Preference Of Parents Towards The Type Of Topical Fluoride Application For Children With Permanent Dentition
R. Saishree Anchana1, Vignesh Ravindran2*
1 Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai- 77, India.
2 Senior Lecturer, Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical
Sciences [SIMATS], Saveetha University, Chennai- 77, India.
*Corresponding Author
Vignesh Ravindran,
Senior Lecturer, Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences [SIMATS], Saveetha
University, Chennai- 77, India.
Tel: +91-9789934476
E-mail: vigneshr.sdc@saveetha.com
Received: September 13, 2021; Accepted: September 22, 2021; Published: September 23, 2021
Citation:Prathiba Reichal, Vignesh Ravindran. Preference Of Parents Towards The Type Of Topical Fluoride Application For Children With Permanent Dentition. Int J Dentistry Oral Sci. 2021;8(9):4544-4548. doi: dx.doi.org/10.19070/2377-8075-21000925
Copyright: Vignesh Ravindran©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Introduction: Topical fluoride application helps in preventing tooth erosion and prevents caries. This fluoride is incorporated
with the tooth structure in the form of fluorapatite crystals thereby making the surface more resistant to acid dissolution.
Fluoride helps in restricting plaque metabolism, alters plaque composition and reduces the activity of plaque to produce large
amounts of acid from carbohydrates.
Materials and Method: the current study was done under a university setting of Saveetha Dental College as a retrospective
study. The total sample size after eliminating bias is 917. Inclusion criteria includes patients with an age group 13-17 years who
all underwent topical fluoride application while exclusion criteria includes unclear photographs of fluoride application and
error data. SPSS software is used for statistical data analysis with the Chi-square test.
Results and Discussion: The results of the current study shows that parents of both male and female pediatric patients
prefer topical fluoride gel (99%) application over varnish (0.9%). There was no difference in the preference based on gender
of the patient (p-value > 0.05).
Conclusion: The current study concludes that parents of both male and female paediatric permanent dentition patients prefer
the usage of topical fluoride gel due to its effective post-treatment action.
2.Introduction
3.Materials and Methods
3.Results
4.Discussion
5.Conclusion
5.References
Keywords
Topical Fluoride; Innovative Method; Permanent Dentition; Dental Caries.
Introduction
Dental caries is described as one of the chronic diseases all around
the world and otherwise it is referred to as tooth decay. This caries
develops either in the crown or roots of the tooth and can arise
at an early childhood stage thereby affecting the primary dentition
of children [1]. These dental caries are caused by the interaction
between the acid-producing bacteria, fermentable carbohydrates
and other host factors that come in contact with the tooth [2]. It
is a kind of biofilm mediated, multifactorial, sugar driven disease
that results in demineralisation of the tooth structure and undergoes
phases of remineralisation of dental hard tissues [3]. The
initiation and progression of dental caries are caused by imbalance
in the pathological and protective factors. Dental caries is
referred to as a preventable disease with substantial economic and
quality of life burdens [4]. Previous studies have documented the
substantial decline of caries prevalence among highly industrialised
countries around the world with reduction of lifetime caries
experience exceedingly more than 75% [5]. Many articles depicted
that the prevalence of dental caries around the world is found to
be 60%-90%, that is six to nine children out of 10 are affected by
dental caries [6]. The progression of caries differs within countries,
economic status, education and employment. The progressive
destruction of dental tissues is accompanied with severe pain
and suffering [7]. This dental caries can be prevented by bringing
up slight changes in the diet and nutrition of the individual [8]. It
can also be prevented by application of fluoride gel and varnishes
[9].
Around the developing countries, application of fluoridated toothpastes was found to reduce the incidence of dental caries
and thereby prevent the dental tissues [10]. The use of fluoridated
toothpaste came into practise and was officially endorsed by
WHO in the 1960's [11]. Fluoride is also added in drinking water
for increasing the amount of fluoride in the body. There is a successful
reduction in incidence of dental caries in many countries
that began from 1940 [12]. Fluoridated salt and water also plays
an important role in decreasing the incidence and progression of
dental caries [13]. Oral fluoride applicants are of two types. One
is biological reservoirs in which fluoride interacts with the bacteria
by forming calcium bonds [14]. The other type is mineral reservoirs.
