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Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 54-57

Oral health-related quality of life among 12–15-year children suffering from dental fluorosis residing at endemic fluoride belt of Uttar Pradesh, India

Department of Public Health Dentistry, Sardar Patel Postgraduate Institute of Dental & Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission13-Oct-2016
Date of Acceptance15-Feb-2018
Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. Saurabh Singh
Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_139_16

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Introduction: Dental fluorosis, a specific disturbance in tooth formation and an esthetic condition, is defined as a chronic fluoride-induced condition in which enamel development is disrupted, and the enamel is hypomineralized. There is potential for excessive exposure to fluorides to cause dental fluorosis, which may change the appearance of teeth and cause negative impacts on oral health-related quality of life (OHRQoL). Aim: The aim of the study was to assess the impact of dental fluorosis on the OHRQoL of 12–15-year-old children residing at an endemic belt of Uttar Pradesh. Materials and Methods: A cross-sectional survey was done with the sample of 220 children aged 12–15 years residing at endemic belt (5.35 ppm f/L) of Uttar Pradesh. Dental fluorosis was measured using Dean's fluorosis index-modified (1942) and quality of life of children was assessed with the help of child's perception questionnaire. Descriptive statistics, ANOVA, and Pearson's correlation coefficient test were used for analysis. Results: The mean overall OHRQoL score for children with questionable fluorosis was 73.9 ± 7.51 and with very mild fluorosis was 81.9 ± 6.88. Statistically significant difference was found across self-assessment (P = 0.012), oral symptoms (P = 0.018), functional limitation (P < 0.001), and spare time activity (P = 0.007) based on dental fluorosis status. Conclusion: This study concluded that there was a high prevalence of dental fluorosis in this area and also dental fluorosis has a greater effect as well as the impact on the OHRQoL.

Keywords: Dental fluorosis, epidemiology, oral health-related quality of life

How to cite this article:
Singh S, Saha S, Singh S, Shukla N, Reddy VK. Oral health-related quality of life among 12–15-year children suffering from dental fluorosis residing at endemic fluoride belt of Uttar Pradesh, India. J Indian Assoc Public Health Dent 2018;16:54-7

How to cite this URL:
Singh S, Saha S, Singh S, Shukla N, Reddy VK. Oral health-related quality of life among 12–15-year children suffering from dental fluorosis residing at endemic fluoride belt of Uttar Pradesh, India. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2024 Mar 3];16:54-7. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2018/16/1/54/228298

  Introduction Top

Fluoride is the most effective and frequently used strategy for the prevention of dental caries. Drinking water, dentifrices, mouth rinses, dietary supplements, and professional products are used to deliver fluoride to the public.[1] Exposures to these multiple sources of fluoride have led to notable improvements in the oral health of some segments of the US population but also to an increase in enamel fluorosis.[2]

Fluorosis is a common childhood disease which is attributed to variations in exposure to fluoride. Dental fluorosis is a disturbance of high prevalence caused by ingestion of fluoride ions present mainly in drinking water.[3] Dental fluorosis is a condition of altered enamel formation caused by excessive intake of fluoride only during tooth formation,[4],[5] with a wide range of severity. Mild dental fluorosis appears as opaque/white parchment enamel, whereas more severe dental fluorosis can be characterized by brown stains or pitting (or mottling) of enamel.[6],[7] Therefore, the potential for a clinical trade-off in oral health with differing levels and timing of exposure to fluorides. Individuals often were reported to notice and/or be concerned about the appearance of dental fluorosis.[6]

Oral health-related quality of life (OHRQoL) is defined as a “self-report specifically pertaining to oral health capturing both the functional, social, and psychological impacts of oral disease.”[8] Quality of life aspects of general and oral health have also recently received more attention, and several specific tools for assessment of OHRQoL have been developed.[9]

There is a lack of evidence to show the impact of the dental fluorosis on the quality of life of children in India. Hence, the study was conducted with the aim to assess the impact of dental fluorosis on the OHRQoL of 12–15-year-old children residing at an endemic belt of Uttar Pradesh.

  Materials and Methods Top

A cross-sectional survey was conducted in the endemic belt of Uttar Pradesh (UP) among 12–15-year-old children residing at the endemic belt of Mohanlalganj and Maurawa zones of Lucknow, Uttar Pradesh, from May 2015 to August 2015. Ethical clearance was obtained from the Institutional Ethical committee. Permission was obtained from the Government authorities and the heads of schools. A written informed consent was obtained from the parents of the children and from principals of schools.

A list of public schools located within the Mohanlalganj and Maurawa area was obtained from District School Officer. Selection of the study population was obtained through cluster random sampling technique.

