1. 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

2. 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

3. 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)

4. 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

5. 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

6. Sample Design
Stratified, cluster probability sample of k-12 classrooms during 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

7. 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

8. 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)

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

10. 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

11. 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.

12. 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
> %: 28.8
> %: 14.2
> %: 7.4
>400%: 21.4
URBAN CODE
Metro: 58.4
Non-metro adjacent: 37.1
Non-metro non adjacent: 4.4

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

14. Prevalence of Fluorosis

15. Descriptive Analysis Mean OHRQoL scores by Fluorosis Categories and Scale Type

16. Descriptive Analysis Mean OHRQoL Scores by DMF Categories

17. 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

18. 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

19. 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.

20. Thank You!