Fluorosis (dentistry)

As early as 1890, tooth changes in fluorosis were described as colored or black teeth. Subsequently, these teeth began to be called "mottled", "pockmarked enamel", "spotted enamel." The last name given by Black in 1916 was most widely used in specialized literature. Only in 1931 it was found that in the drinking water of settlements where spotting of enamel is observed, the content of the trace mineral fluorine was increased. Later it was found that tooth damage with fluorosis is not the only sign of this disease. At significant concentrations, fluorine can also affect the human skeleton.

In accordance with SanPiN 2.1.4.1074-01, the maximum permissible concentration of fluorine in water should be no more than 1.5 mg / l. But even with a fluorine concentration of 1.5 mg / l, teeth can be affected in a certain percentage of people. This is due to the individual reaction of the body of each person, as well as to the average ambient temperature (water consumption increases with increasing temperature). A person receives about 3 mg of fluoride per day (0.5-1.1 mg with food and 2.2-2.5 mg with water). Fluoride found in the foods we eat is much less absorbed than fluoride found in water.

If an adult uses water with a high fluorine content for a long time, his teeth with formed enamel are not affected by fluorosis. But if the concentration of fluoride in water exceeds 6 mg / l, then fluorosis can affect already formed teeth.

There is some pattern in tooth damage with fluorosis, from the degree of fluorine concentration in the endemic zone:

Reasons for occurrence and manifestation

Dental fluorosis (endemic dental fluorosis) is a chronic disease found in areas with excess fluoride in drinking water. A disease that develops before teething. With fluorosis, tooth enamel is mainly affected. Fluorosis is caused by the prolonged intake of the fluorine microelement in the body and is expressed by the formation of spots and defects of various sizes, shapes and colors on the enamel surface. In severe cases, skeleton bones are affected.

The optimal concentration of fluoride in water is considered to be 1 mg / l. At a concentration of more than 1 mg / l. fluorosis develops. Children aged 3-4 years are especially prone to fluorosis if they have lived in an area with a high fluorine content in drinking water for more than 3 years. As a rule, only permanent teeth are affected by fluorosis. It is believed that the placenta delays the intake of excess fluoride in the fetus. Rarely, there are cases of fluorosis damage to erupted teeth in areas with a fluorine content in water of more than 10-15 mg / l.

As a rule, symmetrical teeth (for example, central incisors) are affected with fluorosis. Mostly permanent teeth of children living in an endemic focus since birth. Milk teeth are rarely affected. This is due to the fact that the mineralization of milk teeth ends in the womb, which leads to the delay of a large amount of fluorine by the placental barrier. Of course, if the fluorine content in water is extremely high, then milk teeth are affected.

In Russia, the classification of V.K. Patrikeev (1956) is the most common. Depending on the severity of manifestations of tooth fluorosis, the following forms are distinguished: dashed, spotted, chalky-mottled, erosive and destructive.

The first three forms occur without loss of tooth tissue, and erosive and destructive - with loss.

The dashed form of fluorosis is characterized by the appearance of small chalky strips - strokes located in the subsurface layers of enamel. The strips can be marked well, but often they are weakly expressed and appear when the tooth surface is dried. The fusion of the bands leads to the formation of a spot in which the bands are still distinguishable. The dashed form is more often observed on the vestibular surface of the incisors of the upper jaw, less often on the lower. The spotted form is characterized by the presence of well-defined chalky spots without stripes. Cretaceous spots are multiple, located on the entire surface of the teeth. Sometimes they merge to form a large spot. Cretaceous-changed enamel gradually turns into normal enamel. Spotted enamel damage is observed on many teeth, but is especially pronounced on the incisors of the upper and lower jaws. Sometimes the color of the affected area changes - the spot acquires a light brown color. A feature of this form of tooth fluorosis is that the enamel in the area of ​​the spot is smooth, shiny.

