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Year : 2013  |  Volume : 4  |  Issue : 4  |  Page : 127-130

Assessment of periodontal status of the patients with dental fluorosis in area with natural high levels of fluoride: A cross-sectional survey

1 Assistant Professor, Department of Orthodontics, Sinhgad Dental College, Pune, India
2 Dental Surgeon, Vora Multispeciality Dental Clinic, Pune, Maharashtra, India

Date of Web Publication4-Dec-2013

Correspondence Address:
Ketan Sukumar Vora
Vora Multidpeciality Dental Clinic, Bibwewadi-Kondhwa road, Pune-411037, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2155-8213.122674

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Introduction: Dental fluorosis exhibits as enamel mottling, surface irregularities, leading to plaque accumulation and periodontal diseases. It may cause failure of cemental resorption leading to hypercementosis and causes osteonecrosis of alveolar bone leading to reduced bone height. The study is conducted in Raichur, being known as one of the highest fluoride containing area in Karnataka with level of fluoride in drinking water approximately 3.5-5.5 ppm. This is an effort to find an association between dental fluorosis and periodontal diseases. Aims: The purpose of the study was to evaluate the effect of severity of dental fluorosis on the periodontal status in the patients assessed. Settings and Design: This cross-sectional, epidemiological survey was carried out at rural parts of Raichur. Materials and Methods: One hundred and eleven subjects with dental fluorosis were selected for the study with age range of 15-45 years. Assessment of dental fluorosis and periodontal status was done by Dean's Community Fluorosis Index (DCFI) and Ramfjord's Periodontal Index (RPI), respectively. Statistical Analysis Used: Analysis of variance (ANOVA) test, chi-square test, and Spearman's correlation coefficient. Results: A statistically significant relation was found between severity of dental fluorosis and severity of periodontal diseases (Spearman's correlation coefficient 0.88, significant). Discussion: Dental fluorosis may have significant effect on periodontal condition. But, further studies on the periodontal status of subjects from naturally high water fluoride regions from different parts of India are essential.

Keywords: Dental fluorosis, oral hygiene, periodontitis

How to cite this article:
Vora KS, Vora PK. Assessment of periodontal status of the patients with dental fluorosis in area with natural high levels of fluoride: A cross-sectional survey. Dent Hypotheses 2013;4:127-30

How to cite this URL:
Vora KS, Vora PK. Assessment of periodontal status of the patients with dental fluorosis in area with natural high levels of fluoride: A cross-sectional survey. Dent Hypotheses [serial online] 2013 [cited 2023 Jun 2];4:127-30. Available from:

  Introduction Top

Dental fluorosis is considered the earliest sign of fluoride intoxication. Though the role of topical and systemic fluoride in the inhibition of dental caries is well known, its role on the prevalence and severity of periodontal disease is not as well understood.

Fluorosis may have direct as well as indirect effect on periodontal status. It may cause failure of cemental resorption leading to hypercementosis. It also causes osteonecrosis of alveolar bone leading to reduced bone height. These are some of the direct effects of fluorides. [1]

Indirectly also, fluorides may cause periodontal diseases. It causes mottling of enamel and irregular, rough root surface leading to plaque accumulation. This is difficult to remove by routine oral hygiene measures. Thus, it can cause plaque-associated periodontal diseases. [2]

Periodontitis being multifactorial in nature has various determinants like age, sex, race, socioeconomic status, and risk factors including tobacco usage and oral hygiene status. Thus it is an attempt to find if there is any correlation between periodontal diseases, and dental fluorosis. The study is conducted in and around Raichur. Raichur is being known as one of the highest fluoride containing area in Karnataka. [3] The level of fluoride in drinking water ranges from 3.5 to 5.5 ppm. Till date, no studies have been conducted to find any association between periodontal status and dental fluorosis in and around Raichur. This is an effort to find an association between dental fluorosis and periodontal diseases.

The aim of the study is to investigate the effect of dental fluorosis on the periodontal status in and around Raichur.

