Fluorosis 2015

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DENTAL
FLUOROSIS
Pavel GNATIUC, Corneliu NĂSTASE, Alexei TEREHOV, Oxana SIREŢEANU
Chișinău, 2015
2
CZU 
Aprobat de Consiliul metodic central al USMF Nicolae Testemiţanu;
proces-verbal nr. 2 din 17 noiembrie 2011
Autori: Pavel Gnatiuc - dr. med., conferenţiar universitar
 Corneliu Năstase - asistent universitar, traducere engleză pp.64-68
 Alexei Terehov - dr. med., conferenţiar universitar
 Oxana Sireţeanu - medic, traducere engleză
Redactor literar: Valeriu OJOG - lector superior, 
 catedra Limbi moderne și latină, USMF Nicolae Testemiţanu
Recenzenţi: Gheorghe Nicolau - dr. hab. med., profesor universitar,
 Nicolai Cojuhari - dr. med., doctor conferenţiar.
“DENTAL FLUOROSIS”
Monografie
pentru studenţi, rezidenţi şi medici stomatologi
Ediţia a II-a, adăugită şi corectată
În această lucrare sunt tratate unele elemente fundamentale ale fluorozei dentare, ipoteze şi 
date generale, şi sunt examinate amănunţit cele mai complexe şi dificile de înţeles subiecte studiate în 
procesul didactic. Figurile inserate în context simplifică înţelegerea informaţiilor. Este utilă atât stu-
denţilor şi rezidenţilor, cât şi medicilor stomatologi.
Descrierea CIP a Camerei Naţionale a Cărţii
DENTAL FLUOROSIS /Monografie/ P. Gnatiuc, C. Năstase, 
A. Terehov, O. Sireţeanu. -Ch.: S.n., 2015 (Î.S.F.E.-P. «Tipografia 
Centrală»). - 84 p
Bibliogr. p. 74 (97 tit.)
ISBN 
CZU
50 ex. 
Com. ***
Î. S. Firma editorial-poligrafică “Tipografia Centrală”,
ISBN 
© Pavel Gnatiuc, Corneliu Năstase, 
 Alexei Terehov, Oxana Sireţeanu, 2015
3
Cuprins
GENERAL ASPECTS ........................................................................................................................... 4
CLINICAL MANIFESTATIONS OF FLUOROSIS .......................................................................... 4
FLUORINE CONCENTRATION IN VEGETABLES....................................................................... 7
FLUORINE CONCENTRATION IN ANIMAL PRODUCTS ......................................................... 8
FLUORINE CONCENTRATION IN HUMAN BODY ..................................................................... 8
FLUOROSIS EPIDEMIOLOGY ....................................................................................................... 13
THE STATUS OF DENTAL FLUOROSIS IN MOLDOVA ............................................................ 14
THE ETIOLOGY AND PATHOGENESIS OF DENTAL FLUOROSIS ....................................... 16
RISK FACTORS .................................................................................................................................. 19
THE SENSITIVITY AND RESISTANCE TO FLUORIDE OF THE HUMAN TEETH ............ 20
FLUOROSIS CLASSIFICATION ..................................................................................................... 21
THE CLINICAL PICTURE OF FLUOROSIS ................................................................................. 23
DIFFERENTIAL DIAGNOSIS .......................................................................................................... 33
PSYCHO-EMOTIONAL IMPACT AND SOCIOLODICAL ASPECTS
 OF DENTAL FLUOROSI IN YOUNG PEOPLE IN MODERN SOCIETY ( STUDY ) ........ 36
DENTAL FLUOROSIS TREATMENT ............................................................................................. 42
COMBINED CONSERVATIVE TREATMENT OF THE SUPERFICIAL TEETH
 DISCOLORATIONS ..................................................................................................................... 47
ENAMEL MICROABRASION HISTORY STAGES IN REPUBLIC OF MOLDOVA ............... 51
MODERN BLEACHING SYSTEMS AND PROCEDURES FOR FLUOROSIS TEETH .......... 58
VENEERS ............................................................................................................................................. 64
DENTAL FLUOROSIS PREVENTION ............................................................................................ 70
CONCLUSIONS .................................................................................................................................. 73
BIBLIOGRAPHY ................................................................................................................................ 74
ANNEX ................................................................................................................................................. 81
4
GENERAL ASPECTS
In the last 2-3 decades, with the advent of new technologies in 
dentistry, appeared the problem in the tooth fillings with restoration 
of the primary aspect, as the prosthetic crowns golden era has expired 
a long time ago.
An increasing number of patients want to have not only functional 
restorations, but also a Hollywood smile. Dental defects, especially 
those in the front, inhibit and depress patients, making them unsafe, 
to communicate and to smile less. Moreover, they determine various 
psycho-emotional disorders and the difficulty of integration in the social 
environment.
Researchers in the country and abroad have recently made a number 
of scientific studies analyzing the interrelation between the quality of 
life and the maxillary system status. Modern man is associated with 
visibly healthy teeth, with good health, success in life and career.
One of the diseases that lead to damage the aesthetics is fluorosis.
CLINICAL MANIFESTATIONS OF FLUOROSIS
Fluorosis is a systemic tissue disturbance that develops after ingestion 
of water and food with a high content of fluorine.
Endemic fluorosis is a disease of humans and animals in the animal 
zootechnic sphere, being caused by excess of fluoride in natural waters 
– the main source of water supply to the population. The color and 
relief changes of the dental hard tissues are the first and sometimes the 
only visible clinical manifestation of fluorosis. These morbid signs are 
manifested by the change of the normal enamel color, and in severe 
cases – by its integrity.
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Depending on the severity of the disorder, the enamel coloring 
changes from barely noticeable white mate patches to tan and dark 
brown, there are possible erosions and adamantine destructions, changes 
in the mechanical properties of dental hard tissues – softness, brittleness, 
increased abrasion.
The first scientific works devoted to dental fluorosis describe cases 
of “black teeth” (Kins, 1888) and Vanicker’s report (1891) on the case 
of “erosion of dental enamel” to residents of the city Naples (Italy). 
“Speckled enamel” was described by JM Eager (1901), when he 
discovered pathological changes of dental hard tissues, manifested by 
spotted enamel in the Italian emigrants in the USA.
In 1908, G. Black for the first time thoroughly described the clinical 
manifestation of dental fluorosis, illustrating the text with drawings 
of teeth with varying degrees of involvement by fluorosis, made with 
colored pencils.
In 1916, this disease was described in the State of Colorado (USA), 
macules on the enamel being called “Colorado brown stain”. Underlying 
cause was the excess of fluoride in drinking water. 
There are different hypotheses regarding the etiology of dental 
fluorosis. Only in 1928 it was determined that the etiological factor of 
fluorosis is the fluoride in the drinking water. Since then it is considered 
that the affection has an endemic tempt. 
The title of the element fluorine (F simb.) comes from the Greek word 
“ftoris” – Destroyer (in Latin – fluorum). It occupies the 13th position of 
elements that are part of the earth’s crust (0.08%), exceeding 10 times the 
amount of zinc and 30 times – the amount of lead (Vinogradov, 1957). 
The free fluoride is a colorless or yellow-green, pungent, irritating 
(penetrating) gas. At very low temperatures (-188 ° C) fluoride iscondensed to a yellow-orange fluid, and solidifies at –220 ° C, the 
relative weight is 1.513 g/cm3. 
In Mendeleev’s periodic system, the serial number of fluorine is 9, 
the atomic weight – 19.
Of all the minerals, fluoride is the most active metalloid, possessing a 
special reactivity. It reacts with almost all the elements in direct contact, 
6
at room temperature or a higher one. It forms compounds with inert gas 
even.
In many acids, a polymer molecule is capable of replacing oxygen. 
With most organic compounds, fluoride reacts with explosion. All 
reactions involving fluorine are characterized by high thermal effect 
(calorie). 
The most important fluoride compound is the hydrate fluoride 
– a colorless fluid, unstable, which is easily vaporized, the boiling 
temperature +20 ° C. 
An unusual feature of fluoride is high volatility of its compounds.
There are currently over 100 known minerals containing fluorine. 
A group of simple fluorides includes NaF, MgF2, AlF3H2O. The most 
important mineral containing fluorine is fluoritis – natural calcium 
fluoride (CaF2) which contains 48.7% of fluorine.
Fluoride gets in soil after the disintegration of the rocks. With the 
increasing amount of clay particles in the soil, which is increases, 
the concentration of water-soluble fluorine, soluble in citric acid and 
hydrochloric acid. In most of the soils, the concentration of fluorine 
increases with depth.
An enormous amount of fluorine gets back into the atmosphere, and 
then back in the ground as a result of volcanic acid fumes and industrial 
pollution – in as fluorine hydride and the salt of hydrofluoric acid.
The concentration of fluoride in natural waters varies a lot, being 
dictated largely by the solubility of its compounds. In water, fluoride 
binds usually the sodium, potassium, aluminum. The presence of these 
compounds in groundwater determines fluoride accumulation in plants.
