Read NCHS Data Brief, Number 53, November 2010 text version

NCHS Data Brief No. 53 November 2010

Prevalence and Severity of Dental Fluorosis in the United States, 1999­2004

eugenio d. Beltrán-aguilar, d.m.d., m.s., dr.p.h.; laurie Barker, m.s.p.h.; and Bruce a. dye, d.d.s., m.p.h.

Key findings

Data from the National Health and Nutrition Examination Survey, 1999­2004 and the 1986­ 1987 National Survey of Oral Health in U.S. School Children

· Less than one-quarter of persons aged 6­49 in the United States had some form ofdentalfluorosis. · The prevalence of dental fluorosiswashigherin adolescents than in adults and highest among those aged 12­15. · Adolescents aged 12­15 in 1999­2004 had a higher prevalenceofdentalfluorosis than adolescents aged 12­15 in1986­1987.

Dentalfluorosisreferstochangesintheappearanceoftoothenamelthatare causedbylong-termingestionoffluorideduringthetimeteethareforming (1).Studiesconductedinthe1930sshowedthattheseverityoftoothdecay wasloweranddentalfluorosiswashigherinareaswithmorefluoridein thedrinkingwater(2).Inresponsetothesefindings,communitywater fluoridationprogramsweredevelopedtoaddfluoridetodrinkingwaterto reachanoptimallevelforpreventingtoothdecay,whilelimitingthechance ofdevelopingdentalfluorosis(3).Bythe1980s,studiesinselectedU.S. communitiesreportedanincreaseindentalfluorosis(4,5),parallelingthe expansionofwaterfluoridationandtheincreasedavailabilityofothersources ofingestedfluoride,suchasfluoridetoothpaste(ifswallowed)andfluoride supplements(6).Thisreportdescribestheprevalenceofdentalfluorosis in the United States and changes in the prevalence and severity of dental fluorosisamongadolescentsbetween1986­1987and1999­2004. Keywords: children · dental public health · National Health and Nutrition Examination Survey · National Survey of Oral Health in U.S. School Children

Less than one-quarter of persons aged 6­49 had dental fluorosis.

Figure 1. Percent distribution of dental fluorosis among persons aged 6­49: United States, 1999­2004 2.0 4.8 16.0 60.6 Less than 1 Unaffected Questionable Very mild Mild Moderate Severe

16.5

NOTES: Dental fluorosis is defined as having very mild, mild, moderate, or severe forms and is based on Dean's Fluorosis Index. Percentages do not sum to 100 due to rounding. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 1999­2004.

u.s. department of health and human services

centers for disease control and prevention

national center for health statistics

NCHS Data Brief No. 53 November 2010

Amongpersonsaged6­49,16.0%hadverymildfluorosis,4.8%hadmildfluorosis,2.0% hadmoderatefluorosis,andlessthan1%hadseverefluorosis(Figure1). Fortheremainingthree-quartersofpersonsinthisagegroup,60.6%wereunaffectedbydental fluorosisand16.5%wereclassifiedashavingquestionabledentalfluorosis.

Prevalence of dental fluorosis was higher among younger persons and ranged from 41% among adolescents aged 12­15 to 9% among adults aged 40­49.

Adolescentsaged12­15hadthehighestprevalenceofdentalfluorosis(40.6%)(Figure2).The prevalenceisloweramongolderagegroups.Thelowestprevalencewasamongthoseaged40­49 (8.7%).Theprevalenceofdentalfluorosisamongchildrenaged6­11(33.4%)waslowerthanthe prevalenceamongthoseaged12­15(40.6%).

Figure 2. Prevalence of dental fluorosis among persons aged 6­49, by age group: United States, 1999­2004 50 40.6 40 36.1 33.4 28.4 30 Percent 20

14.3 8.7

10

0

6­11

12­15

16­19

20­29 Age in years

30­39

40­49

NOTES: Dental fluorosis is defined as having very mild, mild, moderate, or severe forms and is based on Dean's Fluorosis Index. Error bars represent 95% confidence intervals. SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 1999­2004.

2

NCHS Data Brief No. 53 November 2010 Children aged 12­15 in 1999­2004 had higher prevalence of dental fluorosis compared with the same aged children in 1986­1987.

