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ORIGINAL ARTICLE
Year : 2016  |  Volume : 14  |  Issue : 2  |  Page : 150-153

A cross-sectional study to assess the effect of dental fluorosis on periodontal status


1 Department of Public Health Dentistry, National Dental College and Hospital, Dera Bassi, Punjab, India
2 Department of Public Health Dentistry, Genesis Dental College, Ferozpur, Punjab, India
3 Department of Public Health Dentistry, Teerthankar Mahaveer Dental College, Moradabad, Uttar Pradesh, India
4 Department of Public Health Dentistry, SDDHDC, Panchkula, Haryana, India
5 Department of Public Health Dentistry, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India
6 Department of Conservative and Endodontics, SGRD, Gurgaon, Haryana, India

Date of Web Publication10-Jun-2016

Correspondence Address:
Amandeep Chopra
Department of Public Health Dentistry, National Dental College and Hospital, Derabassi, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-5932.183818

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  Abstract 


Introduction: The effect of fluoride in the reduction of dental caries is well established, its effect on periodontal tissues is enigmatic. Aim: The aim of this study is to investigate the association between dental fluorosis and the periodontal status. Materials and Methods: A cross-sectional study was conducted on a sample of 600 subjects suffering from fluorosis. Variables such as age, gender, and smoking, which could act as covariates for the periodontal disease were recorded. The oral examination included assessment of oral hygiene index-simplified (OHI-S), community periodontal index and treatment need, and assessment of dental fluorosis by Jackson's fluorosis index. Results: Periodontitis was more common in females than in males. As the age advances, the rate of periodontal disease increases steadily. Periodontitis was significantly associated with poor oral hygiene and tobacco usage. As the degree of fluorosis increased, the severity of gingivitis reduced and periodontitis increased. Conclusion: There is a strong association between the degree of dental fluorosis and periodontal disease along with other factors such as age, gender, OHI-S, and tobacco usage.

Keywords: Community periodontal index and treatment need, dental fluorosis, Jackson's fluorosis index, periodontal disease


How to cite this article:
Chopra A, Kaur G, Lakhanpal M, Gupta N, Suri V, Bhudhiraja S. A cross-sectional study to assess the effect of dental fluorosis on periodontal status. J Indian Assoc Public Health Dent 2016;14:150-3

How to cite this URL:
Chopra A, Kaur G, Lakhanpal M, Gupta N, Suri V, Bhudhiraja S. A cross-sectional study to assess the effect of dental fluorosis on periodontal status. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Sep 23];14:150-3. Available from: http://www.jiaphd.org/text.asp?2016/14/2/150/183818




  Introduction Top


Periodontitis is multifactorial in nature. The various determinants of periodontal disease include age, sex, race, and socioeconomic status, and risk factors are tobacco usage and oral hygiene status. The interaction of these factors might lead to either advanced disease or edentulousness. Although the effect of fluoride in the reduction of dental caries is well established, its effect on periodontal tissues is enigmatic.[1],[2] With some studies reporting a higher level of gingival inflammation in fluorosis than in nonfluorosis areas;[3],[4] others were reporting no difference in periodontal conditions between fluoride and nonfluoride areas;[5] and some suggesting better gingival conditions in fluoride compared to nonfluoride areas have even been reported by others.[6]

The fluoride concentration of drinking water is considerably high in Panchkula District, Haryana, India. The fluoride level ranges from 1.3 to 2.13 ppm in drinking water.[7] This provides us with an opportunity of studying the effect of lifelong exposure of fluoride in drinking water on the periodontal status of those subjects with dental fluorosis. The present study was conducted to investigate the effect of dental fluorosis on the periodontal status.


  Materials and Methods Top


The study population consisted of convenience and judgment sample of subjects with dental fluorosis visiting the Outpatient Department (OPD) of Dental College, Panchkula, in the period between January and March 2014. Ethical clearance was obtained from the Institutional Ethical Committee. Informed written consent was taken from study participants for being a part of the study.

Inclusion criteria

  • Dentate persons 15 years and above
  • Suffering from dental fluorosis
  • Healthy as well as diseased periodontal status.


Exclusion criteria

  • Pregnant women and lactating mothers
  • Subjects who were on medication, any underlying systemic disease/conditions which can influence the periodontal health were excluded from the study
  • Patients who had received periodontal treatment or antibiotics for at least 3 months prior to the study
  • Physically and mentally challenged patients
  • Patients who do not give the written consent to participate
  • Other intrinsic dental stains.


