Fluorine is a common element abundant in the earth’s crust. Naturally, the mineral occurs in the soil, rocks, and water with higher concentrations in places that have experienced geologic uplift. Many industrial processes are dependent on fluorides due to their use. The primary source of systemic fluoride is exposure to food diets and fluoride-containing toothpaste or other dental products. One of the most significant achievements of the 20th century is community drinking water fluoridation to curb dental fluorosis. However, the decline in dental caries has been alongside increased dental fluorosis prevalence and side effects of excessive fluoride exposure.
Fluorine plays a critical role in the development and maintenance of teeth and skeleton. For teeth, excessive fluoride intake may lead to dental fluorosis, but adequate intake reduces dental caries. However, one needs to take fluoride within the limits as the effects can be detrimental to dental health. Fluorosis is a cosmetic condition that affects the teeth. It results from overexposure to fluoride during the first eight years of life. This period is when most permanent teeth are developing. After the teeth come out, those affected by fluorosis may appear to be mildly colored. For example, lacy white markings might be evident, which can be detected. Under severe cases, the teeth can have surface irregularities, pits that are noticeable and yellow strains. Dental fluorosis has been prevalent globally, with the United States recording 23% of people having the diseases. The effect of fluorosis can be embarrassing and difficult to treat. The high prevalence rates depict the disease as a significant population health issue requiring quick redress. The disease burden permeates the social, economic, and medical dimensions within the United States social milieu.
This review examines the existing literature on the spread of Dental Fluorosis due to the current Fluoride levels, the risk factors, and the practical mitigation approaches in the United States of America.
In a bid to unravel the proliferation of the disease in the United States, the relative impacts, and the mitigation measures, a literature search was conducted in various databases spanning PubMed, CINAHL, Google Scholar, and EMBASE. The search terms used included the prevalence of dental fluorosis in the US, the effects of excess fluoride on tap water, how fluoride causes dental fluorosis, and the effective mitigation of dental fluorosis. The criteria for journal selection included examining each article for original research on dental fluorosis in the United States, including human subjects, and publication within the past five years, i.e., between 2017 – 2021. The results yielded over 3800 research trials; upon eliminating duplicates, the journals were examined for inclusion in human subjects bringing the value to 1375, and a check on the publication dates resulted in 337 journals. The remaining articles were then reviewed to identify original research in the United States, bringing the value to 49. Out of the 49, the most 15 relevant articles were selected for analysis.
To adequately address the research problem, the findings were divided into sections spanning the emergence and prevalence of the disease in the United States, its risk factors, the relative impacts, and interventions. It was envisaged that the above approach would offer a clear perspective of the disease burden in the US and new strategies to curb its spread.
Emergence and Prevalence of Dental Fluorosis
Research on the prevalence and severity of dental fluorosis commenced in 1986 and progressed through 2012. The research outcomes revealed trends of disease progressions and their severity within the social scene. The initial findings showed that between 1986 -1987, the disease prevalence rate stood at 22%. This implies that approximately 22% of the population suffered from the condition. Males exhibited higher prevalence at 22.9% compared to females at 20.6%. Notably, the blacks in the United States had the highest disease burden of 25.4% compared to the whites with 21.6%. Finally, the disease prevalence was analyzed through the lens of socioeconomic status in the United States. The disease burden was highest among the poorest of the population at 26%, followed by the averagely poor population at 19.4%, and followed closely by the non-poor population at 18.9%. The above findings reveal that dental fluorosis had not spread mainly in the United States and was felt primarily by people on the lower social strata. The prevalence gap between black and white communities was equally not high, indicating that the disease was spreading equally in the nation.
The subsequent study was conducted by the National Health and Nutrition Examination Survey (NHANES) between 1999-2004. The prevalence rate in 2004 stood at 41.2%, an almost double increase from the rates witnessed in 1987. The males exhibited slightly higher disease infection rates at 41.9% compared to the females at 40.5%. The blacks showed higher rates of infection at 57.9% compared to the whites at 36.1%. In terms of socioeconomic trends, the middle class emerged highest at 43.6%, followed by the poorest at 41.5%, and the not-poor population at 38.3%. The above findings reveal that the disease prevalence to have doubled in the subsequent years. The data shows consistencies in the disease emergence trends, indicating that the condition has increasingly been spreading in the United States. In a different study, the dental fluorosis trends in the United States revealed a rising trend of progression that peaked between the years 2011 and 2012. The Community Fluorosis Index (CFI) shows the lowest values in the 1940s and highest values in 2012, indicating that the disease progression had increased within the social scene.
