Examiner reliability in fluorosis scoring: a comparison of photographic and clinical methods.

OBJECTIVE: To assess examiner reliability when scoring dental fluorosis in Malaysian children using clinical (Dean's Index) and photographic methods. METHOD: The upper central incisors of 111 children were examined both clinically and photographically for fluorosis status using Dean's index. Twenty children were re-examined after a two-week interval for intra-examiner reliability by a single examiner. In addition, two independent examiners and the clinical examiner scored 111 photographic images of the same children in a standardized manner. Fluorosis scores were compared individually between examiners for both clinical and photographic scoring. Examiner reliability was assessed using both simple and weighted kappa statistics at tooth level. Sensitivity, specificity, positive-negative predictive values and a Receiver Operating Characteristic (ROC) curve were also calculated to determine the accuracy of the test. RESULTS: Across the three examiners, the prevalence of fluorosis (Dean's score ≥ 2) using photographs was lower (ranged from 23% to 26%) than the prevalence recorded by clinical examination (30%). The kappa score for intra-examiner reliability for the duplicate clinical examination was excellent (0.89). Inter-examiner reliability between the photographic method and the clinical examination (gold standard) for each examiner was substantial with weighted kappa values ranging from 0.74 to 0.77. The photographic method indicated higher specificity (99%) than sensitivity (79%) and the area under the ROC curve was also high (0.89) which suggests good accuracy of the diagnostic test. CONCLUSION: These results suggest that photographic examination of fluorosis on central incisors can be recorded with good examiner reliability. The recorded fluorosis prevalence was lower using the photographic scores.

Lactotransferrin Gene Polymorphism Associated with Caries Experience.

Dental caries is a common multifactorial disease, resulting from the interaction of biofilm, cariogenic diet and host response over time. Lactotransferrin (LTF) is a main salivary glycoprotein, which modulates the host immune-inflammatory and antibacterial response. Although a genetic component for caries outcome has been identified, little is known over the genetic aspects underlying its susceptibility. Thus, the aim of this study was to investigate the association between LTF polymorphisms and caries susceptibility. Six hundred seventy seven 12-year-old students were selected: 346 with (DMFT ≥ 1) and 331 without caries experience (DMFT = 0). Also, individuals concentrating higher levels of disease (polarization group, DMFT ≥ 2, n = 253) were tested against those with DMFT ≤ 1 (n = 424). Along with clinical parameters, three representative LTF tag SNPs (rs6441989, rs2073495, rs11716497) were genotyped and the results were evaluated using univariate and multivariate analyses. Allele A for tag SNP rs6441989 was found to be significantly less frequent in the polarization group, conferring a protective effect against caries experience [AA + AG × GG (OR: 0.710, 95% CI: 0.514-0.980, p = 0.045)], and remained significantly associated with caries protection in the presence of gingivitis (p = 0.020) and plaque (p = 0.035). These results might contribute to the understanding of the genetic control of caries susceptibility in humans.

The impact of oral health status on the oral health-related quality of life (OHRQoL) of 12-year-olds from children's and parents' perspectives.

OBJECTIVES: To assess the effect of dental caries, periodontal status and dental fluorosis on the oral health-related quality life (OHRQoL) of 12-year-olds and to assess the agreement between parents and children on the children's OHRQoL relative to the children's oral health status. METHODS: A two-stage sampling method was used to select a sample of 12-year-olds from Binzhou, China. Their oral health status was recorded using the DMFT, CPI and Dean's Index. The Child Perception Questionnaire 11-14 (CPQ(11-14)) and the Parental Perception Questionnaire (PPQ) were administered to the children and their parents, respectively, to assess the children's oral health-related quality of life. RESULTS: The data used in the analysis were collected from 1,120 children. The prevalence of tooth decay was 31.6% and that of dental fluorosis was 29.7%; 4.1% of the children had healthy gums and 52.4% had dental calculus. There was a moderate to good correlation between the CPQ and PPQ (ICC = 0.51-0.68). Having dental fluorosis and brushing teeth less than twice a day negatively influenced the emotional well-being domain of the CPQ, but was not related to this domain of the PPQ. Having calculus, dental fluorosis, brushing teeth less than twice a day and having dental visits negatively influenced the social well-being domain of the CPQ, but only tooth brushing was related to this domain of the PPQ. CONCLUSIONS: Children's self-reported CPQ(11-14) scores were more strongly associated with their oral health status and OHRQoL than their parents' PPQ scores were, especially in the social and emotional well-being domains. Having caries, dental fluorosis or dental calculus negatively affected children's oral health-related quality of life.