A decisive importance has the concentration and accessibility in 
plants.
7
FLUORINE CONCENTRATION IN VEGETABLES
The amount of fluorine in vegetables varies a lot. Plants like wheat, 
barley, rice, peas, cabbage, watercress, parsley are able to gather 
microelements, including fluorine. A very big concentration of fluorine 
is in the green parts of the plant, which contains from 30 to 140 mg/l of 
dry matter.
It is shown that agricultural products grown on rich in fluorine soils 
contain this element in greater quantity. The amount of fluorine in 
spinach and in other plants used as condiments is quite high – 21 mg / 
kg. In the tea leaves – a fluorine warehouse – cultivated in an endemic 
area of fluorosis, the amount of fluoride can reach 1757.8 mg / kg. 
It is very important not only the absolute amount of fluorine in the 
food, but also in spices and water, in the technology of food preparation.
The absorption degree by the boiling products of fluoride from water 
is varied. Some vegetables get more fluorine from the water, and other 
get less. Potatoes, unlike beans and carrots, do not gather fluorine during 
cooking. 
Sometimes fluoride accumulation in plants is accompanied by a 
devastating effect.
In the plants that are sensitive to environmental air pollution with 
fluorine, cultivated near industrial factories, there is a low concentration 
of fluorine-chlorophyll in the areas of necrosis of the leaves and an 
increased amount of fluorine. The color of the leaves changes, they 
become more stiff, bigger, covered with white-gray deposits. The excess 
amount of fluorine determines the fruit deformation: apples, instead of 
being round, are oval, and its central part – green. Walnuts are deformed 
and have a yellowish color, and their bark is crushed easily. Vine leaves 
have rust spots and areas of necrosis. Also it delays grapes’ ripening.
There have been detected plants resistant to fluorine – cherry, sugar 
beet, potato, astra, roses etc.
8
FLUORINE CONCENTRATION IN ANIMAL PRODUCTS
The fluoride circulation in nature involves not only the plant world, 
but also the animal. In this connection, a special interest presents data 
on the amount of fluoride in various animal tissues. Fluoride content in 
food of animal origin vary within the following limits:
• in the meat – from 0.16 to 2.0 mg / kg;
• butter – 0.4 to 0.45 mg / kg;
• in milk and dairy products – from 0.3 to 0.71 mg / kg;
• in eggs – 0.00 to 1.48 mg / kg;
• in freshwater fish – from 0.09 to 0.26 mg / kg;
• in sea fish – from 0.02 to 84.47 mg / kg.
The sea fish contains more fluorine than freshwater fish, because the 
fluorine concentration in the sea is considerably bigger.
FLUORINE CONCENTRATION IN HUMAN BODY
Usually, the clinical manifestations of fluorosis are analyzed from 
the dentistry point of view – the form and the visible modifications in 
enamel, and also the teeth features in their relationship with external 
factors.
Serious adverse effects of fluoride on different human organs and 
tissues have been reported in India, China, countries with endemic 
fluorosis areas in which natural levels of fluoride in drinking water and 
food are very high. These shocking data were obtained not following 
basic scientific researches, but as empirical-statistical findings.
But the logical question is: If an individual has minor dental fluorosis 
manifestations, does this mean, by extension, that other organs and 
tissues remain more or less unaffected by chronic fluoride poisoning? 
The answer requires extensive and thorough investigation. 
High concentrations of fluoride can affect the bones, brain, endocrine 
system, etc.
Fluoride, characterized by cumulative properties, gradually 
accumulates in the skeleton. The concentration of fluorine in the bone is 
9
linear, this means that with the increase in the amount of drinking water 
the accumulation in the bones increases. 
Drinking water containing increasing concentrations of fluoride 
serves as the predominant source of supply of the human body with 
fluoride as the main cause of dental fluorosis.
It is known that mineral substances, in particular fluorine, are 
distributed especially in the skeleton. The accumulation of fluoride in 
bones and teeth is approximately equal: it depends on the following 
factors:
1. individual’s age;
2. the amount of the elements that get into the body with water, food 
and oral hygiene remedies and air.
The concentration of fluorine varies in different parts of the tooth, 
and different groups of teeth. 
Fluoride has a very big importance in tooth decay protection. This is 
why the determination of the amount of flouride in the teeth in relation 
to age is very important.
Fig. 1. Fluorosis impairment of the skeleton.
10
The researches led by Avcin A.P, Javoroncov A.A. proved that in the 
regions of endemic fluorosis, milk teeth have a lower fluorine concentration 
than the permanent ones. Decayed tooth enamel contains much less fluoride 
than the intact ones. From the age of 30 years, the concentration of fluoride 
in enamel of all teeth increases and at 50 years – is doubled.
Alcalaev K.K. showed that the maximum amount of fluoride is 
determined in the third molars, canines and then gradually decreases in 
incisors, molars I and II and premolars I and II.
The content of fluorine in different layers of the enamel is not equal, 
the highest concentration is in the surface layers (with a thickness of 
up to 160 mk), and then it gradually decreases to a constant level in the 
deeper layers.
 The amount of fluoride in temporary teeth dentin grows to a certain 
age and depends on the type of teeth (the incisors – up to 5 years in 
canines and molars – up to 7 years).
In the period of the teeth changing, fluoride concentration decreases from 
the reduction of the layer lining the pulp. This is due to active osteoclastic 
process,typical in the period of the physiological exchange of teeth.
According to some authors (Nicolaeva T.A., Beletkii A.S.) fluoride 
content in deciduous teeth affected by fluorosis was from 0.082 to 0.28 
%, while in the permanent ones – 0.3-0.7 %.
It was proved that fluorine accumulates faster and more in growing 
teeth than in the permanent mature ones and, in particular in dentin. 
After stopping the intake, fluoride rapidly disappears in growing teeth, 
but is retained for a long period in permanent teeth. Thus, with age, 
increases the concentration of fluorine in both bone and teeth .
The concentration of fluorine of 8.0 mg/liter in drinking water causes 
skeletal fluorosis to 10% of the population.
Given the fact that in 13 districts of the Republic of Moldova fluoride 
content in drinking water is higher than accepted, and that it is found in 
large quantities in plants and animal bodies with food, the population of 
these districts can occur not only dental fluorosis but bone fluorosis, too. 
Besides the accumulation of the fluorine in the dental hard tissues 
and bones, large accumulations of fluoride were noticed in the skin, hair, 
11
nails. Fluoride concentration in the hair of children in endemic fluorosis 
regions is ten times higher than of children in localities with average 
concentration of fluoride in the environment. Soft tissues contain little 
amount of fluoride. Certain organs such as the aorta and pancreas have 
substantial amounts of fluorine.
The content of fluoride in biological fluids is influenced by the 
overall amount of this element that enters the body. It is shown that as 
the contribution of fluorine in the body of a significant amount in blood 
is short-living. When the concentration of fluoride in drinking water 
increases 23 times, the concentration of the fluoride in the urine increases 
19 times, and in blood – only 3 times , indicating rapid elimination and 
the active role of the kidneys.
In growing body, fluoride is filed more than in adults, and elimination 
of urine is, on the contrary, higher in adults than in children.
The mechanism of action of fluoride on the animal body can be 
explained by:
• formation of complexes with calcium fluoride, magnesium and 
other enzymatic activator systems;
• inhibitory action of fluoride on a number of enzymes, which is 
accompanied by dysfunction in the tissues’ interstitial exchange;
• the chemical activity of fluorine is higher than iodine, after which the 
fluorine can be an iodine competitor in the thyroid hormones formation, 
and therefore, may interfere with its normal function;
• the important role of fluoride in the exchange (metabolism) of 
vitamins.
Fluoride is unevenly distributed in the tissues of the animal body, 
different in function and morphology, showing a special affinity to 
the calcified tissues, in which the fluoride molecules are accumulated 
throughout life.
Under physiological conditions, the role of fluoride is linked to the 
formation of the fluorapatite – a component of the bone and teeth structure.
Currently it is shown that fluoride has an important role not only in 
the development and normal condition of teeth and bones, and in the 
normal growth and overall development of the body. Fluoride can fulfill 
12
specific metabolic functions in tissues even in low concentrations, like 
in soft tissues. 
A special interest is paid to the information of fluoride accumulation 
in the milk of a breastfeeding woman because it is the only food for little 
babies.
It was established that in the milk of the breastfeeding women who 
were living in endemic fluorosis zones, the amount of fluoride in the milk 
is lower than in the milk of the women living outside the endemic zone.
Therefore, an important role in preventing fluorosis is the checking 
of the fluoride amount in the child’s body from the mother’s milk during 
the most intense growth and formation of the skeleton and teeth.