This type is known as phosphate contaminated “calcium
fluoride like deposit” [15]. The content of fluoride reservoirs are
found to be increased through topical fluoride application by using
novel procedures [16]. This fluoride therapy is low-cost and is
an easily operated treatment that is used to arrest active dental caries
[17]. This fluoride is incorporated with the tooth structure in
the form of fluorapatite crystals thereby making the surface more
resistant to acid dissolution [18]. Fluoride inhibits the process of
demineralisation, and enhances the speed of enamel remineralisation
along with increase in the mineral content of affected teeth
[19]. Fluoride helps in restricting plaque metabolism, alters plaque
composition and reduces the activity of plaque to produce large
amounts of acid from carbohydrates [20]. Though the complete
mechanism of fluoride action is unknown, it is generally acknowledged
that fluoride has an effect on the tooth surface.
The other commonly used sources of fluoride are through toothpaste,
diet, fluoride supplements, water supply in developed countries,
dentifrice, and fluoridated toothpaste and fluoride varnish
[21]. Systemically taken fluoride is through fruit juices, carbonated
fluoride, infant formulas and certain cereals contain fluoride
within them [22]. Previous studies have stated that the application
of topical fluoride in combination with the use of fluoridated
toothpaste have achieved a modest decrease of dental caries when
compared with use of fluoridated toothpaste alone [23]. The application
of topical fluoride should be considered only after the
overall review of patient general health and vulnerability to diseases.
Our team has extensive knowledge and research experience
that has translate into high quality publications [24-36, 37-43].
The aim of this study is to analyse the preferences of fluoride
application for children with permanent dentition.
Materials and Methods
The current study was a retrospective study that is conducted under
a university setting in the outpatient department of Paediatric
and Preventive Dentistry, Saveetha Dental College. The advantages
of this study include the population of various strata of society
and available data while the disadvantages include the study being
unicentric, geographical trends that cannot be assessed. Ethical
approval was obtained from the institutional committee (ethical
approval number: SDC/SIHEC/DIASDATA). Data that is procured
by reviewing patient records and analysed data of patients
from June 2019 to February 2021. The total case sheets analysed
for the study were 1,52,890. To eliminate bias, simple random
sampling was done to narrow down the sample size to 917. Verification
of the data was done with the presence of additional
reviewers procedure notes and photographs of application of
fluoride. Stratification and randomisation were done to minimise
sampling error. Data that were incomplete were excluded. The
obtained data were tabulated in excel systematically. Data were
then entered in the SPSS analysis software and descriptive analysis
and correlation statistics (chi-square test) were performed. The
obtained results were tabulated and graphically represented.
Results
Among the study participants, 26.9% and 22.2% of patients
belong to the age of 13 and 17 respectively. 15.7%, 16.9% and
18.2% of patients are with an age group of 14, 15 and 16 (figure
1). Among them 50.6% and 49.2% of patients were male and female
children respectively while 0.11% was transgender (figure 2).
99% of patient’s parents preferred topical fluoride gel application
while 0.9% of patient’s parents preferred topical fluoride varnish
application (figure 3). There was no difference in the preference
based on gender of the patient (figure 4). Pearson’s chi-square
test was done and the p-value was found to be 0.266 which was
statistically not significant.
Figure 1. The graph represents the age group of the patients with the application of topical fluoride. The X-axis represents the age of the patients while the Y-axis represents the percentage of patients with topical fluoride application. 26.7% and 22.3% of patients belong to the age of 13 and 17 respectively. 15.7%, 16.9% and 18.1% of patients are with an age group of 14, 15 and 16.
Figure 2. The graph represents the percentage of patients who underwent topical fluoride application in respect to their gender. The X-axis represents the gender and Y-axis represents the percentage of patients with topical fluoride application. 50.9% and 49% of patients belong to male and female respectively.
Figure 3. The graph represents the prevalence of type of topical fluoride application treatment. The X-axis represents the different types of fluoride application treatment and Y-axis represents the percentage of prevalence of the type of fluoride application treatment. 99% of patient’s parents preferred topical fluoride gel application that is indicated by blue color while 0.9% of patient’s parents preferred topical fluoride varnish application that is depicted by yellow color.
