Caries and Fluorosis Impacts on Children and their Families in North Carolina Uvoh Onoriobe BDS, MPH Gary Rozier DDS, MPH Rebecca King DDS,MPH John Cantrell MA

Background Use of fluoride for the prevention of dental caries – a major public health strategy The exposure to fluoride from multiple sources has led to an increase in enamel fluorosis Enamel fluorosis- hypomineralization of tooth enamel, ranging from barely noticeable lacy, white markings on the enamel to heavily stained, pitted and friable enamel, depending on the amount, timing and length of fluoride exposures in childhood

Background The development of professional guidelines for fluoride use most often considers the biological consequences of fluoride exposures The psychosocial impacts of enamel fluorosis and dental caries on children and their parents should also be considered (Chankanka et al 2010)

Impact of Dental Disease on Oral Health Related Quality of Life (OHRQoL) Poor OHRQoL is associated with: Dental caries (Do and Spencer 2007) Severe fluorosis (Chankanka et al 2010) Conditions causing visible incisor changes (Rodd et al 2011) Improved OHRQoL is associated with: Mild fluorosis (Do and Spencer 2007) Very few studies have evaluated fluorosis and caries impacts on OHRQoL Necessary information to evaluate the risks and benefits

Purpose Determine the prevalence of enamel fluorosis in permanent teeth of 5-17 year old children in North Carolina Determine the impact of enamel fluorosis on the OHRQoL of these children and their families Compare the impacts of enamel fluorosis and dental caries on the OHRQoL of children and their families

Sample Design Stratified, cluster probability sample of k-12 classrooms during 2003-04 academic year Frame: 40,000 teachers, 1.2 million students Stratified on: Grade (K-5, 6-8, 9-12) FMR school in last year, Grades K-5 High risk school (>FRL 40%) Latino (>6%) Disproportional sample of classrooms (n=398) to provide equal numbers per strata

Methods Sources of information: Parent questionnaire Child questionnaire Clinical examination Administrative databases Written informed consent was provided by parents, assent by children IRB approval -NC Division of Public Health IRB and the University of North Carolina at Chapel Hill IRB

Clinical Examination Measuring Fluorosis- Dean’s Index (permanent teeth only) Normal Questionable Very Mild Mild Moderate Severe Measuring Caries Experience- Radike Criteria, supplemented with criteria from Iowa F Study DMFS (permanent teeth) dfs (primary teeth) D1, d1 (Noncavitated) and D2-3, d2-3 (Cavitated)

All instruments measured the frequency of impacts Measuring OHRQoL Child Perceptions CPQ 8-10 (25 items; 0-100 score) CPQ11-14 (37 items; 0-148 score) Parental Perceptions ECOHIS (13 items; 0-52 score) FIS (15 items; 0-60 score) All instruments measured the frequency of impacts

Analysis Strategies Descriptive Analyses Multivariate Analysis Population estimates Bivariate analysis ANOVA or chi-square statistics Multivariate Analysis Ordinary least squares regression Stepwise regression SAS software

Results Clinical or OHRQoL information was available for 6,088 children (response rate=79.2%) 5,300 (68.9%) children had complete information (child & parent questionnaires and child examination). 4,743 children had complete fluorosis and OHRQoL scores.

Demographics: Percent SEX Male: 46.8 Female: 53.1 AGE 5-7: 12.8 8-10: 29.5 ≥11: 57.5 ETHNICITY White non Hispanic: 59.9 Other non Hispanic: 31.3 Hispanic: 8.6 SES (FPL) =/< 100%: 28.0 >100-200%: 28.8 >200-300%: 14.2 >300-400%: 7.4 >400%: 21.4 URBAN CODE Metro: 58.4 Non-metro adjacent: 37.1 Non-metro non adjacent: 4.4

Percent Distribution of Population by Fluorosis Categories N Ant=1,174,231 N Post=1,204,515 N Comb=1,216,759

Prevalence of Fluorosis

Descriptive Analysis Mean OHRQoL scores by Fluorosis Categories and Scale Type

Descriptive Analysis Mean OHRQoL Scores by DMF Categories

Regression Analysis Results Controlling for these covariates: child ever had dental injury, treatment needed, unmet demand, dental home, race-ethnicity, percent poverty level, county urbanicity and parental education

Limitations The sample size of respondents with a definitive case of mild, moderate or severe fluorosis was small Can affect the precision of our estimates of the association between fluorosis in its severest form and OHRQoL We used different quality of life instruments and thus did not do the same analysis across all the respondents

Conclusions Enamel fluorosis was not associated with OHRQoL of either children or their families. Caries was significantly and negatively associated with OHRQoL in older children and parents of children of all ages. Fluorosis appears to be less of a psychosocial concern than dental caries. Risks of caries from exposure to too little fluoride might be of greater concern than risks of fluorosis from too much fluoride. More research is needed on the risks and benefits of fluoride exposure and how it is viewed by the public.

Thank You!