Prevalence and perception of dental fluorosis among the school-going children and its impact on academic performance

Niveditha Balamurali; Noorul Sabina Mohamed Thowbieck; Syeda Safoora Amreen; Divyadharshini Chandrasekaran; Kalaivani Karthikeyan; I Anand Sherwood

doi:10.4103/IJDS.IJDS_108_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 12 | Issue : 1 | Page : 1-6

Prevalence and perception of dental fluorosis among the school-going children and its impact on academic performance

Niveditha Balamurali, Noorul Sabina Mohamed Thowbieck, Syeda Safoora Amreen, Divyadharshini Chandrasekaran, Kalaivani Karthikeyan, I Anand Sherwood
Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences, Madurai, Tamil Nadu, India

Date of Submission	16-Sep-2019
Date of Decision	10-Oct-2019
Date of Acceptance	11-Nov-2019
Date of Web Publication	27-Jan-2020

Correspondence Address:
I Anand Sherwood
Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences and Research, Madurai, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/IJDS.IJDS_108_19

Abstract

Aim: The prevalence of dental fluorosis in Southern India has been reported to be on higher side. In Madurai district, Tamil Nadu, the dental fluorosis incidence among 13–15-year-old school children was observed at 87.7%. The aim of the present investigation is to analyze the prevalence of dental fluorosis among 12–14-year-old school-going children and understand its impact on their academic performance. Materials and Methods: A total 693 students from four different schools were screened for dental fluorosis and severity using Thylstrup–Fejerskov index. Students' academic performance, class attendance, awareness about the condition, esthetic perception about dental fluorosis, and friends' attitude toward their teeth were evaluated. Nonparametric Mann–Whitney U and Kruskal–Wallis tests were employed to assess the influence of dental fluorosis presence on the academic performance. Results: Four hundred and thirteen (59.6%) students had dental fluorosis, and the mean number of teeth affected was 4.15 ± 1.70. Significantly (P < 0.05), marks obtained in each subject, average total marks scored in the last examination, and class attendance percentage were lower in individuals with dental fluorosis. Conclusions: School performance getting significantly affected by the presence of dental fluorosis needs to be further investigated in a controlled environment. Brown stains in dental fluorosis were considered to be of esthetic concern than white opacities among the children.

Keywords: Dental fluorosis, esthetic perception of dental fluorosis, school academic performance, Thylstrup–Fejerskov index

How to cite this article:
Balamurali N, Mohamed Thowbieck NS, Amreen SS, Chandrasekaran D, Karthikeyan K, Sherwood I A. Prevalence and perception of dental fluorosis among the school-going children and its impact on academic performance. Indian J Dent Sci 2020;12:1-6

How to cite this URL:
Balamurali N, Mohamed Thowbieck NS, Amreen SS, Chandrasekaran D, Karthikeyan K, Sherwood I A. Prevalence and perception of dental fluorosis among the school-going children and its impact on academic performance. Indian J Dent Sci [serial online] 2020 [cited 2023 Nov 28];12:1-6. Available from: http://www.ijds.in/text.asp?2020/12/1/1/276880

Introduction

The prevalence of dental fluorosis in Southern India has been reported to be on higher side.^[1] In Madurai district, Tamil Nadu, the dental fluorosis incidence among 13–15-year-old school children was observed at 87.7%.^[2] Psychological impact and dissatisfaction of having enamel defects in anterior teeth among the adolescent population group with increased prevalence for enamel defects has been shown to be negligible.^[3] However, the impact of oral health having negative influence on academic performance of children and attendance has been established in the literature.^[4] Furthermore, developmental esthetic dental disorders such as amelogenesis imperfecta having a negative impact on psychosocial health of individuals have been earlier recorded.^[5] In a study from Iran,^[6] dental fluorosis having negative influence on quality of life (QOL) among the high school and precollege students from a high fluoride-concentrated area was shown.

The observations from these reports show esthetic defects such as dental fluorosis having negative influence on the psychosocial health and also QOL among the adolescent individuals. Literature search also showed that children's intelligence was negatively influenced in severe form of dental fluorosis and patients exposed to higher level of fluoride in drinking water.^[7] This study suggests for policy implications to reduce fluoride levels in drinking water to minimize the long-term toxic effects posed by this element. Several studies from different parts of India observed an inverse relationship between the IQ and fluoride content of urine output for children in age groups between 10 and 13 years.^[8],[9],[10] Therefore, in a district like Madurai with higher incidence of dental fluorosis among the school children and its effects on their academic performance and their perception, awareness needs to be analyzed for evolving a preventive strategy from the early stage onward.