Dental fluorosis: concentration of fluoride in drinking water and consumption of bottled beverages in school children.

OBJECTIVE: The purpose of the study was to identify dental fluorosis prevalence and to analyze its association with tap water fluoride concentration and beverage consumption in school children from the city of Oaxaca, who were receiving fluoridated salt. STUDY DESIGN: A cross-sectional study was performed on elementary public school children. Dean's Index was applied to assess dental fluorosis. The parents of the children who were studied completed a questionnaire about socio-demographic characteristics and type of beverages consumed by their children. A total of 917 school children participated in this study. RESULTS: Dental fluorosis prevalence was 80.8%. The most frequent fluorosis category was very mild (41.0%), and 16.4% of the children were in the mild category. The mean water fluoride concentration was 0.43 ppm (±0.12). No association was detected between tap water fluoride concentration and fluorosis severity. The multinomial regression model showed an association among the mild fluorosis category and age (OR = 1.25, [95% CI 1.04, 1.50]) and better socio-economic status (OR = 1.78, [95% CI 1.21, 2.60]), controlling for fluoride concentration in water. Moderate and severe fluorosis were associated with soft drink consumption (OR = 2.26, [95% IC 1.01, 5.09]), controlling for age, socio-economic status, and water fluoride concentration. CONCLUSIONS: The prevalence of fluorosis was high. Mild fluorosis was associated with higher socio-economic status, while higher fluorosis severity was associated with soft drink consumption.

Use of clinical bleaching with 35% hydrogen peroxide in esthetic improvement of fluorotic human incisors in vivo.

AIM: The aim of the study was to evaluate esthetic improvement with the use of 35% hydrogen peroxide clinical bleaching as related to the different grades of enamel fluorosis in vivo and to study adverse effect of clinical bleaching with 35% hydrogen peroxide on teeth and gingiva. MATERIALS AND METHODS: A total of 60 children of different grades of fluorosis were included in the study. With 35% hydrogen peroxide-based dual activated bleaching system, in-office vital teeth bleaching was carried out for each subject. Clinical evaluation for improvement in esthetics, effect on teeth and gingiva were performed for each child during preoperative, immediate postoperative and later 6 months postoperative period. For evaluation and comparison, all the collected data were subjected to statistical analysis. RESULTS: Although in all the subjects, partial shade relapse was seen over a period of time, good homogeneous and esthetic results were seen in very mild and mild cases. A total of 35% hydrogen peroxide in-office bleaching has no adverse effect on teeth and gingiva. CONCLUSION: Comparing all the three groups who participated in the study, 35% hydrogen peroxide in-office bleaching seems to be very effective in very mild and mild forms of fluorosis. CLINICAL SIGNIFICANCE: In very mild and mild forms of fluorosis, in-office vital tooth bleaching with 35% hydrogen peroxide is the most conservative and effective approach in esthetic improvement.

Validation of fingernail fluoride concentration as a predictor of risk for dental fluorosis.

The aim of this study was to validate the use of fingernail fluoride concentrations at ages 2-7 years as predictors of the risk for developing dental fluorosis in the permanent dentition. Fifty-six children of both genders (10-15 years of age) had their incisors and premolars examined for dental fluorosis using the Thylstrup-Fejerskov index. Fingernail fluoride concentrations were obtained from previous studies when children were 2-7 years of age. Data were analyzed by unpaired t test, ANOVA, and Fisher's exact test when the fingernail fluoride concentrations were dichotomized (≤ 2 or >2 µg/g). Children with dental fluorosis had significantly higher fingernail fluoride concentrations than those without the condition, and the concentrations tended to increase with the severity of fluorosis (r(2) = 0.47, p < 0.0001). Using a fingernail fluoride concentration of 2 µg/g at ages 2-7 years as a threshold, this biomarker had high sensitivity (0.84) and moderate specificity (0.53) as a predictor for dental fluorosis. The high positive predictive value indicates that fingernail fluoride concentrations should be useful in public health research, since it has the potential to identify around 80% of children at risk of developing dental fluorosis.

Dental fluorosis in populations from Chiang Mai, Thailand with different fluoride exposures - paper 2: the ability of fluorescence imaging to detect differences in fluorosis prevalence and severity for different fluoride intakes from water.