Pilot study was carried out 1 month prior to the original study with a sample of 30 individuals (>5 years of age) who were not part of the main sample. The prevalence of periodontal disease was found to be 55%. Based on the results of pilot study, sample size was calculated to be 594. (rounded off to 600).

All the recruited participants received clinical examinations by two trained and calibrated examiners (one measuring periodontal status and one examining for dental fluorosis and oral hygiene index-simplified [OHI-S]). The examination procedure was double-blinded. A presurvey calibration was performed on a group of 30 subjects visiting the OPD (kappa value 0.95). A complete intra-oral examination was done, and the oral hygiene was assessed using OHI-S.[8] Data regarding periodontal status were collected using community periodontal index and treatment need (CPITN).[9] Code 1-2 were categorized as gingival disease and code 3-4 were categorized as periodontal disease. Dental fluorosis was assessed using Jackson's fluorosis index.[10] Variables such as age, gender, and smoking, which could act as covariates for the periodontal disease were recorded.

Statistical analysis

Data were analyzed using IBM SPSS version 20 (Chicago, USA). Standard descriptive statistics were generated. Frequency distribution for the determination of prevalence of a number of variables, cross tabulations, and Chi-square tests were used to find out the significance of differences. Spearman correlation coefficient was computed to find the correlation between periodontal disease, oral hygiene index, and degree of dental fluorosis. The level of statistical significance was fixed at 0.05.


  Results Top


Among 600 subjects (67.4% males; 32.6% females) visiting OPD of the dental college, the mean age of the subjects was 42.70 ± 5.2 years. [Figure 1] revealed that periodontal disease was found to be more in females as compared to males (P = 0.04). [Figure 2] showed that severity of periodontal disease increases as the age increases (P = 0.04).
Figure 1: Percentage distribution of sample according to gender and type of disease

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Figure 2: Percentage distribution according to age and type of disease

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[Figure 3] revealed that a significant difference was observed between oral hygiene status and periodontal disease among the study subjects. Spearman correlation was found to be 0.96 (P = 0.03).
Figure 3: Distribution of sample based on oral hygiene index-simplified

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A significant correlation existed between tobacco usage and periodontal disease [Table 1]. [Table 2] revealed that as the severity of dental fluorosis increases, the periodontal disease also increases. (P = 0.002). Further, spearman correlation was calculated between the degree of dental fluorosis and CPITN, and it was found to be 0.87 (P = 0.049).
Table 1: Distribution of sample based on tobacco usage and periodontal status

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Table 2: Distribution of sample based on the degree of fluorosis and periodontal status

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  Discussion Top


Etiology of periodontal disease is complex and multifactorial. Environmental factor such as dental fluorosis may affect periodontium directly or indirectly.[11],[12] Hence, the present study was carried to investigate the association between dental fluorosis and the periodontal status using CPITN index. This study used a convenience sampling technique to select the subjects with dental fluorosis as the intention was to explore the association between dental fluorosis and the periodontal status.

The study used CPITN to assess periodontal status because despite being a partial recording index only, it is more sensitive in identifying existing periodontal conditions and treatment needs than the periodontal index.[13] Assessment of treatment needs was excluded as it has become complicated due to recent advances in our understanding of the etiology, pathogenesis, and treatment of the disease.[1],[5]

Totally acceptable and valid comparisons could not be done between the present study and already reported studies in the literature due to variations in the study designs, age group, indices, methodologies, and certain other conditions. Nevertheless, a sincere attempt was done to compare wherever possible and to the extent feasible.

In the present study, both males and females suffered from gingivitis and periodontitis. Females were predominantly suffered from periodontitis, the reason for which needs to be evaluated. This was similar to a study done by Vandana et al.,[1] but in contrast to a study done by Weidmann and Wealtherell who reported that males are more affected from periodontitis.[14]

Age is considered as one of the risk factors for periodontal diseases, i.e., the prevalence of periodontal disease varies with the advance of age. Gingivitis was seen in all the age groups. A steady increase was seen in periodontitis as the age advances. Hence, a strong association exists between age and periodontal condition among dental fluorosis subjects. This was in concordance with a study done by Vandhana et al. at Davanagere district, Karnataka.[1] Murray [11] and Haikel et al.[5] reported similar results regarding gingivitis in high-fluoride areas.