Cretaceous-mottled form is characterized by a significant variety. Usually the enamel of all surfaces has a matte shade, and against this background there are well-defined pigmented spots. Sometimes enamel is yellowish with the presence of multiple spots, dots. In some cases, instead of points, there are superficial lesions with a decrease in enamel (1.0-1.5 mm in diameter and 0.1-0.2 mm in depth). With a chalky-speckled form, enamel is rapidly erased with dark brown pigmented dentin exposed.

The erosive form is characterized by the fact that, against the background of pronounced pigmentation of the enamel, there are significant areas on which it is absent, various forms of defects - erosion. With an erosive form, enamel and dentin erasure is expressed. The destructive form is characterized by a violation of the shape of the tooth crowns due to erosive destruction and abrasion of hard tissues. The destructive form is observed in areas where fluorine contains more than 5 mg / l in the water sources. With this form, the tooth tissue is fragile, often breaking off is observed. However, the tooth cavity is not opened due to deposition of replacement dentin.

In severe forms of fluorosis, skeletal bones are affected. The severity of the disease is caused not only by the concentration of fluoride in water, but also depends on a number of factors. Children who have suffered fluorosis during the period of mineralization of the teeth are more affected by fluorosis.

The degree of fluorosis damage, according to the Mueller classification (1965), used by WHO:

Very mild form of fluorosis. Enamel color is practically unchanged.

Mild form of fluorosis. The appearance of milky white stripes or the same small spots on single teeth is observed. Moreover, the affected area does not exceed 25% of the total area of ​​the tooth crown.

A moderate form of fluorosis. The area of ​​lesion with chalky spots and stripes reaches 50%.

Medium - brown or yellow spots appear in addition to the chalk-like spots. Exposure to caries is characteristic of this degree.

Severe form of fluorosis. Most of the crown of the tooth is affected, and a violation of the structure of hard tissues is added to the pronounced pigmentation. Crown deformation occurs, the enamel is subject to abrasion and chipping. In the third degree, fluorosis can affect the skeletal bone.

The nature of the changes largely depends on the form of the clinical lesion (the severity of the changes). With the initial form of the disease (dashed and spotted forms), altered areas of various sizes and shapes are found in the subsurface layer. Gunter-Schroeger bands are sharply pronounced, which bend in an arcuate manner and reach enamel, and the Retzius lines are clearly visible. The enamel surface along with even outlines has separate bulges and depressions. Dentinal enamel compound. The surface layer of enamel has a moire pattern, which is due to an increase in interprism space due to partial resorption of enamel prisms, zones of hypo- and hypermineralization.

Enamel prisms are partially destroyed, interprismatic spaces expand, the replenishment of which with amorphous material occurs due to resorbable prisms. In the affected area, inhomogeneous mineralization of enamel is observed (areas of hypomineralization alternate with areas of hypermineralization). In the future, demineralization processes intensify, enamel permeability increases due to an increase in the volume of micropores (microspaces).

Using X-ray micrographs, it was found that a decrease in density was clearly revealed in the fluorosis spots of the outer layers, which indicates a decrease in mineralization. Similar data explain the cause of pigmentation of enamel. This happens due to the penetration of coloring substances into enamel areas with increased permeability. This is also confirmed by the fact that the pigmentation sites of fluorous teeth contain a greater amount of nitrogen-containing organic substances.

Under an electron microscope with mild degrees of damage, an underline of the structures of hydroxyapatite crystals is noted. In severe forms, the clarity of structures decreases.

Using polarizing microscopy, the most pronounced changes in the outer layers of enamel were established. In areas of the fluorous spot, mainly the interprismatic space is affected.

Fluorosis at the spot stage is differentiated from caries, which is characterized by a single lesion in areas typical of caries (cervical region, contact surface). With fluorosis, multiple lesions are located on the vestibular and lingual surfaces. In addition, fluorosis manifests itself from the moment of teething.

Diagnosing tooth fluorosis in both a child and adults will not be difficult. At the same time, both a dentist and a pediatrician can detect fluorosis in children. Diagnosis of this disease is based on clinical manifestations characteristic of varying degrees of fluorosis. However, the specialist will have to differentiate it from caries in the spot stage. If caries is characterized by single lesions located in typical places, then fluorosis is manifested by multiple changes that appear shortly after eruption of the main teeth.

