica-
tion were similar to others previously reported by

133
Browne et al.
other authors. The advantage of using photo-
graphs is that the study can be administered in
other areas in the country to determine whether
the same responses would obtained in areas that
differed from Cork (for example, Dublin). An
interesting follow-up study to the one described
would be to administer the questionnaire to a
sample balanced for fluoridation status (for exam-
ple fluoridated Republic of Ireland and nonfluo-
ridated Northern Ireland). In doing so, the impact
of each participant’s own fluorosis status on their
rating of the photographs could be further
explored.
The photographs used in this study were digi-
tally contrived, and although they appeared natural
to the study participants, deviation from the natural
appearance of teeth was inevitable. An identical
image of an evenly aligned, unrestored aestheti-
cally pleasing dentition was chosen displaying
upper incisors, canines and first premolars. Because
only one smile was used, variations between the
aesthetic appearances of dissimilar smiles could not
be rated. However, in this way, confounding factors
such as amount of tooth visible, tooth alignment
and level of gingival health could not interfere with
the study participants’ rating of each dental
appearance. Dental health professionals may have
known the images were artificial but the partici-
pants reported them to look realistic. The photo-
graphs formed a very simple tool to assess the
aesthetic impact of enamel fluorosis. The tool was
portable, and participants did not need to be
computer competent to use it. There was also no
variation in the magnification of the images or
differences in brightness ⁄ screen resolution, which
could have occurred if the images were displayed
on a computer screen.
The language used in the questionnaire was
comprehensible for this age group. Combining
positive and negative questions also succeeded in
preventing acquiescence bias as responses for the
photographs appeared consistent regardless of the
direction (positive or negative) of the questions
asked. However, no validity and reliability tests
were conducted using the questionnaire. This
would be recommended for future studies of this
nature. The use of closed statements with set
responses could also be criticized. The range of
possible answers may not have allowed partici-
pants the opportunity to state what they wished,
making them feel somewhat constrained. How-
ever, such questionnaire design did lead to mini-
mal effort from participants and generated
134
unambiguous responses for computation, so that
results could be presented in a clear manner.
The photograph depicting ‘Very White’ teeth
was viewed as the most favourable among these
adolescents (P < 0.002). In reality, the whiteness of
the teeth in this photograph was unnatural, which
could only be attained by bleaching the teeth.
Interestingly, ‘No Defects’ and low levels of fluo-
rosis (‘TF1, ‘TF2’) were viewed similarly suggesting
that mild levels of fluorosis were as acceptable
to these participants as no fluorosis. This is an
important finding as some degree of fluorosis is
inevitable with water fluoridation. It would appear
that low levels of fluorosis did not represent an
aesthetic problem to these participants, whereas
clearly anterior caries did; the photograph depict-
ing dental ‘Caries’ was viewed as the least favour-
able of all of the photographs (P < 0.002). ‘TF3’ was
the level of fluorosis most participants deemed to
be the most aesthetically objectionable (P < 0.002).
This is consistent with the findings of other
researchers (1, 4, 8, 20). The photograph depicting
‘TF3’ level of fluorosis and the ‘Demarcated’
opacity were rated similarly.
Only one type of demarcated opacity was exam-
ined by participants in this study. Demarcated
opacities can vary in size, location and colour
(cream, brown, yellow). The demarcated opacity
used in this study was whiter than the surrounding
enamel and evoked as negative a reaction as the
image of ‘TF3’ level of fluorosis. This suggests that
opacities with enhanced contrast with surrounding
enamel are more aesthetically objectionable than
those which contrast less or blend more into the
enamel.
Nonetheless, it is important to note that when
attention is drawn to a dental anomaly in a
research study, the participant is obliged to make
some form of judgment (22, 23). However, these
findings are not comparable to the real-life social
situation where small deviations from the ‘normal’
dental appearance may not even be noticed by
social on-lookers. A much larger study involving
several smiles that had similar differences would
be required to really test whether the rating break
point of TF3 would be consistently maintained
with all types of smiles. The response rate in this
study was 48.8%. There is no information on the
likely pattern of responses of the 51.2% who did
not give consent. Thus, extrapolation of the results
is limited, and it is important to bear this in mind
when interpreting the results. Caries was also not
recorded among the participants in this sample. In
 The aesthetic impact of enamel fluorosis on Irish adolescents
future studies, it would be wise to examine for
caries as it would enhance the interpretation of the
results in the context of the risks (fluorosis) and
benefits (caries) of water fluoridation. This study
was primarily methodological in nature, and whilst
the results are useful in identifying general ten-
dencies in adolescents’ opinions on photographs of
fluorosis, they are not representative of the general
population. To further validate the findings of this
study, it would be useful to repeat it on a larger,
more representative sample. Future studies of this
nature should also include questionnaires to solicit
the opinions of parents in terms of their ‘willing-
ness to pay’ for correction of their children’s
defects.
