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Appendix 169 TABLE ~ Criteria Dean's Fluorosis Index Diagnosis Normal Criteria The enamel represents the usually translucent semivitriform type of structure. The surface is smooth, glossy, and usually a pale creamy white color. Questionable The enamel discloses slight aberrations from the translucency of normal enamel, ranging from a few white flecks to occasional white spots. This classification is utilized in those instances where a definite diagnosis of the mildest form of fluorosis is not warranted and a classification of Normal is not justified. Small, opaque, paper white area scattered irregularly over the tooth but not involving as much as approximately 25 % of the tooth surface. Frequently included in this classification are teeth showing no more than about 1-2 mm of white opacity at the tip of the summit of the cusps of the bicuspids or second molars. Very mild Mild The white opaque areas in the enamel of the teeth are more extensive but do not involve as much as 50% of the tooth. Moderate All enamel surfaces of the teeth are affected, and surfaces subject to attrition show marked wear. Brown stain is frequently a disfiguring feature. Severe Includes teeth formerly classified as "moderately severe and severe." All enamel surfaces are affected and hypoplasia is so marked that the general form of the tooth may be altered. The major diagnostic sign of this classification is the discrete or confluent pitting. Brown stains are widespread and teeth often present a corroded appearance. Source: Dean, 1942. Reprinted with permission; copyright 1942, American Association for the Advancement of Science.

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170 Health Effects of Ingested Fluoride TABLE A-2 Clinical Criteria and Scoring System for the Tooth Surface Index of Fluorosis Score Criteria o 4 Enamel shows no evidence of fluorosis. Enamel shows definite evidence of fluorosis, namely, areas with parchment-white color that total less than one-third of the visible enamel surface. This category includes fluorosis confined only to incisal edges of anterior teeth and cusp tips of posterior teeth ("snowcappingn). Parchment-white fluorosis totals at least one-third of the visible surface, but less than two-thirds. Parchment-white fluorosis totals at least two-thirds of the visible surface. Enamel shows staining in conjunction with any of the preceding levels of fluorosis. Staining is defined as an area of definite discoloration that may range from light to very dark brown. 5 Discrete pitting of the enamel exists, unaccompanied by evidence of staining of intact enamel. A pit is defined as a definite physical defect in the enamel surface with a rough floor that is surrounded by a wall of intact enamel. The pitted area is usually stained or differs in color from the surrounding enamel. Both discrete pitting and staining of the intact enamel exist. Confluent pitting of the enamel surface exists. Large areas of enamel may be missing and the anatomy of the tooth may be altered. Dark-brown stain is usually present. Source: Horowitz et al., 1984. Reprinted with permission; copyright 1984, American Dental Association.

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Appendix 1711 TABLE A-3 Clinical Criteria and Scoring for Score Criteria Normal translucency of enamel remains after prolonged air-drying. Narrow white lines corresponding to the perikymata. Smooth surfaces: More pronounced lines of opacity that follow the perikymata. Occasionally confluence of adjacent lines. Occlusal surfaces: Scattered areas of opacity < 2 mm in diameter and pronounced opacity of cuspal ridges. Smooth surfaces: Merging and irregular cloudy areas of opacity. Accentuated drawing of perikymata often visible between opacities. Occlusal surfaces: Confluent areas of marked opacity. Worn areas appear almost normal but usually circumscribed by a rim of opaque enamel. Index o 1 3 6 9 Smooth surfaces: The entire surface exhibits marked opacity or appears chalky white. Parts of surface exposed to attrition appear less affected. Occlusal surfaces: Entire surface exhibits marked opacity. Attrition is often pronounced shortly after eruption. Smooth surfaces arid Occlusal surfaces: Entire surface displays marked opacity with focal loss of outermost enamel (pits) ~ 2 mm in diameter. Smooth surfaces: Pits are regularly arranged in horizontal bands ~ 2 mm in vertical extension. Occlusal surfaces: Confluent areas < 3 mm in diameter exhibit loss of enamel. Marked attrition. Smooth surfaces: Loss of outermost enamel in irregular areas involving < 1/2 of entire surface. Occlusal surfaces: Changes in the morphology caused by merging pits and marked attrition. Smooth and Occlusal surfaces: Loss of outermost enamel involving > 1/2 of surface. Smooth and Occlusal surfaces: Loss of main part of enamel with change in anatomic appearance of surface. Cervical rim of almost unaffected enamel is often noted. Source: Thylstrup and Fejerskov, 1978. Reprinted with permission from Community Dentistry and Oral Epidemiology; copyright 1978.

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