Public Perception of Dental Fluorosis: "The crucial issue"?

By George Glasser & Jane Jones

Pictures of Dental Fluorosis

Very Mild	Mild	Moderate	Severe

"Among its [the MRC's] recommendations are . . . further studies to determine the prevalence and public perception of dental fluorosis." (Letter from Hazel Blears, Parliamentary Under Secretary of State for Health, 19 November, 2002.).

"The MRC's recommendation that efforts are made to assess the aesthetic acceptability of dental fluorosis is also highly relevant. As fluorosed teeth are still endowed with the same resistance to decay, the crucial issue may be around public perceptions of what are healthy teeth." (Letter from Hazel Blears, 20 November, 2002.).

According to the US Centers for Disease Control 2001 Report, the primary concern of the USCDC is the increasing prevalence of Dental Fluorosis (DF) in fluoridated and non fluoridated areas: "Cases of moderate and severe forms occurred even among children living in areas with low fluoride concentrations in the drinking water. Although this level of enamel fluorosis is not considered a public health problem, prudent public health practice should seek to minimize this condition, especially moderate to severe forms. In addition, changes in public perceptions of what is cosmetically acceptable could influence support for effective caries-prevention measures." (1)

Dental fluorosis (DF, or "mottled teeth"), has long been recognised as an endemic problem affecting areas of the world with high levels of naturally occurring fluorides in the drinking water.

When artificial drinking water fluoridation schemes began in the United States in the mid twentieth century, the US Public Health Service estimated that 10% of children consuming water fluoridated between 0.9 - 1.2 parts per million would develop mild DF. There was a general assumption that drinking water would be the only source of exposure to fluorides.(2)

Today, half a century later, populations are exposed to fluorides from a wide range of sources, including air pollution, drinking water, toothpaste, mouth rinses, foods, beverages, medicines, anaesthetics, fluoride supplements, pesticide and herbicide residues. The result of these multiple exposures has led to a dramatic increase in the prevalence of mild, moderate and severe DF. It has become a problem even in areas where the public drinking water has never been artificially fluoridated.(3)

The dental profession considers artificial water fluoridation to be an effective way of reducing tooth decay in children and regards DF as "merely a cosmetic effect."

Public health officials consider (and have described) DF as a "classic public health trade-off" - an acceptable minor risk - resulting from "a beneficial, cost-effective public health measure which reduces inequalities in dental health."

In a study published in the British Dental Journal in 2000, leading UK researchers from Newcastle City Health NHS Trust found that the prevalence of dental fluorosis among 8 - 9-year-old children in fluoridated Newcastle was 54%. They also found that in "fluoride-deficient" Northumberland, 23% of 8 - 9-year-old children have DF. They concluded that the prevalence of "aesthetically important" DF in the fluoridated area was 3% - six times higher than found in the non-fluoridated area, where 0.5% of the children were affected.(5) This demonstrates that over-exposure to fluorides can be seen in areas where the drinking water is not fluoridated.

If the findings of the Newcastle researchers are correct then, for every 10,000 children born in fluoridated areas, 300 have developed "aesthetically important" DF and, for every 10,000 children born in non-fluoridated areas, 50 are similarly affected.

In 2000, the same year as the Newcastle study appeared in the British Dental Journal, the British Medical Journal published a systematic scientific review of water fluoridation, commissioned by the UK Government and carried out at the NHS Centre for Reviews and Dissemination at York University. It reported that 48% of the populations living in fluoridated areas develop DF of all types. This figure is somewhat lower than that found by the Newcastle researchers. However, the York reviewers stated that 12.5% of those exposed to water fluoridation - 1,250 people in every 10,000 - exhibit DF "of concern".(6)

In the two studies discussed above, researchers are agreed that DF is widespread. They differ only on the degree of prevalence of aesthetically important DF. In either case, it is clear that fluorosis of aesthetic concern affects a large subset of the population.

Neither of these studies acknowledged that DF may have other profound consequences for individuals and society as a whole.

The psycho-social impact of DF

Numerous studies published in prominent dental journals demonstrate that dental professionals have been aware for many years that unattractive teeth can adversely affect the psychological wellbeing of children and adults.(7)

A 1981 study on the attractiveness of teeth concluded, "The hypothesis that children with a normal dental appearance would be judged to be better looking, more desirable as friends, more intelligent, and less likely to behave aggressively was upheld."(8 - 10)

Spencer, et al (1996), acknowledged the findings of three studies published in 1993 showing that children from 10 - 17 years of age readily recognise "very mild" and "mild" DF and that even mild changes in coloration cause embarrassment and self consciousness. Spencer wrote that the "psycho-behavioural impact was similar to that of crowding and overbite, both considered key occlusal traits driving the demand for orthodontic care."(11 - 14)

