|Year : 2022 | Volume
| Issue : 2 | Page : 94-101
Effect of dental fluorosis on oral health-related quality of life and daily performances among 12- and 15-year-old school-going children residing in high- and low-fluoridated areas of Meerut District
Shivangi Varshney, Ipseeta Menon, Ritu Gupta, Vikram Arora, Anubhav Sharma, Lavanya Rohatgi
Public Health Dentistry, I. T. S Dental College-CDSR, Muradnagar, Uttar Pradesh, India
|Date of Submission||29-Mar-2022|
|Date of Decision||07-Jun-2022|
|Date of Acceptance||27-Jun-2022|
|Date of Web Publication||9-Aug-2022|
I. T. S Dental College-CDSR, Muradnagar, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Dental fluorosis is a clinical situation that leads to changes in esthetic appearance in teeth. Oral health problems can cause problems in performing daily activities and social well-being, which may affect individual's quality of life (QOL). Aim: To assess the effect of dental fluorosis on oral health-related QOL and condition-specific oral impact on daily performance (CS-OIDP) among 12- and 15-year-old children residing in high and low fluoridated areas of Meerut district, UP. Methodology: A cross-sectional study was conducted among 200 12- and 15-year-old school-going children residing in high- and low--fluoridated areas of Meerut district. Dean's fluorosis index was used to evaluate dental fluorosis. A pretested questionnaire, CS-OIDP index, was used to assess the dental fluorosis effect on the oral health-related QOL and daily performances. Results: The mean CS-OIDP score among high-fluoridated area was 39.85 and a significant correlation was found between dental fluorosis, CS-OIDP, and oral health-related QOL (P < 0.005). Conclusion: The results of the present study can act as an alarm for dentists to carry out epidemiological investigation at village and district level to evaluate the risk factors and possible treatment and preventive measures.
Keywords: Condition-specific oral impact on daily performance, impact, well-being
|How to cite this article:|
Varshney S, Menon I, Gupta R, Arora V, Sharma A, Rohatgi L. Effect of dental fluorosis on oral health-related quality of life and daily performances among 12- and 15-year-old school-going children residing in high- and low-fluoridated areas of Meerut District. Asian J Pharm Res Health Care 2022;14:94-101
|How to cite this URL:|
Varshney S, Menon I, Gupta R, Arora V, Sharma A, Rohatgi L. Effect of dental fluorosis on oral health-related quality of life and daily performances among 12- and 15-year-old school-going children residing in high- and low-fluoridated areas of Meerut District. Asian J Pharm Res Health Care [serial online] 2022 [cited 2022 Sep 27];14:94-101. Available from: http://www.ajprhc.com/text.asp?2022/14/2/94/353623
| Introduction|| |
Oral health is an inextricable section of an individual's general health. In recent times, it is being advocated in all situations to ensure the maximum preservations of one's self-esteem as well as general well-being of an individual. Health misconceptions and negative attitude towards oral health affects the general as well as overall well-being. Dental fluorosis and problems occurring due to this condition effect individual's general, mental, and social health. It leads to burden on their guardian or health-care providers. It requires multidimensional approach to restore the oral health.
Dental fluorosis is a condition which occurs during tooth development stage. It involves the incorporation of fluoride crystals fixing and emerging as fluorapatite at the time of tooth development. This leads to the destruction of tooth formation organs (ameloblasts and odontoblasts) of abnormal-looking pitted enamel surface. The World Health Organization (WHO) has laid down the upper limit of fluoride concentration in drinking water at 1.5 mg/l. The Bureau of Indian Standards has, therefore, fixed Indian standards as 1.0 mg/l as maximum permissible limit of fluoride.
Dental fluorosis and its unesthetic appearance of teeth has now become another center of attraction of public health concern across the globe. There is a deep-seated remarkable relationship between fluoride dose and enamel fluorosis in human population.
Around 20 million individuals in India are badly affected by fluorosis, and another 40 million are at danger. Since the disease was found in India in the 1930s, the number of persons affected, as well as the number of villages, blocks, districts, and states endemic for fluorosis, has been constantly increasing. According to the published data, fluorosis is endemic in 15 Indian states (fluoride levels in drinking water >1.5 mg/l), and approximately 62 million Indians suffer from all the different types of fluorosis. In Andhra Pradesh, Gujarat, and Rajasthan, 70%–100% of the districts are affected. Fluoride levels in water in Andhra Pradesh vary from 0.4 mg/l to very high level of 29 mg/l with a prevalence of 30.6%. Uttar Pradesh is one of the fluoride endemic states in India. Drinking water fluoride level in Uttar Pradesh ranges from 0.2 to 25.0 mg/L. A study done by Tuli et al. in Meerut, Uttar Pradesh, among 11–14-year-old school-going children reported the prevalence of dental fluorosis to be 62% and in which 50% had mild dental fluorosis.
