History of Fluoridation

m

÷
After this session the students will be able to:-
to:-
1. Outline the historical background of fluoride

in relation to dentistry
2. Understand fluorosis
3. Understand the metabolism of fluoride
4. Explain the mechanism of actions of

fluoride
6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 2

Definition
ë luorosis is a specific disturbance of
tooth caused by excessive ingestion of
high concentration of fluoride in drinking
water during the formative period of the
dentition.

O
ë Majority of prevalence and severity of
dental fluorosis is due to the concentration
of fluoride in the water consumed by infants
and children during the first five years of
life.
ë Although both primary and permanent
teeth may be affected by fluorosis it tends
to be greater in permanent teeth than in
primary teeth.

ë The intensity of fluorosis ranges from white
striations affecting only a small portion of enamel
to confluent pitting of almost the entire enamel
surface and dark brown to black staining.
staining.
ë Clinically it is characterized by opaque white

patches in the enamel which may become striated,
mottled or pitted. The opaque areas may become
stained yellow to dark brown or black.

may become
ë 6 ,
,
ë V
and/or
ë a ,
, or may be
ë 6

discrete pits and larger areas of (confluent

pitting) of enamel appear to such an extent that
the normal morphology of the tooth is lost.

Dental fluorosis is of developmental origin, the
individual teeth in the dentition are not
affected to the same degree,
ë but the bilateral corresponding teeth are

affected in the same degree of severity.
ë The teeth most affected are usually those

mineralized last, such as premolars and
second molars, upper incisors and canines,
ë where as first molars and lower incisors are
least affected.
r
ë luorine is derived from latin word ³

³luore
luore´´ meaning ³ to flow´ .
ë luorine is a pale, yellow-

yellow- green gas.
ë Atomic Weight : 19 , atomic number : 9 .

ë is the anion , the reduced form
of fluorine.
ë Doth organic and inorganic compounds
containing the element fluorine are
sometimes called fluoride
fluoride..
ë Structurally, and to some extent

chemically, the fluoride ion resembles the
hydroxide ion.

r

!

The mineral fluoride
Many fluoride minerals are known, but paramount

in commercial importance are fluoride
and fluorapatite
fluorapatite..
luoride is found naturally in low concentration in

drinking water and foods.
Water with underground sources is more likely to

have higher levels of fluoride,
m

irst described by Prof. Stefano Chiaie

Chiaie,,
from the Province of Naples, known as
r which
which bears his name.)
Denti di Chiaie Chiaie teeth), J. M. Eager, U.S.M.H.S.

Public Health Reports, Vol. 16 November 1, 1901 No. 44; Reprint
May--June 1976, Vol. 91, No. 3, 285.
May

m

ë In 1901, Dr. rederick McKay,
ë He noticed that the teeth of many of his

patients, who had grown up in Colorado
Springs, had permanent dark stains on
their otherwise healthy teeth.
ë 1908 : McKay presented at the annual

meeting of State Association in Doulder.
McKay
terms the condition as
³Colorado Drown Stains´
Stains´..

³Mottled enamel´ by National Museum of Dentistry
Dr. Greene Vardiman Dlack

ë 1912 : McKay came across an article
written by Dr. J.M. Eager. He reported that
a high proportion of residents in Naples
had ugly brown stains on their teeth known
as ³ Denti di chiaie
chiaie´.
´.
ë 1916 : McKay & Dlack reported that an

unknown causative factor was possibly
present in domestic water during the
period of tooth calcification.

ë Almost 25 years after he first observed the
discolorations, McKay urged the U.S.
Public Health Service PHS) to track down
the cause of the disorder.
ë His appeal led to a collaboration with Dr.

Grover Kempf,
Kempf, a PHS physician.

ë In 1928 Kempf and McKay investigated a
dental defect in Dauxite, Arkansas, a
company town of Aluminum Company of
America ALCOA).
ë 1930 : Kemp & McKay observed no

mottling in the people of bauxite prior to
1909, which changed its supply from
shallow wells to deep drilled wells.

ë The investigators found the same kind of
stain on the teeth of Dauxite children
ë but none in the neighboring town of

Denton, only 5 miles away.
ë A routine PHS water analysis at the time

produced no explanation.

ë The staining problem however, had
aroused the interest of other investigators
one of
ë Chief chemist H. V. Churchill ALCOA)
who found the reports of Kempf and
McKay disturbing.
ë Churchill was then combating rumors that
aluminum pots and pan were poisonous,
and he feared that news of the Dauxite
staining might exacerbate his company¶s
problems.
ë To determine the cause of the
discoloration, Churchill directed his staff to
test Dauxite drinking water for traces of
rare elements not normally screened in
standard water analyses.
ë 1931 : Churchill H.V, chief chemist after

thorough spectra graphic analysis noted
that fluoride was present in bauxite water
at a level of 13.7 ppm and IDENTIIED
THE ELEMENT THE

ë Meanwhile, three Arizona scientists, Dr.
Margaret Cammack Smith, Howard Smith,
and Edith Lantz, conducted animal
experiments to find out what was causing
the browning of children¶s teeth in the
community

ë At almost the same time, and
independent of each other,
ë the ALCOA and the Arizona
investigations provided what appeared to
be the long-
long-sought answer to McKay¶s
search:
ë excessive amounts of fluorine in the

drinking water coincided with the staining.

