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1.  Evaluating the use of fluorescent imaging for the quantification of dental fluorosis 
BMC Oral Health  2012;12:47.
The quantification of fluorosis using fluorescence imaging (QLF) hardware and stain analysis software has been demonstrated in selected populations with good correlation between fluorescent image metrics and TF Index scores from photographs. The aim of this study was to evaluate the ability of QLF to quantify fluorosis in a population of subjects (aged 11–13) participating in an epidemiological caries and fluorosis survey in fluoridated and non-fluoridated communities in Northern England.
Fluorescent images of the maxillary incisors were captured together with standardized photographs were scored blind for fluorosis using the TF Index. Subjects were excluded from the analysis if there were restorations or caries on the maxillary central incisors.
Data were available for 1774 subjects (n=905 Newcastle, n=869 Manchester). The data from the fluorescence method demonstrated a significant correlation with TF Index scores from photographs (Kendall’s tau = 0.332 p<0.0001). However, a number of additional confounding factors such as the presence of extrinsic stain or increased enamel translucency on some subjects without fluorosis or at low levels of fluorosis severity had an adverse impact on tooth fluorescence and hence the outcome variable. This in conjunction with an uneven distribution of subjects across the range of fluorosis presentations may have resulted in the lower than anticipated correlations between the fluorescent imaging metrics and the photographic fluorosis scores. Nevertheless, the fluorescence imaging technique was able to discriminate between a fluoridated and non-fluoridated population (p<0.001).
Despite confounding factors the fluorescence imaging system may provide a useful objective, blinded system for the assessment of enamel fluorosis when used adjunctively with photographic scoring.
PMCID: PMC3549943  PMID: 23116324
2.  Dental fluorosis in populations from Chiang Mai, Thailand with different fluoride exposures - Paper 2: The ability of fluorescence imaging to detect differences in fluorosis prevalence and severity for different fluoride intakes from water 
BMC Oral Health  2012;12:33.
To assess the ability of fluorescence imaging to detect a dose response relationship between fluorosis severity and different levels of fluoride in water supplies compared to remote photographic scoring in selected populations participating in an observational, epidemiological survey in Chiang Mai, Thailand.
Subjects were male and female lifetime residents aged 8-13 years. For each child the fluoride content of cooking water samples (CWS) was assessed to create categorical intervals of water fluoride concentration. Fluorescence images were taken of the maxillary central incisors and analyzed for dental fluorosis using two different software techniques. Output metrics for the fluorescence imaging techniques were compared to TF scores from blinded photographic scores obtained from the survey.
Data from 553 subjects were available. Both software analysis techniques demonstrated significant correlations with the photographic scores. The metrics for area effected by fluorosis and the overall fluorescence loss had the strongest association with the photographic TF score (Spearman’s rho 0.664 and 0.652 respectively). Both software techniques performed well for comparison of repeat fluorescence images with ICC values of 0.95 and 0.85 respectively.
This study supports the potential use of fluorescence imaging for the objective quantification of dental fluorosis. Fluorescence imaging was able to discriminate between populations with different fluoride exposures on a comparable level to remote photographic scoring with acceptable levels of repeatability.
PMCID: PMC3478182  PMID: 22908997
3.  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.
To determine the severity of dental fluorosis in selected populations in Chiang Mai, Thailand with different exposures to fluoride and to explore possible risk indicators for dental fluorosis.
Subjects were male and female lifetime residents aged 8–13 years. For each child the fluoride content of drinking and cooking water samples were assessed. Digital images were taken of the maxillary central incisors for later blind scoring for TF index (10% repeat scores). Interview data explored previous cooking and drinking water use, exposure to fluoride, infant feeding patterns and oral hygiene practices.
Data from 560 subjects were available for analysis (298 M, 262 F). A weighted kappa of 0.80 was obtained for repeat photographic scores. The prevalence of fluorosis (TF 3+) for subjects consuming drinking and cooking water with a fluoride concentration of <0.9 ppm was 10.2%. For subjects consuming drinking and cooking water >0.9 ppm F the prevalence of fluorosis (TF 3+) rose to 37.3%. Drinking and cooking water at age 3, water used for infant formula and water used for preparing infant food all demonstrated an increase in fluorosis severity with increase in water fluoride level (p < 0.001). The probability estimate for the presentation of aesthetically significant fluorosis was 0.53 for exposure to high fluoride drinking (≥0.9 ppm) and cooking water (≥1.6 ppm).
The consumption of drinking water with fluoride content >0.9 ppm and use of cooking water with fluoride content >1.6 ppm were associated with an increased risk of aesthetically significant dental fluorosis. Fluoride levels in the current drinking and cooking water sources were strongly correlated with fluorosis severity. Further work is needed to explore fluorosis risk in relation to total fluoride intake from all sources including food preparation.
PMCID: PMC3478176  PMID: 22720834
4.  Adolescents' perceptions of the aesthetic impact of dental fluorosis vs. other dental conditions in areas with and without water fluoridation 
BMC Oral Health  2012;12:4.
The use of fluorides for caries prevention is well established but is linked with an increased risk of dental fluorosis, some of which may be considered to be aesthetically objectionable. Patient opinion should be considered when determining impact on aesthetics. The aim of this study was to assess participant rating of dental aesthetics (from photographic images) of 11 to 13 year olds participating in an epidemiological caries and fluorosis survey in a fluoridated and a non-fluoridated community in Northern England.
Consented participants were invited to rank in order of preference (appearance) a collage of 10 computer generated images on a touch-screen laptop. The images comprised an assortment of presentations of teeth that included white teeth, a spectrum of developmental defects of enamel and dental caries. Data were captured directly and exported into SPSS for analysis.
Data were available for 1553 participants. In general, there were no significant differences in the rank positions between the fluoridated and non-fluoridated communities, with the exception of teeth with caries and teeth with large demarcated opacities. Very white teeth had the highest rating in both localities. Overall, there was a trend for teeth with fluorosis to be ranked more favourably in the fluoridated community; for TF 1 and TF 2 this preference was significant (p < 0.001).
The results of this study suggest teeth that are uniformly very white have the highest preference. The rankings suggest teeth with a fluorosis score of TF 1 may not be considered aesthetically objectionable to this population and age group. The image depicting a tooth with caries and the image with large demarcated opacities were deemed to be the least favoured. Participant preference of images depicting fluorosis falls with increasing severity of fluorosis.
PMCID: PMC3306760  PMID: 22325055

Results 1-4 (4)