The aim of the present investigation is to analyze the prevalence of dental fluorosis among 12–14-year-old school-going children and understand its impact on their academic performance. The secondary objective is to report the perception and awareness about dental fluorosis among these individuals.

Materials and Methods

Home institution ethical committee approval was obtained for this observational study before commencement (CSICDSR/IEC/0073/2019). Four randomly selected schools from rural north regional zone of Madurai revenue district were selected. School children in classes sixth and seventh participated in the study. Written informed consent was obtained from the parents or guardians or teachers. A sample of 495 students was estimated to be sufficient to detect statistical difference using G power software (Universität Kiel, Germany) with effect size of 0.2 and alpha error probability of 0.05. Dental fluorosis was evaluated in the maxillary and mandibular incisors and canines by five independent calibrated examiners using disposable mouth mirror and cheek retractor and a white light-emitting diode. Dental fluorosis was recorded using Thylstrup–Fejerskov fluorosis (TF) index scoring system [Figure 1] and [Figure 2]. Each individual was allotted TF score of the highest value in the teeth examined. Intraoral photographs were taken for select individuals for each TF score. The presence of brown stains was also noted and its intensity was recorded in scores of mild, moderate, and severe according to the brown color intensity. In teeth which are questionable, photographs were recorded and reevaluated by an experienced evaluator for score allotment.

Figure 1: Photographs of dental fluorosis of Thylstrup–Fejerskov fluorosis index scores 1 (a), 2 (b), 3 (c), 4 (d), and 5 (e)

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Figure 2: Photographs showing different brown stain intensities. Mild stain (a), moderate (b), and severe (c)

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Students' academic performance was assessed by obtaining the marks scored in the last examination of the subjects including language, mathematics, science, and social and also the average total marks scored. Furthermore, their class attendance percentage was also recorded. Students with dental fluorosis were enquired about their awareness of the condition, whether they sort treatment for this condition, their esthetic perception about dental fluorosis, and their friends' attitude toward their teeth.

Statistical analysis

TF index score data were analyzed for normality of the distribution using Shapiro–Wilk test, and it showed the data not following normal distribution (P = 0.00). Nonparametric Mann–Whitney U and Kruskal–Wallis tests were employed to assess the influence of dental fluorosis presence, TF index scores, and brown stain presence on the academic performance. SPSS version 23.0 (Microsoft Inc., Washington, USA) was used for statistical analysis.

Results

A total of 693 students participated in the study, of which 437 (63.1%) and 256 (36.9%) were males and females, respectively. The mean age of the participants was 12.58 ± 0.66 years. Four hundred and thirteen (59.6%) students had dental fluorosis and the mean number of teeth affected was 4.15 ± 1.70. Cohen's kappa statistic values was 0.80 and 0.79, respectively, for inter- and intraexaminer agreement. The occurrence of brown stains was seen in 77 (27.9%) individuals, which was mostly of mild intensity (52 [67.5%] individuals) [Table 1]. Among the genders, males had significantly (Mann–Whitney– U-test; P = 0.008) higher prevalence of dental fluorosis [Table 1], whereas the presence of brown stains and TF index scores were not significantly different. Among the students with dental fluorosis, TF index score of 1 was the most prevalent in 132 (32%) individuals [Table 2]. Significantly (Mann–Whitney U-test; P < 0.05), marks obtained in each subject, average total marks scored in the last examination, and class attendance percentage were lower in individuals with dental fluorosis [Table 3]. Marks obtained and class attendances of students with brown stains were lower than individuals without stains, but it was not significantly different [Table 3]. TF scores and intensity of brown stains did not significantly influence the marks scored and class attendance percentage. In students with dental fluorosis, awareness about the condition was negligible, very low numbers of students have sort for treatment, and most of them felt the condition was not a concern to them and to their friends and this was similar between the two genders with no significant difference [Table 4]. The presence of brown stains was significantly (P = 0.00; Kruskal–Wallis test) higher in individuals with higher TF index scores [Table 5]. With increased TF index scores, there was significantly (P < 0.05; Kruskal–Wallis test) increased number of individuals with awareness about the condition, esthetic perception about the condition concerning increased, and also the friends' attitude toward the appearance being negative raised [Table 5]. Higher number of individuals had sort treatment when the TF index scores were higher, but this was not significant [Table 5]. Furthermore, in individuals with brown stains, there was significantly (P < 0.05; Kruskal–Wallis test) increased awareness about the condition, seeking treatment, associating the appearance of being esthetic concern, and friends' attitude being less appreciative [Table 4].