It is obvious that the breastfeeding woman’s body is working a 
physiological mechanism that maintains the concentration of fluoride in 
milk at the optimum level for the child. The concentration of the fluoride 
in the milk of cows from fluorosis endemic zones varies from 0.01 to 
0.7 mg/l. This demonstrates that the mammary glands serve as a natural 
barrier for fluoride molecules and the elimination from the body with the 
milk does not play a significant role.
Our research showed that children from the fluorosis endemic zones 
who were breastfed for a year or more, and then consumed milk products, 
were less exposed to fluorosis.
Out of 60 children in the village Pârliţa, Ungheni who had clinical 
manifestations of fluorosis, 22 had various diseases of internal organs: 
hepatitis (13), gastritis (4), pyelonephritis (3) cardiac system disorders (2). 
The worsening of the fluorosis manifestation in children was favored by 
daily consumption of 2-3 glasses of tea and milk deficit (Gnatiuc P.I., 1988). 
•••
Currently is established that fluoride deficiency in drinking water and 
in the body is manifested by the increase of the dental caries. Deficiency 
of fluoride in the body is accompanied not only by the increased tooth 
decay, but also by the metabolic disorders. In areas with the fluoride 
insufficiency in drinking water, the deaf morbidity in children is 
approximately twice more often than in areas with normal fluoride 
content in drinking water.
13
Medical condition due to a long and excessive intake of fluoride was 
called fluorosis. The most sensitive to fluoride poisoning are the children, 
especially in the age of high growth and formation of bone and teeth.
The role of fluoride in the drinking water concentration:
• 1 mg/l – is optimal and has an active prophylactic effect against 
caries;
• 2 mg/l – causes fluorosis teeth; 
• 8 mg/l – skeletal fluorosis in 10% of the population;
• 20-80 mg/l – during the 10-20 years – serious crippling skeletal 
fluorosis;
• more than 50 mg/l – changes in structure and function of the thyroid;
• 100 mg/l – growth retardation;
• more than 125 mg/l – the manifestation of functional-structural 
changes in the kidney;
• from 2.5 to 5.0 g is lethal to humans.
FLUOROSIS EPIDEMIOLOGY
Environmental Protection Agency (USA) considers fluorosis as a 
“cosmetic defect” and not a “disease” and the World Health Organization 
(WHO) – as a disease that affects millions of people worldwide (WHO 
Information , 2001, 2002).
The prevalence of endemic fluorosis is directly related to the 
distribution of fluoride in the environment, particularly water. In 1931, 
it was found that in areas where residents had macular enamel, drinking 
water had an increased content of fluoride.
Teeth fluorosis is the dental hard tissues pathology that occurs 
during the formation of the teeth. The condition is the result of increased 
content of fluoride in drinking water, food and so on, which enters the 
child’s body during the formation and mineralization of the dental hard 
tissues. The excess of fluorine contained in food is less toxic than in 
drinking water.
14
The literature describes endemic impairment, in mass of the 
population with fluorosis.
Endemic fluorosis is in more than a thousand zones, it can be noticed 
in Norway, Sweden, Finland, Denmark, UK, Spain, Italy, USA, Poland, 
Kazakhstan, Ukraine, Russia, Turkmenistan, Azerbaijan, Canada, China, 
Mexico, Chile, Australia, India, Sri Lanka, Saudi Arabia, South Africa, 
Kenya, Nigeria, Tanzania, Sudan, Morocco, etc.
It is generally accepted that when the fluoride content in water is :
< 0.5 mg/l , fluorosis does not occur ;
= 0.8-1.2 mg/l , fluorosis affects 10 to 12% percent of the population ;
= 1.2-1.5 mg/l, – 20-30% of the population ;
= 1.5-1.8 mg/l , – about 40 % of the population ;
> 2-2.5 mg/l, – about 50 % of thepopulation ;
> 2.5 mg/l , the percentage of people suffering from fluorosis ( 
“enamel maculation” ) increases sharply, sometimes, the disease affects 
almost the entire population consuming water from that source.
The status of dental fluorosis in Moldova
The aesthetic problem of the affected teeth with dental fluorosis 
is actual to Moldova, because, according to the National Centre of 
Preventive Medicine, in the country there are some areas with high 
concentration (> 1.5 mg/l) of fluoride in drinking water :
• Glodeni ≈ 5-11 mg/l in water natural reservoirs and 1.2-1.7 mg/l – in 
ordinary wells. 
• Făleşti ≈ 4-8 and 1.0-1.8 mg/l in water natural reservoirs;
• Ungheni ≈ 4-8 and 0.85 to 1.5 mg/l in water natural reservoirs;
• Călăraşi ≈ 3-5 and 0.8-1.5 mg/l in water natural reservoirs;
• Nisporeni, Anenii Noi, Hânceşti ≈ 2,0-4,0 and the range of 0.8-1.5 
mg/l;
• Căinari, Taraclia Basarabeasca ≈ 3.0 to 8.0 and 0.8-1.2 mg/l;
• Ceadâr-Lunga ≈ 11.0 to 16.0 and from 1.0 to 1.6 mg/l;
• Floreşti, Criuleni ≈ 2,0-4,0 and 0,8-1,2 mg/l.
15
In many residents in the 
affected areas have been detected 
clinical manifestations of dental 
fluorosis, such as color and texture 
changes of the teeth.
Dental fluorosis is the most 
frequent non carious disease of 
dental hard tissues.
The damage and the 
frequency of the endemic 
fluorosis (morbidity) of the teeth 
to the minor population of an 
endemic zone depend largely 
on the concentration of fluoride 
in drinking water. The higher 
is the amount of fluoride in 
water, more evident the clinical 
manifestations are in the affected 
teeth in the growing period and 
the more children are suffering 
from fluorosis.
However, it was noticed that in 
the fluorosis endemic regions not all children are affected by fluorosis. 
The morbidity depends on the health of the mother during pregnancy, 
the alimentation of the child (breastfeeding), the nature of the food, 
duration of water consumption, which contains increased amounts of 
fluoride, and the overall body strength.
In fluorosis endemic regions, the morbidity is 50-96 % of children.
Fig. 2. The map of fluorosis en-
demic areas in Moldova.
16
THE ETIOLOGY AND PATHOGENESIS
OF DENTAL FLUOROSIS
In regions with hot climates can be observed dental fluorosis 
manifestations in the presence of moderate content of fluoride in drinking 
water (0.5-0.7 mg/l). This is due to the active consumption of water. 
The presence of significant quantities of calcium in water reduces the 
development of fluorosis.
Clinical researches have shown that the optimal concentration of 
fluoride in the drinking water should be – 1 mg/l. At such concentrations, 
fluorosis is rare (or present in mild forms), also being noticed strong 
cariostatic effect.
For a long time fluorosis was considered an endemic disease, related 
to fluoride concentration in drinking water. The mechanism of action of 
fluoride in endemic fluorosis pathogenesis has not yet been fully elucidated.
 I.G. Lucomskii (1940) said that fluorosis is the result of the 
interaction of the fluoride with calcium, magnesium, manganese and 
other microelements of hard dental tissue, affecting their participation 
in histophysiology processes, which ultimately lead to damages in the 
enamel during training. Fluoride is a calcium antagonist. According to 
some authors, fluoride binds calcium and removes it from the body, and 
on this background fluorosis occurs.
I.O. Novik (1951) explained the occurrence of fluorosis by the fact 
that the chemical activity of the fluoride is greater than that of iodine, 
which causes suppression of thyroid function, accompanied by the 
disturbance of formation of dental hard tissues.
The most plausible theory is the toxic action of fluoride on ameloblasts 
during the genesis of the enamel, causing subsequent structural disorders 
(PO Pedersen, Scott D. В., 1959; Patrikeev V.K. 1968 A. Matsuo, 1998).
17
Other authors think that fluoride inactivates the alkaline phosphatase, 
cholinesterase, etc., leading to impaired mineralization of dental hard 
tissues.
According to the hypothesis of А.К. Nikolishin (1996) during tooth 
development (amelogenesis), the excess of fluoride, between the follicular 
sac vessels and intracellular spaces get to the ameloblasts and form close 
links with the protein retaining calcium of the immature enamel. 
As a result, in the differentiation of the hard tissue is formed the 
hidroxifluorapatite. Complete substitution of hydroxyl groups with 
fluorine cannot occur because the fluoride ions penetrate the epithelial 
cells (ameloblasts) of the internal and external layers of the enamel 
organ in limited quantities necessary for vital processes and to maintain 
cellular metabolism. In the process of mineralization the epithelial 
barrier function of the ameloblasts (property of retaining excess fluoride 
ions to pass through biological membranes) are gradually depleted.
For this reason, after calcification of the ameloblasts and reducing 
the amount of fluoride in the blood, the development of fluorosis at 
this stage is stopped. This development is characteristic of early forms 
of dental fluorosis. But, if a high concentration of the fluoride in the 
body, the long-acting on the surface of the hard tissues (teeth, bones) 
determines the fluoride sedimentation as insoluble calcium compounds 
in water. The process manifests with epistaxis: on the surface of the 
enamel fluorapatite is formed calcium fluoride. 