Dental fluorosis causes physical, social, and psychosocial problems affecting oral health-related quality of life (QOL). According to the WHO, oral health-related QOL (OHRQoL) is a multidimensional construct that includes a subjective evaluation of the individual's oral health, functional well-being, emotional well-being, expectations and satisfaction with care, and sense of self. It is rapidly growing with the progression of oral health problems. The branch of OHRQOL relates to the oral anomalies disrupting the natural functioning of the individual. To assess the patients' oral health needs and evaluation, OHRQOL index has been developed. In the last few decades, many research studies have focused on establishing the link between various oral health related events such as dental caries, periodontal infections, maxillofacial trauma, dental fluorosis, neuralgias, developmental defects, and tumors of the head and neck region, which are associated with poor OHRQoL. It has been reported that individuals affected with dental fluorosis often experience negative feelings and suffer from low self-esteem because of their inability to smile and socialize.
According to one of the studies by Singh et al. among 12–15-year-old school-going children, it was reported that a positive significant correlation existed between dental fluorosis and functional limitation, and according to one of the studies, it was reported that with the severity of dental fluorosis increasing, there was an overall increase in scores and mean scores across all the indicated parameters. In the study of Rustagi et al., dental fluorosis may be linked to the feelings of unattractiveness and other negative emotions. In a study of dental fluorosis in Colombian students, they noticed an unusual appearance in their teeth and expressed embarrassment and concern about their esthetic appearance of teeth. Sixty percent of these children were hesitant to grin due to their teeth's appearance.
Few studies have been conducted till date among children to know about the association of dental fluorosis and QOL, but none of them has been conducted in Uttar Pradesh taking into consideration dental fluorosis and QOL considering clinical, psychological, and social domains with regard to oral health and oral health-related QOL among school-going children residing in both high- and low-fluoridated areas in Meerut, UP. Hence, the aim of the study was to assess the effect of dental fluorosis on QOL and condition-specific oral impact on daily performance (CS-OIDP) among 12- and 15-year-old children residing in high and low areas of Meerut district, UP.
| Methodology|| |
Study design and setting
A cross-sectional study was conducted to assess the effect of dental fluorosis on OHRQoL and CS-OIDP among 12- and 15-year-old children residing in high and low areas of Meerut district, UP.
A study was conducted among 200 school-going students aged 12 and 15 years residing in Siwalkhas (high fluoridated) and Dabana (low fluoridated) villages, Meerut district, UP [Figure A].
A total of 100 students from high-fluoridated area, Siwalkhas, and 100 students from low-fluoridated area, Dabana, were enrolled in the study.
List of high- and low-fluoridated areas were obtained from the Central Ground Water Board fluoride mapping.
- Study subjects of age group 12 to 15 years
- Study subjects who were born in high- (Siwalkhas) and low-fluoridated (Dabana) areas/permanent residents of the specified area
- Study subjects who had dental fluorosis residing in high-fluoridated areas
- Study subjects who gave informed consent
- Study subjects who were there (present) on the day of clinical examination.
- Study subjects with restored, multiple dental caries, malocclusion, orthodontic treatment, and missing teeth due to any reasons
- Study subjects who were mentally challenged and had systemic diseases which can affect in performing daily activities and QOL.
Ethical approval and informed consent
The study protocol was approved by the Institutional Ethical and Review Board (ITSCDSR/IIEC/RP/2020/012), and written informed consent was sought from all the study subjects after explaining them the aim and objectives of the study.
Before the commencement of the study, a pilot study was carried out among 30 study subjects (15 students from high-fluoridated area and 15 students from low-fluoridated area).
Sample size estimation
The sample size was estimated based on the prevalence of CS-OIDP index domain (eating) obtained from the pilot study, considering 80% power and 5% error.