DF is visible as soon as the secondary teeth erupt. While developing social and early life skills, children are at their most vulnerable to the psychological impact of discrimination.(15 - 18)

Further research in 2002 confirmed that participants in a study of the psycho-social perception of dental abnormalities, such as DF, believed that people with dirty (stained) teeth have a "lack of social skills, lower intelligence and poor psychological adjustment."(19)

Studies sponsored by Government and industry have repeatedly established that DF and dental abnormalities have negative psycho-social impacts and that the public commonly perceives people with dental abnormalities to have:

poor health
low intelligence
poor psychological adjustment
poor personal hygiene
lack of social skills
(Refs. 20 - 46)

This negative public perception has led to a defined pattern of prejudice, discrimination and social exclusion. Teachers often prejudge a child's intellect and personality based on appearance alone. Such negative perceptions have been found to impact adversely on the victims' personalities.

The impact

The consequences of artificial water fluoridation and widespread, poorly- or unregulated use of fluoridated products have created a growing subset of the population more likely to endure lifelong discrimination and develop psycho-behavioural problems.(47 - 50)

In 1984, following a review commissioned by the United States Environmental Protection Agency, an independent panel of behavioural scientists stated that people with moderate to severe fluorosis are at increased risk of experiencing psychological and behavioural problems.(51)

In 1997, Rodd, et al observed: "Although in its mild form the condition is not considered to be of cosmetic significance, the more severe forms can cause great psychological distress to the affected individual."(52)

Children who develop DF-related behavioural problems are more likely to

be disruptive in school
underachieve, academically
regularly truant from school
have histories of antisocial behaviour (police records)
become drug and/or alcohol abusers

Many of these children carry these negative behavioural traits into adulthood and are more likely to

live on welfare benefits
fail to obtain or retain work
become homeless
fail to make or maintain relationships
be more prone to violence
spend time in prison
become repeat offenders
suffer from some form of mental illness
suffer from drug addiction/alcoholism
have suffered from child abuse
are child abusers

Such well-documented negative outcomes indicate the existence of an important socio-economic element which is never included in 'cost-benefit' analyses of water fluoridation.(53 -55)

The socio-economic consequences

In the most optimistic case scenario mentioned above, if 'only' 3% of artificially fluoridated populations develop moderate to severe DF, this minority of 'problematic people' can have a significant impact on the wellbeing of communities with all the attendant costs to society.

For example, the recorded births for 2001 at four of fluoridated Birmingham's hospitals were 21,806. At the lower, 3% estimate, 654 of these children will go on to develop moderate to severe DF. If the higher, 12.5% estimate is correct, the number of children with DF will be 2,725. It is worth noting that these figures are compounded year on year with the addition of annual births.

In a 1997 study on toothpaste use, published in the British Dental Journal, the authors found that 34% of children at five Birmingham primary schools have dental fluorosis.(56)

Birmingham has been fluoridated for about 40 years. The 0 - 39 age group population is approximately 566,556 people. Taking the Newcastle estimate of 3%, almost 17,000 people have "aesthetically important" DF. Using the York estimate of 12.5% the number could be as high as 70,819.

Whichever estimate is correct, there is no doubt that all of these individuals have been over-exposed to fluorides. A substantial part of that exposure is contributed by artificial water fluoridation. These individuals were not able to avoid DF because they have never been made aware of the existence of any risk to the appearance of their teeth.

In a response to a query about remedial treatment under the NHS for people with DF, Ms Hazel Blears wrote: "Under the General Dental Services the fitting of veneers on permanent upper teeth anterior to the first premolar is permitted, normally for patients of 17 years or over. Treatment is subject to the patient charge specified in the Statement of Dental Remuneration unless the patient is exempt from charges." In other words, the victim pays!

A paper published in the British Medical Journal in 1996 made suggestions for improving the performance and accountability of research ethics committees. It stated: "As the most independent bodies regulating the practice of research, we believe that research ethics committees should be held accountable if, in the light of present understanding of the importance and principles of research synthesis, they continue to allow two forms of scientific malpractice to occur: the execution of unnecessary, sometimes harmful, research and the failure to ensure that the results of research are publicly accessible." (57)

A large body of published, peer reviewed work reveals that Government policy has led to the creation of a significant subset of the population which is more susceptible to social and employment discrimination. The effects on health, education and social services budgets and on the wider economy have been completely overlooked in the quest for a substantial reduction in the cost of dental care.

29 Abstracts on the perception of dental fluorosis

Dental Fluorosis: Smile please - but don't say 'Cheese'

Dental Fluorosis: Stolen smiles - ruined lives.

NPWA dental fluorosis brief

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