Depending on the stage of the pathological process, either local bleaching and subsequent remineralization are used, or restoration of the damaged surface with a seal or orthopedic construction.

With fluorosis, accompanied only by changes in the color of enamel (dashed, spotted and chalky-speckled form), local treatment is carried out - bleaching with subsequent remineralizing therapy. Solutions of inorganic acids, hydrogen peroxide in concentrations of 6% and 30% ( perhydrol ), carbamide peroxide of 10% concentration, a mixture of hydrochloric acid (19-36%) and hydrogen peroxide are used as a bleaching preparation. After thorough removal of plaque and isolation of the tooth from saliva with cotton swabs, the tooth surface is dried and treated with a 20-30% acid solution (hydrochloric or phosphoric) for 2-3 minutes until the enamel becomes clear. After that, the tooth surface is washed with water and dried. It is very important that after tooth treatment with acid and drying, it does not come into contact with saliva. It is not recommended to eat within two hours after the procedure. Subsequent remineralization is carried out with a 10% solution of calcium gluconate for 15-20 minutes. On the next visit (no more than 1-2 days), the procedure is repeated with the only difference that only the enamel areas changed in color are carefully treated with an acid solution. The course of treatment, according to various sources, is 3-4, 10-15 or 15-20 procedures, probably depends on the degree of damage to the teeth. During the treatment period, it is recommended to take calcium gluconate, glycerophosphates inside. A persistent effect is observed for 6-8 months. Repeated courses of treatment should be carried out after 6-8 months, with the appearance of pigmented spots. At the initial stage of fluorosis, the remodeling drug has a positive effect in terms of remineralization. Strict observance of the rules of personal hygiene is recommended. A remineralizing paste is used for brushing your teeth. After completing the course of remineralizing therapy, it is advisable to cover the surface of the teeth with fluoride varnish.

With erosive and destructive forms of damage, accompanied by a violation of the integrity of the enamel, the color and shape of the tooth crowns are restored using composite filling materials or an orthopedic construction. In some cases, when crowns are broken off or a significant part is broken, pins are used for fixation.

Prevention of fluorosis should be carried out wherever there is an increased content of fluoride in water sources. Particular attention should be paid to areas where water contains more than 2 mg / l of fluoride. According to modern concepts, fluorine absorbs onto ameloblasts, disrupting the process of formation and mineralization of enamel. In this regard, intensive preventive measures should be carried out during the laying of teeth and their mineralization.

Preventive measures are divided into collective measures aimed at reducing the fluoride content in drinking water, and individual preventive measures.

A decrease in the amount of fluorine in drinking water can be achieved by replacing the water source or reducing the fluorine content by mixing the water sources using, for example, wells and glacial water in the mountains. There are methods for purifying drinking water from excess fluoride. However, it should be borne in mind that it is impossible to fully provide the population of endemic areas with purified drinking water, although this can be done for small contingents of the child population. Individual preventive measures should be carried out from the moment of birth. First of all, you should avoid artificial feeding and early feeding of the child. With the beginning of feeding, a large amount of water should not be introduced into food, but should be replaced with milk and juices. Clinical observations have shown that the additional introduction of vitamin C, D, calcium gluconate to food significantly reduces the manifestation of fluorosis. The composition of the diet is important. In particular, products containing fluorine (sea fish, animal oil, spinach, etc.) should be excluded or limited. Of particular importance in the prevention of fluorosis is the removal of children in the summer from the endemic area. Clinical observations have shown that replacing water sources for 3-4 months every year in the first 8-10 years of a child's life contributes to the normalization of enamel formation and significantly reduces the percentage of tooth damage with fluorosis.

• “Therapeutic dentistry” edited by E. Borovsky. 2nd edition, Moscow 2004, 840 pp., Ill. Chapter 5, paragraph 5.3 .. Page 163-168
• “Therapeutic dentistry” Usevich T. L., edited by B. Kabarukhin. Rostov 2003, 284 p. Chapter 6. Page 121-125.

• Dental fluorosis: symptoms and treatment