ATLAS OF DENTAL FLUOROSIS (ENGLISH)

DDS. MARÍA GABRIELA LUQUE

DENTAL FLUOROSIS IDENTIFICATION, DIAGNOSIS

DDS. ALFREDO NATERA

AND CLASSIFICATION VOLUME I

DDS. MARÍA GABRIELA LUQUE

DENTAL FLUOROSIS IDENTIFICATION, DIAGNOSIS

DDS. ALFREDO NATERA

AND CLASSIFICATION VOLUME I

ABOUT THE

COVER PHOTOGRAPH The photograph on this cover is a composition created from a molar section, carefully designed to showcase its proximal surfaces and central pit. It consists of four images of the same section taken under different lighting conditions. From left to right: flash at 4000 K, flash at 4000 K with a blue filter, ultraviolet light, and tungsten light. Post-production was carried out to clean up the images and create the composition you see here.

Although the teeth shown do not have dental fluorosis, they represent our photographic work and demonstrate the possibilities of what we can achieve and showcase in Dentistry with this remarkable tool.

Photograph by Alfredo Natera Post-production by Eng. María Ysabel Luque Gutiérrez. @Natera_Fotografía

DDS. MARÍA GABRIELA LUQUE

DDS. ALFREDO NATERA

ABOUT THE

SECOND COVER PHOTOGRAPH The second cover photograph features a ten-year-old girl with TF2 (mild) dental fluorosis, a cheerful and always smiling child. The photograph was taken using a backlighting technique, where the flash is positioned facing the photographer, rather than attached to the lens or camera.

Additionally, a contrastor was used, and the photo was taken from the operator's perspective, which is why the incisal edge of the teeth is positioned at the top of the photograph. This angle allows us to capture details that a frontal photograph might miss, such as the perikymata and the hypomineralization affecting them due to dental fluorosis.

ABOUT THE

COPYRIGHT AND EDITION OF THE ATLAS To ensure that everyone can see, learn from, and analyze this Atlas, I have invested over thirty years collecting photographs and more than seven years bringing this project to fruition. I also dedicated considerable time traveling to various locations inside and outside of Venezuela, wherever I was informed of a patient with dental fluorosis. In addition, I invested substantial amounts of money on equipment, travel, accommodation, and accessories. The time spent selecting all the photographs, and waiting even longer for those we didn’t yet have—making additional investments to acquire them—is all part of the effort to share our vision and achieve the goals of this Atlas.

Likewise, the publication of this Atlas has been a significant personal investment in order to offer it at an accessible cost for the future of our profession. I could elaborate on arguing against NOT respecting copyright, it's NOT illegal reproduction, and honoring the work of others, emphasizing that doing the right thing contributes to preserving the scientific value of this Atlas and supports the continued development of other valuable projects like this one. Unauthorized reproduction of this work would not only violate the law but also diminish its scientific contribution, hindering future editions and disappointing readers—the primary beneficiaries of this tremendous effort. For books like this to exist, the dedication of many is necessary. Unauthorized reproduction, without the authors' permission, violates both the law and common sense, as it contributes to the demise of future editions and harms those who still appreciate reading and learning.

In your hands is your own investment in acquiring this Atlas, learning from this work and collection of photographs to raise awareness of a problem for both patients and professionals. If this work is lost, we all lose.

ABOUT THE

AUTHORS OF THE ATLAS DDS. ALFREDO NATERA DDS. MARÍA GABRIELA LUQUE

This Atlas has been registered with the Ministry of Culture of the Kingdom of Spain Intellectual property registration number O00019981e24P0033083 ISBN: 978-84-09-65827-5

ODONTOLOGIST

ALFREDO NATERA Graduated from the Faculty of Dentistry at the Central University of Venezuela Retired Professor of the Chair of Operative Dentistry, Faculty of Dentistry, Central University of Venezuela Director of the Venezuelan Center for Clinical Research for the treatment of Dental Fluorosis and Enamel Defects Professional Photographer

ODONTOLOGIST

MARÍA GABRIELA LUQUE Graduated from the Gran Mariscal de Ayacucho University, Venezuela Oral Surgeon from the Pontificia Universidad Javeriana, Bogotá, Colombia

DEDICATION To our beautiful baby "Santiago Andrés Natera Luque" for being our source of love, our colorful future, our star every night, and our sun every morning. You are our nature and represent the hope of every child with Dental Fluorosis, to whom we are dedicated to providing a new generation of healthy men and women.

ACKNOWLEDGMENTS To our country, Venezuela, you have given us each sunrise, days filled with sunshine and blue skies, leading to the creation of this remarkable Atlas, dedicated to all generations of fellow odontologists.

To our parents, José Rafael (†), Nellys María, Juan José, and Mildred Josefina (†), creators of every dream in our minds, for we are their lives and the children of their love.