This can last throughout intramaxillary tooth development. In 
addition, during the intramaxillary development of the permanent teeth 
follicles occurs the process of root and the alveolar bone resorption. 
It can be assumed that the fluoride released from the alveolar bone is 
included in the new compounds of calcium (calcium fluoride) and settles 
on the surface of the enamel. These processes are typical to advanced 
forms of dental fluorosis. The most intensive period of formation of the 
calcium fluoride in the enamel is at the age of 2-4 years. 
It is possible that the formation of CaF2 on the enamel surface may 
continue after the tooth erupts, due to the high concentrations of fluoride in 
drinking water and oral fluid of the children in endemic fluorosis regions. 
18
The connection between the CaF2 from the superficial layers and the 
CaF2 from the fluorapatite layers in the severe forms of fluorosis is not 
lasting. From the structural point of view calcium fluoride is loose and 
fragile. 
Therefore, the action of mechanical factors, on the surface of the 
enamel can be formed cavities, defects. Clinically it was determined 
that dental hard tissue destruction in severe forms of fluorosis occurs 
particularly evident during enamel mineralization immediately after 
permanent teeth erupt. The degree of damage is determined by the 
thickness of the enamel deposition of CaF2 on the surface of the enamel, 
the nature of food and saliva mineralization properties.
According to the data of the local and foreign researchers at 
concentrations of 0.8-1.0 mg/l of fluoride in drinking water mild fluorosis 
can occur in 10-20% of the population, to 1.0-1.5 mg/l 20-30% of the 
population is affected, at 1.5-2.5 mg/l – 30-45% at 2.5 mg/l and more, 
the rate reached 50% of those affected.
A study of the Pediatric Dentistry Department researchers of the 
SMFU “Nicolae Testemiţanu” demonstrated that, with increasing 
concentration of fluoride in drinking water, increases the frequency and 
extent of damage to the teeth with fluorosis. In children of 6 years, the 
frequency of dental fluorosis was 81.77%, in 12 years – in 82.57% and 
those 15 years – 89.87%. The average degree of damage by fluorosis 
was 2.01 ± 0.33: in the children 6 years – 1.73 ± 0.53, in children 12 
years – 2.22 ± 0.47 and in children 15years – 2.24 ± 0.77.
Some scientists indicate anticarious action of fluoride. The works 
of other authors, however, and our research shows that fluoride has an 
anticarious effect only in small quantities and only in the shaded and 
macula forms of fluorosis. 
19
RISK FACTORS
Currently, it is demonstrated that fluorosis is the result of a cumulative 
effect of intake of fluoride from various sources.
The main risk factors are:
• fluoride toothpaste and frequency of its use;
• Fluoridation of drinking water;
• the use of tablets containing fluorine;
• the use of fluorinated salt.
Fluorosis affects teeth during their formation. Recent studies have 
shown that fluoride, the parenteral administration (or local) quickly 
penetrates the blood and disturbs the thyroid function, leading ultimately 
to adverse effects on enamel mineralization.
Fluoride that entered the body, act on enameloblasts, leading to 
imperfect enamelogenesis. It is unlikely the microelement to act 
locally, as changes occur also in parenteral administration of fluoride 
preparations.
Voynar A.V. (1953) believes that fluoride reduces alkaline phosphatase 
activity, and this negatively affects the enamel mineralization.
In a series of studies performed in different countries, it was found 
that the critical period for developing fluorosis of permanent teeth is at 
the age of 20-36 months of life, although the study by Erdal S., Buchanan 
SN indicates significant risks to children of 3-5 years because at this age 
remains a risk of excessive intake of fluoride. According to Erdal S. and 
Buchanan SN, in children from 3 to 5 years, the fluoride tablets and 
toothpaste increase the daily intake of fluoride (EDI) from 2-6 times.
It should be mentioned that, with increasing age at which children 
start to drink water that contains fluoride, they decrease the frequency 
20
and severity of damage. This is manifested most intensely at the age 
of 6-7 years, when it is already completed the crown calcification of 
permanent teeth except molars two and three.
When the enamel is already formed, the use of even long-term, high 
water-containing fluoride does not result in change of color enamel. 
However, if the amount of fluorine will be more than 6 mg/l, it can 
produce changes in the tissues of teeth already formed.
High concentrations of fluoride in drinking water can produce 
macules in milk teeth, although much less frequently than in permanent 
ones. This is because their complete mineralization is finished in the 
intrauterine period. Fluoride, that enters the mother’s body is stopped by 
the placenta, which protects the fetus from intoxication.
THE SENSITIVITY AND RESISTANCE
TO FLUORIDE OF THE HUMAN TEETH
It is considered that the population prevalence of dental fluorosis 
in endemic regions increases in accordance with the increasing 
concentration of fluoride in drinking water.
In most people the clinical manifestations of fluorosis are significant, 
and in some – only minor changes. Moreover, in such areas live children 
whose teeth are perfectly healthy. This is due to the fact that at the same 
concentration of fluoride in water, the body may respond differently to 
that micro-nutrient intake.
The severity of dental fluorosis depends on the body’s sensitivity to 
fluoride poisoning and its ability to resist the harmful effects of this 
microelement.
21
FLUOROSIS CLASSIFICATION 
The clinical picture of endemic fluorosis is varied. All the authors 
classify fluorosis, from smaller events and progressing to larger ones, 
for an appropriate examining and assessing, a comfortable and not 
cumbersome classification is needed.
The results of our clinical work of more than 30 years have 
strengthened the view, in that fluorosis can affect or the two central 
incisors of the upper jaw and the first molars, or all the permanent teeth 
of both jaws, although in a variable severity. 
Some classifications are:
Dean (1937), which contains seven degrees of dental fluorosis;
Patrikeev (1956), Thylstrup and Fejerskow (1978), Horowitz (1984), 
Pendrys (1990) – 5 degrees:
Maksimenko and Nicolishin (1976) – 4 degrees, etc..
The degree of damage can vary from striped to destructive form. 
Therefore, we believe it is useful to classify the local and generalized 
fluorosis.
Local dental fluorosis is characterized by the lack of yellow-brown or 
brown pigmentations, characteristic to generalized form of the disease, 
and generalized fluorosis – the enamel looking “dead”. In addition to 
pigmented macules, erosions and defects of the crowns of the teeth are 
often detected because of the abrasion and fracturing.
We present you the USMF “Nicolae Testemiţanu” classification of 
the dental fluorosis (1986-2011), which includes five ascending degrees 
of the enamel damage.
• Level I – vestibular hatches on the enamel surface of the anterior 
crowns, in the cervical region of the teeth – fine chalky strips, barely 
visible, but easily detectable with converging lens. Sometimes these 
hatches confluence in chalky macules.
22
• Level II – yellow or yellow patches. Incisors’ enamel is affected, but 
can be affected all the teeth. Enamel color intensity is more pronounced 
in the central part of the macula passing without clear demarcations to a 
normal enamel. Macules are spread over the entire tooth, including the 
incisal edge.
• Level III – beige patches, reddish-brown to chocolate and pinching 
of the tooth enamel, which occupies more than a half of the tooth surface.
• Level IV – dark brown patches and erosions on dental enamel.
• Level V – enamel destroyed. Such teeth are fragile and the abrasion 
is easily. Enhanced abrasion is usually associated with tainted enamel, 
leading to rapid destruction of the tooth.
These events were observed both in local fluorosis and in the general 
forms of dental fluorosis.
WHO (1965) recommended the classification of fluorosis after I. 
Müller, which includes five forms of dental fluorosis:
• Questionable – A few white flecks or white spots
• Very Mild – Small opaque, paper white areas covering less than 
25% of the tooth surface
• Mild – Opaque white areas covering less than 50% of the tooth 
surface
• Moderate – All tooth surfaces 
affected; marked wear on biting 
surfaces; brown stain may be present
• Severe – All tooth surfaces 
affected; discrete or confluent pitting; 
brown stain present.
Fig. 3. Severe forms of dental fluorosis
23
THE CLINICAL PICTURE OF FLUOROSIS
Depending on the concentration of the fluoride in drinking water 
and consumed food, can occur both dental caries and fluorosis. Low 
content of fluoride in drinking water leads to tooth decay and the high 
concentration – to the occurrence of fluorosis. 
Patients complain of the presence of patches, lines and chalky, yellow 
or brown bands on the tooth surface.
The changings in the normal enamel staining intensity states the 
severity of the disease of the dental hard tissues. Usually, dark brown 
coloration of the macules, erosions and enamel damage are signs of 
severe forms of fluorosis.
The variety of the macroscopic picture of teeth affected by fluorosis 
in children from Ungheni in our study presents a particular interest.
After detection of the disease frequency, the teeth groups were distributed 
in the following order: incisors, premolars, molars. In severe cases the 
damages can be noticed in all the teeth – both maxilla and mandible.
