INDICES FOR FLUOROSIS

Dental Fluorosis, is a specific disturbance in tooth

formation and an esthetic condition and is defined as a
chronic, fluoride induced condition, in which enamel
development is disrupted and the enamel is hypomineralised
.

(Fejerskov et al, 1990)

Dean’s fluorosis index
Community fluorosis index
Tooth surface index of fluorosis
Thylstrup and Fejerskov index for fluorosis
Fluorosis risk index
Single tooth surface index of enamel fluorosis
Chronological fluorosis assessment index
Young’s classification of enamel fluorosis
Murray and Shaw’s classification of enamel fluorosis
Simplified fluoride mottling index
DEAN’S FLUOROSIS INDEX
Introduced by TRENDLEY H.DEAN in 1934
known as ‘DEAN’S CLASSIFICATION SYSTEM
FOR DENTAL FLUOROSIS’ OR ‘DEAN’S
FLUOROSIS INDEX’.
The fluorosis index set criteria for categorisation
of dental fluorosis on a seven point scale; ‘Normal’,
‘Questionable’, ‘Very Mild’, ‘Mild’, ‘Moderate’,
‘Moderately Severe’, and ‘Severe’.
Procedure method
Recording is based on two teeth most affected

If two teeth are not equally affected score for less
affected tooth is recorded

Examiner should start at higher end of index

(severe) & eliminate each score to arrive at the
present condition

In doubts, lower score is recorded

Dean’s fluorosis index-original criteria(7 point)
classification Criteria

Normal(0) The enamel represent the usual translucent

semi- vitriform type of structure. The
surface is smooth, glossy, & usually pale
cream in color.

Questionable(0.5) slight aberrations in the translucency of

normal enamel,ranging from few flecks to
occasional white spots.

Very mild(1.0) small, paper white areas are scattered

irregularly or streaked over the tooth

surface.It is principally observed on the
labial & buccal surfaces, & involve
less than 25% of the tooth surface small
pitted white areas are frequently found.
Class Criteria

Mild(2.0) The white, opaque areas on the surface of

the teeth involve at least half of the tooth
surface. The surfaces of molars, bicuspids,
& cuspids subject to attrition show thin white
layers worn off & bluish shades underlying
normal enamel. Brown stains are sometimes
apparent, generally in upper incisors

Moderate(3.0) No change is observed in the form of the

tooth, but generally all of the tooth surfaces
are involved. Surfaces subject to attrition are
definitely marked.Minute pitting is often present
generally on the labial & buccal surfaces. Brown
stain is frequently a disfiguring complication.
Classification Criteria

Moderately severe A greater depth of enamel appears to be

involved. A smoky white appearance is often
noted. Pitting is more frequent & generally
observed on all tooth surface.Brown stain if
present will be more deeper In hue & involve
more of affected tooth surface.

Severe(4.0) The hypoplasia is so marked that the

form of the tooth is at times affected.
The pits are deeper & often confluent.
Stains are wide spread & range from a
chocolate brown to black.
Dean’s fluorosis index-modified criteria(1942)
Classification Criteria

Normal(0) The enamel represent the

usual translucent
semi-vitriform type of
structure. The
surface is smooth, glossy, &
usually pale cream in color

Questionable(0.5) slight aberrations in the

translucency of normal
enamel, ranging from few
flecks to occasional white
spots.
 Very mild(1.0) small, paper white areas are scattered

irregularly or streaked over the tooth

surface., but not involving as
much as 25% of the tooth surface.

Mild(2.0) The white opaque areas in the

teeth are more extensive, but
do not involve as much as
50% of the tooth.
Modreate(3) All enamel surface of the tooth
are affected. Brown staining is
frequently disfiguring feature

Severe(4) All enamel surface of the tooth

are affected & hypoplasia is so
marked that the general form of
the tooth may be affected. Major
sign is discrete confluent pitting is
seen & brown stains are often
present.
COMMUNITY FLUOROSIS INDEX(CFI)
 Developed by Trendley.H.Dean in 1935
 In CFI numerical statistical values (weights) as a score fir each degree
of mottling is given
 Each individual is given a score according to the following scale

Fluorosis category Numerical weight

Normal 0
Questionable 0.5
Very mild 1.0
Mild 2.0
Moderate 3.0
Severe 4.0
Score assigned to an individual is the one which
corresponds to the two most severely affected teeth in
the mouth
CFI can be calculate by the formula

Fci = Sum of (number of individual X statistical weights)

number of individuals examined
Public health
Range of scores significance
for communityof Community
fluorosis index Fluorosis index
Public health scores 1 – Dean 1946
significance

0.0 – 0.4 Negative

0.4-0.6 Borderline

0.6-1.0 Light

1.0-2.0 Medium

2.0-3.0 Marked

3.0-4.0 Very marked

Tooth surface index of fluorosis (TSIF)
• Developed by Herschel.S.Horowitz,
William.S.Driscoll, Rhea.J.Meyers,
Stanley.B.Heifetz and Albert Kingman in 1984.