The sample size was calculated using the formula:
Fluoride content analysis
Fluoride map was taken from the Central Ground Water (Jal Board) site. After allocating the affected areas, water samples were collected from tap, handpump, and well from the study areas and sent to the lab for fluoride content analysis, and according to the reports of fluoride content analysis, the study was conducted.
Eight drinking water samples were collected in plastic bottles, and labeling was done on adhesive tape stuck on the bottle with the details written using pencil. The fluoride level in water was evaluated by the potentiometric method using ion-selective electrode technology. The results were reported in mg/L.
Evaluation of dental fluorosis, childoral impact on daily performance index, and oral health-related quality of life
Two schools were selected: one school (100 students) from high-fluoridated area and one school (100 students) from low-fluoridated area. A total of 200 students were recruited in the study.
A pretested questionnaire was used in this study for dental appearance to assess the effect of dental fluorosis on the OHRQoL and daily performances.
Study subjects were examined according to the Dean's Fluorosis WHO criteria.
Oral health-related quality of life
A questionnaire was used in this study for dental appearance to assess the effect of dental fluorosis on the OHRQoL. Factors indicating the QOL were assessed through domains indicated in the.
The effect of dental fluorosis on the OHRQoL was assessed through a validated questionnaire by CS-OIDP index. Responses to the questions regarding 8 domains and responses were recorded in 6- and 4-point scale, respectively.
Condition-specific oral impact on daily performance
CS-OIDP questionnaire was included to assess oral health-related OHRQoL. Questionnaire was divided into two sections:
If the interviewee answered yes to the question about tooth color change in the oral complication section, the reported alterations would be examined in the CS-OIDP questionnaire's fluorosis section. This index includes eight functions that are divided into three categories: psychological, bodily, and social. The study subjects were asked to respond about the impact of oral health on the following eight functions indicated in [Figure B].
In face-to-face interviews, the interviewer completed the questionnaires.
To determine the outcome of tooth-related QOL, multiply the sum of perceived responses by the maximum score, which is 21.
The result of the CS-OIDP index is calculated by multiplying the sum of function grades (multiplication of frequency and intensity scores) by the attainable maximum grade (120).
Finally, questionnaires were stacked altogether, entered into Excel sheet, and the results were obtained from international business machines corporation (IBM) SPSS software 25 version. Statistical Package for Social Sciences, (Chicago, IL). Statistical software.
- Spearman's correlation coefficients between dental fluorosis and CS-OIDP and domains among high- and low-fluoridated areas.
- Pearson's correlation coefficient between tooth-related QOL and dental fluorosis intensity
- Pearson's correlation coefficient between tooth appearance-related QOL and CS-OIDP scores among high- and low-fluoridated areas.
| Results|| |
The contents of fluoride in water samples were 1.8 ppm and 1.2 ppm in high- and low-fluoridated areas, respectively.
In the present study, there were 24 males and 76 females from high-fluoridated areas, whereas 36 males and 64 females from low-fluoridated areas. The study subjects belonged to the age group of 12 and 15 years of high- and low-fluoridated areas were equally enrolled in the study [Table 1].
In high-fluoridated areas, higher number of study subjects (18; 36%) with the age group of 12 years had mild dental fluorosis, whereas 23 (46%) of the study subjects with the age group of 15 years had mild fluorosis. In low-fluoridated areas, none of the study subjects had dental fluorosis [Table 2].
|Table 2: Distribution of dental fluorosis among study subjects in high-fluoridated area|
Click here to view
[Table 3] shows that the mean CS-OIDP score among high-fluoridated area was 39.85. It also shows that students find difficulty mostly in socializing (7.98) with maximum mean score followed by minimum mean score (3.25) in eating.
|Table 3: Average scores of condition-specific oral impact on daily performance (condition-specific oral impact on daily performance) and domains in the study subjects (high-fluoridated area)|
Click here to view
[Table 4] shows that study subjects with 12 years of age group faced difficulties mostly involving in school activities followed by socializing with people, smiling, and talking clearly, whereas students with the age of 15 years faced more difficulties in performing daily activities with maximum involving in school activities followed by socializing, smiling, emotional control, and relaxing. All the mentioned CS-OIDP domains' values were significant (P < 0.05).
|Table 4: Spearman correlation of dental fluorosis and condition-specific oral impact on daily performance domains|
Click here to view
In the [Table 5], 17 study subjects with 15 years of age group in high-fluoridated area had considerable embarrassment for their appearance of teeth as compared to only 1 study subject in low-fluoridated area. Maximum study subjects, 37 residing in low-fluoridated area, were not at all embarrassed of the appearance of their teeth.
