A Comprehensive Review on the Techniques and Indexes Used for the Analysis of Fluorosis in Humans and Cattle

Abstract

Fluoride is known to play a significant role in dental formation. High fluoride intake leads to different symptoms one of them is dental fluorosis, which is chronic dental toxicity. Various indexes have been introduced to measure the intensity and severity of dental fluorosis. Some of these indexes are fluoride specific, such as Dean’s index, Thylstrup and Fejerskov index, the Tooth Surface Index of Fluorosis index, ICMR index. While others are non-fluoride descriptive indexes such as the
Developmental Defects of enamel index. Dental fluorosis is most commonly assessed by clinical examination by experts in these indexes, but nowadays, technical assistance such as photographs is used for diagnosis. Recent advancements have also witnessed the development of Visual analog
scales and quantitative light fluorescence methods for dental fluorosis assessments. This review article focuses on important techniques and indexes used in the evaluation and characterization of dental fluorosis. A comparative review analysis of available indexes and the scope of future advancements have also been compiled.

Full text

ORIENTAL JOURNAL OF CHEMISTRY
www.orientjchem.org
An International Open Access, Peer Reviewed Research Journal
ISSN: 0970-020 X
CODEN: OJCHEG
2023, Vol. 39, No.(5):
Pg. 1120-1132
This is an Open Access article licensed under a Creative Commons license: Attribution 4.0 International (CC- BY).
Published by Oriental Scientific Publishing Company © 2018
A Comprehensive Review on the Techniques and Indexes
Used for the Analysis of Fluorosis in Humans and Cattle
PRADEEP KHYALIA, HIMANI JUGIANI, JYOTI DANGI, JITENDER SINGH LAURA*
and MEENAKSHI NANDAL*
Department of Environmental Science, Maharshi Dayanand University Rohtak-124001, Haryana, India
*Corresponding author Email: Nandalmeenakshi23@gmail.com,
Jitender.env.sc@mdurohtak.ac.in
http://dx.doi.org/10.13005/ojc/390505
(Received: July 27, 2023; Accepted: September 10, 2023)
ABSTRACT
Fluoride is known to play a significant role in dental formation. High fluoride intake leads to
different symptoms one of them is dental fluorosis, which is chronic dental toxicity. Various indexes
have been introduced to measure the intensity and severity of dental fluorosis. Some of these
indexes are fluoride specific, such as Dean’s index, Thylstrup and Fejerskov index, the Tooth Surface
Index of Fluorosis index, ICMR index. While others are non-fluoride descriptive indexes such as the
Developmental Defects of enamel index. Dental fluorosis is most commonly assessed by clinical
examination by experts in these indexes, but nowadays, technical assistance such as photographs
is used for diagnosis. Recent advancements have also witnessed the development of Visual analog
scales and quantitative light fluorescence methods for dental fluorosis assessments. This review article
focuses on important techniques and indexes used in the evaluation and characterization of dental
fluorosis. A comparative review analysis of available indexes and the scope of future advancements
have also been compiled.
Keywords: Cattle, Dental, Skeletal, Fluorosis, Indexes.
INTRODUCTION
The health of the population of an area
is significantly determined by the quality of water
consumed. Groundwater is the most crucial water
source for any nation and has a critical role in the
community's health1. While the quality of water is
determined by several parameters like pH, turbidity,
total hardness2-3, heavy metals4-8, and ions such
as chloride, nitrate and fluoride. However, different
parameters have different types of effects on living
beings, so is the case with fluoride. It is highly reactive9.
Fluoride-containing minerals such as fluorspar,
cryolite, sellaite, and fluorapatite are the primary
source of it in the earth's crust10. Secondary sources
are granite, gneissic rocks and sediments of marine
origin in mountainous areas11. Whereas anthropogenic
sources of fluoride toxicity include mining activities,
industrial processes, pesticides, agrochemicals,
industrial effluents, and brick kiln12-13. WHO has set the
permissible limit of fluoride up to 1.5 mg/L14 in drinking
water, whereas US Public Health Service suggested a

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fluoride limit of 0.7 mg/L in drinking water15; as it plays
a significant role in healthy tooth growth at a low level
of 0.7-1 mg/L16-17. Worldwide 25 countries are affected
by the high concentration of fluoride18-20, including
China21-22, India23-27, Africa28-29, Korea30, Kenya31,
Nigeria32. In India alone, 177 districts in 21 states are
affected by high fluoride contamination in water33-35.