Table 1: Dental fluorosis incidence among the two genders and incidence and intensity of brown stains

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Table 2: Thylstrup-Fejerskov index score distribution

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Table 3: Marks obtained in individual subjects, total average marks in the last examination, and class attendance percentage for students with and without dental fluorosis/brown stain presence and absence analyzed using Mann-Whitney U-test

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Table 4: Distribution of individuals with awareness of dental fluorosis, seeking treatment for the condition, esthetic perception about the condition, and friends' attitude toward their teeth among the two genders and individuals with/without brown stains

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Table 5: Distribution of individuals with brown stains, awareness of dental fluorosis, seeking treatment for the condition, esthetic perception about the condition, and friends' attitude toward their teeth with respect to Thylstrup.Fejerskov index scores

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Discussion

The high incidence of dental fluorosis in the results of our study is in agreement with an earlier report from Madurai district,^[1] highlighting the persistent problem of dental fluorosis in the district. Regions selected in the present report represent areas with high water fluoride level.^[11] Significantly higher prevalence of dental fluorosis in male students in the present observation is contrary to a previous study from Kolar district in Southern India;^[2] this could be because of demographic and cultural differences as we have not assessed the actual number of individuals residing in the locality who have attended the schools. TF index scoring criteria was employed to assess the fluorosed teeth as it is based on histopathological features of dental fluorosis and is more precise in recording early signs of fluorosis as well as severe grades.^[12] Highest TF index score assigned for the teeth examined was allotted for the individual; this was done to know the maximum severity of the prevailing condition. Higher number of individuals (88%) affected with dental fluorosis had TF index scores of 1–3 in the present study. The results showed that the marks obtained in examinations and attendance percentage were significantly lower in students with dental fluorosis; this observation is in agreement with earlier reports of adverse impact of fluorine level on intelligence of school children.^{[7],[8],[9],[10]} Even though the mean average total mark difference is only 3 in the current investigation, long-term influence of this difference needs to be analyzed. Children's IQ or intelligence is susceptible to various natural and social factors, economic conditions, cultural and geological environment, and parents' influence.^[7] These influences were not evaluated in the present observation. Future studies could take up these parameters also and executed in a more controlled environment to precisely understand the influence of presence of dental fluorosis in children's school performance. Ding et al.^[7] suggested that the very mild or mild form of dental fluorosis scored by Dean's index did not have adverse impact on children's IQ, but our study demonstrates that manifestation of fluorosis even in milder form with or without brown stains has influenced the mark scoring ability. This difference could be because of the difference in methodology of the current investigation to the study cited; also, children's IQ and mark scoring ability in examinations are completely two different skills. Severity of dental fluorosis as indicated by TF scores had no adverse influence on the children's marks; this might be due to in the current study only very few individuals above TF 3 index scoring. Further research will be needed to evaluate the impact of more severe form of fluorosis on children's school activity.

Awareness about dental fluorosis and seeking treatment for the condition was very minimal; this observation underpins the efforts to be needed for creating more awareness about this condition and treatment options that could be exercised for these children. In concurrence to an earlier report from Malaysian students,^[3] the present results also reflect that when enamel defects are present in higher incidence of the population group, many of them are not concerned with this defect and also their friends' attitude also not affected by the teeth appearance. The presence of increased severity of dental fluorosis with brown stains increased the children awareness and seeking treatment of dental fluorosis and also associated with considering the condition to be of esthetic concern both for themselves and friends. These findings from our study show that the white opacities in milder form of dental fluorosis were not considered being problematic, whereas the brown stains made the children observe teeth to be defective and requiring attention. In an earlier clinical observation by the authors (submitted for publication), it was also seen that most of the patients were satisfied with microabrasion procedure as esthetic treatment for dental fluorosis which was able to remove the brown stains and not the white spots.^[13]

The evidence from this study provides valuable insights into the influence of dental fluorosis in children's school performance and their perception about this condition. More studies are needed for in-depth information on effects of dental fluorosis presentation on children's intelligence and school performance. Furthermore, long-term follow-up for these students after esthetic management of dental fluorosis to assess their improvement in school performance is required. In known endemic fluorosis regions, water defluoridation projects needs to be implemented not only to eliminate the esthetic effects of dental fluorosis but also its potential adverse effect on the children's intellectual activity.

Conclusions

The prevalence of dental fluorosis is high in school children necessitating need for improvement in water quality and also treatment interventions.

Awareness about dental fluorosis was negligible which needs to be addressed.

School performance getting significantly affected by the presence of dental fluorosis needs to be further investigated in a controlled environment.

Brown stains in dental fluorosis were considered to be of esthetic concern than white opacities among the children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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