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| Year : 2008 | Volume
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| Issue : 4 | Page : 297-303 |
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| Prevalence of dental fluorosis and associated risk factors in 11-15 year old school children of Kanyakumari District, Tamilnadu, India: A cross sectional survey |
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Jagan Kumar Baskaradoss1, Roger B Clement1, Aswath Narayanan2
1 Department of Community Dentistry, Rajas Dental College and Hospital, Dr. MGR Medical University, Tamilnadu, India
2 Department of Public Health Dentistry, Tamilnadu Government Dental College and Hospital, Chennai, Tamilnadu, India
Click here for correspondence address and email
| Date of Submission | 13-Jun-2007 |
| Date of Decision | 19-May-2008 |
| Date of Acceptance | 26-May-2008 |
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 Abstract | | |
Objectives: This study presents data on the prevalence and severity of dental fluorosis in 11-15-years-old school children of Kanyakumari district, TamilNadu, India, and also the relationships between prevalence of dental fluorosis and selected risk factors.
Materials and Methods: A total of 1800 children, from all the nine blocks of Kanyakumari district, studying in classes 6-10 were examined using type III examination. The assessment form designed specifically for this study was used while examining each student.
Results: Dental fluorosis was present in 15.8% (285 children) of the study population and the community fluorosis index was calculated to be 0.27. The prevalence of dental fluorosis varied from as low as 1.4% in some blocks to as high as 29.4% in some others. There was a significant difference in the level of dental fluorosis between rural and urban residents ( P < 0.001). The prevalence of dental fluorosis was higher in children who consumed pipe water as compared to children who consumed ground water. 65% of the children with dental fluorosis had no caries, indicating the positive effects of fluoride.
Conclusions: The prevalence of dental fluorosis can be attributed to the level of fluoride in the drinking water as it exhibited a step-wise increase when the water fluoride levels increased from 1.5-1.7 ppm. Measures for defluoridation of drinking water before distribution has to be taken in the high prevalence blocks to lower the burden of dental fluorosis in this community. Keywords: Deans fluorosis index, dental fluorosis, oral health, prevalence, risk factors, school children, severity, water fluoridation
How to cite this article:
Baskaradoss JK, Clement RB, Narayanan A. Prevalence of dental fluorosis and associated risk factors in 11-15 year old school children of Kanyakumari District, Tamilnadu, India: A cross sectional survey. Indian J Dent Res 2008;19:297-303 |
How to cite this URL:
Baskaradoss JK, Clement RB, Narayanan A. Prevalence of dental fluorosis and associated risk factors in 11-15 year old school children of Kanyakumari District, Tamilnadu, India: A cross sectional survey. Indian J Dent Res [serial online] 2008 [cited 2023 Mar 22];19:297-303. Available from: https://www.ijdr.in/text.asp?2008/19/4/297/44531 |
The recognition of the protection against dental caries provided by fluoride in drinking water is considered one of the major public health advances of this century. [1] It is also recognized, however, that dental mottling occurs at fluoride levels in excess of those that provide most of the protection against dental caries. Mottled enamel (dental fluorosis) was associated with the presence of fluoride in drinking water long before the relationship with lower caries prevalence was noted. [2]
The epidemiological studies conducted by Dean in the 1930s demonstrated the relationship between the prevalence of mottling and the level of fluoride in drinking water. The, now-standard, classification of the degree of mottling exhibited by an individual as normal, questionable, very mild, mild, moderate, or severe was proposed by Dean at that time. [3],[4],[5],[6],[7]
India lies within the geographical fluoride belt that extends from Turkey to China. Nearly 12 million of the 85 million tons of fluoride deposits on the Earth's crust are found in India. It is therefore not surprising that dental fluorosis is endemic in 15 states of India. The highest rates of endemicity have been reported from AndraPradesh, Haryana, Karnataka, Punjab, and TamilNadu. [8] Kanyakumari district in TamilNadu which forms the southern most tip of India, where the three great waterscapes meet was considered an ideal location for conducting this survey.
The objective of the present study was to assess the oral health status of 11-15- years-old school children of Kanyakumari district. This survey focuses on determining the prevalence and severity of dental fluorosis along with assessing the various risk factors involved.
| Materials and Methods | |  |
Permission was obtained from the principal of Rajas Dental College for conducting the survey. Permission to survey the various schools of the district was obtained from the Chief Educational Officer and also from the Department of Public Health and Preventive Medicine, Kanyakumari, TamilNadu. Prior consent for conducting the survey in the selected schools was taken from the respective principals. Copy of the district profile for the year 2005 was obtained from the statistical department in the collectorate office.
For administrative purposes the whole of Kanyakumari district was divided into nine blocks [Table 1]. This natural division was used in this survey to obtain a uniform sample distribution. A stratified cluster sampling method was used to select the samples. Two schools were randomly selected from each block from the list of higher secondary schools obtained from the office of the Chief Education Officer. In the end, 18 schools were selected from a total of 152 schools in the district.