|Table 5: Quality of life factors associated to study subjects residing in high- and low-fluoridated areas|
Click here to view
Similarly, maximum study subjects, i.e., 27 and 26 from high-fluoridated area of 12 and 15 years of age group, respectively, were considerably worried about the appearance of their teeth, whereas almost all 47 study subjects residing in low-fluoridated area were not at all worried about the appearance of their teeth. Due to this, more than half of the study subjects, 28 and 29 from high-fluoridated area, limited their smiling because of the appearance of teeth, whereas maximum number of study subjects (45) were not at all ashamed or limited their smiling because of appearance of teeth. A few study subjects, 18 and 16 with the age group of 12 and 15 years, respectively, residing in high-fluoridated area thought that their teeth are somewhat very stained, whereas none of the study subjects in low-fluoridated area were concerned about the same.
[Table 6] shows a negative correlation between dental fluorosis and oral health-related QOL. As intensity of dental fluorosis increases, there is a decrease in performances in daily activities of subjects residing in high-fluoridated area. A significant correlation is found between dental fluorosis, CS-OIDP, and oral health-related QOL (P < 0.005).
|Table 6: Pearson's correlation among dental fluorosis and condition-specific oral impact on daily performance score with oral health quality of life in high-fluoridated area|
Click here to view
[Table 7] shows a positive correlation between CS-OIDP score and oral health-related QOL. As performances in daily activities increase, the QOL increases. A significant correlation was found between the dental fluorosis, CS-OIDP, and oral health-related QOL (P < 0.001).
|Table 7: Pearson's correlation among condition-specific oral impact on daily performance score with oral health-related quality of life in low-fluoridated area|
Click here to view
| Discussion|| |
Oral health problem leaves a serious impact on the health parameters that are physical, social, and mental factors. Oral health is reflected or seen by only clinical criteria. However, oral health problems can cause social, physical, and psychosocial problems. These changes may affect the oral health-related QOL of individuals.
This is the first study conducted in Uttar Pradesh to assess and evaluate the correlation between dental fluorosis intensity with oral health-related QOL and CS-OIDP.
In the present study, there were 24 males and 76 females from high-fluoridated areas, whereas 36 males and 64 females from low-fluoridated areas. In the present study, there were 24 males and 76 females from high fluoridated areas, whereas 36 males and 64 females from low fluoridated areas. Whereas, a study done in Karnataka reported with 50.4% of females and 49.6% of males and the studies done in AQ5 Thailand and Muradnagar reported with 47.6% females; 50.4% males and 54.1% females; 45.9% males respectively. This may be attributed to an equal number of females taking admission in schools as compared to boys and in some states equal to boys.
The results of this study proved that dental fluorosis lowers the oral health-related QOL and children's daily activities. Majority of the study subjects were affected with grade mild and moderate dental fluorosis drifting their daily activities negatively. This study showed average total CS-OIDP score to be 39.85 out of 100. Majority and least problems were seen with socializing and talking clearly, respectively. It was revealed that as dental fluorosis intensity increases, daily performances score decreases, lowering the tooth-related QOL among study subjects residing in high-fluoridated area. On the other side, study subjects residing in low-fluoridated area had no signs of dental fluorosis, so they had increased QOL and daily activities.
A study done by Nilchian et al. in 2018 in Iran reported with the higher number of study subjects with moderate dental fluorosis and there were no participants in severe grade, whereas in the present study, dental fluorosis intensity was distributed among all the grades. This may be due to high content of fluorosis in drinking water or other supplements as compared to a former study. Another study done by Baskaradoss et al. in Tamil Nadu among 11–15-year-old children in 2008 reported that dental fluorosis was present among all the study subjects and majority (80%) of the study subjects were in mild grades. According to a study conducted in 2015 in Pakistan among 12-year-old school-going children, dental fluorosis was high (63.6%) among children with a majority of moderate and mild degree at 32.1% and 27.5%, respectively. The prevalence of dental fluorosis in the present study showed that maximum students of 12 (36%) and 15 (46%) years of age group had grade mild dental fluorosis. The difference in dental fluorosis intensity in different regions might be due different fluoride concentrations in different people and fluoride supplements among people.