The images provided a range of dental anomalies
for the participants to examine. However, they only
represented a selection of enamel opacities. Levels
of fluorosis from TF1 to TF3 were included as these
are the levels of fluorosis most prevalent in Ireland.
TF1, TF2 and TF3 scores approximate to question-
able (TF1) and very mild fluorosis (TF2 and TF3) as
scored by Dean’s index. In full-fluoridated areas in
the Republic of Ireland 19.7% and 10.6% of 15-year-
olds had these levels, respectively in 2002 (11).
However, each of these levels of enamel fluorosis
was represented by a single image in this study,
whereas in reality, each score represents a spec-
trum of appearances falling into a single descrip-
tion. For example, TF2 includes teeth with varying
proportions of the tooth surface affected by ‘more
pronounced opaque white lines, which frequently
merge to form small cloudy areas’. Future studies
could investigate the impact of using more than
one image to represent each category of fluorosis.
However, care must be taken to avoid rater fatigue.
It would also have been beneficial to include
more severe levels of fluorosis, TF4 and TF5. A
recent study has shown that moderate fluorosis
(equivalent to a TF score of 5) whereby the entire
tooth surface is affected can be judged more
favourably than mild fluorosis where diffuseness
of the opacities is more striking (22).
It could be argued that the image displaying
dental ‘Caries’ looks unnatural as it is a solitary
lesion in an otherwise clean and healthy mouth. A
useful adjunct to the study would be to include
images of the cavity treated with restorations of
varying shades and quality.
Participants were aware of the purpose of this
study; hence, the results are not comparable to
normal social interactions or situations. Viewing
conditions have a strong influence on the results of
aesthetic studies when participants are asked to
rate dental images (8, 22). The photographs, whilst
randomized, were presented to each participant in
the same order: ‘No defects’, ‘TF1’, ‘Demarcated’,
‘TF3’, ‘Caries’, ‘TF2’ and ‘Very White’. Therefore,
viewing the photograph depicting the ‘Demar-
cated’ opacity after the photographs displaying
‘No Defects’, and ‘TF1’ may have made them more
critical of the former than if the order of viewing
had been reversed. As an extension to this study,
the order of viewing the images could be random-
ized and the study repeated to identify if partici-
pants rate the images in the same manner.
In conclusion, ‘TF3’ would appear to be the level
at which enamel fluorosis became aesthetically
objectionable to these participants. Bearing in mind
differences between the two indices, ‘TF3’ is
equivalent to a high grade ‘very mild’ case of
fluorosis as per Dean’s index (24, 25). According to
the results of the national survey conducted in 2002
(11), 18.0% of 15-year-olds in full-fluoridated areas
in the Republic of Ireland had ‘very mild’ or
greater fluorosis. Continued efforts are currently
being made to reduce the prevalence and severity
of fluorosis in the Irish population. Currently, 71%
of the population in the Republic of Ireland is
exposed to fluoridated water. In 2002, the Forum
on Fluoridation (26) in Ireland recommended
measures to reduce the prevalence of fluorosis,
including the reduction in the level of fluoride
added to water supplies from 0.8 to 1.0 ppm to
between 0.6 and 0.8 ppm. The Forum also advo-
cated issuing guidelines to parents advising them
not to use fluoride toothpaste in children younger
than 2 years of age, to supervise children aged
2–7 years when brushing and for these children to
use only a pea-sized amount of toothpaste. These
recommendations have been implemented; the
fluoride level in the water supply was reduced
from 0.8–1.0 to 0.6–0.8 ppm with a target of
0.7 ppm fluoride in July 2007. The Forum’s tooth-
paste recommendations for parents have also been
disseminated to dentists for their patients. Litera-
ture was posted to each dentist in a clear and
simple format, appropriate for discussion with
their patients. Media analysis and discussion in
the national and regional press were also used to
disseminate the findings of the Forum report.
National and local radio and television coverage
added to this information flow. Similar strategies
were implemented in Southern Australia and
have been successful in reducing the fluorosis
prevalence (27).
135
Browne et al.
This study did not seek to determine the adoles-
cents’ knowledge about enamel fluorosis and its
treatment, but rather sought to identify their
opinions on its aesthetic impact. Future studies
should determine the wider impact of fluorosis on
the individual and the family including the finan-
cial impact of treatment of fluorosis and the impact
of fluorosis on quality of life. The study described,
however, has shown that low levels of enamel
fluorosis (TF1 and TF2) were seen as no more
aesthetically objectionable among these partici-
pants as no fluorosis (TF0). If efforts are continually
made to reduce the prevalence of ‘TF3’ fluorosis in
the population, the benefits of water fluoridation
considerably outweigh the risks.
Acknowledgements
Funded by the Health Research Board, Dublin, Ireland.
Dental images provided by Colgate Palmolive, UK.
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