The research trends since the 1930s started
visualizing the toxic effects of high concentrations of
fluoride not only on humans but on animals also36.
The fluoride acts by forming hydrofluoric acid that
is very corrosive to the bones and acts on the
carbonated hydroxyapatite, forming an insoluble salt
(CaF2), which weakens the bones37-38. As a result,
it significantly affects calcified tissues resulting in
dental or skeletal fluorosis39-40. Fluoride toxicity can
be acute or chronic depending on fluoride exposure41.
Symptoms of skeletal fluorosis in humans include
chronic joint pains, stiffness in joints, calcification of
ligaments, and osteosclerosis42 while in livestock, hoof
deformity, lessons in mandible, enlargement of bones
and joints, extra bone development, calcification of
ligaments, stiffness, and lameness43-44. Dental fluorosis
is characterized by hypo-mineralization, resulting in
loss of luster in enamel, white chalky patches, and
brownish striations, which results in pitting, mottling
enamel, and finally loss of teeth in severe cases45-49.
These fluoride-related enamel alterations start during
the enamel development stage as deciduous teeth
mineralize before birth50. Thus, the placenta serves as
a passive barrier for passing high fluoride concentration
from the maternal plasma to the fetus51-52. In addition to
these, recent studies have found that fluoride toxicity
is also related to other diseases such as Alzheimer's,
neurological problems, hypertension53-55.
History of Dental Fluorosis Indexes
Dental Fluorosis in Human
Dental fluorosis studies gained wide
recognition with the work of HT Dean in the 1930s.
The relation between fluoride contamination and its
dental effects was precisely understood and outlined
by HT Dean and his colleagues at the US Public Health
Service. While conducting surveys of dental fluorosis
severity in fluoride-stricken areas, Dean felt the need to
quantify and measure the degree of severity of enamel
mottling in people56. As a result, an ordinal scale of
0-7 was introduced by Dean, widely accepted and
popularly known as the Dean’s Index. After the work of
Dean, several researchers came forward to introduced
different indexes to quantify and classify dental fluorosis
in humans and animals. These indexes were laterally
categorized into two groups, fluoride-specific indexes
and descriptive indexes. This paper deals with a
detailed literature review of different dental fluorosis
indexes in humans and cattle. A comparative analysis
of these indexes is helpful for examiners to select the
correct index for the study in the field.
Dean’s Index
Dean developed a characterizing and grading
criterion that can assess dental fluorotic lesions. Dean
proposed an index on an ordinal scale of 0-7 in 1934 with
seven classifying groups “Normal, Questionable, very
mild, mild, moderate, moderately severe and severe”56.
Later in 1942, this index was modified by converging
the moderately severe and severe57, as shown in Table
1. After that, this index became widely accepted. The
scale 0 to 4 covers all the classifications, “normal (0),
questionable (0.5), very mild (1), mild (2), moderate (3)
and severe (4)”. According to the diagnostic procedure
used by Dean, teeth are to be diagnosed under good
natural light with mirrors and probes needed. A person
was characterized based upon the two most affected
teeth. This index has been recommended by WHO in the
Basic survey manual, 4th edition, 199758, since it is easy
and straightforward to use. However, Dean's index has
been questioned because it does not include details on
fluorosis distribution within the dentition, its lowest score
"questionable" is too ambiguous, and its higher scores
are not sensitive enough59.
Table 1: Criteria for Dean’s system of classication for uorosis
Score Criteria
0 (Normal) Enamel surface- smooth, shiny, and generally pale, creamy white color Enamel Structure-Translucent semi
vitri form type
0.5 (Questionable) Enamel-Slight aberrations, few white flecks to occasional white spots.