Figure 4. The graph represents the correlation between the percentage of patients with fluoride gel and varnish application with respect to their gender. The X-axis represents the gender of the patients and Y-axis represents the percentage of patients with fluoride application. Blue color indicates the prevalence of parents about the use of topical fluoride gel that was observed to be 48.8% in female patients and 50.2% in male patients. Similarly, the preference of parents for the application of fluoride varnish was found to be 0.22% in female and 0.76% in male patients. There was minimal difference in the preference based on gender of the patient. Pearson’s chi-square test was conducted and the p-value is found to be 0.268 which is statistically not significant.
Discussion
The Council of Scientific Affairs (CSA) of the American Dental
Association (ADA) issued recommendations for the professional
application of topical fluorides for prevention of caries. Topical
fluorides are mostly found to be incorporated in toothpaste due
to their defensive properties against caries [44]. These fluorides
are applied for children whose teeth comprehend certain structural
defects or those who exhibit decalcified areas with high risk
for caries development. Patients with early childhood caries are
highly prone for application of topical fluoride treatment other
than fluoridated toothpastes [45]. This accounts for the current
study stating that application of topical fluoride is predominantly seen in 13 year old children that is followed by 17, 16, 15 and 14
years of age with permanent dentition. Previous studies have reported
that parents preferred the use of topical fluoride gel application
in children which is found to be the most effective method
of preventing early childhood caries than fluoride rinse or varnish
[46]. The current study is on par with the former study affirming
that fluoride gel application preference is higher when compared
to that of fluoride varnish. Application of topical fluoride gel has
supplementary advantages since it acts by restoring the minerals
to tooth surfaces. Fluorides does not help in removal of caries,
rather it creates a strong outer surface over the tooth that prevents
the decay from further penetrating into the surfaces [47].
The only disadvantage of topical fluoride gel is the treatment time
is 6 minutes whereas for topical fluoride varnish it is 2minutes.
this time consumption is due to the technique of application of
fluoride gel using trays [48].
The concentrated form of topical fluoride is referred to as fluoride
varnish which has a concentration of 22,600ppm (2.26%)
that is applied to tooth structures by using small brushes with
sodium fluoride as its active ingredient. The use of fluoride varnish
is the application time that is shorter than fluoride gel, since
shorter duration procedures are well tolerated by pediatric patients.
Similarly, fluoride varnishes can be applied by both dental
and non-dental health care professionals with a variety of settings
[49]. The only risk factor that is attained in fluoride application
is the development of fluorosis where there is an ingestion of
fluoride into the developing bone and tooth structures [50]. The
other way of application of fluoride is by the over-the-counter
fluoride rinse that has a lower concentration of sodium fluoride
when compared to gel and varnishes. This rinse is not recommended
for children with primary and mixed dentition since there is a high risk for swallowing the rinse water and limited ability to
rinse and spit [51]. The other risk factor of application of fluoride
supplements is fluoride toxicity, that is rarely and particularly seen
in children due to ingestion of large quantities of fluoride supplements.
The lethal dose of fluoride in children is found to be
between 8 and 16mg/kg [52].
The advantages of this study imply that this study was performed
with available data and population of variant economic stature.
The limitations of the study include that it was performed as a
unicentric study, smaller sample size, unequal distribution and
geographical trends not assessed. Larger sample size and different
ethnicity of the participating patients can yield better results. It is
also essential to create awareness of the importance of fluoride
with respect to various factors such as control early childhood
caries, reduce caries risk in children among parents and the general
population.
Conclusion
Within the limits of the present study, fluoride gel was more preferred
by the parents of children with permanent dentition. There
was no gender based preference noticed. Furthermore studies
have to be conducted with increased sample size to affirm this
statement with significant statistical data reports.
Acknowledgement
The authors are thankful to the department of pediatric dentistry,
saveetha dental college and Hospitals, Saveetha Institute of Medical
and Technical Science, Saveetha University for providing a
platform in expressing their knowledge.
Source of Funding
The present project was sponsored by
• Saveetha Dental College,
• Saveetha Institute of Medical and Technical science (SIMATS),
• Saveetha University and
• Loyola higher secondary school, cheyyur.