In1986­1987,22.6%ofadolescentsaged12­15haddentalfluorosis,whereasin1999­2004, 40.7%ofadolescentsaged12­15haddentalfluorosis(Figure3).Theestimatesforseverealone werestatisticallyunreliable. Theprevalenceofverymildfluorosisincreasedfrom17.2%to28.5%andmildfluorosis increasedfrom4.1%to8.6%.Theprevalenceofmoderateandseverefluorosisincreasedfrom 1.3%to3.6%.

Figure 3. Change in dental fluorosis prevalence among children aged 12­15 participating in two national surveys: United States, 1986­1987 and 1999­2004 60 47.1 50 39.6 40 30.2 Percent 28.5 30 19.7 20 8.6 4.1 1.3 0 Unaffected Questionable Very mild Dental flourosis Mild 3.6 17.2 NIDR, 1986­1987 NHANES, 1999­2004

10

Moderate and severe

NOTES: Dental fluorosis is defined as having very mild, mild, moderate, or severe forms and is based on Dean's Fluorosis Index. Percentages do not sum to 100 due to rounding. Error bars represent 95% confidence intervals. SOURCES: CDC/NCHS, National Health and Nutrition Examination Survey, 1999­2004 and National Institute of Dental Research, National Survey of Oral Health in U.S. School Children, 1986­1987.

3

NCHS Data Brief No. 53 November 2010 Summary

Twenty-threepercentofpersonsaged6­49haddentalfluorosisin1999­2004.Approximately 2%hadmoderatedentalfluorosisandlessthan1%hadseveredentalfluorosis.Dentalfluorosis wasmostprevalentamongchildrenaged12­15,andlessprevalentamongolderagegroups.The prevalenceofdentalfluorosisamongchildrenaged6­11waslowerthantheprevalenceamong adolescentsaged12­15.Thismaybeexplainedbyanincompletesetofpermanentteethamong childrenaged6­11;someposteriorpermanentteeth,includingpremolarsandsecondmolars, eruptbetweenages10and12. Thelevelsofverymild,mild,andmoderateorseveredentalfluorosiswerehigheramong adolescentsaged12­15in1999­2004thanin1986­1987. Intheanalysesofchangesinprevalencebetweenbothnationalsurveys,moderateandsevere dentalfluorosiswereaggregatedintoonecategorybecauseallestimatesofseverefluorosiswere statisticallyunreliableafterstratification(standarderrorofthepercentagewasgreaterthan30% thevalueofthepercentage).

4

NCHS Data Brief No. 53 November 2010 Definitions

Dentalfluorosis:Definedasachangeinthemineralizationofthedentalhardtissues(enamel, dentin,andcementum)causedbylong-termingestion(eatinganddrinking)offluorideduring theperiodoftoothdevelopmentpriortoeruptionintothemouth(first8yearsoflifeformost permanentteethexcludingthirdmolars).Oncethetootherupts,dentalfluorosisreferstoarange ofvisuallydetectablechangesinenamel.Changesrangefrombarelyvisiblelacywhitemarkings inmildercasestoconvergedopaqueareasandpittingoftheteethinsevereforms.Aftereruption thepittedareascanbecomestainedyellowtodarkbrown. Dean'sFluorosisIndex:Developedinthe1930sbyH.T.Deantoassesstheprevalenceand severityofdentalfluorosisinvariouscommunitiesintheUnitedStates(2).Majorcriteriafor eachcategoryarelistedbelow: · Unaffected:Theenamelistranslucent.Thesurfaceofthetoothissmooth,glossy,and usuallyhasapalecreamywhitecolor. · Questionable:Theenamelshowsslightchangesrangingfromafewwhiteflecksto occasionalwhitespots.Thisclassificationisutilizedinthoseinstancesinwhichadefinitive determinationofthemildestformoffluorosisisnotwarrantedandaclassificationof unaffectedisnotjustified. · Very mild:Smallopaquepaper-whiteareasarescatteredoverthetoothsurface,butdonot involveasmuchas25%ofthesurface. · Mild:Whiteopaqueareasonthesurfacearemoreextensive,butdonotinvolveasmuchas 50%ofthesurface. · Moderate:Whiteopaqueareasaffectmorethan50%oftheenamelsurface. · Severe:Allenamelsurfacesareaffected.Themajoraspectofthisclassificationisthe presenceofdiscreteorconfluentpitting. Prevalenceofdentalfluorosis:Definedastheproportionofthepopulationwithverymildor higherlevelsofdentalfluorosis,byconventionestablishedbyH.T.Dean(2).Thequestionable categoryisexcluded.