BACKGROUND: To assess the ability of fluorescence imaging to detect a dose response relationship between fluorosis severity and different levels of fluoride in water supplies compared to remote photographic scoring in selected populations participating in an observational, epidemiological survey in Chiang Mai, Thailand. METHODS: Subjects were male and female lifetime residents aged 8-13 years. For each child the fluoride content of cooking water samples (CWS) was assessed to create categorical intervals of water fluoride concentration. Fluorescence images were taken of the maxillary central incisors and analyzed for dental fluorosis using two different software techniques. Output metrics for the fluorescence imaging techniques were compared to TF scores from blinded photographic scores obtained from the survey. RESULTS: Data from 553 subjects were available. Both software analysis techniques demonstrated significant correlations with the photographic scores. The metrics for area effected by fluorosis and the overall fluorescence loss had the strongest association with the photographic TF score (Spearman's rho 0.664 and 0.652 respectively). Both software techniques performed well for comparison of repeat fluorescence images with ICC values of 0.95 and 0.85 respectively. CONCLUSIONS: This study supports the potential use of fluorescence imaging for the objective quantification of dental fluorosis. Fluorescence imaging was able to discriminate between populations with different fluoride exposures on a comparable level to remote photographic scoring with acceptable levels of repeatability.

Prevalence of dental caries among 13 and 15-year-old school children in an endemic fluorosis area: a cross-sectional study.

AIM: To assess the prevalence of dental caries and dental fluorosis among 13- to 15-year-old school children in Panyam, Andhra Pradesh, India. MATERIALS AND METHODS: The cross-sectional study was conducted among 202 school children and were examined for dental fluorosis and dental caries. RESULTS: This study shows that male students have a decrease in DMFT (Decayed, missing, filled, teeth) index and increase in Dean's index when compared with females. Among students with 13 to 15 years of age, 13-year-old student has increase in DMFT score when compared with other age groups and 14-year-old students has increase in Dean's score when compared with other age group students. CONCLUSION: The prevalence of dental caries decreased with the increase of fluorosis among the students examined. CLINICAL SIGNIFICANCE: Patients with dental fluorosis show a decreased prevalence of dental caries.

Differences in exposure and biological markers of fluoride among White and African American children.

OBJECTIVE: To determine differences in self-reported fluoride exposure and fluoride exposure biomarkers between two racial groups. METHODS: Questionnaires regarding fluoride exposure, urine and water collection kits were distributed to African American and White 7-14-year-old children. Children received a dental exam for fluorosis. Water, urine, and saliva were analyzed for fluoride content. Questionnaire responses and results of sample analyses were compared and observed differences were analyzed. RESULTS: 83 African American and 109 White children completed the study. Dental fluorosis was observed in 62.5 percent White and 80.1 percent African American children. Significant differences were found for fluorosis prevalence and severity between the groups (P < 0.05). Less African American children reported having used fluoride supplements in the past. White children began brushing their teeth at an earlier age. More White children visited a dentist for the first time before age 3. African American children reported currently using larger amounts of toothpaste. More Whites than African Americans had received topical fluoride treatments over the previous year. All of these differences were significant. Multivariate models showed that supplement use and amount of toothpaste used for brushing had significant associations to a child's fluorosis scores. Fluoride concentration of water and saliva was not different for the two groups; however, the fluoride content in urine was significantly higher in African Americans than in Whites [P < 0.05; 1.40 +/- standard deviation (SD) 0.65 ppm versus 1.08 +/- SD 0.28 ppm]. CONCLUSIONS: Differences in fluoride exposure between two racial groups were observed. These differences are complex and need to be better defined.

Perceptions and concerns about dental fluorosis as assessed by tooth surface index of fluorosis among high school children in an area of endemic fluorosis--Kaiwara.

PURPOSE: The aim of this study was to assess the perceptions and concerns about dental fluorosis among high school children in an area that is endemic to fluorosis, and to correlate the children's perceptions of dental fluorosis with different scores of tooth surface index of fluorosis. MATERIALS AND METHODS: The study was conducted among 155 children affected with fluorosis, aged between 12 and 16 years, studying in all four high schools of Kaiwara, Karnataka, India. Fluorosis was assessed on labial surfaces of maxillary anterior teeth using tooth surface index of fluorosis, and the data were collected using a self-administered pretested questionnaire that was given to the study subjects. Analysis was performed using frequency distribution, chi-square test and Spearman's correlation coefficients. RESULTS: Significant high correlations were found between tooth surface index of fluorosis scores and the perception of the importance of the condition (r = 0.226, chi2 = 72.065, P < 0.01), considering the condition to be a disadvantage in the future (r = 0.166, chi2 = 73.097, P < 0.05) and also the last visit to the clinician for the condition (r = -0.184, chi2 = 14.252, P < 0.05). CONCLUSION: Perceptions and concerns of dental fluorosis among this age group of children appear to be of aesthetic concern making it essential to focus on this issue and to intervene.