Grade I – the presence of the hatches on the maxilla incisors’ enamel.
Grade II – the presence of a pale yellow spots or yellow, located on 
the incisors and premolars and molars. Stains are oriented horizontally 
along the equator tooth or cutting edge region of the incisors, rarely, 
pigmented bands are arranged vertically along the axis of the tooth .Grade III – the presence of inclusions and brown spots (light brown), 
located on the enamel of a group of teeth or of all the teeth. 
Grade IV – the presence of spots and brown enamel erosions (dark) on 
all the teeth. The size and shape of erosion varies, often they are solitary, 
but more often multiple, sometimes the enamel defects confluence. The 
edges are irregular, the bottom – rough and usually pigmented .
Grade V – the presence of the enamel destructions of isolated groups 
of teeth. At this stage, the teeth are gradually destroyed after increasing 
their brittleness.
24
Teeth with mild degrees (I, II) of fluorosis maintain functional 
properties: strength, abrasion, shape. The possibility of these teeth to be 
attacked by caries is very low.
Teeth with significant levels (III , IV, V) of fluorosis are characterized 
by marked disturbances of mineralization, as a result they are more 
fragile, brittle and are easily exposed to abrasion. All this leads to 
accelerated destruction.
A particularity of teeth damaged from fluorosis is that mandibular 
teeth are much less affected by erosive and destructive forms.
In the cervical region, normal enamel loses its luster and gets milky 
matte color.
The higher is the severity of fluorosis, the enamel affected area 
expands. Sometimes, all teeth have a matte milky tint all at the same 
level.
Children of the same age have varying degrees of fluorosis. Of 376 
children investigated from the regions of endemic fluorosis in 59 children 
living permanently in that place were not detected signs of fluorosis of 
the teeth, although they had the same living conditions as the children 
with fluorosis.
In this context we find that individual susceptibility of the organism is 
the decisive factor for the manifestation of fluoride lesions.
In the case of low fluoride concentrations (1.5-2.0 mg/l) in the 
drinking water can be detected enamel changes in the form of small 
individual “porcelain” patches, or coated , transverse ribbed (that can be 
longitude, too), which normally occupy a small part of the surface of the 
dental crown, located on any of the surfaces of the tooth. 
Such changes are most commonly seen on the vestibular surfaces 
of the teeth and are noticed especially in incisors and first molars, the 
mineralization of which occurs simultaneously.
If supplying water contains high fluoride concentrations (2.0 – 2.5 
mg/l), in the enamel are noticed yellow colored patches, especially in 
children who were not breastfed or were weakened by illness.
When consuming water containing 2.5-3.0 mg/l fluoride besides the 
yellow patches, can be noticed intense dark yellow or brown pigmentations. 
25
These pigmented patches can be located in any part of the tooth. In dark 
pigmented macules there may be observed and some inclusions.
If children drink the water containing high concentrations of fluoride 
(3-4 mg/l) usually they develop severe forms of enamel damage – 
erosions, which are arranged usually erratic and scarcely on the surface 
of the dental crown. The erosions unite with pigmented or chalky 
macules and they assign to the teeth the “pinched” look. In more serious 
cases, the dotted erosions confluence and this may lead to changes in the 
tooth crown.
The concentration above 4.0 mg/l of fluoride in the drinking water 
leads to the destruction of the tooth enamel. Most often, this form of 
fluorosis occurs in children weakened by chronic illness and living in 
inadequate and unfavorable living conditions.
As a characteristic sign of the enamel fluorosis damage is the 
symmetrical location of the macules on the surface of dental crowns. 
Homonymous teeth are affected by the same form of fluorosis, repeating 
the exact macular drawing in the symmetrical teeth. In the same person, 
different dental groups may be affected by fluorosis in different degree 
and form. 
One form of fluorosis may not, in the future, move to a different form, 
even if the child starts to use water which contains a bigger amount of 
fluorine.
So a form of fluorosis is kept throughout their life. And conversely, 
people that began drinking water containing a lower fluoride 
concentration noted sometimes that macules on their teeth become less 
obvious, getting a dimmed look.
In fluorosis, the teeth that have already erupted have a poppy aspect, 
of one degree or another.
It is well known that dental fluorosis occurs after consumption of 
water with high content of fluoride during the tooth development. The 
consumption of drinking water containing even very high concentrations 
of fluoride during the finished tooth calcification does not cause fluorosis.
Usually, fluorosis macules locate in the permanent teeth, most often 
– incisors and first molars. 
26
This is because the time of calcification of the permanent central 
incisors and first molars coincide.
The damage causes to these teeth are:
• the amount of water consumed by the infant per 1 kg of weight, with 
time is reduced;
• the child’s body is more susceptible to various diseases in the first 
years of life when these teeth mineralization occurs.
The mineralization of upper central incisors and first molars begin at 
5-6 months after birth and ends at 4-5 years. 
The mineralization of lateral incisors and canines start over 8-10 
months after childbirth and ends: the lateral incisors – 4-5 years, and the 
canines – from 6-7 years. 
The premolars mineralization starts in the second year of life, and 
ends at 6-7 years. 
Molars begin mineralization at 6 years and the mineralization process 
ends at 7-8 years; molars III – 12-16 years.
The later starts the mineralization of a group of teeth, the more 
rarely these teeth are affected by fluorosis. Periods of mineralization 
disturbances correspond to the location of morbid fluoride changes.
Our researches carried out in a number of regions of endemic 
fluorosis allow us to support the hypothesis that clinical picture of dental 
fluorosis is not the same in all outbreaks, even at the same concentration 
of fluoride in drinking water. 
Even in the same outbreak not all the children are affected by the 
same form of fluorosis. 
It depends on pregnancy period complications, infant feeding – 
natural or artificial – and further feeding of the child.
Children that consumed food with large amounts of calcium and 
phosphorus were less affected by caries.
The consumption of water containing high fluoride concentration 
(3-4 mg/l) reduces the buffer action of favorable environmental factors 
and almost all the children are affected by fluorosis.
In case of very high concentrations of fluoride, the number of serious 
forms of fluorosis grows. 
27
The older children are from an endemic outbreak, the less clinical 
manifestations are observed, and the fluorosis form is easier. This 
phenomenon manifests itself at 6-7 years when the mineralization of 
permanent teeth crowns ends, excluding the third molars.
When the concentration of fluoride in drinking water is very high, the 
deciduous teeth are also affected by fluorosis, although, less frequently 
than the permanent ones.
The investigation of 136 primary school pupils in Pârliţa, Ungheni, 
where water fluoride concentration is 13 mg/l, has revealed that the 
incidence of fluorosis in the deciduous teeth is 23.7%, the macular form 
was diagnosed at 94.4%. 
Fluorosis attacked especially the IV-th and the V-th maxilla and 
mandible teeth, and only 4 cases have revealed impairment of all the 
teeth. Colouring macules vary from chalky to tan-dark.
In all the children who had fluorosis of the temporary teeth was 
detected and a severe fluorosis form of permanent teeth.
The distribution of decay among the first grade pupils constituted 
57.4%, of which only temporary teeth decay – 46% of cases, temporaryand permanent teeth – 7.4%, the first permanent molar tooth decay – 
4%. Decay intensity amounted to 1.3, the intensity of fluorosis – 4.0.
In the specialized literature there are reported facts that fluorosis 
teeth show a high fragility and increased abrasion. These features are 
probably related to modification of the enamel.
It should be noted that the inhabitants of endemic outbreaks often 
occur minor enamel chipping. Almost always enamel chipping is 
accompanied by the increased tooth abrasion. Bare surface after 
chipping becomes, over time, smooth, hard and glossy, with a yellowish 
tint. Crowns fractures can be observed in anterior teeth.
Analyzing the clinical manifestations of dental fluorosis: increased 
tooth abrasion, enamel chipping, relatively high susceptibility to injuries 
– we can conclude about functional incompetence of teeth affected by 
severe forms of fluorosis.
The presence of enamel macules on tooth can be seen in other diseases 
of the teeth. 
28
Therefore, the differential diagnosis of fluorosis should be done with 
the decay in the macula stage and dental hypoplasia.
These pathological processes are characterized by the following 
differential-diagnostic signs: 
1. Chalky macules in decays are usually solitary, and in fluorosis – 
multiple.
2. Chalky macules in decays are a sign of an acute evolution of the 
disease, and the pigmented – a sign of chronic evolution. In fluorosis, 
the presence of chalky or pigmented patches is an index of the severity 
of the process, and not of its intensity.
3. Chalky macules in decays are characterized by a tendency to 
change (pigmentation, the formation of a defect). Fluorosis enamel 
macules are stable.
4. In macula decays, the pigmentation has a dirty greyish indefinite 
unhealthy looking, in fluorosis, pigmentation has a stable yellow-brown 
color. 