5

NCHS Data Brief No. 53 November 2010 Data source and methods

DatafromtheNationalHealthandNutritionExaminationSurvey(NHANES)wereusedfor mostoftheseanalyses.NHANESisacross-sectionalsurveydesignedtomonitorthehealth andnutritionalstatusoftheciviliannoninstitutionalizedU.S.population.Theoralhealthexam wasconductedinmobileexaminationcentersbytraineddentists.In1999,NHANESbecamea continuoussurveywitheachyearofdatacollectionbasedonarepresentativesamplecovering allages.TheNHANESsampleisselectedthroughacomplex,multistagedesignthatincludes selectionofprimarysamplingunits(PSUs)(countiesorcountyequivalents),householdsegments withinthePSUs,andfinally,samplepersonsfromselectedhouseholds.Thesampledesign includes oversampling in order to obtain reliable estimates of health and nutritional measures for populationsubgroups.In1999­2004,oversamplingincludednon-HispanicblackandMexicanAmericanpersonsaswellasadolescents.AdditionalinformationonNHANEScanbelocatedat http://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm. Datafromthe1986­1987NationalSurveyofOralHealthinU.S.SchoolChildrenwerealso used,whichwasconductedbytheNationalInstituteofDentalResearch(NIDR,currentlythe NationalInstituteofDentalandCraniofacialResearch).Theoralhealthexamwasconducted usingportabledentalequipmentontheschoolpremisesbytraineddentists.The1986­1987 NIDRsamplewasselectedthroughamultistagedesignthatincludedselectionofschooldistricts, schools,andclassrooms.Becausethe1986­1987NIDRsurveywasschool-based,childrennot attendingschoolwerenotpartofthesamplingframe.Additionalinformationforthe1986­1987 NIDRsurveyisavailableinthepublic-usedatafiledocumentationandsurveymethodology report(7). Bothsurveysincludedintraoralassessmentofallpermanentteethconductedbytrainedand standardizeddentalexaminerswhousedtheDean'sFluorosisIndex(2).Accordingly,eachtooth wasassignedoneofsixdiagnosticcodes:unaffected,questionable,verymild,mild,moderate, andsevere.Examinersinbothsurveysreachedacceptablelevelsofinterexaminerreliability againstastandardexaminer(8­10).Datafromthe1986­1987NIDRsurveyrepresentthefirst nationaldataondentalfluorosis,whiledatafromthe1999­2004NHANESrepresentthemost recentnationaldata.Theagegroup12­15wasusedtocomparechangesbetweensurveys because,onaverage,allpermanentteetharefullyeruptedatthatage. Publiclyavailabledatasetsfrombothsurveyswereusedtocalculateaperson-basedscorefor dentalfluorosisfollowingDean'scriteria,thatis,usingthescorecorrespondingtothetwomost affectedteeth.Forexample,inordertohaveacategoryof"moderate"fluorosis,theperson shouldhaveatleasttwopermanentteethwiththescoreofmoderate.Foranalysesusingage,data fromthe1999­2004NHANESweregroupedintosixagegroups(6­11,12­15,16­19,20­29, 30­39,and40­49)andcomparisonstothe1986­1987NIDRsurveyuseddatafromrespondents aged12­15. PopulationestimatesandstandarderrorswerecalculatedinSAS-callableSUDAANsoftware (release9.0;ResearchTriangleInstitute,ResearchTrianglePark,N.C.).Sampleweightsprovided bytheNationalCenterforHealthStatisticsandNIDRtoaccountfordifferingprobabilitiesof selection,nonresponse,andnoncoverage,wereusedforanalysis.Thestandarderrorsofthe percentageswereestimatedusingTaylorSeriesLinearizationtotakeintoaccountthecomplex samplingdesign.Graphsinclude95%confidenceintervals.