• More sensitive than Dean’s fluorosis index for the

mildest form of fluorosis .

• TSIF accounts for each tooth surface in the mouth.

PROCEDURE METHOD
Each fully erupted, unrestored tooth surface is examined
and assigned a score on a 0 to 7 scale.
Two scores are assigned to the anterior teeth from the
labial and lingual aspects, and three scores are assigned to
the posterior teeth from the buccal , lingual and occlusal
aspects.
Tooth surfaces are not dried before the examination .the
thought being that teeth should be assessed in their
natural state.
If more than one category of fluorosis exists on a
tooth surface , the highest numerical score is
assigned to that surface.
score descriptive criteria

0 enamel shows no evidence of

fluorosis

1 enamel shows definite evidence of

fluorosis namely areas of parchment

– white color that total less than
1/3rd of the visible enamel surface.
2 parchment – white fluorosis totals
at least 1/3 of the visible enamel
surface , but less than 2/3.
3 parchment white fluorosis that totals about
2/3 of visible enamel surface.

4 enamel shows staining in conjunction with any of the

preceding levels of fluorosis.

5 discrete pitting of enamel exists ,

unaccompanied by evidence of staining
of intact enamel.

6 both discrete pitting and staining.

7 confluent pitting of the enamel surface

exists .large areas of enamel may be

missing .dark brown stain is usually
present.
Thylstrup and Fejerskov index for fluorosis

This fluorosis index was developed by

Thylstrup.A and Fejerskov.O in 1978.

Procedure method
To obtain the TF index , the teeth first should be
cleaned and dried with cotton rolls before the
examination.
For each tooth the labial ,lingual and occlusal
surfaces are examined and assigned a score.
This index system includes 10 scores of fluorosis designed
to characterize the macroscopic appearance of teeth in
relation to the underlying histologic condition of enamel
involved with each score.

Thylstrup and Fejerskov index-original criteria and

scoring.(1978)

.
In 1988, the Thylstrup and Fejerskov index was modified by
O.Fejerskov.

Only one surface per tooth be examined since fluorosis

affects all tooth surfaces equally and because of the
difficulty of getting an accurate assessment of fluorosis on
occlusal surfaces due to the likelihood that scores would
be affected by occlusal wear.
score criteria
TF score0 the normal translucency of the
glassy creamy white enamel
remains after wiping and drying
of the surface.

TF score1 thin white opaque lines are seen running

across the tooth surface .such lines are
found on all parts of the surface.
in some cases a a slight “snow-capping”
of the cusps/incisal edges may may also
be seen.
TF score2 the opaque white lines are more
pronounced and frequently merge to
form small cloudy area scattered over
the whole surface.

TF score3 merging of white lines occurs,cloudy

areas of opacity occurs spreads

over many parts of the surface.
In between the cloudy areas white
lines can also be seen
TF score4 The entire surface exhibits a marked
opacity , or appears chalky white. Parts
of the surface exposed to attrition or
wear may appear to be less affected.

TF score5 The entire surface is opaque , there are

round pits of less than 2mm in
diameter.
TF score6 the small pits may frequently be
seen merging in the opaque
enamel to form bands that are
less than 2mm in vertical height.

TFscrore7 there is loss of outermost enamel

in irregular areas ,and less than
½ surface is involved. The
remaining intact enamel is
opaque.
TF score8 The loss of the outermost enamel
involves more than half the enamel. The
remaining intact enamel is opaque.

TF score9 The loss of the major part of the outer

enamel results in a change of the
anatomical shape of the surface/tooth.
A cervical rim of opaque enamel is
often noted.
FLUOROSIS RISK INDEX

The fluorosis risk index was developed by David

G. Pendrys in 1990.

The FRI is designed to permit a more accurate

identification of associations between age specific
exposure to fluoride source and the development
of enamel fluorosis in permanent dentition.
The FRI divides the enamel surfaces of the permanent
dentition into two developmentally related groups of
surface zones designated as:

Classification I – Enamel surface zones that begin

formation (i.e. with commencement of secretary phase)
during first year of life.