To Dentistry, a beautiful profession, full of life, science, new paths, great friends, and a promising future.

To our lifelong Professors, to all those who know us well but are not mentioned here, so as not to commit the terrible mistake of leaving anyone out. There are many exemplary and worthy educators who should be included in these lines. You have shown us this path, guided us, instructed us, and believed in our dreams and projects. To “you,” dear professor, we offer our special recognition and reverence, for you have built us from nothing, inspired us, and become a builder of the future, a beacon of light, and an integral part of this achievement.

ACKNOWLEDGMENTS To Drs. Alfonso Maldonado Dueñas and Carlos Acosta Prado, friends in many aspects of life, companions on numerous journeys across Venezuela, PROFESSORS AND TEACHERS AMONG THE GREATS, whose names grace these lines. You are defenders of dental science. “We have made the difference, which is the key to success, through excellence and innovation.”

To Dr. Luis Alonso Calatrava Oramas, in addition to being the author of the foreword and a friend, he is a leader and a great example to all who know him. His confidence in this Atlas encouraged me to pursue the highest quality for this and other future projects.

Thank you, godfather, for granting us the honor of carrying your name.

To Dr. Andreína Da Silva, for your support and companionship, as a collaborator and an excellent professional who worked at the institute every day. These years we have had your smile and “special friendship” have been truly wonderful, without a doubt.

ACKNOWLEDGMENTS To Dr. Gusmelia Fuenmayor, from afar, I wish that with your strength, you continue to progress and, as always, give your very best to so many, just as you have consistently shown us. You are responsible for a significant portion of the photographs displayed here. For that and so much more, you have our hearts and our friendship each and every day.

To Dr. Teresita Pannaci, an intelligent, smiling, and enthusiastic woman who also believed in our work, pushing us beyond all limits.

You have our hearts and our unconditional friendship. Let us continue forward with our “mission.”

To Dr. María Alexandra Celis, for your wonderful support, tireless days of work, conversations, and discussions, and for welcoming us into your practice, creating spaces and opportunities for learning for everyone. Alex, you are a peacemaker and a truly exceptional human being. And to you, our friend María Carolina González, we send you a heartfelt embrace filled with warmth and friendship.

ACKNOWLEDGMENTS To Dr. Rosa Rojas, a dentist, friend, and pastry chef, full of smiles and flavors, with a heart that generously helps many. You gave us so much, and we pass that on to others in the same way.

To our friend Luis Jiménez, a kind, visionary, and collaborative man, always ready to contribute, bringing together efforts toward what we believe in: a solution for Dental Fluorosis.

To Dr. María José Póveda, a sweet woman and friend who always enters others' lives to make a positive difference.

To Dr. Maglynert Montero Baptista, a researcher, diligent student, transparent transmitter of knowledge, and a faithful believer in minimal intervention. Your approach to dentistry focuses on the person and on science based on evidence, where opinion holds little weight. You have become a true friend, and I must say: THANK YOU.

ACKNOWLEDGMENTS To Dr. Oscar Quirós, always a friend, professor, and advisor in every moment.

To Dr. María Julia Fernández, a hyperactive individual, a great friend, creative, and with a vision beyond our comprehension. Your support, suggestions, and work were pivotal long before this project even took shape in our dreams.

To all the friends who are unknowingly present in every letter and every color of the photographs in this book, know that the universe is infinite.

To all our patients, you are the reason for our work, our projects, and everything we do in dentistry. Thank you for allowing us to take photographs, for your time, your affection, and your hope in less invasive solutions that are reshaping the minds and goals of dentists worldwide. Now, you will be part of all the eyes that study the photographs in this Atlas, and therefore, part of their smiles and the solution, helping many other patients.

"From our dream, we greet you all."

The Authors.

Atlas Content PROLOGUE ........................................................................................17 ABOUT THE AUTHORS ......................................................................21 ABOUT THE CVIC FLUOROSIS INSTITUTE ..........................................26 ABOUT THE WATER WELLS AND THE CHILDREN ..............................29 ATLAS OBJECTIVES ............................................................................35 BIBLIOGRAPHY ..................................................................................37 CLINICAL PHOTOGRAPHS ..................................................................39 PHOTOGRAPHS OF THE CANINE .......................................................43 DEAN´S CLASSIFICATION ...................................................................45 THYLSTRUP & FEJERSKOV INDEX (TF) ...............................................50 COMPARISON OF DEAN'S CLASSIFICATION AND THE TF INDEX .......53