6

NCHS Data Brief No. 53 November 2010 About the authors

EugenioD.Beltrán-AguilarandLaurieBarkerarewiththeCentersforDiseaseControland Prevention's(CDC)NationalCenterforChronicDiseasePreventionandHealthPromotion, DivisionofOralHealth.BruceA.DyeiswithCDC'sNationalCenterforHealthStatistics, DivisionofHealthandNutritionExaminationSurveys.

References

1. AobaT,FejerskovO.Dentalfluorosis:Chemistryandbiology.CritRevOralBiolMed 13(2):155­70.2002. 2. DeanHT.Theinvestigationofphysiologicaleffectsbytheepidemiologicalmethod.Report no19.Washington,DC:AmericanAssociationfortheAdvancementofScience.1942. 3. CDC.Fluoridationofdrinkingwatertopreventdentalcaries.MMWR48:933­40.1998. 4. LeverettD.Prevalenceofdentalfluorosisinfluoridatedandnonfluoridatedcommunities--A preliminaryinvestigation.JPublicHealthDent46(4):184­7.1986. 5. SzpunarSM,BurtBA.Dentalcaries,fluorosis,andfluorideexposureinMichigan schoolchildren.JDentRes67(5):802­6.1988. 6. MascarenhasAK.Riskfactorsfordentalfluorosis:Areviewoftherecentliterature.Pediatr Dent22(4):269­77.2000. 7. NationalInstituteofDentalResearch.OralhealthofUnitedStateschildren.TheNational SurveyofOralHealthinU.S.SchoolChildren,1986­1987.Public-usedatafiledocumentation andsurveymethodology.Bethesda,MD:NationalInstitutesofHealth.1992. 8. NationalInstituteofDentalResearch.OralhealthofUnitedStateschildren.TheNational SurveyofDentalCariesinU.S.SchoolChildren,1986­1987.Nationalandregionalfindings. NIHPublno89­2247.Bethesda,MD:NationalInstitutesofHealth.1989. 9. DyeBA,BarkerLK,SelwitzRH,LewisBG,WuT,FryarCD,etal.Overviewandquality assurancefortheNationalHealthandNutritionExaminationSurvey(NHANES)oralhealth component,1999­2002.CommunityDentOralEpidemiol35(2):140­51.2007. 10. DyeBA,Nowjack-RaymerR,BarkerLK,NunnJH,SteeleJG,TanS,etal.Overviewand qualityassurancefortheoralhealthcomponentoftheNationalHealthandNutritionExamination Survey(NHANES),2003­04.JPublicHealthDent68(4):218­26.2008.

7

NCHS Data Brief No. 53 November 2010

Suggested citation

Beltrán-AguilarED,BarkerL,DyeBA. Prevalence and severity of dental fluorosis intheUnitedStates,1999­2004.NCHS databrief,no53.Hyattsville,MD:National CenterforHealthStatistics.2010.

Copyright information

All material appearing in this report is in the public domain and may be reproduced orcopiedwithoutpermission;citationasto source,however,isappreciated.

National Center for Health Statistics

EdwardJ.Sondik,Ph.D.,Director JenniferH.Madans,Ph.D.,Associate Director for Science Division of Health and Nutrition Examination Surveys CliffordL.Johnson,M.S.P.H.,Director

U.S.DEPARTMENTOF HEALTH&HUMANSERvICES CentersforDiseaseControlandPrevention NationalCenterforHealthStatistics 3311ToledoRoad Hyattsville,MD20782 OFFICIALBUSINESS PENALTyFORPRIvATEUSE,$300

Toreceivethispublicationregularly,contactthe NationalCenterforHealthStatisticsby calling1­800­232­4636 E-mail: [email protected] Internet: http://www.cdc.gov/nchs

first class mail postage & fees paid cdc/nchs PermitNo.G-284

ISSN 1941­4927 (Print ed.) ISSN 1941­4935 (Online ed.)

CS218649 T3804111/2010 DHHSPublicationNo.(PHS)2011­1209

Information

NCHS Data Brief, Number 53, November 2010

8 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

1191491