In consultation with the statistician, the sample size of the study group was fixed at 1800 students from across the district. One division of each class from 6-10 was randomly selected and all the students from that division were examined. Though the entire class was examined, only the first 20 students were taken as a part of the study sample. Thereby, 100 students from each school belonging to classes 6-10 were examined. This procedure was followed through out the study, in the end, totaling to 1800 students from the selected 18 schools. The survey was performed between the months of May and December, 2006, spanning a period of 8 months.
Assessment form
To encompass all the objectives of the study, two types of questionnaires were used in the study. One was the WHO schedule on the oral health assessment (WHO 1997) and the other was an individual questionnaire, specifically developed for this study, for collecting information on the prevalence and severity of dental fluorosis along with assessing the possible risk factors.
Severity of dental fluorosis was assessed using Deans fluorosis index. Oral hygiene habits like brushing pattern (tooth brush, hand, neem stick, or others), brand of toothpaste used (Colgate, Pepsodent, Close-up, others), frequency of brushing (once daily, twice daily, thrice daily), and age of starting to brush (less than 5 years, 5-10 years, more than 10 years) were considered as possible risk factors. The source of drinking water (municipal water or ground water) and the amount of water consumed per day (less than 2 glasses, 2-4 glasses, more than 4 glasses) were included in the questionnaire. Assessment of the child's diet (vegetarian, nonvegetarian, or mixed) and the regularity of seafood intake (regular, irregular, or nil) along with the amount of daily tea intake (less than 2 glasses, 2-4 glasses, more than 4 glasses) were assessed.
Instruments
120 sets of sterile no-4 mouth mirrors and no-23 explorers, with each set packed inside separate polythene covers were used for patient examinations.
Oral examination
Two dentists trained in the field of public health performed the oral examinations. One of them examined the children with sterile mouth mirror and explorer, and the other recorded the data in the oral health assessment form. The examination of each student was carried out in a common hall of the school or outside the concerned class room with the subject seated in an ordinary chair under bright day light.. The children were educated about the importance of oral health and the various oral hygiene habits. Emergency care was provided to 14 children with severe debilitating conditions. After every examination, the used instruments were placed in a steel box and were autoclaved at the end of the day.
Water fluoride content
The fluoride content in water supplies was obtained from the TamilNadu Water and Drainage Department (TWAD) of Kanyakumari district. TWAD board had performed a districtwide fluoride mapping in the year 2000 and had measured the fluoride content in the drinking water of every municipality and panchayat* in the district(*Local government bodies smaller than towns). These data were used in the current study.
Intraexaminer variability
This was largely reduced since both the dentists, who carried out the field work received the same formal training in the field of logistics, data collection, and standardization of the assessment of oral health problems (kappa = 0.54).
Deans fluorosis index
An index for assessment of dental fluorosis using a six-point scale was introduced by Trendley H. Dean in 1942.[Additional file 1]
Community fluorosis index (CFI)
Introduced by Trendley H. Dean in 1935.[Additional file 2]
Statistical analysis
In consultation with the statistician at the start of this study, a sample size of 1800 students was estimated to be sufficient. The prevalence of dental fluorosis was calculated by taking all the cases of dental fluorosis as the numerator and the total sample size as the denominator. Severity of dental fluorosis was based on the Deans fluorosis index. A Community Fluorosis Index (CFI) was computed by summating the scores of individual grades and dividing the sum by the total sample size (as described by Dean). A CFI of greater than 0.4 was used to identify if the condition was a major public health problem. The association of dental fluorosis with selected individual risk factors was studied using Chi-square tests. All the analysis was performed with SPSS 11.5 version and a P value of < 0.05 was taken to indicate the statistical significance.
| Results | | |
Study sample characteristics
The study sample comprised of 1800 students (boys = 1042; girls = 758) in the age group of 10-15 years. More than half the study sample lived in rural areas. 46% of the study population belonged to the lower socioeconomic strata. Caries prevalence was found to be less in children with dental fluorosis. Oral hygiene habits were analyzed and it was found that Colgate was the most popular brand of toothpaste. 85% of the children used toothbrushes and majority of them brushed once daily. Pipe water was the major source of drinking water for the district. Majority of the children had a mixed diet with regular seafood intake and nearly 95 % of the children drank up to two glasses of tea/day. [Table 2]
Prevalence of dental fluorosis and associated risk factors
The overall prevalence of dental fluorosis in school children of the study sample was 15.8% [Table 3]. The calculated CFI was 0.27, indicating that the severity and prevalence of dental fluorosis was low in the examined sample. Severity of dental fluorosis was calibrated according to Deans fluorosis index and it was found that majority of the fluorosed population belonged to the very mild category [Table 4] and [Figure 1]. Three out of the nine blocks stand out from the rest in terms of the prevalence of dental fluorosis namely, Thovalai, Rajakkamangalam, and Agasteeswaram [Table 5] and [Figure 2]. This reinforces the results obtained from the TWAD board, which shows that many Panchayats of these three blocks have a water fluoride level greater than 1.7 ppm [Table 6]. A stepwise increase in the prevalence of dental fluorosis was noted with a corresponding increase in the water fluoride content in the various blocks.