References
-
[1]. Marinho VC. Applying prescription-strength home-use and professionally
applied topical fluoride products may benefit people at high risk for caries
- the American Dental Association (ADA) 2013 clinical practice guideline
recommendations. J Evid Based Dent Pract. 2014 Sep;14(3):120-3.Pubmed
PMID: 25234211.
[2]. Petersen PE, Ogawa H. Prevention of dental caries through the use of fluoride-- the WHO approach. Community Dent. Health. 2016 Jun;33(2):66-8. PMID: 27352461.
[3]. Carey CM. Focus on fluorides: update on the use of fluoride for the prevention of dental caries. J Evid Based Dent Pract. 2014 Jun 1;14:95-102. [4]. Petersen PE, Lennon MA. Effective use of fluorides for the prevention of dental caries in the 21st century: the WHO approach. Community Dent Oral Epidemiol. 2004 Oct;32(5):319-21.
[5]. Gibbons RJ, Houte JV. Dental caries. Annu Rev Med. 1975 Feb;26(1):121- 36.
[6]. Caries D. Selwitz RH, Ismail AI, Pitts NB. Lancet. 2007;369:51–9. [7]. Marthaler TM. Changes in dental caries 1953-2003. Caries Res. 2004 May- Jun;38(3):173-81.Pubmed PMID: 15153686.
[8]. Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al. Dental caries. Nat. Rev. Dis. Primers. 2017 May 25;3(1):1-6. [9]. Featherstone JD. Dental caries: a dynamic disease process. Aust Dent J. 2008 Sep;53(3):286-91.
[10]. Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007 Jun;35(3):170-8.
[11]. Zero DT. Dental caries process. Dent Clin North Am. 1999 Oct 1;43(4):635-64.
[12]. Al-Ansari MM, Al-Dahmash ND, Ranjitsingh AJA. Synthesis of silver nanoparticles using gum Arabic: Evaluation of its inhibitory action on Streptococcus mutans causing dental caries and endocarditis. J Infect Public Health. 2021 Mar;14(3):324-330.Pubmed PMID: 33618277.
[13]. Kidd EA, Fejerskov O. Essentials of dental caries. Oxford University Press; 2016:2016.
[14]. Chauncey HH, Glass RL, Alman JE. Dental caries. Caries Res. 1989;23(3):200-5.
[15]. Wong MC, Glenny AM, Tsang BW, Lo EC, Worthington HV, Marinho VC. Topical fluoride as a cause of dental fluorosis in children. Cochrane Database of Systematic Reviews. 2010(1) ;20;(1):CD007693.
[16]. Richards D. Fluoride gel effective at reducing caries in children. Evid Based Dent. 2015 Dec;16(4):108-9.
[17]. Shah N. Dental caries: the disease and its clinical management. Br. Dent. J. 2009 May;206(9):640.
[18]. Marinho VC, Higgins JP, Sheiham A, Logan S. One topical fluoride (toothpastes, or mouthrinses, or gels, or varnishes) versus another for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2004;1.
[19]. Shah S, Bhaskar V, Venkataraghavan K, Choudhary P, Ganesh M, Trivedi K. Efficacy of silver diamine fluoride as an antibacterial as well as antiplaque agent compared to fluoride varnish and acidulated phosphate fluoride gel: an in vivo study. Indian J Dent Res. 2013 Sep-Oct;24(5):575-81.Pubmed PMID: 24355958.
[20]. Davies G. Topical fluoride for preventing caries in children and adults. Dental Nursing. 2010 Jul;6(7):372-6.
[21]. Harris R. Observations on the effect of topical sodium fluoride on caries incidence in children. Aust Dent J. 1959;4:257-60.
[22]. Marinho V. Fluoride gel inhibits caries in children who have low caries-risk but this may not be clinically relevant. Evid Based Dent. 2004 Dec;5(4):95. [23]. Marinho VC, Higgins JP, Sheiham A, Logan S. Combinations of topical fluorides (varnishes, gels, rinses, toothpastes) versus one topical fluoride for preventing dental caries in children and adolescents. Cochrane Database Syst. Rev. 2000;1.
