SUMMARY

Some dental health professionals manage and treat dental fluorosis as a simple cosmetic problem and not as a problem that affects the general health of patients. The reality is that dental fluorosis is the result of the toxic effect of fluoride on the cells of the teeth. But what is not taken into account is that the cells of the teeth are not the only cells affected by this phenomenon. A bibliographic comparison is made to deepen the understanding on the clinical characteristics of the effects of Fluorosis at the systemic level. It is concluded that fluorosis not only damages dental structures, therefore, it should not only be treated by the dentist because dental fluorosis represents only the earliest sign that the patient has been exposed to very high levels of fluoride.

INTRODUCTION

In the 1940s, it was discovered that water with high fluoride content generated a discoloration in the teeth that was not normal. Because of this discovery, several investigations were generated on the fluorine content in natural substances and how they were absorbed and metabolized by the organism as well as what manifestations and consequences were reflected in the body.
The severity of fluorosis is directly related to the eruption of the teeth and the amount of fluoride ingested. Long term ingestion of fluoride when the enamel is in formation is what produces the changes in the structure of the teeth from thin white lines to very serious defects in structure. This is better known as dental fluorosis.

Fluorosis is found in different specific geographical areas of the world. Fluorosis has endemic characteristics since it´s effects are permanent and occur at specific times.
In the United States and other countries Fluorosis has increased in prevalence and has almost become an epidemic in the last 50 years. The alarming thing is that not only is there increases in the number of cases but also in the severity of the condition. There is an increase in the damage to the enamel and a decrease in dental function in the most severe and advanced cases.
Some dental health professionals regard dental fluorosis as an aesthetic problem and not as a condition that can damage health. It is known that fluorosis has a toxic effect on the cells of the teeth but the issue is that other cells of the body are also seen to be affected by the toxicity of fluoride.
There are many questions on this subject as it is not well known. There is little literary evidence and there are different opinions from health professionals. It is important to know more about the signs and symptoms of this condition and to analyze all of the theoretical knowledge available in order to go deeper into the subject.

DISCUSSION

Dental fluorosis is an irreversible condition that appears as a result of excessive intake of fluoride during the time of development of the teeth, from birth to approximately 6-8 years. It is the first symptom that a person has been exposed to the excessive intake of fluoride. The ingestion of very high levels of fluoride damages the function of the cells that form the enamel, known as odontoblasts, and does not allow the enamel to mature properly. When enamel cells are damaged by fluoride, correct mineralization is affected, which results in hypomineralization or hypermineralization. This increases the porosity of the enamel. The damage is related to the amount of fluoride and the time at which the teeth was exposed to fluoride.

Dental Fluorosis causes a mottling in the teeth that is first observed as white spots that are pigmented to brown until they reach the mottled teeth. This condition leads to the initiation of the destruction of the enamel, thus helping the formation of cavities, non-carious cavities or other types of injuries. Depending on the severity of the fluorosis, the teeth becomes more porous in turn. The degree of fluorosis is related to the amount of Fluoride that exist during the eruption of the teeth. The more severe the Fluorosis is, the longer it takes the teeth to erupt, and the longer it takes the teeth to make their appearance in the mouth, and thus, the more serious and severe the damage from fluorosis will be.

In some countries the first mottled tooth is the first sign of fluoride poisoning, while in some other countries it is only taken as a non-serious cosmetic condition. It has been shown in studies that children with dental fluorosis present more respiratory diseases, bone and muscle, gastrointestinal diseases, nervous system disorders, mental disorders among others. Also, people with Fluorosis have a higher prevalence of cavities.

There are different degrees of fluorosis from mild to acute. In mild Fluorosis, white spots appear, while in the acute Fluorosis, the teeth are mottled or with major defects in the enamel. The degree of Fluorosis depends on the time the teeth had been exposed to fluoride during the maturation and development period.