Prevalence and severity of dental fluorosis among 13- to 15-year-old school children of an area known for endemic fluorosis: Nalgonda district of Andhra Pradesh.

OBJECTIVES: The present study was conducted to assess dental fluorosis and to compare fluorosis in incisor teeth among 13- to 15-year-old school children of Nalgonda district, Andhra Pradesh. METHODS: Cross-sectional analytical study was conducted. A total of 1000 school children aged 13 to 15 years were selected by stratified cluster sampling from 4 different areas with different levels of naturally occurring fluoride in drinking water. Fluorosis was recorded using TF index (TFI). RESULTS: Prevalence of fluorosis (TFI score, > or = 1) was 100% at all the 4 different fluoride levels. The prevalence and severity increased with increased fluoride levels in drinking water. Prevalence and severity of fluorosis did not show any significant variation between maxillary and mandibular incisor teeth. CONCLUSION: There is a high prevalence of mild-to-moderate fluorosis in Nalgonda district, even in areas with optimal fluoride levels in water.

Dental fluorosis in 12- and 15-year-olds at high altitudes in above-optimal fluoridated communities in Mexico.

OBJECTIVE: The purpose of this study was to determine the prevalence and severity of dental fluorosis in Mexican adolescents. MATERIALS AND METHODS: A cross-sectional epidemiological study was carried out in 1,024 adolescents 12 and 15-years-old residing in three naturally fluoridated locales at high altitudes above sea level (> 2,000 m or > 6,560 ft) in Tula de Allende, Hidalgo, Mexico. Participants had lived in those communities from birth to their sixth birthday. Both the Modified Dean Index and the Community Fluorosis Index were calculated. RESULTS: The overall fluorosis prevalence was 83.8 percent. Fluorosis prevalence in El Llano (3.07 ppmF), San Marcos (1.38 ppmF), and Tula Centro (1.42 ppmF) was 94.7, 89.8, and 81.9 percent, respectively. Overall, the Community Fluorosis Index was 1.85. We observed a high prevalence of dental fluorosis--mostly very mild (35.9 percent), but also uncommonly severe (20.6 percent). CONCLUSIONS: At least 8 out of 10 adolescents had some level of fluorosis, and such prevalence is considered to be a dental public health problem. A relationship between fluoride concentration in water in each community and fluorosis was observed. The high fluorosis prevalence and severity might possibly be associated with the high altitude of the communities.

Prevalence of dental fluorosis and associated risk factors in 11-15 year old school children of Kanyakumari District, Tamilnadu, India: a cross sectional survey.

OBJECTIVES: This study presents data on the prevalence and severity of dental fluorosis in 11-15-years-old school children of Kanyakumari district, TamilNadu, India, and also the relationships between prevalence of dental fluorosis and selected risk factors. MATERIALS AND METHODS: A total of 1800 children, from all the nine blocks of Kanyakumari district, studying in classes 6-10 were examined using type III examination. The assessment form designed specifically for this study was used while examining each student. RESULTS: Dental fluorosis was present in 15.8% (285 children) of the study population and the community fluorosis index was calculated to be 0.27. The prevalence of dental fluorosis varied from as low as 1.4% in some blocks to as high as 29.4% in some others. There was a significant difference in the level of dental fluorosis between rural and urban residents ( P < 0.001). The prevalence of dental fluorosis was higher in children who consumed pipe water as compared to children who consumed ground water. 65% of the children with dental fluorosis had no caries, indicating the positive effects of fluoride. CONCLUSIONS: The prevalence of dental fluorosis can be attributed to the level of fluoride in the drinking water as it exhibited a step-wise increase when the water fluoride levels increased from 1.5-1.7 ppm. Measures for defluoridation of drinking water before distribution has to be taken in the high prevalence blocks to lower the burden of dental fluorosis in this community.

Automatic detection and classification of dental fluorosis in vivo using white light and fluorescence imaging.