1 (Very Mild) Twenty-five percent area of the tooth has irregularly scattered small, opaque, paperwhite areas. Teeth show
white opacity of approximately 1-2mm at the tip of their summit of cusps of the bicuspid or second molar
2 (Mild) White opacities are more extensive but present in less than fifty percent of too
3 (Moderate) Brown stains are frequently observed. All enamel surfaces show wear and are affected
4 (Severe) The general form of the tooth is affected and hypoplasia is observed. Discrete and confluent pitting; widely
spread brown stains and often corroded-like appearance

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Thylstrup and Fejerskov Index (T-F)
A new criterion formulated for measuring
fluoride origin defects was proposed by Thylstrup
and Fejerskov (1978)60. This index suggested
classifying a 10-point scale to categorize degrees
of fluorosis in each tooth on buccal, lingual,
Fig. 1. various teeth examined using T-F index
and scoring (Source: Fejerskov et al.,1994)
and occlusal surfaces Table 2. Fig. 1 represents
different scores given to teeth using the TF
index. Drying teeth with the cotton wool roll was
recommended under the methodology. This index
attempts to validate visual appearance against
histological defects.
Table 2: Classication of Thalystrup and Fejerskov index
Score Criteria
0 After prolonged drying, normal translucency of enamel is observed
1 Narrow white lines are observed, which are located corresponding to the perikymata.
2 Occasionally confluence of adjacent lines and more pronounced lines of opacity are observed on smooth surfaces. These
lines of opacities follow the perikymata.
The occlusal surface is marked with opacity<2mm in diameter scattered on surface areas and pronounces opacity of
cuspal ridges.
3 Cloudy areas of opacities that merging and irregular are observed on the smooth surface. Accentuated drawing of
perikymata is often seen in between opacities. Occlusal Surfaces are observed with confluent areas of marked opacity.
However, worn areas appear normal but are generally circumscribed by a rim of the opaque enamel.
4 The entire smooth surface appears chalky white and also exhibits marked opacities. However, those parts of the surface
that are exposed to attrition look less affected. The entire occlusal surface exhibits marked opacities. Attrition is often
pronounced shortly after the eruption.
5 Marked opacities are observed over entire smooth and occlusal surfaces. These opacities are with pits < 2mm in diameter.
6 Smooth surfaces have pits that are regularly arranged in horizontal bands <2 mm in vertical extensions. Occlusal surface
Confluent areas <3mm in diameter exhibit loss of enamel. Marked attrition
7 Loss of outermost enamel in irregular areas involving<1/2 of the entire smooth surface Changes in the morphology caused
by merging pits and marked attrition in occlusal surfaces
8 Loss of outer enamel involving>1/2 of the smooth and occlusal surface.
9 Loss of the main part of tooth enamel and change in the anatomic appearance of smooth and occlusal surfaces. The
cervical rim of nearly unaffected enamel is generally observed.
The only index which tries to associate
the clinical appearance to the pathological
variations inside the tissue was the TF index,
and therefore, it is a suitable tool while assessing
dental fluorosis severity in epidemiologic studies.
Granath et al., (1985) conducted a study to
compare Dean’s and TF indexes61. He discovered
that the TF index was more detailed and sensitive
as this was based upon histological changes
of the tooth with hypomineralisation. Fig. 1
represents various teeth affected by excessive
fluoride and scoring given according to Thylstrup-
Fejerskov index. One of the drawbacks of the TF
index is that replicate examination in field surveys
is not possible using this index59.
In a comparative study of the TF index and
Dean’s index, Burger et al., (1987) found that both
the indexes resulted in similar prevalence values, but
the severity values differed across the two scales;
in general, the TF index showed higher scores62.
Further, the authors recommended using the TF
index for field studies considering its ease and well-
defined parameters.
Tooth Surface Index of Fluorosis (TSIF)
This index was recommended by Horowitz
et al., (1984) to diminish the DEAN and TF index
shortcomings63. This index assesses the fluorosis
prevalence from a tooth surface perspective. The
Tooth Surface Index of Fluorosis (TSIF) gives
different scores to each tooth surface where anterior
teeth get two scores while three were assigned
to posterior teeth. When more than two scores

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were assigned to one tooth, a higher score was
considered for that tooth. The teeth were classified
into eight categories from 0-7 Table 3. Artificial lights
and wet examination were recommended to be
used and to get a score, at least one tooth surface
should have erupted.
Table 3: TSIF classication and identication criteria
Score Descriptive Criteria
0 Normal tooth appearance and no evidence of fluorosis is observed
1 Definite fluorosis can be seen. Less than one-third of enamel is observed with parchment-white color. The fluorosis is
confined only to incisal edges of anterior teeth and cusp tips of posterior teeth (“snow capping”) is considered under
this category.