In final research by the National Health and Nutrition Examination Survey (NHANES), the rates of disease progression had risen further to 64.7%. Unlike previous research, the females emerged highest in the prevalence cases, with values of 66.6% compared to males at 62.9%; in terms of race, the whites exhibited higher rates of 69.3% compared to 65.3% for blacks. Finally, the non-poor groups showed the highest scores in the disease burden at 69.5%, followed by the middle class at 62.5%, and ultimately the poorest at 59.5%. The findings, in this case, reveal a twist in the prevalence trends. The groups that initially exhibited minimal spread in the past research suddenly showed major improvements, which indicated a rise in the occurrence rates. The periods between 1986 to 2012 reveals the changes in trends of the disease occurrences. These rising levels of fluoride in drinking water account for the prevalence within the social scene. Over the years, the exposure of the United States population groups to water with high fluoride levels predisposed the groups to dental fluorosis.
Risk Factors for the Disease
Risk factors for dental fluorosis have also been examined in multiple research. The risk factors include the use of fluoridated drinking water, high intake of fluoride supplements, and the use of infant formulas before the attainment of 10 years. The increased exposure of children to the above risk factors could account for disease prevalence within the social scene. This section delves into each of the above risk factors and possible relationships with the observed trends of the disease spread in the United States. A succinct understanding of the risk factors would offer a clear perspective of the disease and its relative impacts on the social and economic status of the affected population groups.
The use of fluoridated water results in the excessive deposit of chloride when the permanent teeth are forming. Fluoride plays an integral role in the process of teeth formation in children. It mixes with the tooth enamel, leading to a hard coating on the teeth. Excessive fluoride translates to an increased fluoride deposit on the enamel structure, leading to pits and spots. In the United States, fluoride levels in drinking water have been set at 0.40 mg/dL; however, study findings revealed that tap water had fluoride levels of 0.49 mg/dL compared to bottled water fluoride levels below 0.40 mg/dL. The distinction in the fluoride levels in water accounts for the rising prevalence rates in the United States. Majority of children below the age of 8 risks developing the disease, which adversely affects their dental health.
The high intake of fluoride supplements also constitutes a significant risk factor. Fluoride supplements are often administered in the form of tablets, lozenges, or liquids to aid in strengthening the bones. Excessive use or intake of supplements has emerged as a critical threat to users’ health, especially children under the age of 10. The excess fluoride gets deposited into the enamel leading to the disease. In the United States, fluoride supplements have been used over the years as remedies for certain conditions. The supplements are administered to prevent tooth decay in children and other vulnerable groups. Despite the increased use of the supplements as effective interventions, studies have shown that they increase vulnerability to dental fluorosis. The state should examine the supplements and enact policies for safe use; this would ensure that only recommended doses are provided.
Finally, infant formulas have been perceived among the causative factors for the disease. Infant formulas comprise foods meant for babies under 12 months. They are often in powdered form and contain numerous minerals to aid in forming major body parts. One of the significant component minerals is fluoride. Certain studies have established that increased exposure to the minerals predisposes the children to dental fluorosis. The excessive deposit of fluoride causes the teeth to become brittle, develop spots, and fail to develop properly. The use of infant formulas is widespread in the United States among mothers that do not wish t breastfeed for lengthy periods. The government should examine the infant formulas, determine their components, and further regulate their quantity to the recommended levels. The above risk factors reveal the increased predisposition of children to public health issues.
The deplorable findings in the past research have led to various measures to eradicate the vice from the social scene. Some of the significant interventions against the public health issue include setting standards for fluoride levels in drinking water to prevent the disease prevalence, alongside the creation of awareness on the ideal approaches for preventing dental fluorosis among the vulnerable groups. Notably, multiple techniques such as teeth whitening and crowns have been used to treat the condition. Through the Department of Health and Human Services Federal Panel, the measures instituted by the United States government have been objective and aimed at eliminating the vice. Nonetheless, the prevalence rates have risen over the years.