5. In macula decays, the tooth has a bluish tint, the enamel appears 
transparent; in fluorosis, the macules are noted on white enamel 
background.
6. Macula decays are arranged typically in the vicinity of the contact 
surfaces of the tooth crown and the fissure region. Fluorosis macules are 
localized on the vestibular and lingual surfaces of the teeth and on the 
cusps of the lateral teeth.
7. The symmetrical localization of the teeth decay can happen, but 
affects it only singular teeth. Fluorosis macules are localized strictly 
symmetrical, affecting homonymous teeth of the right side and the left 
with patches of the same shape and color. Even if decay macules are 
localized symmetrically, the design is not strictly repeated as in fluorosis.
8. Chalky decay macules is the symptom of acute severe caries and 
is characterized by the presence of cavities in teeth. In fluorosis, cavities 
are missing or are solitary.
9. The decay primarily affects the first molars; in fluorosis, macules 
are observed in all groups of teeth, although most often they locate in 
the central incisors.
29
10. In case of caries, both – temporary and permanent teeth are 
affected; and in fluorosis – mainly is affected the permanent dentition.
11. In fluorosis, the enamel surface is smooth, glossy, and painless when 
probing; in dental caries, the enamel surface is matt, rough, sometimes 
sensitive when probing, there may be present a decrepit wall cavity.
12. In caries, the reaction to thermal factors is positive, and in 
fluorosis – is negative.
13. Decay occurs after the tooth eruption; in fluorosis – when tooth 
erupts.
14. In decay, the coloration with methylene blue is positive, while in 
fluorosis – negative.
15. In fluorosis it is detected a high concentration of fluoride in the 
drinking water, while in caries – a low concentration.
The clinical picture of dental fluorosis is extremely varied – through 
its forms and nature of the external manifestations of the tooth enamel, 
but also the teeth features in their relationship with external factors. The 
drawing of the enamel macules is also multiform. 
Depending on the shape and extent of damage, changes the character 
of the macula – from small, chalky (white) spots (or warped) barely 
perceptible to the naked eye on the labial surface of the enamel, to 
multiple confluent macules and erosions, that disfigure or destroy the 
tooth crown.
Chalky solitary patches (Fig. 
4)
Small solitary patches with 
chalky or “porcelain” aspect and 
sometimes with transverse stripes, 
which usually occupy a small part 
of the surface of the tooth crown are 
common. These kinds of changes 
are rarely noticed simultaneously Fig. 4. Chalky solitary patches
30
on several sides of the same tooth. When there is a slight damage, the 
“porcelain” macules can be observed having an intense natural light, in 
more severe cases, the chalky macules are easily detected. These types 
of macules are a little similar to the hypoplasia macules. Such mild 
fluorosis forms (enamel maculation) are unnoticeable and some people 
(even the dentists) do not pay attention. 
Yellowish patches (Fig. 5)
In some cases, on the enamel are 
encountered pale yellow patches. 
This yellow macular pigmentation 
gives a “tiger aspect” to the tooth.
Yellow or brown patches (Fig. 
6)
This is a more severe form 
of fluorosis and is characterized 
by intense dark yellow or brown 
pigmentation.
Brown patches (Fig. 7)
These patches can locate in any 
part of the tooth. However, very 
often they appear on the labial surfaces of the anterior teeth. If brown 
macules are located near the incisal edge of the incisors, the teeth have 
a “burned” look.
Fig. 5. Yellowish patches
Fig. 6. Yellow or brown patches
31
In the dark pigmented macules 
sometimes can be noticed some 
included small white patches. 
In such cases, the teeth have a 
monstrous look.
Enamel erosion (“enamel 
pinching”) (fig. 8)
A very high concentration 
of fluoride in drinking water 
causes damages characterized 
by impaired integrity of the 
enamel in the form of erosions 
located chaotically, dispersed on 
the surface of the crown and associated with pigmented chalky patches, 
giving a “pinched” (“eaten”) look to the teeth.
Destructive form of fluorosis 
(Fig. 9)
In the most severe cases, small 
erosions confluence between them, 
it can lead to the tooth crown 
shape changes or even destruction. 
Such forms of enamel maculation, 
even in case of very high levels of 
fluoride in drinking water, usually 
appear in children weakened by 
chronic illnesses and those living 
Fig. 7. Brown patches
Fig. 8. Enamel erosion
Fig. 9. Destructive form of fluorosis
32
in unfavorable conditions (inadequate and insufficient nutrition, poor 
housing conditions, etc.).
Fluorosis degenerated chalky 
teeth (fig. 10)
In a number of cases, it can be 
noticed a form of enamel dystrophy 
characterized by a lifeless look of 
the teeth, chalky degenerated, with 
a lack of luster, and their surface is 
sometimes rough. A characteristic 
feature is symmetric location 
of the macules on the surface of 
dental crowns. Homonymous teeth 
are affected by the same form of 
enamel maculation or erosion, repeating the exact same macules design 
in symmetrical teeth. Different groups of teeth at the same person 
may be affected by various degrees and forms of fluorosis (enamel 
maculation). In the literature there are reports proving that endemic 
fluorosis determine functional deficiency of the teeth, especially – the 
fragility and increased abrasion.
Fig. 10. Fluorosis degenerated 
chalky teeth
33
DIFFERENTIAL DIAGNOSIS
In making the differential diagnosis between fluorosis and hypoplasia 
it should be taken into account the fact, that besides the differences, they 
also have many things in common, both in clinical and in etiology.
In hypoplasia as in fluorosis usually areaffected the permanent teeth. 
Deciduous teeth are rarely affected by fluorosis and by hypoplasia – less 
often.
The localization of the fluorosis macules, as in hypoplasia, is directly 
dependent on the age, time and duration of event factors action that 
disturb the normal mineralization of the enamel.
A. fluorosis:
• the consumption of water with high concentration of fluoride.
B. hypoplasia:
• Artificial feeding at an early age;
• rickets;
• toxic dyspepsia;
• scarlet;
• measles;
• other pediatric disorders.
Depending on the localization of hypoplasia enamel changes can be 
judged by the duration of action of unfavorable factors or other factors 
on the body.
Both fluorosis and hypoplasia affects symmetrical teeth. In both 
conditions it can be altered the shape of the dental crown.
Clinical differences between fluorosis and hypoplasia
1. In hypoplasia, enamel is thinning or the defects, localized some in 
a row in the form of dimples having a round or oval shape, surrounding 
34
the tooth like a sulcular string. The sulcuses can be single or in group 
– scalar (in the form of steps). In fluorosis, enamel defects are detected 
only in severe cases and the erosions are singular. Rarely can be noticed 
more than one erosion on the same tooth.
2. Hypoplasia is met in seemingly intact enamel. Fluorosis enamel 
erosions are seen on the background color changes. Macules are detected 
not only in the region of erosion, but also on dental surfaces without 
erosions.
3. In fluorosis, the caries develops slowly, in hypoplasia the teeth 
affected by the decay are destroyed quickly.
4. In hypoplasia, the dental crown shape is characterized by one 
or more of strangulations, which causes the tooth contours change. In 
fluorosis, the dental crown shape changes rarely.
5. The coloring of fluorosis affected areas is chalky-white, from 
yellow to dark- brown, while in hypoplasia – white or yellowish.
6.In fluorosis, with age, the macules may change their colour or can 
disappear at all, while in hypoplasia the macules are steady, without 
changes.
7.In fluorosis the fluoride concentration in drinking water is elevated, 
while in hypoplasia the fluoride concentration isn’t important. 
The diagnosis of fluorosis is established on the basis of the clinical 
signs and of the informations about the fluoride concentration in drinking 
water from the locality where the investigated person lived during the 
early infant period.
35
Table 1. 
Macular fluorosis, caries and hypoplasia characteristics
Features Fluorosis Decay Hypoplasia
The 
appearance
Before 
eruption 
After eruption Before 
eruption 
Teeth 
impairment
Mostly 
permanent teeth 
permanenţi
Both permanent and 
temporary teeth
Mostly 
permanent teeth
The 
localization
On all the 
surfaces
On the vestibular 
and proximal surfaces
On all the 
surfaces
The number of 
macules
A lot Singular Mostly 
singular
The 
permeability
Reduced or 
normal
Manifested Reduced or 
normal
Macule’s 
evolution
For the rest of 
the life
Disappear rarely Don’t 
disappear
Fluoride 
concentration in 
water
High Reduced or normal Reduced or 
normal
Table 2.