  Materials and Methods Top

This is a cross-sectional study conducted in rural parts of Raichur. Camps were conducted in Kalloor and Devadurga which are considered as high fluoride areas near Raichur, where the fluoride level in drinking water is approximately 5.15 ppm. [4],[5] Taking into consideration the pilot study conducted, and after determining the expected incidence of fluorosis (42% in Karnataka) [6] with the precision of 5%, a total of 268 patients were screened of which 111 individuals with dental fluorosis were identified and were included in the study with age range of 15-45 (mean age of 42 ± 1.62) years. All the subjects were having varying degree of dental fluorosis. Subjects with known systemic diseases, subjects with other intrinsic dental stains, subjects with adverse habits, pregnant females, and patients with age more than 45 years were excluded. As dental fluorosis is related to excessive intake of fluorides during odontogenesis, only permanent residents were included in this study.

After taking patient's consent and approval from ethical committee of college as well as from village panchayat, a brief case history was recorded which included patient's oral hygiene habits; type of water he/she is drinking; and patient's personal, medical, and drug history. Thorough oral examination was carried out. This is a single blind study as all oral examinations were carried out by one blinded examiner in natural light conditions and with the aid of both a plain mouth mirror and a periodontal probe.

Dental fluorosis was recorded by Dean's Community Fluorosis Index (DCFI, 1935). [7] Oral hygiene status was recorded by Oral Hygiene Index-Simplified (OHI-S; Greene and Vermillion 1964). [7] Periodontal status of the population was recorded by Ramfjord's Periodontal Index (RPI, 1959). [7]

To correlate dental fluorosis with patient's oral hygiene and periodontal status, one-way analysis of variance (ANOVA) test was used. Chi-square test was used to calculate gender wise prevalence of dental fluorosis and Spearman's correlation coefficient was used to find correlation between DCFI, OHI-S, and RPI. The statistician was also blinded. The software used for the study was Statistical Package for Social Sciences (SPSS) version 17 (SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc.).

  Results Top

Distribution of the sample based on sex and periodontal status, OHI-S, and degree of dental fluorosis are tabulated.

The mean values for DCFI, OHI-S, and RPI were 2.85, 3.03 and 4.04, suggesting marked dental fluorosis, poor oral hygiene, and poor periodontal status, respectively [Table 1] and [Figure 1].
Figure 1: Mean levels of DFI, OHI and RPI

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Table 1: Mean and range of dean's community fluorosis index, oral hygiene index-simplifi ed, and ramfjord's periodontal index

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The prevalence of very marked dental fluorosis was 62.2% amongst the population examined [Figure 2].
Figure 2: Prevalence of dental fluorosis

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The association between severity of dental fluorosis and status of oral hygiene was significant and inversely proportional [Table 2]. As the severity of dental fluorosis increased, severity of periodontal disease increased proportionately. Spearman's rank correlation coefficient was 0.88; which was significant [Table 3] and [Table 4], [Figure 3] and [Figure 4] There was no significant relationship between male and female population for severity of dental fluorosis as well as periodontal conditions noted [Table 4].
Figure 3: Correlation between dental fluorosis and oral hygiene

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Figure 4: Correlation between dental fl uorosis and periodontal status

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Table 2: Correlation of oral hygiene and periodontal disease according to severity of dental fluorosis

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Table 3: Spearman's correlation coefficient

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Table 4: Gender wise prevalence of DCFI

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  Discussion Top

Periodontitis is a multifactorial disease. Dental fluorosis is an environmental factor which may affect directly as well as indirectly to the periodontium. [8],[9]

In the present study, the OHI status was poor in a majority of subjects because of the nonavailability of regular dental care and poor educational status. Majority of the patients were having very marked dental fluorosis according to DCFI. As the severity of dental fluorosis increased, the oral hygiene was equally affected.

The possible reasons for the susceptibility of this population to periodontitis are based on the following study.