The findings of the study done in 2018 by Nilchian et al. reported that the average score of CS-OIDP was 23.5 out of 100. The majority and least problems were reported in the tooth cleaning and school activity domains, respectively, whereas in our study, the CS-OIDP average score was 39.85 out of 100. The maximum and minimum problem were seen in socializing and talking clearly, respectively. A study done in 2006 in Thailand by Gherunpong et al. among children reported C OIDP score to be 39.50 which is almost same to our study but the differences lie in both studies is that child oral impact on daily performance index was taken into the latter study with eight domains regarding dental needs assessment like enamel defects and dental injuries whereas CS OIDP index in our study consisting of eight domains regarding smiling, social activities, emotional control, etc.
Editing is done right: The majority of the study subjects in the present study found difficulty mostly in socializing with a maximum mean score (7.98) followed by a minimum mean score (3.25) in eating. In our study, the majority of the study subjects with 12 and 15 years of age group in high-fluoridates area had considerable embarrassment for the appearance of their teeth, whereas no embarrassment was seen among study subjects of low-fluoridated area. These results are similar with the present study. It was also reported that the majority of the study subjects were somewhat or not at all upset or limited smile due to dental fluorosis. A few study subjects were worried about their appearance and the majority of them felt that their teeth were somewhat white in color. The results of this study are completely different from the present study because almost 50 students residing in high-fluoridated area were worried about their appearance and smiling. 16 and 18 study subjects with the age group of 12 and 15 years residing in high-fluoridated area felt that their teeth are somewhat very stained. The probable reason for the contrast result between both the studies may be due to differences in the years, studies being conducted. More and more people are conscious for their esthetics. Martínez-Mier et al. in 2004 reported feeling embarrassed (“a lot of embarrassment” to “a little bit”: 64%), worried (“very worried” to “somewhat worried”: 70%), and avoided smiling (“a lot” to “somewhat”: 59%) due to their dental fluorosis. The dental appearance is an integral component of facial beauty. Differences in the results may be due to the inclusion of different OIDP indexes in studies. We included CS-OIDP index and the later study used child-OIDP index.
In the present study, there is a negative correlation between dental fluorosis and oral health-related QOL. As intensity of dental fluorosis increases, there is a decrease in performances in daily activities of subjects residing in high-fluoridated area. A significant correlation is found between dental fluorosis, CS-OIDP, and oral health-related QOL (P < 0.005). Nilchian et al. reported no significant unpleasant effect of dental fluorosis on appearance and emotional status. These results are inconsistent with ours that could be due to very low severity of dental fluorosis in their study.
In the present study, there is a positive correlation between CS-OIDP score and oral health-related QOL of study subjects residing in low-fluoridated area. As performances in daily activities increase, the QOL increases. A significant correlation is found between dental fluorosis, CS-OIDP, and oral health-related QOL (P < 0.001).
| Conclusion|| |
Findings of the study can act as a startle or urge to public health dentists to carry out epidemiological investigation at village and district level to evaluate the risk factors and possible treatment and preventive measures. Dental fluorosis effects the overall well-being by effecting daily activities and lowering oral health-related QOL. In this study, condition-specific impacts and QOL conditions did not differ by gender. In low-fluoridated areas, almost all study participants did not suffer from low QOL except few participants had problem with daily activities performances due to malocclusion.
- In high-fluoridated areas, it is recommended to reduce the fluoride concentration of drinking water by making alternate water sources available or providing water with a lower fluoride content
- It is recommended to organize workshops and camps educating people regarding high doses of fluoride in early age and its overall health problems
- It is recommended to provide treatment of dental fluorosis to people at discount or camps.
I would like to thank my faculties for guiding and my study subjects for cooperating.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaur P, Singh S, Mathur A, Makkar DK, Aggarwal VP, Batra M, et al.
Impact of Dental disorders and its influence on self esteem levels among adolescents. J Clin Diagn Res 2017;11:C05-8.
Bronckers AL, Lyaruu DM, DenBesten PK. The impact of fluoride on ameloblasts and the mechanisms of enamel fluorosis. J Dent Res 2009;88:877-93.
Prevention and control of fluorosis in India. New Delhi: Rajiv Gandhi National Drinking Water Mission, Government of India; 1993.
DenBesten P, Li W. Chronic fluoride toxicity: Dental fluorosis. Monogr Oral Sci 2011;22:81-96.