ë Those findings triggered a major research
effort by the new Public Health Service¶s
National Institute of Health.
ë NIH dental officer,

j

j

j
j,,
ë was assigned to study the mottled enamel
problem and determine its extent in the
United States.
ë Dean conferred with McKay and studied the old scientific

literature

ë Shortly after assuming his new duties,
Dean named the condition ³fluorosis
fluorosis.´
.´
ë 1934 : Trendley H. Dean introduced the

mottling index which is popularly known
as Dean¶s Index for luorosis
luorosis..
ë He classified fluorosis into seven

degrees of severity.

j"
The codes and criteria are as follows:
@X V The enamel surface is smooth, glossy and usually pale creamy white color.

6 .
. The enamel shows slight aberrations from the translucency of normal
enamel, which may range from a few white flecks to occasional spots.

V

V.. Small, opaque, paper-
paper-white areas scattered irregularly over the tooth but
involving less than 25% of the labial tooth surface. White opacity of 1-1-2 mm appeared at
the tip of the summit of the cusps of the premolars.

The white opacity of the enamel of the teeth is more extensive than for code
2, but covers less than 50% of the tooth surface.

. . The enamel surface of the teeth shows marked wear and brown stain is
frequently a disfiguring feature.
!
! "#
"#.. The enamel surfaces are badly affected and hypoplasia is so marked that
the general form of the tooth may be affected. There are pitted or worn areas, which may
be discrete or confluent pitting and brown stains are widespread, the teeth often have a
corroded appearance.
$
$ %&
%& e.g.
e.g. a crowned tooth).
'
' .
.

ë Normal (0) - The enamel represents usual
translucent semi-
semi-vitriform type of structure.
The surface is smooth , glossy and usually of a
pale creamy white colour
colour..

ë ouestionable fluorosis (1) - The enamel discloses a
slight aberration from the translucency of normal enamel
ranging from a few white flecks to occasional white
spots. This classification is used in those instances
where a definite diagnosis of the mildest form of
fluorosis is not warranted and classification of ¶normal·
not justified.

ë ·ery mild fluorosis (2) - Opaque, paper-
paper-white areas
scattered irregularly over the tooth but involving less
than 25% of the labial tooth surface

ë |ild Fluorosis (3) - The white opacity of the
enamel of the teeth is more extensive than for
code 3, but covers less than 50% of the tooth
surface

ë |oderate fluorosis (4) - The enamel surfaces
of the teeth show marked wear and brown
stain is frequently a disfiguring feature.

ë ÷evere fluorosis (5) - The enamel surfaces are badly
affected and hypoplasia is so marked that the general
form of the tooth may be affected. There are pitted or
worn areas and brown stains are widespread; the teeth
often have a corroded appearance.

ë 1931 : Shoe Leather Survey by Trendley H.
Dean.
ë shoe leather survey was conducted among

21 cities in 10 states of U.S.A.
ë During this survey Trendley Dean visited
each and every house in that particular
community.
ë Usually any door to door or house to house

survey is also called as shoe leather survey.

ë He discovered that even in the earliest
descriptions of mottled enamel, teeth with
this condition not only appeared to be
healthy but also seemed to show less
decay than normal.

ë 1942 : Dean et al discovered that 1 ppm
in drinking water & 60% reduction in caries
experience was observed .
ë He demonstrated the existence of an

inverse relationship between the
prevalence of dental caries and the
fluoride content of the drinking water.
water.

ë In 1935, upon finding fluorosis
especially widespread in Texas, Dean
and his colleagues declared the
situation in that state ³an acute and
urgent public health problem´.
problem´.
ë Dean hypothesized a link between the

ingestion of fluoride and the prevention
of tooth decay.

ë He pursued this hypothesis
Dean compared the rates of tooth decay
between cities with and without the
mottled enamel condition from data
collected in a massive 1933-
1933-1934 dental
survey of US elementary schoolchildren.
ë He concluded that the water provided

some immunity to caries, even at levels
that did not contribute toward fluorosis.
ë Dean¶s research team from the NIH found
that children in cities with fluoride-
fluoride-free
water had three times as many caries as
those in cities with an excess of 1.0 part
per million ppm
ppm)) fluoride in the drinking
water supply.
ë In 1942, Dean and his coworkers published

the classical epidemiological studies carried
out by the U.S. Public Health Service on
children, 12 to 14 years of age, living in 29
towns, relating caries experience and the
fluoride content of the water supply.
ë Dy 1942 Dean concluded that
1.0 ppm fluoride level in drinking
water reduced the rate of new dental
caries without inducing fluorosis in
schoolchildren who were examined.