2 At least one-third of the visible surface is covered with Parchment-white fluorosis, but less than two-thirds.
3 At least two-thirds of the visible surface is covered with Parchment-white fluorosis.
4 Staining in addition to any of the earlier mentioned effects may be observed on enamel. Staining is defined as “an area
of definite discoloration that may range from light to very dark brown.”
5 Discrete enamel pitting is present, but there is no evidence of staining of intact enamel. A pit can be defined as “a definite
physical defect in the enamel surface with a rough floor surrounded by a wall of intact enamel. The pitted area is generally
stained or of a different color from the surrounding enamel.”
6 Both discrete pitting and staining of the intact enamel are observed.
7 Enamel surface with confluent pitting is seen. The anatomy of the tooth may be changed because large enamel areas are
missing. A dark brown stain is usually present.
Cleaton-Jones and Hargreaves (1990)
examined the three indexes (DEAN, T-F, and TSIF)
in deciduous dentition, discovering that the TF index
detected fluorosis more commonly in individual
teeth64. They concluded that the T-F index was most
appropriate for the work that requires comprehensive
knowledge about the issue. This index improves the
sensitivity of diagnosis in severe cases of fluoride
exposure. A distinction between discrete pitting and
confluent pitting has been provided under this index. At
the same time, Rozier (1994) pointed out some of the
pitfalls in the index. This index scores each surface of
the tooth, which increases inter-examiner variability59.
Indian Council of Medical Research (ICMR) Index
In order to address fluorosis, ICMR
formed a task force with four subgroups, one of
which was on dental fluorosis65. The subgroup
recommended formulation of dental fluorosis
grading and identification criteria that the health
professional could use with basic training.
As per that, ICMR index for dental fluorosis’
was introduced in 2013 (Table 4). The index
characterizes dental fluorosis on an ordinal scale
of 0-3. In addition, the guidelines for the diagnosis
of teeth were also given by ICMR65:
1. All 28 permanent teeth are to be examined
except the third molar using natural light and
probe.
2. All surfaces of teeth should be examined
with special attention to the labial surface of
anterior teeth and buccal of posterior.
3. A dried examination is recommended.
4. Each tooth should be examined and graded
individually and an individual must be graded
based upon two teeth having the most
severity grade.
Table 4: ICMR Index for Dental Fluorosis
Grade Description
0(normal) Enamel surface appears smooth, glossy, translucent, creamy white/pale in color.
1(mild) Enamel surface showing extensive chalky white opaque areas in two or more teeth.
2(moderate) Enamel surface showing extensive chalky white opaque areas in two or more teeth.
3(severe) Enamel surfaces showing brown color with the pitted, discrete or confluent, eroded or
destroyed structure of two or more teeth.
The pilot study was conducted by Goyal
et al., (2016), to authenticate the ICMR index65. The
study indicated that the inter-examiner agreement
was nearly perfect. It was also concluded that
non-dental personals could use ICMR Index in field
studies since it is more straightforward and reliable.
Kumar et al., (2018), after comparing Dean, TSIF,
and ICMR index, found that the cases that were

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classified as “moderate” using Dean’s index were
dispersed into “mild (white opacities alone) and
moderate category (brown stains also present)” by
TSIF index and ICMR index respectively66. There was
an apparent discrepancy between teeth with white
opacities (mild fluorosis) and brown stains (moderate
fluorosis), according to TSIF and the ICMR index.
This discrepancy highlights the advantage of using
the TSIF or ICMR index in dental fluorosis studies
compared to Dean’s index, which sometimes
overvalues the severity of fluorosis, particularly in the
moderate category. The ICMR index is easy to use
and less time-consuming than Dean’s index, which
may overestimate the severity of fluorosis; the ICMR
index gives the actual severity of dental fluorosis.
Developmental Defects of Enamel (DDE) Index
In 1982, a working group of FDI group
recommended using descriptive criteria for analysis
of fluorosis and introduced the “Developmental
Defects of Enamel” index. In the DDE index, type,
number, demarcation and location of defects on the
buccal and lingual surfaces of teeth were recorded.
