Dental fluorosis, unguided flouride dosing and oral health advocacy practitioners perception of the emerging paradigm

Madukwe I. U

*Department of Oral Surgery and Pathology College of Medical Science,
University of Benin, Nigeria

ABSTRACT
Background
Oral health day is an international day to highlight the benefits of a healthy mouth and to promote worldwide awareness of issues around oral health.  In Nigeria oral health policy was developed by the Federal Ministry of Health, approved by the National Council on Health and launched in November 2012.
Objectives
Fluoride is a topical issue world over. Knowledge of sources of fluoride is a pre-condition to adjusting of the existing natural occurring fluoride level in drinking water.
Materials and methods
 259 questionnaires were administered to oral health practitioners in University of Benin Teaching Hospital, Consultants through Senior Registrars to Dental students.  182 (70.27%) were returned.  Aggregate percentage response was 42.88%.

Conclusion:
We therefore conclude that a deliberate policy on fluoride dosing through regulation of quality of fluoride sources from Dental products to sea food is very necessary and timely.

Keywords: dental, fluorosis, fluoride,oral health advocacy

INTRODUCTION
Nigeria joined the rest of the world to mark oral health day, which is celebrated every year on the 20th of March.1 It is an international day to highlight the benefits of a healthy mouth and to promote worldwide awareness of issues around oral health.  This day is set aside to stress the importance of the awareness that ninety percent of the world's population will suffer from oral disease in their life time.  This is avoidable through awareness campaign, prevention, detection and treatment programmes, through increase governmental, health association and society support and funding.  These diseases range from caries, periodontal disease, to oral tumors.  Unfortunately, only 60% of the world's population enjoys oral healthcare. Toothache and dental caries is common among school children and most absenteeism from school in many countries is due to toothache.  There are very inadequate number of qualified dentists and they are equally inequitably distributed, leaving many of the poorest and most needed regions with fewer than one dentist to 300,0001 population, exemplified by Nigeria situation with registered dentist population currently stands at below 3,000.  This number include both the dead and the living.  Among the living it includes those that have travelled out of the country.  Those in the country include the old, retired and some practicing dentist.  Taking the upper figure of 1250, practicing dentist and Nigeria population of about 168.8 million in 2012.2-3  This gives one dentist to 135,040, heavily skewed in favour of municipality.
In Nigeria, oral health policy was developed by the Federal Ministry of Health, approved by the National Council on Health in May 2011 and subsequently launched in November 2012.  Nigeria joined the world to commemorate world oral health day which emphasized twice-brushing with fluoride containing tooth paste4; in an environment with very unclear fluoridation policy, worsening oral health populace and high oral health morbidity.5  Only a fraction of Nigerians receive water from water works, so water fluoridation would affect only a few people. About twenty-one percent of other natural water sources are naturally fluoridated to naturally occurring range of 0.3 - 0.6ppm, and more in some other areas than seventeen percent above this naturally occurring range6. The optimal recommended range is put at 0.7 - 1.2ppm.  Therefore, there is serious implication fluoride from extraneous dosing in areas with above normal fluoride range.  These extraneous sources whether recommended or not are inimical if unguided and unguarded in an area with above normally specified range, this extraneous dosing will likely skew the fluoride balance in favour of dental fluorosis.  It is therefore the aim of this study to outline these extraneous sources and assess the depth of understudying by oral health practitioner of this constant dosing, especially in our vulnerable pediatric population in which the risk of fluorosis is greater at 1-3 years of age.7

Methodology
The School of Dentistry, University of Benin, has a dental center, Dental/maxillofacial emergency unit and an out station at Udo Village for community oral health.  Internet sources from Fluoride Action Network provided a comprehensive source of fluoride, which served as a template for development of these questionnaires used to ascertain  among oral health practitioner on the possible danger of fluorosis among the underage (< 8 years).  A total of 259 questionnaires were administered in this close setting.  The respondent spread from consultants through Dental residents, house officers to dental students, with no gender or age consideration.  The respondents knowledge of sources fluoride outside drinking water, possible long term development of fluorosis especially from the vulnerable age group, possible combination of these other sources in an optimal and high level fluoride area to produce fluorosis.  These were the spread of the questionnaires administered to a population of oral health practitioners, in University of Benin Teaching (UBTH).  26 consultants, 11 senior registrars, 29 registrars, 17 house officers and 176 dental students.
Questionnaires were designed to elicit information on respondent knowledge of the under listed sources of fluoride.