Shahroom NS, Mani G, Ramakrishnan M. Interventions in management of dental fluorosis, an endemic disease: A systematic review. J Family Med Prim Care 2019;8:3108-13.
] [Full text]
Mehta DN, Shah J. Reversal of dental fluorosis: A clinical study. J Nat Sci Biol Med 2013;4:138-44.
Chaudhary M, Prabhakar I, Gupta B, Anand R, Sehrawat P, Thakkar SS. Prevalence of dental fluorosis among adolescents in schools of Greater Noida, Uttar Pradesh. J Ind Assoc Public Health Dent 2017;15:36-41.
Singh M, Saini A, Saimbi CS, Bajpai AK. Prevalence of dental diseases in 5-to 14-year-old school children in rural areas of the Barabanki District, Uttar Pradesh, India. Indian J Dent Res 2011;22:396-9.
] [Full text]
Tuli A, Rehani U, Aggrawal A. Caries experience evidenced in children having dental Fluorosis. Int J Clin Pediatr Dent 2009;2:25-31.
Sischo L, Broder HL. Oral health-related quality of life: What, why, how, and future implications. J Dent Res 2011;90:1264-70.
Barbosa TS, Gavião MB. Oral health-related quality of life in children: Part II. Effects of clinical oral health status. A systematic review. Int J Dent Hyg 2008;6:100-7.
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. [Full text]
Astrøm AN, Mashoto K. Determinants of self-rated oral health status among school children in Northern Tanzania. Int J Paediatr Dent 2002;12:90-100.
Rustagi N, Rathore AS, Meena JK, Chugh A, Pal R. Neglected health literacy undermining fluorosis control efforts: A pilot study among schoolchildren in an endemic village of rural Rajasthan, India. J Family Med Prim Care 2017;6:533-7.
] [Full text]
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.
Nilchian F, Asgary I, Mastan F. The effect of dental fluorosis on the quality of life of female high school and precollege students of high fluoride-concentrated area. J Int Soc Prev Community Dent 2018;8:314-9.
Gabre P, Martinsson T, Gahnberg L. Incidence of, and reasons for, tooth mortality among mentally retarded adults during a 10-year period. Acta Odontol Scand 1999;57:55-61.
Allen PF. Assessment of oral health related quality of life. Health Qual Life Outcomes 2003;1:40.
Locker D, Jokovic A, Stephens M, Kenny D, Tompson B, Guyatt G. Family impact of child oral and oro-facial conditions. Community Dent Oral Epidemiol 2002;30:438-48.
Sebastian ST, Soman RR, Sunitha S. Prevalence of dental fluorosis among primary school children in association with different water fluoride levels in Mysore District, Karnataka. Indian J Dent Res 2016;27:151-4.
] [Full text]
McGrady MG, Ellwood RP, Srisilapanan P, Korwanich N, Worthington HV, Pretty IA. Dental fluorosis in populations from Chiang Mai, Thailand with different fluoride exposures – Paper 1: Assessing fluorosis risk, predictors of fluorosis and the potential role of food preparation. BMC Oral Health 2012;12:16.
Aggarwal C, Sandhu M, Sachdev V, Dayal G, Prabhu N, Issrani R. Prevalence of dental caries and dental fluorosis among 7-12-year-old school children in an Indian subpopulation: A cross-sectional study. Pesqui Bras Odontopediatr Clín Integr 2021;21:e0141-7.
Baskaradoss JK, Clement RB, Narayanan A. Prevalence of dental fluorosis and associated risk factors in 11-15 year old school children of Kanyakumari District, Tamil Nadu, India: A cross sectional survey. Indian J Dent Res 2008;19:297-303.
] [Full text]
Sami E, Vichayanrat T, Satitvipawee P. Dental fluorosis and its relation to socioeconomic status, parents' knowledge and awareness among 12-year-old school children in quetta, Pakistan. Southeast Asian J Trop Med Public Health 2015;46:360-8.
Gherunpong S, Tsakos G, Sheiham A. The prevalence and severity of oral impacts on daily performances in Thai primary school children. Health Qual Life Outcomes 2004;2:57.
Martínez-Mier EA, Maupomé G, Soto-Rojas AE, Ureña-Cirett JL, Katz BP, Stookey GK. Development of a questionnaire to measure perceptions of, and concerns derived from, dental fluorosis. Community Dent Health 2004;21:299-305.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]