Clarkson and Mullane later recommended the
modified form of the DDE index in 198967. The
modified index classifies defects into three main
categories, namely: demarcated, diffuse and
hypoplastic. The degree of tooth surface covered by
a defect was also scored. This index recommends
a wet examination of lingual and buccal surfaces
of all erupted permanent teeth except third molars.
Maxillary central and lateral incisor; maxillary first
premolar and mandibular first molars were to
examined. Natural light was used for examining
index teeth, and fibre optic source was used for full
mouth (Table 5).
This index gives a detailed measurement
including a wide range of defects with information
on the spreading and locations of defects. However,
since this index is non-fluoride specific, it cannot
access fluoride-induced effects.
Several researchers have introduced
indexes of dental fluorosis apart from the indexes
mentioned above. Fluoride-specific indexes
were recommended by Zimmerman (1954) and
Nevitt et al., (1963)68,69. Many other researchers
stated that many dental lesions are aesthetically
similar to fluorotic lesions but are caused by
reasons other than fluoride. Indexes depending
on the clinical appearance of defects were also
recommended by Alousi et al., (1975), Jackson
et al., (1975), and Murray and Shaw (1979)70-
72. These indexes although did not gain wide
acceptance and recognition.
Dental Fluorosis Indexes in Cattle
Dental fluorosis is commonly observed
in cattle in fluoride-contaminated areas due
to fluoride-contaminated water and fodder
consumption. Choubsia et al., (2011) worked on
Dental fluorosis in different domestic animals
in the Rajasthan state of India73. The research
found that the severity of dental fluorosis in grass
eaters was higher than in plant parts eaters. They
concluded that edible parts of the plant (such as
leaves, pods, small fruits) are rich in calcium and
vitamin C, which can counteract fluoride toxicity.
Sometimes, the index introduced by Dean is
used for characterizing dental fluorosis in cattle.
However, many fluoride-specific indexes for
cattle have been recommended by Shupe and
colleagues, the National Academy of Sciences,
and L. Krook. For example, a classification and
characterization criteria for Dental fluorosis
in cattle was recommended by Shupe et al.,
(1972)74. This classification classified the
dental lesions on a scale of 0 (normal) to
5 (excessive effects). This classification criterion
was widely accepted and is still used by examiners
in field surveys for cattle dental fluorosis studies.
The Committee on Animal Nutrition,
Table 5: Modied DDE index
Code Description
0 Normal
Demarcated opacities:
1 White/ Cream
2 Yellow/brown Diffuse Opacities:
3 Diffuse-lines
4 Diffuse-confluent
6 Confluent/patchy+staining+loss of enamel Hypoplasia:
7 Pits
8 Missing Enamel
9 Any other defects Extent of Defects:
0 Normal
1 <1/3
2 At least 1/3<2/3
3 At least 2/3

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National Research Council (NRC) in 1974 published
a report on fluoride effect on animals75. That study
found that fluoride sensitivity occurs in the growing
teeth between the ages of six months and eight
years. Gross fluorotic lesions of the tooth enamel
are usually termed as “mottling (white, chalk-like
patches or strains in the enamel), chalkiness
(dull-white, chalk-like appearance), hypoplasia
(defective enamel), hypo calcification (defective
calcification)”. As cheek teeth are hard to inspect in
live animals, dental fluorosis is generally diagnosed
by incisor teeth. Characterization criteria given by
National Academy divides animals into six classes
and an ordinal scale of 0-5, which is very similar
to the classification recommended by Shupe and
colleagues (Table 6).
Table 6: Fluorosis classication criteria given by the Shupe et al., (1972), NRC (1974) and Shupe et al., (1979)74-76
Score Criteria
Normal (0) The normal shape of the tooth having a translucent, smooth, and glossy white appearance.
Questionable effects (1) Teeth show little deviation from normal; the cause is not determined exactly; enamel flecks may be present
but not mottles.
Slight effects (2) There is a little mottling of enamel that is seen as horizontal striations; may have light staining but no
significant increase in the normal rate of wear.
Moderate effects (3) Teeth show definite mottling of the entire tooth and a large area of chalky enamel; the tooth has a little
higher rate of wear and may be stained.