Result
A total of 259questionnaires were administered in a close setting University of Benin Dental Centre to Consultants, Senior Registrars, Registrars, House Officers and some senior dental students.  These questionnaires were designed to elicit information on sources of fluoride (Table 1).  Out of 259 actually administered questionnaire (Consultants 26, Senior Registrars II, Registrars 29, House officers 17, Dental students 176), 182 (70.27%) was returned (Table II).  Respondent's knowledge of tooth paste and water as sources of fluoride was highest (Table III).  The least was respondent's knowledge of deboning and Teflon pans as sources of fluoride (Table III).  Fluoride mapping in Nigeria, pharmaceuticals, pesticides were very poor.  (2%, 15% and 3%) respectively (Table III).  Aggregate percentage knowledge was 42.53%.

Discussion
Oral health advocacy entails promotion of worldwide awareness of issues around oral health.  Oral health encourages twice brushing with fluoride tooth paste. Fluoridation of community water supplies is simply the adjustment of the existing, naturally occurring fluoride levels in drinking water usually of the range of 0.3  0.6ppm  to an optimal fluoride level of 0.7  1.2 parts per million with an upper limit of 1.5ppm.  With a daily in-take put at 0.04  0.07mgF/kg/body weight.8 Here the emphasis is on adjustment of the existing naturally occurring fluoride level in drinking water. In Nigeria, there is no clear fluoridation policy.  Sources of fluoride range from uncontrolled influx of dental products (tooth paste), which aggregate oral health practitioners' results showed the following: Tooth paste percentage knowledge (100%) (Table III A1, Figs. II).  Processed beverages and food (69%), (fluoride in water will be used to process these beverages and food) (Table III A2, Fig. II).  Tea (50%) trees absorb fluoride from the soil to the leaves (Table III A3, Fig. II), Fluorinated pharmaceuticals (15%), as most drugs contain carbon-fluorine bond (Table III A4, Fig. II); deboning of meat (5%), as mechanical deboning break bone particles that will contaminate the meat with fluoride (Table III A5, Fig. II); pesticides (3%) used because of its fluoride toxicity content are inadvertently deposited on stored fruits, beans etc. (Table III A6, Fig. II); Teflon pans (2%) which are common feature in most kitchen this increases fluoride content (Table III A7, Fig. II); work place exposure (25%) (Table III A8, Fig. II); Fluoridated drinking water (98%) (Table III A9, Fig. II); and sea food (48%) bones of tinned fish (Table III A10, Fig. II); these are sources of fluoride. While the graphic presentation by professional status revealed that all the categories of oral health staff understand tooth paste, processed food, water and sea food as main sources of fluoride, except house officers and dental students who lack information. Tea, and Sea food as source of fluoride (Table III, Fig. I).  All categories lack information on fluorinated pharmaceuticals, mechanical deboning of meat, pesticides, Teflon pans, and work places; as sources of fluoride (Table III, Fig. I).  Most worrisome is lack of information of fluoride mapping in Nigeria (Table III, Fig. I). These sources contribute individually or in combination with one another to skew fluoride content level in favour of fluorosis.  More so in a country where knowledge of fluoride mapping is poor (2%) among oral health practitioners (Table III B, Fig. II).  The joint impact of all these unregulated sources on age most at risk (< 3 years) of dental fluorosis is a skew in favor of fluorosis (Table III C, Fig. II). In dental fluorosis there is usually an increase above optimal level of ingestible environmental fluoride.  It is an aesthetically objectionable dental appearance.9 Age below 3 years is the most formative period of the dentition.  This disturbance affects enamel during the late secretory and maturation phases of amelogenesis.10 The cosmetic appearance of the teeth to the naked eye ranges from white lines on the enamel to chalky white appearance of the entire enamel.  Aging process introduce severe discoloration due to extrinsic stains.  The enamel may detach on slight trauma.  This appearance may create  psychosomatic and psychosocial problems in these young children that may last to adult life.  We therefore recommend a deliberate policy on fluoride dosing through regulation of influx into the country of questionable quality of fluoride sources from dental products to sea foods (Tables I).  More so these children at risk (< 3 years) are known to swallow tooth paste during brushing. This heightens the extraneous sources.

Conclusion
We therefore conclude that an enlightenment policy is overdue in view of the low aggregate percentage responses by the respondents (42.83%) who are incidentally the frontline proponents of oral health advocacy (Table III).

References:

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