As severity of fluorosis increased (A to F), gingivitis was observed in all the degrees and periodontitis increased from 7.8% to 36.8%. No effort has been made in the literature to quote reasons for the association of periodontal disease in dental fluorosis subjects apart from blaming oral hygiene and plaque levels. This could be explained by the fact that increased fluoride intoxication results in failure/toxic effect on resorption of cementocytes; toxic action on alveolar bone and root portion and calcification of muscular attachments, ligaments, and ossification, which further predisposes to periodontal disease [Figure 4].[12],[15],[16]
Figure 4: Reasons for increase in periodontal disease with increased severity of dental fluorosis

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This study had some limitations such as convenience sampling and cross-sectional nature of the study in which causal relationships cannot be established and the observed association could be due to other unexplored factors. However, strength of our study remains in the fact that it provides an overview on the effect of dental fluorosis on the periodontal status using CPITN index in Panchkula and can prove to be a benchmark for future comparisons by the public health personnel and decision makers.


  Conclusion Top


A possible relationship may exist between periodontal disease and degree of dental fluorosis based on the results of the study. Other factors such as age, gender, OHI-S, and tobacco usage also impact the severity of periodontal disease.

There is a need for longitudinal study considering the most important host and environmental factors which can affect periodontal disease along with microbiological analysis of dental plaque and periodontium to confirm the effects of fluoride on periodontal conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Vandana KL, Reddy MS. Assessment of periodontal status in dental fluorosis subjects using community periodontal index of treatment needs. Indian J Dent Res 2007;18:67-71.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Kumar PR, John J. Assessment of periodontal status among dental fluorosis subjects using community periodontal index of treatment needs. Indian J Dent Res 2011;22:248-51.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Day M. Chronic endemic fluorosis in Northern India. Br Dent J 1940;68:409-24.  Back to cited text no. 3
    
4.
Massler M, Schour I. Relation of malnutrition, endemic dental fluorosis and oral hygiene to the prevalence and severity of gingivitis. J Periodontol 1951;22:206-11.  Back to cited text no. 4
[PUBMED]    
5.
Haikel Y, Turlot JC, Cahen PM, Frank R. Periodontal treatment needs in populations of high- and low-fluoride areas of Morocco. J Clin Periodontol 1989;16:596-600.  Back to cited text no. 5
    
6.
Englander HR, Kesel RG, Gupta OP. The effects of natural fluoride on the periodontal health of adults. Am J Public Health 1963;53:1233-42.  Back to cited text no. 6
    
7.
Deswal S, Gupta S. Water quality of Panchkula district, Haryana – A case study. Environ Pollut Control J 2010;14:24-8.  Back to cited text no. 7
    
8.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.  Back to cited text no. 8
[PUBMED]    
9.
World Health Organization. Oral Health Surveys – Basic Methods. 4th ed.. Geneva: WHO; 1997.  Back to cited text no. 9
    
10.
Jackson RD, Kelly SA, Katz BP, Hull JR, Stookey GK. Dental fluorosis and caries prevalence in children residing in communities with different levels of fluoride in the water. J Public Health Dent 1995;55:79-84.  Back to cited text no. 10
    
11.
Murray JJ. Gingivitis and gingival recession in adults from high-fluoride and low-fluoride areas. Arch Oral Biol 1972;17:1269-77.  Back to cited text no. 11
[PUBMED]    
12.
Vazirani ST, Sing H. Endemic dental fluorosis, radiological features of dental fluorosis. J Indian Dent Assoc 1968;299:302.  Back to cited text no. 12
    
13.
Cutress TW, Hunter PB, Hoskins DI. Comparison of the periodontal index (PI) and community periodontal index of treatment needs (CPITN). Community Dent Oral Epidemiol 1986;14:39-42.  Back to cited text no. 13
[PUBMED]    
14.
Weidmann SM, Wealtherell JA. Flouride and Human Health. Geneva: WHO; 1970.  Back to cited text no. 14
    
15.
Reddy DB, Mallikharjunarao C, Sarada D. Endemic fluorosis. J Indian Med Assoc 1969;53:275-81.  Back to cited text no. 15
[PUBMED]    
16.
Krook L, Maizein J, Lillie JH, Wallace RS. Dental fluorosis in cattle. Cornell Vet 1983;73:340-62.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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