Marked effect (4) Hypoplasia and hypocalcification are observed along with definite mottling and pitting of enamel; the rate
of wear and staining in the tooth increases with use.
Severe effects (5) Teeth can be stained or discoloured. Teeth show definite mottling, hypo calcification, and hypoplasia.
Increase rate of wear, erosion, and pitting of teeth with use.
Krook et al., (1983), worked on a new
scale and identified some of the defects in
the enamel of cattle that had been overlooked
by the Scaling criteria given by the National
Academy of Sciences77. He defined five
principle defects and gave an ordinal scale of
1-5 as follows:
Score 1: Hypercementosis with tooth ankylosis,
cementum necrosis, and cyst formation.
Score 2: Permanent incisor teeth to show delayed
eruption.
Score 3: Necrosis in alveolar bone with the bone and
gingiva recession.
Score 4: Permanent teeth can be visualized
erupted in an oblique fashion. In addition,
hypoplasia of teeth accompanied by
diastema.
Score 5: Increased progression of the lesions in teeth
along with tooth loss.
In 2002, Swarup and Dwivedi gave scoring
criteria for examining dental fluorosis in cattle45.
This criterion was based on a numerical scale of
0-5 that recognized cattle dental fluorosis from
the range of normal to severe Table 7. Although
different authors have used different indexes for
their studies, studies with their outcomes have
been compiled in Table 8.
Table 7: Scoring and classication of the dental lesion by Swarup and Dwivedi (2002)
Score (Type) Description
0 (Normal) Translucent, glossy, and white enamel. The normal shape of teeth is observed.
1 (Questionable effect) Tooth appearance has deviated from normal translucent enamel; the cause of which is not known. Mottling
is not observed, but unilateral and bilateral cavities may be present; flecks observed
2 (Slight effects) The shape of teeth is normal but little mottling of enamel and some discoloration may be observed
3 (Mild effects) Moderate mottling and chalky enamel are observed. Discoloration and slight abrasion are seen.
4 (Moderate effects) Definite mottling, hypo calcification along with hypoplasia, and discoloration are present. The colour of the
enamel maybe cream. Pitting of enamel is observed, teeth abrasion.
5 (Excessive effects) Definite mottling, hypo calcification, may have enamel pitting, discoloration or cream-colored, excessive
teeth abrasion.

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Table 8: Dental uorosis Studies in humans and cattle
References Country Fluoride (ppm) Indexes Age group Fluorosis Examination Remark
Human Studies
78 Brazil 0.06-1.98 The European Academy 610(age group-Clinical Molar-incisor hypomineralisation was likely to be
of Pediatric Dentistry 6 to 12 years) associated with dental fluorosis
Criteria, TF index,
WHO index
79 India >1.5 Dean’s Index 1299 (age group- Clinical The overall prevalence of dental fluorosis was 21%
12 to 18 years)
80 Malaysia 0.5-0.7 Dean’s index 1155 (age group- Photographic Fluorosis prevalence was lower among younger children
9 to 12 years)
81 India 1.5-4.5 Dean’s Index, TSIF, 300 (12-15 years) Photographic and visual ICMR index is easy to use and better as compared to others
ICMR index
82 England Water fluoridation- TF index 580 (18- 52 years) Digital photography Aesthetic impacts of fluoride seem to diminish with age
1ppm and non-
fluoridated areas
83 Nigeria 0.07-2.13 TF index and 322 (8 years old) Clinical Drinking water fluoride was a positive predictor of
modified DDE dental fluorosis
index
84 Georgia 0.08-0.4 (fluoride TF Index 570 (1-6 years) Descriptive analysis Indoor coal-burning that led to the exposure of fluoride
deficit regions) during pregnancy was a reason for dental fluorosis
risk in children
85 US 2.5-5.1 TF Index 308 (15 years old) Clinical Self-perception of dental fluorosis affects adolescents
86 Iran 1.2-1.4 Dean’s Index 100 (15-18 years) Clinical, Quality of life was Dental fluorosis is associated with a decrease in
evaluated through a questionnaire Quality of Life.