The differential diagnosis of erosive form of fluorosis
Features Fluorosis Superficial 
decay
Hypoplasia Wedge-shaped 
defect
Erosion
Complaints Esthetic 
defect 
Enamel 
defect 
Esthetic 
defect
None Esthetic de-
fect
The localiza-
tion
All the 
surfaces
In the fis-
sures, on 
the proxi-
mal sur-
faces
All the sur-
faces
On the vestibu-
lar surfaces
On the vestib-
ular surfaces
Clinical 
signs
Enamel 
defect
Enamel 
defect
Pinching 
enamel
Wedge-shaped 
defect
The erosion 
defect
Permeability 
for dyes
Reduced 
or normal
Pronounced Reduced or 
normal
Low pro-
nounced
Low pro-
nounced
36
PSYCHO-EMOTIONAL IMPACT AND SOCIOLODICAL 
ASPECTS OF DENTAL FLUOROSI IN YOUNG PEOPLE IN 
MODERN SOCIETY ( STUDY ):
Topicality of the study:
In recent years the aesthetic orientation has become very popular 
in modern dentistry, as an increasing number of patients want to have 
not only functional restorations, but also a brilliant smile (“Hollywood 
smile”). Tooth discolorations or defects, especially those in the front 
teeth, make the patients uncertain, leading them to communicate and 
smile less. Finally, this determines psycho-emotional problems and non-
integration in the social environment.
Researchers in the country and abroad have made in recent years 
a number of scientific studies which serve as the foundation for the 
concept of the interrelation of the quality of life and dental-maxillary 
system status. Healthy teeth, beautiful smile is associated with good 
health, success in your personal life and career. One of the diseases that 
affects the aesthetic and change color and relief is the dental fluorosis.
The issue of affected aesthetic by dental fluorosis gets a special 
actuality in Moldova, because there are several outbreaks of endemic 
fluorosis, in which many children and young people show changes color 
and texture of the teeth.
Purpose of the study:
Most of the scientific researches on this issue are devoted to dental 
fluorosis etiology, pathogenesis, diagnosis, treatment and prevention. 
Until now, appeared a lot of different techniques and whitening 
substances. 
Many times were argued the problems regarding the safe methods 
and substances used in the treatment of dental fluorosis. In this article, 
37
our group of authors will not target any whitening method, but will 
discuss only the psycho-emotional effects of fluorosis.
At present there are a few studies that report a possible negative 
impact of dental fluorosis on psycho-emotional state of the patient, and 
all of them are contradictory. Some authors argue that dental fluorosis is 
not a problem for young people; others recognize that this is an important 
aesthetic issue, and the third – they could not get a clear answer, univocally.
The purpose of this study: the identification and characterization of 
psycho-emotional problems caused by fluorosis discoloration of teeth 
within sociological methods in various categories of young people.
Research materials and methods: 
The research was lead by the Department of Therapeutic Dentistry 
of the Dentistry Faculty of USMF “Nicolae Testemiţanu” within Dental 
University Clinic during practical classes, involving, during 2009-
2011, 136 students from 3, 4 and 5 years performing dental screening 
examinations.
The study consisted of interviewing patients aged between 19 and 25 
years – born in regions with high fluoride content in drinking water (up 
to 4.0 mg/l).
Each student – examiner during all cycles reserved by the Therapeutic 
Stomatology Department USMF “Nicolae Testemiţanu” examined 
(under the supervision of the teacher – coordinators of this study) on an 
average 4 patients, most of the patients being students from the Chisinau 
universities and colleges.
344 patients were examined, of which 263 – boys and 281 – girls. To 
evaluate the severity of dental fluorosis, we used to investigate the mass 
population by the WHO recommended classification.
Sociological component of the study consisted of the investigation, 
using a simplified questionnaire. 
The questioning was performed during the examination of the 
patient and only in patients that lived or live in an endemic outbreak of 
fluorosis. 
Overall there were selected 78 girls and 74 boys.
38
All respondents (originating from endemic regions) were 
conventionally divided into 4 groups according to the severity of dental 
fluorosis:
• Group 0 – 21 people without morbid signs;
• Group A – 19 people with suspect forms of fluorosis;
• Group B – 74people with mild fluorosis (gr. II, III);
• Group C – 38 people with severe fluorosis (gr. IV, V).
The questionnaire contained six questions that were optimized during 
the pilot study, in accordance with the objectives of this study. 3 of these 
questions were related to patient’s ID, age, sex, residence.
Results and discussions:
The dental fluorosis frequency was determined being quite high. 
Standardized index was 73.55 ± 3.24 %, the prevailing forms of fluorosis 
were questionable and mild (60.63 ± 3.86%), the severe form was rare 
– 14.44 ± 4.26 % of cases. Numerically speaking, this means that 27 of 
544 patients selected had brown pigmentations on the enamel, and in 
many cases – defects.
Because in Moldova in fluorosis endemic outbreaks live about 600 
000 people, the number of young people aged 19-25 years, suffering 
of severe dental fluorosis, may reach 19 000 (!!!). It is unlikely that 
they will feel comfortable in a modern society, due to the psychological 
peculiarities of this age.
The number presented is only a mathematics deduction (speculation), 
and for determining the de facto situation, we started questioning patients 
regarding the matter.
We were interested in the following:
• the patient ‘s attitude to the color of his teeth ; 
• if the patient wants to treat fluorosis ;
• if the patient feels the social repercussions of this disease with 
dental manifestations.
The first question was intended to determine patient’s satisfaction 
about the color of their teeth and required an answer – yes or no.
The information obtained was ambiguous and a little bit unexpected. 
39
On average, 37.73 % of respondents answered yes to the question, and 
62.27 % – negative. The detailed analysis of the results revealed that the 
views of young people correlate with the intensity of dental fluorosis.
The highest percentage of positive responses was recorded in groups 
A (42.73 %) and B (40.23 %), the lowest – in group C (41.44 %). 
In accordance to the classification presented, the questionable and 
the mild fluorosis are characterized by impaired translucency of normal 
enamel, ranging from a few isolated chalky white spots or patches to 
manifested small white patches that cover less than ¼ of the labial 
surface. 
Such tooth discolorations usually do not attract the attention not 
only of others, but even of the patients – confirmed during the course 
of trial.
The study revealed a significant difference of the gender indicators: 
on average, 59.17 % of girls and 36.81 % of boys were unhappy with 
the color of teeth. The boys were less worried by fluorosis discolorations 
that can be noticed in the mathematic difference of the values of all 
groups sampled that is up to 10-20%.
The second question “Do you consider teeth discoloration a problem?” 
requested one of the proposed answers (listed below): • no problem in 
itself; • mild discomfort; • bearable problem; • serious problem.
The purpose of the question was to identify the existence of psycho-
emotional problems associated with fluorosis discoloration of teeth. So 
55.55% of respondents affirmed the existence of the problem itself. In 
the research prevailed the mild discomfort (32.48%), which probably 
does not exert a negative effect on the psycho-emotional state of 
young people. However, 21.08% of respondents, that means every 5th 
respondent with dental fluorosis, periodically or permanently faced with 
significant anxiety and communication difficulties.
The study was attempted to determine the dependency of the severity 
of the intensity manifestations of dental fluorosis and sex. The female 
students have proved to be more demanding to tooth color, which often 
has negative psychological consequences if they were found discolored 
teeth. In the group of girls with severe dental fluorosis was observed an 
40
increased severity of certain psycho-emotional tension from 52.21 % to 
73.21 %. 
The last question discussed was “ Do you want to treat fluorosis, and 
if not – why?”.
From the answers to the last question we found out that the main 
reason why some patients do not like the idea of whitening teeth is the 
previous failed attempts of treatment. 
For example, two patients in the studied group complained that, after 
whitening, they become darker than before bleaching. In both cases 
we found that bleaching was performed in the center of endemic areas, 
which very likely was the reason for treatment failure.
Some patients think that the restoration of the natural color is not long 
lasting and that this treatment is more harmful than useful. Of course, 
there is the fear of cavity formation after completing treatment. 
Taking in consideration that the patients live in a limited endemic 
area, they usually tell the following: “One person that I know has made 
teeth whitening and after more than a year appeared caries”. Intensity 
of fluorosis damage was not reflected on the number of refusals of the 
treatment.
Patients with severe forms of fluorosis were afraid of operative 
treatment and the uncertainty of the outcome duration.
For the students it is characteristic the reversed situation – with the 
worsening of the pathology decreases the manifestations of the psycho-
emotional disorders.
The patients with minor fluorosis very often after finishing the 
treatment (bleaching), they desire to do additional whitening treatment 
for whiter teeth. They often compare the color of their teeth with the 
Hollywood stars or Negroid race or Arabs and stubbornly insisting on 
the continuation of the cosmetic treatment.
From the point of view of a specialist, a young man with fluorosis 
discoloration of teeth should suffer psycho-emotional problems, the 
depth of which is due to the severity of the disease and age. Severe 
forms of fluorosis, hypothetically, are accompanied by more serious 
disorders of psychological and emotional status. 
41
However, the results of this survey do not coincide with the above 
assumptions.
Conclusions: 
1.The study results have proved to be ambiguous.
2. Discolorations of teeth caused by dental fluorosis are undoubtedly 
a risk factor for psychological difficulties forming a large part of young 
people. In this case, a predominant importance has the severity of 
pathology and sex of the patient.