ë They showed that when the drinking
water contained about 1ppm of fluoride
the teeth of the lifelong inhabitants of that
area had low caries prevalence but no
signs of dental fluorosis.
ë or example, children aged 12-

12-14 years
had 30% less caries than those with no
fluoride in the water.

ë The identification of this relationship led
to the idea of adjusting the fluoride
content in fluoride-
fluoride-deficient drinking
drinking--
water.
ë That is called ()% *j)*
ë In ' ! the water supply of Grand

Rapids, Michigan, was artificially
fluoridates at this level.

ë 1946 : Klein observed teeth in eruption received
maximal benefits & teeth were also protected.
ë Using data from the dental surveys in 1991-

1991-1992 and
1993--1994,
1993
a Dritish study demonstrated that children in lower

socio--economic groups derive an even greater benefit
socio
from water fluoridation with an average 54% reduction
in dental decay.
ë Therefore, children with the greatest dental need
benefit the most from water fluoridation.

ë In 2003, studies on initiation and
discontinuation of fluoridation were
systematically reviewed.
ë The best available evidence on cessation of

water fluoridation indicates that when
fluoridation is discontinued caries
prevalence appears to increase at a faster
rate in the area that had been fluoridated
ë luoridation has substantial lifelong
decay preventive effects and
ë is a highly cost-
cost-effective means of
preventing tooth decay in countries with
established municipal water systems,
ë regardless of socioeconomic status

The three primary agents used in drinking
water fluoridation are
1. sodium fluoride,
2. sodium fluorosilicate and
3. fluorosilicic acid.

1. Achievements in Public Health, 1900-
1900-1999: luoridation of
Drinking Water to Prevent Dental Caries; CDC Centers for
Disease Control and Prevention.
`. Fluoridation Facts.
Facts. American Dental Association. 2005. p. 6-8.
3. luoride in Drinking-
Drinking-Water; J. awell
awell,, K. Dailey, J. Chilton, E.
Dahi,L.. ewtrell and Y. Magara; World Health Organization WHO)
Dahi,L
2006.
4. Oral Health Surveys, Dasic Methods, 4TH Edition, WHO, 1997.
5. Denti di Chiaie Chiaie teeth), J. M. Eager, U.S.M.H.S. Public

Health Reports, Vol. 16 November 1, 1901 No. 44; Reprint May
May--
June 1976, Vol. 91, No. 3, 285.

) +
+ )% *

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m 

1. Outline the historical background of fluoride

3. Understand the metabolism of fluoride

4. Explain the mechanism of actions of

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 3

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 4

ë Clinically it is characterized by opaque white

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 5

discrete pits and larger areas of (confluent

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 6

ë but the bilateral corresponding teeth are

ë The teeth most affected are usually those

ë luorine is derived from latin word ³

ë luorine is a pale, yellow-

ë Atomic Weight : 19 , atomic number : 9 .

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 8

ë Structurally, and to some extent

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 9

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 10

Many fluoride minerals are known, but paramount

luoride is found naturally in low concentration in

Water with underground sources is more likely to

irst described by Prof. Stefano Chiaie

  Denti di Chiaie Chiaie teeth), J. M. Eager, U.S.M.H.S.

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 12

ë He noticed that the teeth of many of his

ë 1908 : McKay presented at the annual

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 14

Dr. Greene Vardiman Dlack

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 15

ë 1916 : McKay & Dlack reported that an

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 16

ë His appeal led to a collaboration with Dr.

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 17

ë 1930 : Kemp & McKay observed no

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 18

ë but none in the neighboring town of

ë A routine PHS water analysis at the time

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 19

ë 1931 : Churchill H.V, chief chemist after

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 22

ë excessive amounts of fluorine in the

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 23

ë NIH dental officer,

ë Dean conferred with McKay and studied the old scientific

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 24

ë 1934 : Trendley H. Dean introduced the

ë He classified fluorosis into seven

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 26

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 27

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 28

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 29

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 30

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 31

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 32

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 33

ë shoe leather survey was conducted among

ë Usually any door to door or house to house

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 34

6th September 2010 Year3, IIUM, KOD, Dr. Tin Maw 35

m

ë luorine is derived from latin word ³

ë luorine is a pale, yellow-

luoride is found naturally in low concentration in

irst described by Prof. Stefano Chiaie

Denti di Chiaie Chiaie teeth), J. M. Eager, U.S.M.H.S.

ë or example, children aged 12-

ë That is called ()% j)

ë In ' ! the water supply of Grand

5. Denti di Chiaie Chiaie teeth), J. M. Eager, U.S.M.H.S. Public