[24]. Subramanyam D, Gurunathan D, Gaayathri R, Vishnu Priya V. Comparative evaluation of salivary malondialdehyde levels as a marker of lipid peroxidation in early childhood caries. Eur J Dent. 2018 Jan-Mar;12(1):67-70. Pubmed PMID: 29657527.
[25]. Ramadurai N, Gurunathan D, Samuel AV, Subramanian E, Rodrigues SJ. Effectiveness of 2% Articaine as an anesthetic agent in children: randomized controlled trial. Clin Oral Investig. 2019 Sep;23(9):3543-50.
[26]. Ramakrishnan M, Dhanalakshmi R, Subramanian EMG. Survival rate of different fixed posterior space maintainers used in Paediatric Dentistry - A systematic review. Saudi Dent J. 2019 Apr;31(2):165-172.Pubmed PMID: 30983825.
[27]. Jeevanandan G, Thomas E. Volumetric analysis of hand, reciprocating and rotary instrumentation techniques in primary molars using spiral computed tomography: An in vitro comparative study. Eur J Dent. 2018 Jan- Mar;12(1):21-26.Pubmed PMID: 29657521.
[28]. Princeton B, Santhakumar P, Prathap L. Awareness on Preventive Measures taken by Health Care Professionals Attending COVID-19 Patients among Dental Students. Eur J Dent. 2020 Dec;14(S 01):S105-S109.Pubmed PMID: 33321549.
[29]. Saravanakumar K, Park S, Mariadoss AVA, Sathiyaseelan A, Veeraraghavan VP, Kim S, et al. Chemical composition, antioxidant, and anti-diabetic activities of ethyl acetate fraction of Stachys riederi var. japonica (Miq.) in streptozotocin-induced type 2 diabetic mice. Food Chem Toxicol. 2021 Sep;155:112374.Pubmed PMID: 34186120.
[30]. Wei W, Li R, Liu Q, Seshadri VD, Veeraraghavan VP, Mohan SK, et al. Amelioration of oxidative stress, inflammation and tumor promotion by Tin oxide-Sodium alginate-Polyethylene glycol-Allyl isothiocyanate nanocomposites on the 1, 2-Dimethylhydrazine induced colon carcinogenesis in rats. Arab. J. Chem. 2021 Jun 3;14(8):103238.
[31]. Gothandam K, Ganesan VS, Ayyasamy T, Ramalingam S. Antioxidant potential of theaflavin ameliorates the activities of key enzymes of glucose metabolism in high fat diet and streptozotocin - induced diabetic rats. Redox Rep. 2019 Dec;24(1):41-50.Pubmed PMID: 31142215.
[32]. Su P, Veeraraghavan VP, Krishna Mohan S, Lu W. A ginger derivative, zingerone- a phenolic compound-induces ROS-mediated apoptosis in colon cancer cells (HCT-116). J Biochem Mol Toxicol. 2019 Dec;33(12):e22403. Pubmed PMID: 31714660.
[33]. Mathew MG, Samuel SR, Soni AJ, Roopa KB. Evaluation of adhesion of Streptococcus mutans, plaque accumulation on zirconia and stainless steel crowns, and surrounding gingival inflammation in primary molars: randomized controlled trial. Clin Oral Investig. 2020 Sep;24(9):3275-3280.Pubmed PMID: 31955271.
[34]. Sekar D, Johnson J, Biruntha M, Lakhmanan G, Gurunathan D, Ross K. Biological and clinical relevance of microRNAs in mitochondrial diseases/ dysfunctions. DNA Cell Biol. 2020 Aug 1;39(8):1379-84.
[35]. Velusamy R, Sakthinathan G, Vignesh R, Kumarasamy A, Sathishkumar D, Priya KN, et al. Tribological and thermal characterization of electron beam physical vapor deposited single layer thin film for TBC application. Surf Topogr: Metrol Prop. 2021 Jun 24;9(2):025043.
[36]. Aldhuwayhi S, Mallineni SK, Sakhamuri S, Thakare AA, Mallineni S, Sajja R, et al. Covid-19 Knowledge and Perceptions Among Dental Specialists: A Cross-Sectional Online Questionnaire Survey. Risk Manag Healthc Policy. 2021 Jul 7;14:2851-2861.Pubmed PMID: 34262372.