Children aged 12–15 years who were lifetime residents of the study site and those children who used local supply of drinking water were included in the study. Children with physical or mental disability, long-standing systemic illness, children with a history of professional topical fluoride therapy, children with developmental defects of teeth such as enamel hypoplasia, and children undergoing fixed orthodontic treatment were excluded from the study.

A pilot study was carried out on thirty participants to check for the feasibility of the study, and necessary changes were made accordingly. Sample size was calculated using the standard formula:

n = z2 (p [1 – p])/e2 where n = size of the sample

p = approximate prevalence rate

z = critical value at a specific level of confidence

e = difference between sample proportion and population proportion.

The investigator was trained in the department regarding the contents of the pro forma and the method of recording. Kappa statistics that were used to assess the intraexaminer reliability (0.86) and Cronbach's alpha was used to assess the reliability of the questionnaire (0.74). According to the above-mentioned equation, a sample of 220 participants was obtained. The sampling technique is shown in the [Figure 1]. The survey instrument consisted of a self-administered questionnaire, containing demographic information, personal information regarding oral hygiene followed by assessment of dental fluorosis and the quality of life using Child Perception Questionnaire which addresses the frequency of events occurring during the previous 3 months. The questionnaire composed of 48 items distributed among 5 domains: self-assessment (11 questions), oral symptoms (14 questions), functional limitations (10 questions), social well-being (4 questions), and spare time activity (8 questions). A 5-point Likert scale was used with the following options: “never” = 0, “once/twice” = 1, “sometimes” = 2, “often” = 3, and “very often” =4. The children filled the questionnaire themselves in the presence of examiner and teachers, followed by clinical examination for recording dental fluorosis using Dean's fluorosis index-Modified given by Dean. A single investigator interviewed and examined the participants. Method of estimation of fluoride content of water was done by ion selective electrode. Fluoride level was found to be 5.35 ppm. Type III examination was done using the plane mouth mirror and explorer under adequate natural light in school premises.
Figure 1: Sampling technique

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The data were analyzed using Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) version 22. Frequency tables were computed. ANOVA and Pearson's correlation coefficient tests were used to assess the impact of varying degrees of dental fluorosis on quality of life of children. P ≤ 0.05 was considered statistically significant.

  Results Top

The mean overall OHRQoL score for children with questionable fluorosis was 73.9 ± 7.51 and with very mild fluorosis was 81.9 ± 6.88. Statistically significant difference was found across self-assessment (P = 0.012), oral symptoms (P = 0.018), functional limitation (P< 0.01), and spare time activity based on dental fluorosis status [Table 1].
Table 1: Mean and overall scores for oral health-related quality of life based on dental fluorosis status

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A positive significant correlation was found between dental fluorosis and functional limitation (P = 0.025) and spare time activity (P = 0.035). A negative significant correlation was found between dental fluorosis and oral symptoms (P = 0.027).

  Discussion Top

Fluorosis is an endemic condition prevalent in 22 states of India.[10] Out of 6 lakh villages in India at least 50% have fluoride content in drinking water exceeding 1.0 ppm.[11] Various epidemiological studies have been conducted till date regarding the prevalence of dental fluorosis, but the impact of dental fluorosis on OHRQoL is yet unknown.

The prevalence of dental fluorosis was pretty higher (31.4%) among the study population the reason for such finding is that the fluoride levels in drinking water were higher in that region and the similar finding was also found in Tamil Nadu.[12] The similar findings were also reported by Dhar et al.[13] (36.36%) and Baskaradoss et al.[14] (29.4%) in their studies. Although the area was a known endemic area, no case of severe fluorosis was reported among the study participants in our study.

Higher prevalence of moderate-to-mild dental fluorosis among the study participants not only harmed the dental tissues but also had a great impact on their quality of life. Chankanka et al.[15] and Michel-Crosato et al.[16] reported that mild or very mild fluorosis had little or no effect on OHRQOL, but higher the scores of dental fluorosis might increase the impact on the OHRQoL.

In the present study, there was an increase in the overall scores and the mean scores across various domains such as “self-assessment,” “oral symptoms,” “functional limitations,” “social and well-being,” and “spare time” with the increase in severity of dental fluorosis and the studies carried out by Do et al.[6] (15.1 [14.4]) and Vargas-Ferreira et al.[17] (18.20 [13.33]) were in agreement with the results of the present study. Dental fluorosis had a measurable impact on the quality of life of affected study participants. This was evident from the results obtained from the study population, and it was similar to the studies by Do et al.,[6] Vargas-Ferreira et al.,[17] and Tellez et al.[18]


There was an association of fluorosis on the functional domain among 12–15 age groups independently as measured by the overall scores. This component of the questionnaire examines issues mainly relating to chewing, which is the process of breaking and crushing of food using the posterior teeth (premolars and molars). These results were expected because usually fluorosis is associated with esthetic implications and functional implications.[19] Similar results were observed in a study that evaluated the relationship between enamel defects and quality of life in schoolchildren between 11 and 14 years of age.[17],[19],[20]

A possible reason for the significant relationship between different levels of fluorosis and self-assessment, oral symptoms, functional limitations, social well-being, and spare time activity is that dental fluorosis affects functional and esthetic value of a person directly and indirectly.

