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Dental fluorosis in populations from Chiang Mai, Thailand with different fluoride exposures – Paper 1: assessing fluorosis risk, predictors of fluorosis and the potential role of food preparation

Michael G McGrady1*, Roger P Ellwood2, Patcharawan Srisilapanan3, Narumanas Korwanich3, Helen V Worthington1 and Iain A Pretty1

Author Affiliations

1 School of Dentistry, University of Manchester, Manchester, M13 9PL, England, UK

2 Colgate Palmolive Dental Health Unit, 3A Skelton House, Lloyd Street North, Manchester, M15 6SH, England, UK

3 Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand

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BMC Oral Health 2012, 12:16  doi:10.1186/1472-6831-12-16

Published: 21 June 2012



To determine the severity of dental fluorosis in selected populations in Chiang Mai, Thailand with different exposures to fluoride and to explore possible risk indicators for dental fluorosis.


Subjects were male and female lifetime residents aged 8–13 years. For each child the fluoride content of drinking and cooking water samples were assessed. Digital images were taken of the maxillary central incisors for later blind scoring for TF index (10% repeat scores). Interview data explored previous cooking and drinking water use, exposure to fluoride, infant feeding patterns and oral hygiene practices.


Data from 560 subjects were available for analysis (298 M, 262 F). A weighted kappa of 0.80 was obtained for repeat photographic scores. The prevalence of fluorosis (TF 3+) for subjects consuming drinking and cooking water with a fluoride concentration of <0.9 ppm was 10.2%. For subjects consuming drinking and cooking water >0.9 ppm F the prevalence of fluorosis (TF 3+) rose to 37.3%. Drinking and cooking water at age 3, water used for infant formula and water used for preparing infant food all demonstrated an increase in fluorosis severity with increase in water fluoride level (p < 0.001). The probability estimate for the presentation of aesthetically significant fluorosis was 0.53 for exposure to high fluoride drinking (≥0.9 ppm) and cooking water (≥1.6 ppm).


The consumption of drinking water with fluoride content >0.9 ppm and use of cooking water with fluoride content >1.6 ppm were associated with an increased risk of aesthetically significant dental fluorosis. Fluoride levels in the current drinking and cooking water sources were strongly correlated with fluorosis severity. Further work is needed to explore fluorosis risk in relation to total fluoride intake from all sources including food preparation.