An animal study conducted by Krook et al., (1983) in cattle with dental fluorosis has showed that hypercementosis resulted from failure of resorption of cementum as an expression of fluoride intoxication. Fluoride had a toxic effect on the resorbing cementocytes that finally died and cementum necrosis leads to cyst formation. Toxic action of fluoride on alveolar bone of permanent teeth eventually leads to osteonecrosis and recession of the alveolar crest. The gingiva also recedes with the receding bone. [2]

Vazirani and Sing (1968) reported that on gross examination of teeth with mottled enamel, the most important point was observed in the root portion of tooth. The root surfaces were irregular, rough, and revealed heavy deposits of calcified marks in the form of excessive amounts of fluoride or osteocementum at the apical region of the teeth. These teeth were having osteosclerosis, cementosis, and periapical root resorption. [8]

The direct toxic effects of fluoride on teeth and bone in literature tells the possibility of toxic effect of fluoride such as cemental necrosis, osteosclerosis, and calcification of ligament in human periodontal region as a result of long-term exposure to high fluoride water levels. [10]

Poor periodontal status of the population may also be attributed to the poor oral hygiene due to improper teeth cleaning habits. More than 70% population were using finger for cleaning the teeth. It was reported by Reddy et al., (1985) that dental fluorosis results in more plaque accumulation resulting in severe gingivitis .[11] It was observed in the present study that around 62% of the population screened were having very marked degree of dental fluorosis, in those 52% were having poor oral hygiene leading to periodontitis. The limitation of this study was that the sample size was less. Also, estimation of fluoride content in the drinking water of the villages from which the samples were collected would have been more appropriate in calculating the extent of dental fluorosis and periodontal disease. Interventional study in the form of oral hygiene awareness and improving oral hygiene in future are necessary. Even, scanning electron microscopy (SEM) studies would show the effect of fluoride on cementum and would more appropriately show the effect on periodontal status. The studies of periodontal status of subjects residing in naturally high water fluoride regions from different parts of India are necessary.

Proper brushing methods are explained to the villagers while conducting the dental check-up camps. The patients should be educated about the oral hygiene. Also, the importance of good and ill effects of fluorides should be explained.

  Acknowledgement Top

We thank the Government schools and Gram panchayat at Devdurga and Kalloor for allowing us to conduct the camp.

  References Top

1.Haikel Y, Tiirlot JC, Cahen PM, Frank R. Periodontal treatment needs in populations of high-and low-fluoride areas of Morocco. J Clin Periodontol 1989;16:596-600.  Back to cited text no. 1
2.Krook L, Maylin GA, Lillie JH, Wallace RS. Dental flurosis in cattle. Cornell Vet 1983;73:340-62.  Back to cited text no. 2
3.Central Ground Water Board, Ministry of Water Resources, Government of India. Available from: [Last accessed on 2013 Jun 21].  Back to cited text no. 3
4.Suma Latha, Ambika SR, Prasad SJ. Fluoride contamination status of groundwater in Karnataka, Central Ground Water Board, Ministry of Water Resources, Bangalore. Available from: [Last accessed on 2013 Jun 21].  Back to cited text no. 4
5.Bureau of Indian Standards, Drinking water specification (First Revision) IS 10500; 1991.  Back to cited text no. 5
6.Banavaram AA, Arjunan, Nandagudi SM, Nallur SS, Suradhenupura PS, Sreekantaiah P.Prevalence and severity of dental fluorosis and genu valgum among school children in rural field practice area of a medical college Asian Pac J Trop Dis 2012;2:465-9  Back to cited text no. 6
7.Soben P. Indices. Textbook of-Essentials of preventive and community dentistry, 4 th ed. 311-325  Back to cited text no. 7
8.Vazirani SJ, Sing A. Endemic fluorosis. Radiological features of dental fluorosis. J Indian Dent Assoc 1968;40:299-303.  Back to cited text no. 8
9.Murray JJ. Gingivitis and gingival recession in adults from high-fluoride and low fluoride areas. Arch Oral Biol 1972;17:1269-77.  Back to cited text no. 9
10.Reddy J, Grobler SR The relationship of the periodontal status to fluoride levels of alveolar hone and tooth roots. J Clin Periodontol 1988;15:217-21.   Back to cited text no. 10
11.Reddy J, Parker JR, Africa CW, Stephen LX. Prevalence and severity of periodontitis in a high fluoride area in South Africa. Community Dent Oral Epidemiol 1985;13:108-12.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]

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