Classification II – Enamel surface zone that begin

formation between the third and sixth year of life. The
second year of life was not assigned to either classification.
Method
The buccal surface and incisal edge/occlusal table
of each permanent tooth have been divided into four
scoring zones.
The incisal edge / occlusal table defined as the enamel
surface with 1 mm of the incisal edge of the tooth
The incisal / occlusal third of the buccal surface
The middle third of the buccal surface
Cervical third of the buccal surface
The zones assigned to
classification I - incisal edges of mandibular central
and lateral incisors and maxillary central incisors, and
occlusal tables of the mandibular and maxillary first
molars.
Claasification II – cervical thirds of incisors, middle
third of the canines and the occlusal table, incisal
third and middle third of bicuspids and second molars
in both the mandibular and maxillary arches.
Scoring Criteria

The identification of fluorotic enamel was based on

the classical criteria established by Dean and Moller.

The differential diagnosis of non fluorotic lesions was

made using the criteria of Zimmerman and Russell.
Scoring Criteria
Negative finding:

Score = 0 – A surface zone will receive a score of 0, when

there is absolutely no indication of fluorosis being
present. There must be a complete absence of any
white spots or striations, and tooth surface coloration
must appear normal.
Questionable finding:
Score = 1
Any surface zone that is questionable as to whether
there is fluorosis present (i.e. white spots, striations,
fluorotic defects cover 50 percent or less of the surface
zone) should be scored as 1.

Score = 7
Any surface zone that has an opacity that appears to be
non- fluoride opacity should be scored – 7.
Positive findings:
Score = 2
A smooth surface zone will be diagnosed as being positive for
enamel fluorosis if greater than 50 percent of zone displays
parchment - white striations typical of enamel fluorosis.
Incisal edges and occlusal tables will be scored as positive for
enamel fluorosis of greater than 50 percent of that surface is
marked by the snow capping typical of enamel fluorosis.

Score = 3
 A surface zone will be diagnosed as positive for severe
fluorosis, if greater than 50 percent of the zone displays
pitting, staining and deformity indicative of severe fluorosis.
Surface zone excluded:

Score = 9 - A surface zone is categorized as excluded

(i.e. not adequately visible for a diagnosis to be made)
when any of the following conditions exist.

In complete eruption

Orthodontic appliances and bands
Surfaces crowned or restored
Gross plaque and debris
DISADVANTAGE OF DEANS INDEX

The differentiation between normal, questionable and

very mild fluorosis was difficult and the classification
of ‘questionable’ is often a problem.
Clarkson (1989) summarized the main criticisms
of Dean’s classification

Since the index is based on the two most severely

affected teeth it does not allow for the measurement of
the extent of defect in the remaining teeth

It gives no indication of the location of the teeth or

tooth surface affected.
The index appears to describe the milder form of
fluorosis accurately but is not sensitive enough to
distinguish between degree of fluorosis in high
fluoride areas.

The use of the term ‘questionable’ is too vague.

The statistical basis for using the arithmetic mean to
calculate the CFI is questionable on the grounds that
the classification is based on an ordinal and not an
interval scales.

The community fluorosis index, because of its method

of calculation may not give true reflection on the
severity of fluorosis work in a community.
SINGLE TOOTH SURFACE INDEX OF ENAMEL
FLUOROSIS
This index was developed by Thylstrup and Fejerkov in
1978 designed to characterize the degree of fluorosis
affecting buccal, lingual and occulusal surfaces.

Method
For clinical study child was examined in portable dental
chair by one investigator prior to the examination of the
teeth were dried with cotton wool rolls.
Daylight was used with mouth mirror and probe for
examination.
Scoring criteria

0 - Normal translucency of enamel remain after

prolonged air drying
1 - Narrow white lines located corresponding to the
perichymata
2 - Smooth surfaces
More pronounced lines of opacity which follows the
perichymata, occasionally confluence adjacent lines
Occlusal surfaces
Scattered areas of opacity < 2 mm in diameter and
pronounced opacity of cuspal ridges.
3 - Smooth surfaces
Merging and irregular cloudy areas of opacity
accentuated drawing of perichymata often visible
between opacity

Occlusal surfaces
Confluent areas of marked opacity. Worn areas appear
almost normal but usually circumscribed by a rim of
opaque lines.
4 - Smooth surfaces
The entire surface exhibits marked opacity 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
5 - Smooth and occlusal surfaces
 Entire surface displays marked opacity with
focal loss of outer most enamel (pits) < 2 mm in
diameter