Attractive appearances of a person are assumed to possess more socially desirable personalities and are happier and more successful than others who are less attractive.[19] Oral cavity is an important area for the appearance of a person, so the dental diseases could not only affect the physical health of patients but also influence the psychological health, which could impact their day-to-day living or life quality in turn.[21] Social and emotional well-being is an important component of overall health. Dental fluorosis affected the social well-being of the children as fluorosis affecting the anterior teeth had an esthetic impact on the quality of life of the children; this was in accordance with the study by Williams et al.[22]

The reason for that might be enamel defects started in the moderate fluorosis stage; therefore, there might be discomfort, pain, or sensitivity to the children. No author had reported similar results as the present study.

Although the present study assessed the OHRQoL among children suffering from dental fluorosis of endemic fluoride belt of UP (5.35 ppm), there is a need for the further epidemiological study with a wide range of study participants. Suitable measures of health education along with preventive measures should be taken to reduce the risk of fluoride exposure. Parents should be encouraged to use ready-to-feed formulas or use nonfluoride-containing bottled water to dilute formula concentrate. Dental public health professionals can interact with children in a mutually beneficial manner.

  Conclusion Top

The high prevalence of dental fluorosis was associated with the school children's negative perception about their dental health. We also conclude that dental fluorosis has a greater effect as well as impact on the OHRQoL. These results also reflect the need to propose effective dental public health policies to regulate limited exposures to fluoride at an early age and to improve health outcomes in a highly vulnerable population in the endemic area.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Dye BA, Thornton-Evans G. Trends in oral health by poverty status as measured by healthy people 2010 objectives. Public Health Rep 2010;125:817-30.  Back to cited text no. 2
Leverett DH. Fluorides and the changing prevalence of dental caries. Science 1982;217:26-30.  Back to cited text no. 3
Burt BA, Eklund SA. Dentistry, Dental Practice, and the Community. 6th ed. St. Louis, Missouri: Elsevier Saunders; 2005. p. 287.  Back to cited text no. 4
Ast DB, Smith DJ, Wachs B, Cantwell KT. Newburgh-Kingston caries-fluorine study. XIV. Combined clinical and roentgenographic dental findings after ten years of fluoride experience. J Am Dent Assoc 1956;52:314-25.  Back to cited text no. 5
Do LG, Spencer A. Oral health-related quality of life of children by dental caries and fluorosis experience. J Public Health Dent 2007;67:132-9.  Back to cited text no. 6
Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep 2001;50:1-42.  Back to cited text no. 7
Gift HC, Atchison KA. Oral health, health, and health-related quality of life. Med Care 1995;33:NS57-77.  Back to cited text no. 8
Jokovic A, Locker D, Tompson B, Guyatt G. Questionnaire for measuring oral health-related quality of life in eight- to ten-year-old children. Pediatr Dent 2004;26:512-8.  Back to cited text no. 9
Teotia SP, Teotia M, Singh KP. Highlights of forty years of research on endemic skeletal fluorosis in India. 4th International Workshop on Fluorosis Prevention and Defluoridation of Water; 2004. p. 107-25.  Back to cited text no. 10
Teotia SP, Teotia M. Endemic fluorosis in India: A challenging national health problem. J Assoc Physicians India 1984;32:347-52.  Back to cited text no. 11
TWAD Map and Report on Fluoride Affected Regions in Tamil Nadu. Available from: http://www.twadboard.gov.in/twad/map2.aspx. [Last accessed on 2012 Jul 03].  Back to cited text no. 12
Dhar V, Jain A, Van Dyke TE, Kohli A. Prevalence of gingival diseases, malocclusion and fluorosis in school-going children of rural areas in Udaipur district. J Indian Soc Pedod Prev Dent 2007;25:103-5.  Back to cited text no. 13
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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.  Back to cited text no. 14
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Michel-Crosato E, Biazevic MG, Crosato E. Relationship between dental fluorosis and quality of life: A population based study. Braz Oral Res 2005;19:150-5.  Back to cited text no. 16
Vargas-Ferreira F, Ardenghi TM. Developmental enamel defects and their impact on child oral health-related quality of life. Braz Oral Res 2011;25:531-7.  Back to cited text no. 17
Tellez M, Santamaria RM, Gomez J, Martignon S. Dental fluorosis, dental caries, and quality of life factors among schoolchildren in a Colombian fluorotic area. Community Dent Health 2012;29:95-9.  Back to cited text no. 18
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