3. At the presence of a brown pigmentation of the enamel young 
people appreciate their teeth color as being in acceptable limits and the 
problems created by this – as insignificant.
4. When deciding on the possibility and necessity of dental fluorosis 
aesthetic treatment it must be taken into account the patient’s wishes.
5. In patients with minor fluorosis of the teeth very often after 
finishing the treatment (bleaching), they desire to do an extra whitening 
treatment, for “whiter teeth”.
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DENTAL FLUOROSIS TREATMENT
Dental fluorosis treatment includes: 
• the reduction of the excessive doses of fluoride in consumed 
drinking water;
• the application of various methods to remove pigmentation and 
dental defects;
• the raising of the body resistance of the child;
• the indication of a reasonable diet (rich in calcium, phosphorus, 
vitamins) and medicinal preparations with beneficial effect on mineral 
metabolism. 
Early forms (grades I, II) do not require special treatment if patients’ 
aesthetic requirements are fulfilled.
S. K. Gupta and coauthors (1996) affirms that some forms of dental 
fluorosis can be treated by administration of ascorbic acid, calcium and 
vitamin D3.
There are many well-known and practiced methods of “whitening” 
(of depigmentation) in the case of pigmented macules, and in particular 
of the teeth located in the front.
Professional literature describes various teeth whitening methods 
(Murrin JR, Barkmeier WW, 1982; Hanosh FN, Hanosh GS, 1992,Cohen S., Burns, R., 1998, etc..): 
• Vital or devitalized (vital techniques involve only drug vestibular 
applications (the big majority) or all tooth surfaces, and the devitalized 
method is achieved after endodontic treatment, through the pulp 
chamber);
• Internal, external and combined;
• performed at home (by the patient) or in the dental office.
Many authors have proposed methods for dental depigmentation 
action “whitening” drugs that release free oxygen (hydrogen peroxide).
43
As substances for the bleaching of teeth affected by dental fluorosis 
G.D. Ovrutkii (1962) proposed acetic and lactic acid.
I.O. Novik applied for removal of fluorosis macules the solution 
composed of 5 parts of 33 % H2O2 and 1 part of ether. The technique 
of processing of the fluorosis macules consists of embrocating affected 
area with cotton balls soaked in the mixture mentioned above. Then the 
rays of a quartz lamp are directed to the teeth. When the cotton balls dry 
they are replaced with wet ones. The session lasts about 30 minutes. The 
first results of treatment are noticed after the third session. In some cases 
it is necessary to do 15-20 sessions. 
V.K. Patrikeev (1958 ) and G.P. Colon (1980 ) proposed for the 
depigmentation of the dark–brown macules on the front teeth the 
saturated solution of citric acid (or tartaric acid), which, after application, 
was neutralized with a sodium bicarbonate paste. After this, it was 
recommended the polishing with pumice and wood stone. The treatment 
was continued until the disappearance of the coloration.
I.G. Lucomskii proposed for the removal of the pigmentations and 
for whitening the fluorosis macules the embrocating with fluoride paste 
of 75%, and enamel exposure to ultraviolet radiation for 3 minutes. 
The expected number of procedures is 3-5, with an interval of 1-2 days 
between sessions.
G.D. Ovrutkii removed pigmented fluorosis macules by grinding the 
affected areas with carborundum stone, and then on the polished enamel 
surface applied for 10 minutes a cotton ball soaked in hydrogen peroxide 
33%. The tooth, thus processed was irradiated with a quartz lamp within 
3-4 min. And then the tooth surface was grinded with a 75% fluorine 
paste. Later, after depigmentation, the tooth surface was polished with 
wooden stone. Respective mechanical and chemical treatments of the 
enamel were performed in 2-3 sessions with intervals of 5-7 days and 
were intended to remineralize the tooth surface. 
At the Therapeutic Dentistry Department of the ММDI (Moscow 
Medical Dental Institute N. А. Semashko), the fluorosis pigmentations 
are removed by the following method: the tooth surface is processed 
with a cotton swab dipped in a solution of 36% hydrochloric acid, with 
44
subsequent application of a solution of calcium gluconate for a period 
of 15-20 min.
А . К . Nikolishin (1977 ) performed the whitening of the teeth affected 
with fluorosis, by applying on the vestibular surface of the anterior teeth 
a cotton swab dipped into a hydrochloric acid solution 36 % and 33 % 
H2O2 in a ratio of 1:2, for a period of 5-7 min. After that, he applied on 
the tooth a cotton pad moistened with a 33 % solution of H2O2 for a 
period of 10-15 minutes. The oral cavity was rinsed with water at the 
room temperature. On the same day, for stimulating the mineralization of 
dental hard tissues, teeth whitening session was completed by introducing 
therein by electrophoresis of a solution of calcium chloride for over 20 
minutes. In addition, he invented a device – a spoon which is adapted 
to the jaws containing alginate impression material, in which through 
two pins, the bleaching solution was introduced. For severe forms of 
dental fluorosis, А. К. Nikolishin recommend a complex treatment 
administering orally and by electrophoresis the calcium preparations.
The professional literature describes methods of bleaching using 
the heat and light, which involve the release of oxygen from hydrogen 
peroxide. On the teeth is applied hydrogen peroxide solution 30-35 %, 
after which they are exposed to the temperature of 40-57 ° C up to 20 
min. this method requires at least 3 meetings with subsequent periodic 
checks ( JR Murrin and WW Barkmeir , 1982).
J.R. Murrin and W.W. Barkmeir (1982) also proposed for the treatment 
of dental fluorosis the following materials: vaseline, pumice stone sand, 
36 % hydrochloric acid, sodium hypochlorite 5.25 % , H2O2 30 % , tin 
fluoride in solution, tin oxide .
A mixture of pumice stone sand and a few drops of hydrochloric acid 
were applied to the affected tooth surfaces using a circular motion for 
over 5 min. And then it was neutralized with sodium hypochlorite, and 
the teeth were rinsed with water. Cotton rolls, previously flattened and 
soaked with H2O2 and heated to a temperature of 48.8 ° C, were applied 
on the teeth vestibular surfaces for 5-10 minutes. The oral cavity was 
rinsed with water at the room temperature and then – dried. For the next 
processing step, on the teeth was applied a solution of tin fluoride. After 
45
this was done, followed the gradual grinding of the superficial enamel 
with tin oxide in association with carborundum stones or paper discs.
N.B. When using aggressive substances in the stages described above 
must be strictly respected the caution measures. Personnel must be 
provided with protective glasses and rubber gloves and patients should 
be provided with special bibs and towels applied on the eyes and nose.
For the treatment of incipient forms of dental fluorosis is indicated 
the remineralization therapy with calcium preparations (calcium 
gluconate, calcium glycerophosphate), administered by applications or 
by electrophoresis ( Lebedeva G.K., Galcenco V. М., 1981; Gnatiuc P. 
Ia. , Burlacu V.Z. , Elaşco M.L. , 1984; Gnatiuc P. Ia. , Sirbu S.V. , 
Burlacu V.Z. , 1989).
In Moldova, for the treatment of shaded, maculous and chalky-
granular forms of fluorosis is widely and successfully practiced the 
teeth whitening method proposed by the Therapeutic Stomatology 
Department of the State Medical University of Moldova (Gnatiuc P. Ia. 
and the coauthors, 1984).
At the Dental Clinic of the State Medical University were treated 
patients with all forms of fluorosis and all degrees of damage. Their 
treatment was performed in complex volume (general, local and 
physiotherapy). All the patients were recommended a diet rich in protein, 
vitamins and microelements. Considering the fact that fluoride is calcium 
antagonist, a particular importance was given to its content in foods.
Bleaching itself includes: 
• the application of a labial plastic extensor for the isolation of the 
oral mucosal surfaces;
• teeth isolation for saliva;
• the application of the Vaseline on the marginal, vestibular and oral 
gingiva (or other neutral ointment – combustion chemical prophylaxis);
• the application on the vestibular surfaces of the affected teeth (5 
min.) of a cotton swab soaked in 18% hydrochloric acid;
• rinsing of the mouth cavity with sodium bicarbonate 2% liquid;
• the application on the same surface of a roll of cotton soaked in 33% 
H2O2 liquid for a period of 5-10 min.;
46
• rinsing the mouth with sodium bicarbonate 2% liquid;
• the application on the bleached surfaces of the Calmecin paste for 
20 min., or the Calcium gluconate 10% liquid;
• the enamel polishing with Calmecin or Calcine glycerin based pastes.
N.B. The food containing pigments (coffee, grapes, etc.) is 
contraindicated and the tooth brushing is recommended to be performed 
with toothpastes that do not contain fluoride “Jemciug” “Arbat” etc..
After whitening was finished it was recommended to combine the 
fluctophoresis action of the 5% of calcium gluconate liquid, and the 
ultraviolet ray irradiation device of the nasopharynx. Irradiation began