OBJECTIVES: To assess a novel method of automatic fluorosis detection and classification from white light and fluorescent images. METHODS: Dental images from 1,729 children living in two fluoridated and two non-fluoridated UK cities were utilised. A novel detection and classification algorithm was applied to each image and TF scores were obtained using thresholding criteria. These were compared to clinical reference standard images. Comparisons between reference and automated assessments were undertaken to record correct and incorrect classifications and the ability of the system to separate the fluoridated and non-fluoridated populations. RESULTS: The automated system performed well and was able to differentiate the two populations (P < 0.0001) to the same degree as the reference standard. When using the highest score from the clinical assessment the agreement between automated and clinical assessments was 0.56 (Kappa SE = 0.0160, p < 0.0001). CONCLUSIONS: Assessment of dental fluorosis is typically undertaken by clinical examiners in epidemiological studies. The training and calibration of such examiners is complex and time consuming and the assessments are subject to bias - frequently because of the examiner's awareness of the water fluoridation status of subjects. The use of remote scoring using photographs has been advocated but still requires trained examiners. This study has shown that image-processing methodologies applied to white light and fluorescent images could automatically score fluorosis and statistically separate fluoridated and non-fluoridated areas. The system requires further refinement to manage confounding factors such as the presence of non-fluoride opacities and tooth stain.

Disparities in oral health-related quality of life in a population of Canadian children.

OBJECTIVES: To assess socioeconomic disparities in the oral health-related quality of life in a group of Canadian children. METHODS: Data were obtained as part of a study designed to assess the functional and psychosocial impact of traumatic dental injury. Clinical data were collected on a random sample of children during a school-based dental screening program that included measures of dental decay experience, treatment needs, dental trauma, fluorosis, and malocclusion. Children with dental trauma and a comparison group of trauma-free children were selected for follow-up. Their parents were mailed a questionnaire concerning the child's personal and family characteristics. Also enclosed was a questionnaire for the child that contained a short form of the Child Perceptions Questionnaire (CPQ) 11-14. Bivariate and multivariate analyses were undertaken to determine whether there were disparities in oral health-related quality of life according to household income. RESULTS: Complete data were collected from 370 children. Mean CPQ11-14 scores showed a gradient across income categories with children from low income households having poorer oral health-related quality of life. Children from households containing only one adult also had higher scores than children living with two or more adults. In both linear and logistic regression analyses household income and family structure remained significant predictors of CPQ11-14 scores after controlling for oral disease variables. Further analyses suggested that oral disorders had little impact on the health-related quality of life of higher income children but a marked impact on lower income children. The highest mean CPQ11-14 scores were observed among low income children with the more severe levels of oral disease. CONCLUSION: The data indicate that in this group of children there were socioeconomic disparities in oral health-related quality of life. A potential explanation may be differences in psychological assets and psychosocial resources.

Agreement amongst examiners assessing dental fluorosis from digital photographs using the TF index.

OBJECTIVE: To compare the scoring of dental fluorosis by experienced examiners from digital photographs using the TF index. BASIC RESEARCH DESIGN: 120 images were selected from 703 photographs obtained during a clinical trial (Tavener et al., 2004). The selection process was stratified so that the full range of defects seen in the main study was included. The children, aged 8-10 years, were from deprived areas of Manchester, England with fluoride levels in the drinking water of less the 0.1 ppm F. The photographs of the upper and lower anterior sextants were taken after cleaning and drying the teeth. The examiners were identified by searching Medline for individuals who had previously used the TF index or had experience of scoring dental fluorosis. Of the 12 examiners identified, 10 agreed to take part. Each examiner was provided with identical CDs containing a PowerPoint presentation of the images. Twelve images were duplicated and interspersed amongst the 120 images to assess intra examiner agreement. Each examiner was also supplied with a table listing the criteria and illustrations for each of the TF index scores (Fejerskov et al., 1988). RESULTS: The prevalence of fluorosis (TF > 0) amongst the 10 examiners ranged from 43% to 70% and from 2% to 13% for the more severe scores (TF 3 or 4). Paired agreements amongst subject scores for the 10 examiners, measured using a weighted Kappa score, ranged from 0.40 to 0.71. CONCLUSION: It is concluded that although the criteria for the TF index are well defined, it is possible that examiners may interpret the criteria in different ways and conditions in which images are viewed may need to be standardised. This study may explain some of the differences in the prevalence and severity of fluorosis reported in different studies. There is a need to standardise the methods used to score dental fluorosis.

Enamel hypoplasia in children with renal disease in a fluoridated area.