Degrees of fluorosis:

Mild: striae or lines are formed on the surface of the teeth.
Moderate: the enamel presents opaque white spots and the teeth are resistant to decay.
Severe: the teeth have brown spots and the enamel is usually very brittle.
In the first two years of life we must avoid excess fluoride consumption since this would cause Fluorosis in the permanent dentition which begins between 5 to 7 years of age. In the early stages the teeth can be restored conservatively and a carbohydrate-free diet should preferably be taken so as not to aggravate the problem.
When there is an excess of fluoride, Bone Fluorosis and Osteoporosis can also occur.

DENTAL FLUROSIS IN DECIDUOUS TEETH

Fluorosis affects children and adolescents from various parts of the world. This creates a public health problem. Although Fluorosis affects both dentitions, it has not been well investigated at present, nor has much been described about Fluorosis in the deciduous dentition, which does not allow easy diagnosis. It is known that Fluorosis in the deciduous dentition is not as severe as in the permanent one. However, in endemic areas where the water contains high fluoride contents, severe fluorosis has been observed and with high incidence.

The fluorosis in the deciduous dentition is very different than in the permanent one. In the deciduous dentition the molars are more affected and the spots are mostly white, unlike the permanent one that shows more damage in the anterior teeth and with darker spots. This is because in the deciduous dentition the damage starts from the intrauterine life.

It is important to diagnose Fluorosis in the deciduous dentition since it precedes the fluorosis in the permanent dentition, and thus be able to take preventive measures by decreasing the intake of fluoride and thus not affect the permanent dentition or other cells of the body.

FLUROSIS AND DENTAL CAVITIES

The use of fluorides to prevent cariogenic activity is a very important discovery since it is one of the most effective and easy to use measures to prevent this disease. However, we must be very careful not to exceed the recommended concentrations to avoid causing Fluorosis.

Caries is a multifactorial disease that occurs in the vast majority of the population. Pathogens, diet and intraoral environment are among other factors that play a role in the development of caries.
Mainly the carbohydrates are converted into acids which demineralize the teeth. We add bad oral hygiene and lack of fluoride as a preventive measure and result in dental caries.

Dental caries is a very expensive pathology to treat and prevent and the human being is the one that most present it. Dentists are health professionals who are fully trained to treat the pathologies of the oral environment.

Dental Fluorosis occurs with the excessive consumption of this mineral, although the fluoride found in water and toothpastes helps the teeth to be more resistant against decay. An adequate intake of fluoride helps the teeth surface to be less vulnerable to dental caries, as well as a good brushing technique to remove the dentobacteriae plaque. The use of mouth rinses to reduce the amount of bacteria and a good diet free of carbohydrates and sucrose is helpful. In theory, the combination of all these measures will help to control and moderate the appearance of dental caries. Adequate dental development requires several nutrients such as calcium, phosphorus and vitamin D. Vitamin A and proteins help teeth growth and vitamin C helps maintain healthy gums. Fluoride helps keep teeth free of caries and is valued as the most important of all the nutrients.

It was shown that people who drink water with 1 to 2 parts per million of fluoride had less incidence to caries than those who consumed water with lesser amounts of fluoride. In cases with 1 part per million of fluorine the incidence was reduced in a 60-70%. Currently, each city can choose the level of fluoride in water according to their needs, but it is generally acceptable 1 ppm in urban water. The fluorination of water is one of the most important means of health since this protects the majority of the population. Health professionals are invited to support this measure whenever necessary. The fluorination is taken as an increase of the nutrient in the water so 1ppm is not considered unsafe or toxic for any person of any age so that human rights are not violated at any time.

There are other products with fluoride such as toothpastes, pills, among others, but none is as effective as water fluorination since the population in general sometimes does not have easy access to them.
There are places in the world like in India where the water contains 4ppm of fluoride which results in a high rate of Fluorosis in the population.

SIGNS OF FLUROSIS

Fluorosis causes effects on the dental and on the skeletal system. It is known that the effects of Fluorosis on the teeth occur before the effects on the skeletal system in people who have been exposed for a long time. For this reason it is extremely important to control the amount of fluoride in the water in each population.