[37]. Sekar D, Nallaswamy D, Lakshmanan G. Decoding the functional role of long noncoding RNAs (lncRNAs) in hypertension progression. Hypertens Res. 2020 Jul;43(7):724-725.Pubmed PMID: 32235913.
[38]. Bai L, Li J, Panagal M, M B, Sekar D. Methylation dependent microRNA 1285-5p and sterol carrier proteins 2 in type 2 diabetes mellitus. Artif Cells Nanomed Biotechnol. 2019 Dec;47(1):3417-3422.Pubmed PMID: 31407919.
[39]. Sekar D. Circular RNA: a new biomarker for different types of hypertension. Hypertens Res. 2019 Nov;42(11):1824-5.
[40]. Sekar D, Mani P, Biruntha M, Sivagurunathan P, Karthigeyan M. Dissecting the functional role of microRNA 21 in osteosarcoma. Cancer Gene Ther. 2019 Jul;26(7-8):179-182.Pubmed PMID: 30905966.
[41]. Duraisamy R, Krishnan CS, Ramasubramanian H, Sampathkumar J, Mariappan S, Navarasampatti Sivaprakasam A. Compatibility of Nonoriginal Abutments With Implants: Evaluation of Microgap at the Implant-Abutment Interface, With Original and Nonoriginal Abutments. Implant Dent. 2019 Jun;28(3):289-295.Pubmed PMID: 31124826.
[42]. Parimelazhagan R, Umapathy D, Sivakamasundari IR, Sethupathy S, Ali D, Kunka Mohanram R, et al. Association between Tumor Prognosis Marker Visfatin and Proinflammatory Cytokines in Hypertensive Patients. Biomed Res Int. 2021 Mar 16;2021:8568926.Pubmed PMID: 33816632.
[43]. Syed MH, Gnanakkan A, Pitchiah S. Exploration of acute toxicity, analgesic, anti-inflammatory, and anti-pyretic activities of the black tunicate, Phallusia nigra (Savigny, 1816) using mice model. Environ Sci Pollut Res Int. 2021 Feb;28(5):5809-5821.Pubmed PMID: 32978735.
[44]. Weyant RJ, Tracy SL, Anselmo TT, Beltrán-Aguilar ED, Donly KJ, Frese WA, et al. Topical fluoride for caries prevention. J. Am. Dent. Assoc. 2013 Nov 1;144(11):1279-91.
[45]. Ritter AV, de Dias WL, Miguez P, Caplan DJ, Swift Jr EJ. Treating cervical dentin hypersensitivity with fluoride varnish. J. Am. Dent. Assoc. 2006 Jul 1;137(7):1013-20.
[46]. Akbar AA, Al-Sumait N, Al-Yahya H, Sabti MY, Qudeimat MA. Knowledge, Attitude, and Barriers to Fluoride Application as a Preventive Measure among Oral Health Care Providers. Int J Dent. 2018 Apr 16;2018:8908924. Pubmed PMID: 29849638.
[47]. Clark MB, Slayton RL. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014 Sep 1;134(3):626-33.
[48]. Clark MB, Keels MA, Slayton RL. Fluoride Use in Caries Prevention in the Primary Care Setting. Pediatrics. 2020 Dec 1;146(6).
[49]. Maguire A. ADA clinical recommendations on topical fluoride for caries prevention. Evid Based Dent. 2014 Jun;15(2):38-9.
[50]. Newbrun E. Current regulations and recommendations concerning water fluoridation, fluoride supplements, and topical fluoride agents. J Dent Res. 1992 May;71(5):1255-65.Pubmed PMID: 1607443.
[51]. Osuji OO, Leake JL, Chipman ML, Nikiforuk G, Locker D, Levine N. Risk factors for dental fluorosis in a fluoridated community. J Dent Res. 1988 Dec;67(12):1488-92.Pubmed PMID: 3198847.
[52]. Mascarenhas AK. Risk factors for dental fluorosis: a review of the recent literature. Pediatr Dent. 2000 Jul 1;22(4):269-77.