The aim of this study was to compare the frequency of enamel hypoplasia in children with renal disease and healthy children, all of whom live in a fluoridated area. A cross-sectional study was made in 42 children divided into 2 groups. To describe enamel changes, 3 diagnostic criteria were applied: TSIF Index to describe dental fluorosis, Jackson-Al-Alousi Index to describe enamel hypoplasia, and Russell criteria to differentiate mild forms of dental fluorosis and enamel hypoplasia. The frequency of enamel hypoplasia in patients with renal disease was 38.09%. This frequency is smaller than that seen in other studies. There was no difference in the frequency of dental fluorosis between patients with renal disease and patients without renal disease. However the patients with renal disease presented more severe dental fluorosis than children without renal disease.

Attitudes to fluorosis and dental caries by a response latency method.

BACKGROUND: Understanding socially relevant attitudes to fluorosis and dental caries is important. Previous studies have concentrated mainly on aesthetic implications. AIMS: To investigate social judgements beyond the aesthetic, made when viewing digitally manipulated extraoral images of dental fluorosis of varying degrees of severity and images of dental caries. METHODOLOGY: Using a response latency technique, which allowed both the direction and strength of attitudes to be measured, 40 volunteers made judgements on 144 image/characteristic combinations. RESULTS: Participants made social judgements which extended beyond the aesthetic to factors such as sociability, reliability and cleanliness. Judgements on mild fluorosis were not markedly different from those made about the same individual with normal enamel, but severe fluorosis had a significant negative impact on social judgements. Untreated dental caries was judged less favourably than normal enamel and mild fluorosis. CONCLUSIONS: Attribution of characteristics that go beyond the aesthetic are significantly influenced by altered tooth appearance.

Changes in dental fluorosis following the cessation of water fluoridation.

OBJECTIVES: To determine changes in the prevalence of dental fluorosis, and in perceptions of aesthetic concerns due to dental fluorosis after water fluoridation ceased. METHODS: Schoolchildren in second and third grades were examined in 1993-94, 1996-97 and 2002-03 to determine changes in the prevalence of dental fluorosis following fluoridation cessation of the public water supplies in 1992. The Thylstrup-Fejerskov Index (TFI) was used to quantify dental fluorosis. Perceptions of aesthetics were assessed by questionnaires which were sent home to parents. Residence and dental histories were confirmed on all children to determine the extent of exposure to all types of fluorides. Comparisons between the three surveys were used to establish the influence of fluoridated water and other fluoride sources on the occurrence and severity of dental fluorosis. Aesthetic ratings from parents were used to assess the aesthetic conditions of maxillary anterior teeth across the three surveys. RESULTS: When fluoride was removed from the water supply in 1992, the prevalence and severity of TFI scores decreased significantly from the 1993-94 survey cycle when compared with the 1996-97 and 2002-03 survey cycles. The use of fluoride supplements and fluoride dentifrice also decreased during this study period. Analyses were unable to determine the influence of these different fluoride exposures on the changes in TFI scores over time. Comparisons of aesthetic ratings from parents between survey cycles failed to show any significant differences.

Subjective impacts of dental caries and fluorosis in rural Ugandan children.

OBJECTIVE: Describe the oral health related quality of life among a group of children in rural Uganda and compare impacts on oral health related quality of life associated with dental caries and fluorosis. BASIC RESEARCH DESIGN: Cross-sectional clinical and questionnaire analytical study. PARTICIPANTS: Proportional sample of 174 12 year olds attending primary schools in a rural sub-county of Uganda. OUTCOME MEASURES: Clinical assessments using WHO basic methods and the Thylstrup and Fejerskov index of Fluorosis (TFI). Child Oral Health Related Quality of Life data collected with self-administered child perception questionnaire (CPQ11-14). RESULTS: Two thirds of children reported a dental impact 'often' or 'everyday'. The mean number of impacts per child at this threshold was 2.6 and the mean total CPQ11-14 score was 25.8 (sd 21.1). Mean DMFT was 0.68. No children had fillings. Forty-one children had dental fluorosis with 10 having scores greater than 2. CPQ11-14 showed acceptable criterion validity and reliability. The number of sites with gingivitis or the presence of calculus or trauma were not associated with summary measures of CPQ11-14 whereas having any dental caries or treatment experience was associated with higher total scores and more impacts. Socially noticeable fluorosis (TFI >2) was associated with more impacts but not with higher total scores. CONCLUSIONS: Despite low levels of oral disease these children experience appreciable impacts on oral health related quality of life. The greatest burden was associated with dental caries and to a lesser extent, fluorosis.