The first signs are white spots, and in the most severe cases occurs in most enamel. But it is necessary for the dentist to know that not only fluoride is responsible for causing damage to the enamel or spots. It can also be due to malnutrition, deficiency of vitamins A, D and C and a poor diet of proteins.
It is also important that the health professional and the population in general is aware that after 6-7 years of age, fluoride can no longer cause dental fluorosis.

Skeletal fluorosis occurs when a person drinks water for long periods with excessive amounts of fluoride ranging from 4ppm to 15ppm. This has much more serious consequences such as back pain, stiffness, including neurological deformities. The first symptoms of this type of Fluorosis are joint pain and stiffness, but changes in bone structures and ligaments can also occur. It is believed that dental and skeletal Fluorosis affects many people in the world without distinction of sex and age.

It has been discovered that excess fluoride not only damages teeth and the skeletal system but also affects the digestive, urinary, reproductive, endocrine, immune systems and the central nervous system generating toxic and in some cases carcinogenic effects in cells.
Fluoride poisoning acutely is not very common and usually occurs accidentally. This causes abdominal pain, vomiting, nausea, excess saliva, in some cases muscle spasms, although its effect is different in each person.

SKELETAL SYSTEM: conditions in the sacrum and femur, osteoporosis, fractures among others.
RENAL SYSTEM: necrosis of renal tubules, nephritis and renal toxicity in general.
DIGESTIVE SYSTEM: stomach irritation and gastritis.
It is a fact that the sale of products with fluoride and the dosage of water without adequate control and extensive research are a danger for the population, since the damage that fluoride could cause is not yet fully known.

PREVENTION AND FLUOROSIS

At present it is not known exactly what is the mechanism of action of fluoride to prevent caries, but there are several hypotheses about this. It is said to decrease solubility, increase crystallinity and promote remineralization of hydroxyapatite. It acts as an enzyme inhibitor and is an antibacterial that reduces the cariogenic flora directly in the bacterial plaque. It inhibits the binding of proteins and bacteria, decreases the surface tension in the enamel surface. It can change the morphology of the teeth and delay its eruption. Although the mechanism of action is not completely known, it is said that fluoride helps the teeth to be more resistant to dissolution in acids, increases remineralization and decreases the cariogenic action of dentobacterial plaque.

ROUTES OF ADMINISTRATION

There are two routes of systemic and topical administration.
SYSTEMIC: fluoride is inert and goes to a systemic level deposited mainly in the bone system and teeth. Before the eruption is when we get the most benefit of fluoride in the mineralization and post-mineralization phases. To avoid fluoride toxicity, administration of low and continuous doses is necessary.
TOPICAL: its application is directly on the surface of the teeth once it has erupted, from 6 months of age it is already possible to start and continue throughout life and especially in periods of more vulnerability to decay.
Fluoride gel or solution is the most recommended for professional practice and at home toothpaste or mouth rinses. The method used must be specific for each patient taking into account the place where he lives, water supplies and whether caries index is low or high, because if all the measures are taken together could cause unwanted Fluorosis.

To prevent dental Fluorosis, it is necessary to avoid having two systemic fluoride routes. It is necessary to take into account that the daily consumption of salt contains fluoride. We must avoid the vitamin supplements that contain fluoride, children under six years do not have to rinse with fluoride, children under two years do not have to use toothpaste and after two years you have to use one with less fluoride content and use a minimum amount until the child knows how to rinse his mouth well and not swallow the paste.
It is recommended to periodically check with the dentist at least every 6 months, to control the consumption of salt in the house and not to increase the normal salt doses since no benefit is obtained from this.

CONCLUSIONS

Oral health specialists should not treat Fluorosis as a simple cosmetic problem since it is the first sign that the patient has been exposed to high levels of fluoride concentration.
Fluorosis is a global health problem that in addition to affecting dental structures, affects other body systems. Thus, when using it as a preventive measure against caries you have to be careful.
To give the best treatment to dental Fluorosis, we must know the causes and mechanisms that led us to the problem and thus treat each patient in the best way possible.


Treatment

The use of ENAMELIN mouthwash is the best treatment for Dental Fluorosis. ENAMELIN remineralizes teeth, strengthens teeth and completely eliminates dental hypersensitivity.