The impacts of dental fluorosis have equally been researched in multiple studies. The key areas of impact include quality of life for the affected patients. A tool known as the oral health-related quality of life (OHRQoL) was used to determine the effects of the disease. The research findings revealed that the OHRQoL significantly diminished, indicating the adverse impacts of the public health issue. The effect of dental fluorosis was also assessed through the lens of the psychological, perceptional, and social impact. Regarding the psychological impacts, the affected students experienced demeaned self-esteem and increased anxiety while interacting with cohorts in schools and other environmental settings. The social impacts hinge on factors such as bullying and isolation of the affected groups within the social scene. The students lack confidence in their social life and cannot properly fit into the social scene. The research study among affected students also revealed a significant reduction in their performance. The feeling of indifference caused by the conditions lowered their self-esteem and the ability to mingle freely with the other students at the learning institutions. The result is a decrease in the interest to attend school and low performance in the given subjects. The above impacts pose a significant threat to the wellbeing of the victims; the disease is detrimental to their social and psychological wellbeing, and failure to incorporate effective mitigation measures could escalate the adverse impacts.
Impacts of the Disease
Dental fluorosis remains a significant public health threat in the United States and worldwide. The challenge that mainly affects children and the effects into adulthood has become a major public health issue. The adverse impacts span social, economic, and psychological paradigms. Individuals affected by the menace suffer from low self-esteem and fail to adapt to public lives appropriately. Notably, the affected persons often experience rejection and marginalization due to their inferior condition. This section analyzes the impacts through the lens of the social, economic, and psychological challenges.
Social challenges stemming from the disease impact include reduced self-esteem, predisposition to bullying, and discrimination. The reduction in self-esteem stems from the deterioration in their public images. Children with discolored teeth are often ridiculed by others within the social scenes; such children suffer from a dent in their self-images which translates to low self-esteem. Bullying has become a major subject in the contemporary scene; teeth discoloration predisposes children to abuse by others. The bullies take advantage of their conditions to make fun of their body images. Such bullying may also occur on social media, where the pictures posted by such persons are subjected to body shaming to make them behave in a given manner. On the other hand, discrimination occurs when the individuals are negatively stereotyped based on their conditions. This results in low perceptions of their body images leading to a decline in self-esteem. Eliminating the disease would enable the prospects to gains self-confidence and lean normal lifestyles.
Economic impacts stem from the costs incurred in treating the disease. The data findings revealed that the most affected people comprise the poor population that lacks access to quality drinking water. The high disease prevalence places an economic burden on the individuals, causing them to spend large sums of money receiving treatments such as tooth whitening, bonding, and crowns. The tooth whitening procedure removes surface stains on the teeth resulting in sparkling white teeth. The procedure is costly and may only be adequately accessible to people on top of the social strata. Bonding entails teeth coating using a hard resin to protect the enamel; the process costs approximately $300 – $600 per tooth. Such costs are not easily affordable by the largely affected poor population.
The disease may also cause psychological challenges among the affected groups. The psychological challenges stem from the constant trolling, discrimination, and body shaming of the individuals. As a result, they develop depression and anxiety, leading to mental disorders. The depressive symptoms could escalate to suicide ideation or become severe, resulting in poor performance in daily activities of living. For instance, if the affected parties are children, the depressive symptoms may freely affect their ability to interact with other children within the social scene.
In mitigating the dental fluorosis threat, interventions such as water fluoridation, the introduction of fluoride toothpaste, and dietary changes have been implemented in the United States. The above interventions exhibited significant impacts in reducing the disease progression. The country further engaged in awareness creation about the prevalence and dangers of the disease, causing the public members to exercise caution to mitigate the disease. Agencies such as the World Health Organization have also sponsored numerous researches to offer a clear perspective of the disease. The review findings, however, reveal that the interventions have not yielded effective results. The government needs to institute a raft of measures to ensure complete eradication of the vice.
The gist of the review premised on examining the existing literature regarding the prevalence, risk factors, impacts, and mitigation approaches used against the disease in the United States. The prevalence rates have risen over the years, with the values standing at 22% in 1987, 41.2% in 2004, and 64.7% in 2012. The rising trend reveals the inefficiency of the existing interventions. The risk factors include the use of fluoridated drinking water, high intake of fluoride supplements, and the use of infant formulas before the attainment of 10 years. The disease impacts span the social, economic, and psychological dimensions. Finally, the mitigation approaches include water fluoridation, changes in diet, use of fluoride toothpaste, and awareness creation on the disease prevalence have been used. The existing interventions are not efficient, and more effective approaches are necessary.