The use of fluorides in dentistry has been associated with a decline in the prevalence of dental caries through the use of optimally fluoridated community water supplies and fluoridated oral care products. However, the presence of multiple vehicles for fluoride delivery has also been associated with concerns regarding increased prevalence of dental fluorosis in both fluoridated and non-fluoridated communities [1
It has been demonstrated that exposure to fluoridated water supplies in addition to the use of fluoridated dentifrices is more effective than the use of fluoridated dentifrice alone in preventing caries [1
]. However, the increase in the prevalence of enamel fluorosis has led to concerns over the risk benefit ratio with respect to the use of fluorides to reduce caries and the risk of enamel fluorosis. Studies addressing the aesthetic impact of fluorosis suggested teeth with Thylstrup and Fejerskov (TF) index scores of 3 or higher elicited concerns regarding appearance [5
]. This was in contrast to mild fluorosis (TF index 1 or 2) [6
In the UK, a systematic review commissioned by the government known as the York Report [7
] stated the occurrence of fluorosis at water fluoride levels of 1 ppm was found to be high (predicted 48%, 95% CI 40 to 57). Of this fluorosis, the proportion considered to be aesthetically objectionable was lower (predicted 12.5%, 95% CI 7.0 to 21.5). Dental fluorosis was deemed to be perceived as a potential aesthetic problem [5
] and despite the increase in prevalence of fluorosis it was not perceived by clinicians to be an important consideration, particularly for patients with less severe presentations [8
]. A recent review of the literature relating to fluorosis aesthetics and Oral Health Related Quality of Life (OHRQoL) concluded very mild and mild fluorosis was not associated with negative effects on OHRQoL, but more severe presentations of fluorosis was consistently reported less favourably [3
It is probable there are differences in perception of aesthetics between clinicians and patients [9
], but there is inconsistency in the literature with respect to this [5
]. However, this does not take into consideration the different social norms and beliefs between the various study populations that could have an impact upon the outcome of perception of aesthetics, nor does it reconcile the desire to record clinically significant or aesthetically objectionable fluorosis with the need to record all forms of fluorosis for epidemiological purposes.
Nevertheless, a report from the Medical Research Council (UK) [12
] that followed the York Report added a further qualification on the viewpoint of the aesthetic component of fluorosis by stating:
"Further studies should determine the public's perception of dental fluorosis with particular attention to the distinction between acceptable and aesthetically unacceptable fluorosis."
The ability of a group of lay persons to reliably comment upon the aesthetic appearance of fluorosis is difficult to assess. The level of agreement between study groups which include lay people has been shown to reduce as the TF score (severity of fluorosis) increases [13
Studies have highlighted the effects of facial features, viewing distance and tooth morphology and alignment as factors that can influence an individual's perception of aesthetics [14
]. The display media employed may also have an effect on a viewer's capacity to rate images with image magnification, and ambient lighting acting as confounding factors. Whilst standardized techniques can be used to capture images, the decision to capture images of wet or dry teeth will also have an effect on the degree of hypomineralization that is recorded.
The aim of this study was to evaluate participant rating of dental aesthetics. The main focus was the rating of aesthetics relating to enamel fluorosis in sample populations residing in a fluoridated and a non-fluoridated urban communities.