6 - Smooth surfaces
 Pits are regularly arranged in horizontal bands <
2 mm in vertical extension occlusal surfaces
Confluent areas < 3 mm in diameter exhibit loss of
enamel. Marked attrition.
7 - Smooth surfaces
 Loss of outer most enamel in irregular areas
involving less than one – half of entire surface

Occlusal surfaces
 Changes in the morphology caused by merging
pits and marked attrition
8 - Smooth and occlusal surfaces
 Loss of outermost enamel involving > ½ of
surfaces

9 - Smooth and occlusal surfaces

 Loss of main part of enamel with change in
anatomic appearance of surface. Cervical rim of
almost unaffected enamel is often noted.
 They applied their classification system to
samples of children born in areas 3.5, 6.0 and 2.10 ppm
F. They attempted to validate the visual appearance
against histological defect.

 They concluded that as clinical score increases

the microscopic change showed an ever increasing
width of the porous subsurface lesion.
 YOUNG’S CLASSIFICATION OF ENAMEL FLUROSIS

 Developed by YOUNG.M.A in 1973.

 Classification criteria

 Type A white areas less than 2mm in

diameter.

 Type B white areas of , or greater than,

2mm in diameter
Type C coloured (brown) areas less than
2mm in diameter, Irrespective of
there being any white areas.

 Type D Diameter greater than 2mm , irrespective of

there being any white areas.

 Type E Horizontal white lines
irrespective of there being
any white non-linear areas.

 Type F Coloured or white ares or

lines associated with pits or
hypoplastic ares
MURRAY AND SHAW’S CLASSIFICATION OF
ENAMEL FLUOROSIS
Developed 1979
The Occlusal , Buccal and Lingual surface of
teeth are scored.

Score Criteria
1 White opaque spots less
than 2 mm in diameter

2 White opaque spots greater

than 2 mm in diameter
3 Coloured Spots, flecks or
patches
4 Horizontal white lines,
irrespective of there being
any white or non-linear
lines.
5 Hypoplasia in association
with any of categories ‘1’ to
‘4’
6 Possible early carious
lesions
7 Missing
SIMPLIFIED FLUORIDE
MOTTLING INDEX
Introduced By Rahmatulla M and Rajasekhar A in 1984

Based on Enamel Opacities / Lesions present on the facial

surface of the 6 upper and lower anterior teeth.

Score Criteria
0 No involvement of facial
surface . Enamel is
translucent, smooth and has
a glossy appearance
1 Less than 1/3 of the facial
surface show evidence of
lesion.
2 Above 1/3 but less than 2/3
of the surface affected.
3 Over 2/3 of facial surface
involved
4 Brownish-Black
discoloration of entire facial
surface
 CHRONOLOGICAL FLUOROSIS
ASSESSMENT
This Index was developed by R. W. Evans in the year
1993.

CFA index was developed for assessing dental fluorosis

on the labial surfaces of the maxillary central incisors,
since these teeth are among the first permanent teeth
to erupt and are also of esthetic concern.

An Epidemiological Assessment of the Chronological Distribution of Dental Fluorosis in

Human Maxillary Central Incisors
Journal of Dental Research. May1993, Vol. 72 Issue 5, p883-890.
Method
 The labial surface of maxillary central incisor
crown is divided into three parts. The cervical, middle
and incisal third.

 A tooth should be excluded unless 3 mm of the

crown has emerged.

All three thirds are scored when, in principle, the ratio

of crown length to incisal width is 3:2.
Scoring criteria
0= The enamel has a normal appearance

1= Sign of dental fluorosis – that is opaque paper –

white Areas scattered irregularly over the tooth surface
(Dean – 1942) affect less than 10% of the area.

2= 10-49% of the area is affected

3= 50-89% of the area is affected.

4= 90-100% of the area is affected.

5= Presence of pitting

6= The surface is excluded from assessment due to

non-eruption or the presence of a defect that
precludes a proper assessment, such as for example,
tetracycline staining, caries.
REFERENCES
DENTISTRY, DENTAL PRACTICE AND THE
COMMUNITY – BRIAN A BRUT, STEPHAN A
EKLUND
ESSENTIALS OF PREVENTIVE AND COMMUNITY
DENTISTRY – SECOND EDITION – SOBEN PETER
TEXTBOOK OF COMMUNITY DENTISTRY –
JOSEPH JOHN
COMMUNITY DENTISTRY – VIMAL SIKRI
Journal of Dental Research. May1993, Vol. 72 Issue 5,
p883-890.