87 India 1.5 4.5 Dean’s Index 30 extracted teeth Ground sections of teeth analyzed Dental fluorosis features are comparable to those
(patient’s age–15 to under light micrograph under specialized microscopes
40 years)
88 Brazil 0.06-1.14 DDE Index 566 (5-year-old children) Clinical Enamel defects
89 Sweden <0.1 DDE Index 796 (Children- 11, 15, Clinical Incisors (upper central) and permanent first premolars
and 19 years) were more affected
90 Poland 0.3-0.9 DDE Index 2,522 (11 to 15 years) Clinical The prevalence of DDE in
and 3,122 (5 to 8 years) populations was low
Cattle Studies
91 Kenya 1-30 Dean’s Index 242 Clinical Most animals were affected by fluoride at the early
stages of their growth
92 India 5-6.2 Shupe et al., 197960 (20 buffaloes, Clinical Buffaloes were more severely affected as compared to
20 cattle, 20 goats) other animals.
93 India 1.37 Shupe et al., 1979 270 Clinical Interaction between fluoride and other minerals affects
the severity of fluorosis.
94 India 4-4.75 Swarup and Dwivedi, 492 Clinical Reduced plasma calcium levels and elevated alkaline
2002 phosphate activity

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Future Perspective in Dental Lesion Characterization
Dental fluorosis indexes are most commonly
and widely used for the assessment of dental fluorosis.
Direct clinical methods are the traditional techniques that
have been used ever since. With the advancements of
technologies, imaging technologies came into existence
for assessing dental fluorosis. Imaging techniques
include conventional images and digital photographs95.
Photography for assessing dental fluorosis can be
advantageous to remove bias and better reliability.
High-quality photographs can be remotely sensed
and analyzed by several examiners96, but such
analysis requires trained examiners, Image processing
techniques, and skills. Since all current dental fluorosis
indexes recommend using ordinal scales thus, the
scores can be considered only subjective points and a
range of change69. To develop a continuous scale Vieira
et al., (2005) developed a Visual Analog Scale (VAS).
T-F index was used in the development of VAS for
dental fluorosis. A 100 mm scale was graded based
upon the best and worst tooth surface. A total of five
photographs were used as an indicator of the scale
Fig. 2. The advantages of using such scales lie in the
fact that this is a continuous scale and simple to use. In
addition, the analysis is more robust and has meaningful
parameters97. The main reason for disapproval of the
VAS is that it does not give specified criteria for its scale
points that can be susceptible to examiner bias. Even
though images of fluorosis with varying degrees of dental
fluorosis were utilized as indications, the assessment
was still regarded as subjective, making examiner
training and calibration problematic. More research and
usage of the score in epidemiological surveys using
images or other appropriate techniques are needed to
validate this indicator.
the use of Quantitative Light Fluorescence98. Their
study had the objective to use the fluorotic system and
analyze its association with the TF index. The principle
of QLF is that it compares differences in fluorescence
between sound enamel and ‘unsound enamel’
(loss of fluorescence intensity in areas of enamel
hypomineralisation). The use of computer software
was recommended for assessing the images. Guerra
et al., (2015) worked on the Developmental Defects of
Enamel (DDE) index99. They used spectrophotometric
evaluation for examining the defects. 39 teeth that
represented DDE defects on the labial surface were
collected for this study. These samples were then
analyzed using a spectroshade evaluation. The
study found this method to be more reliable and
concludable. Results obtained were free from bias
and the data obtained were correct99. Such methods
can be used for analyzing dental fluorosis studies.
CONCLUSION
1. All the dental Fluorosis Indexes reviewed
in this paper have been used extensively
and find a place in the literature. However,
it should also be considered that none is
without limitations.
2. Employing new diagnosis techniques can
be used to overcome certain limitations and
prevent biases.
3. New techniques proposed by different
researchers can be employed for In vivo
diagnosis of teeth and scoring; however, pilot
studies need to ensure the reliability of such
techniques.
4. Apart from aesthetic appearance and
histological conditions, other optical
properties, chemical, and spectroscopic
analysis can be employed as an alternative
to clinical diagnosis.
5. Extensive research and detailed analysis are
needed for improvement and advancement in
this direction.
ACKNOWLEDGMENT
This research did not receive any
specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
Conict of interest
Authors have no relevant financial or non-
financial interest to declare.
Fig. 2. Visual Analog Scale for Dental Fluorosis
with visual indicators97
In 2006, Pretty and colleagues recommended

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