Compared to rural areas, the prevalence of dental fluorosis was higher in urban areas. Almost 60% of the children with dental fluorosis lived in urban areas [Figure 3]. Interestingly, an inverse association was seen between the caries status and the prevalence of dental fluorosis. It is evident from the data [Figure 4] that 65% of the children with dental fluorosis had no caries and this was found to be statistically significant (P < 0.001).
The source of drinking water for about 60% of the study sample was pipe water and the rest ground water. The prevalence of dental fluorosis was highest among children who consumed pipe water [Figure 5]. Similarly, children who consumed more than four glasses of water were found to be more prone to dental fluorosis [Figure 6].
Differences between the fluorosed and nonfluorosed population in terms of gender, socioeconomic status, age, oral hygiene habits, and diet were insignificant as presented in the [Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15],[Figure 16],[Figure 17].
| Discussion | | |
Though the prevalence of dental fluorosis in Kanyakumari district may not be considered significant, it is still more than the average percentage of 10% found in TamilNadu, according to the survey conducted in 2002-2003. [9] A few blocks have been found to have significantly higher prevalence of dental fluorosis as compared to the rest, which can be attributed to the level of fluoride in the drinking water. Many studies in the past have proved the direct link between the degree of dental fluorosis and the amount of fluoride in drinking water in the respective communities and countries. [10],[11],[12],[13] The prevalence of dental fluorosis was higher in the urban areas as compared to that in the rural areas (P < 0.001). This can be attributed to the increased use of pipe water for drinking purposes in the urban area in relation to rural areas, where ground water is still in use. The same can be said about the increase in prevalence of dental fluorosis as the amount of water consumption increased (P < 0.01). It is also observed that 65% of the children with dental fluorosis had no caries, indicating the cariostatic actions of fluoride (P < 0.001).
Risk factors
There have been an increasing number of studies on the prevalence of dental fluorosis and its risk factors. [14],[15],[16],[17],[18],[19],[20] There is a significant positive association between water fluoride content and prevalence of dental fluorosis in the current study sample. A stepwise increase of dental fluorosis was noted with corresponding increase in the water fluoride content in the various blocks. The prevalence of dental fluorosis is high among children who use pipe water for drinking purposes (P < 0.001). The reason for this may be that the fluoride content of pipe water is higher compared to other water sources.
Neither the socioeconomic status, age, nor the gender of the child had any influence on the prevalence of dental fluorosis in our study group (P > 0.05). Furthermore, no significant association was found between the various oral hygiene habits and dental fluorosis. Diet, seafood intake, and tea intake did not influence the prevalence of dental fluorosis.
Implications
Fluoride has been considered to be very effective at preventing dental caries, but it does not remove the cause of the disease. On the contrary, the brittleness of moderately and severely mottled teeth may be associated with elevated caries levels. [21],[22] To paraphrase Denis Birkett, "If water is making a mess on the floor, it is better to turn off the tap than to mop the floor". High fluoride content in drinking water is the main reason for dental fluorosis in Kanyakumari district. Measures like finding an alternative source of drinking water for the affected blocks or a mass defluoridation of the drinking water before distribution have to be implemented. Creating public awareness on the various home defluoridation techniques is also equally important. This requires the synergistic action of health planners, health administrators, and water supply authorities.
| Limitations | | |
This was a cross sectional survey. The major risk factor in the development of dental fluorosis is drinking water. Dental fluorosis develops in an individual during the time of teeth calcification and the fluoride content of water during that period is of prime importance. It is presumed in this study that the fluoride content of the water in each area has not changed over the last 15 years. School children were selected for the study because they can be easily examined and also review can be carried out if necessary. On considering the fact that Kanyakumari district has more than 150 schools, the 18 schools that were surveyed represent only a small fraction. A larger-scale study would have been more appropriate. Finally, water samples from each block were not collected and screened due to lack of resources, and the data provided by the TWAD board was used. TWAD board had performed the survey in the year 2000 and a more recent data source could not be obtained.
| Conclusion | | |
This study establishes the relationship between the prevalence of dental fluorosis and the fluoride in the drinking water. The prevalence of dental fluorosis varied from as low as 1.4% in some blocks to as high as 29.4% in some others, as the level of fluoride in water increased. Compared to rural areas, the prevalence of dental fluorosis was higher in urban areas. Almost 60% of the children with dental fluorosis lived in urban areas. There is an urgent need to improve the quality of water and institute defluoridation of drinking water in affected areas to lower the burden of dental fluorosis in this community.
| Acknowledgment | | |
The authors are thankful to Dr. C Geetha, Principal of Rajas Dental College; Dr. P Padmanaban, Director of Public Health; Mr. C Karmegam, Chief Education Officer; Dr Kurian Mathew, Chief Statistician; and TWAD Board of Kanyakumari district, TamilNadu. The authors are thankful to the headmasters, school teachers, students, and other nonteaching staff for their cooperation with the survey.
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Correspondence Address:
Jagan Kumar Baskaradoss
Department of Community Dentistry, Rajas Dental College and Hospital, Dr. MGR Medical University, Tamilnadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.44531
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6] |
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