Atlas Content CLINICAL CASES TFO - DEAN NORMAL ...............................................55 CLINICAL CASES TF1 - DEAN QUESTIONABLE .....................................67 CLINICAL CASES TF2 - DEAN VERY MILD ............................................89 CLINICAL CASES TF3 - DEAN MODERATE ..........................................165 CLINICAL CASES TF4 - DEAN MODERATE ..........................................233 CLINICAL CASES TF5 - DEAN SEVERE ................................................317 CLINICAL CASES TF6 - DEAN SEVERE ................................................359 CLINICAL CASES TF7 - DEAN SEVERE ................................................405 CLINICAL CASES TF8 - DEAN SEVERE ................................................453 CLINICAL CASES TF9 - DEAN SEVERE ................................................475 PHOTOGRAPHS OF THE TWO BACK COVERS ...................................494 CLOSING OF THE ATLAS ...................................................................497

PROLOGUE When this ATLAS was conceived, its author recognized the explosion of knowledge in our times, presenting a continuous challenge today. However, within the vast thematic universe, the focus had to be on a specific area of clinical practice in everyday activities, while still remaining indispensable. The aim was to strike a balance between theoretical aspects and clinical application, expressing the author's experiences where interdisciplinary and multidisciplinary approaches are essential for addressing oral health challenges.

The primary goal of this Atlas on DENTAL FLUOROSIS AND THE DEAN AND TF CLASSIFICATION is to present and impart the necessary information to today's and tomorrow's dental experts and their auxiliary staff.

It is presented for the consideration and reflection of dentistry scholars, from beginners and specialists to experienced educators. This Atlas serves as a working tool, enabling practitioners to address the increasing clinical challenges they face.

The content is presented with clear and concise details that can be easily analyzed and immediately understood, featuring high-quality clinical photographs selected from several years of laborious work. These images show different perspectives of the levels of dental fluorosis according to the globally adopted Dean and Thylstrup Fejerskov (TF) classifications. The paragraphs are brief, and the essential vocabulary has been included to help readers understand the stages of both codifications.

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PROLOGUE The development of this Atlas is aimed primarily at undergraduate dental education, though it can also be useful for postgraduate instruction, dental assistants, or hygienists.

The increasing complexities of theoretical and practical dental education demand new challenges, which is why this Atlas seeks to familiarize readers with the details of these lesions, allowing for the formation of clear clinical images.

This text, with its multiple illustrations, is organized to be used by educators as a teaching manual in classes, discussions, and clinical sessions. It includes information that encourages readers to apply the knowledge immediately in practice. The Atlas offers a broad sector of the profession access to a methodology that is presented with great clarity and promises to be innovative and forward-looking.

I might not have been able to adequately respond to this honorable invitation if I had not known Professor Alfredo Natera for over 30 years. A retired professor from the Central University of Venezuela and an expert in the field, he shares his significant teaching and clinical experience in this text. He embraces a wide range of learning opportunities necessary for the training of a modern professional in addressing complex health problems and their interdisciplinary connections.

In reading this work, the author has put his years of teaching experience into written form, in an area that has long been his passion and which he has successfully shared with others. It reflects once again his role as an educator, researcher, mentor, and trainer of many generations of Venezuelan dentists.

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PROLOGUE

The profession must develop critical thinking and acquire the tools for comprehensive, methodological evaluation. Universities should provide this foundational training and encourage their graduates to maintain it throughout their careers, promoting the lifelong education paradigm. The author, with his forward-thinking vision, helps to uphold these principles.

LUIS ALONSO CALATRAVA ORAMAS

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ABOUT THE

AUTHORS Having this fabulous Atlas in our hands has been a wonderful journey, full of learning and not without many difficult moments.

However, every challenge presents an opportunity, and we have taken full advantage of each one.

I am a clinical dentist and photographer, deeply passionate about dentistry and enamel development defects, their origins, their implications for patients, and the best use of dental materials for the future health of all those who trust us as professionals.

My wife, María Gabriela Luque Gutiérrez, co-author of this Atlas, is a dentist, surgeon, and oral pathologist—areas that may not seem closely related to enamel development defects or Dental Fluorosis.

But it all depends on perspective, because we are “Dentists,” and our knowledge must be broad and responsible. She has engaged with my ideas, understands the time and resources invested over the years, and has endured my endless debates. More than that, she has guided my aspirations to make visible everything I have observed and felt with more than a thousand patients documented with Dental Fluorosis in our files—their suffering, their hardships, and their sadness—because we have been able to offer them a viable, patient-centered solution.

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ABOUT THE

AUTHORS We both have dedicated the past seven years to this project. She has driven away the fatigue, the loss of inspiration, and disorientation.

With our baby in her arms and nursing on demand, we spent eleven months selecting the photographs for this Atlas. Some days we approved certain photos, other days we discarded them, always searching for the right ones. Yet something was always missing—the maturation that only time and good conversation can bring. For me, her approval at every step, her review, her reading, her corrections, her observations, and her glances have been a tremendous relief in the path we embarked upon as two good partners, traveling together until we could deliver these lines, along with these photographs, to all those brave enough to absorb them.

This is the path we have chosen: to publish many of the photographs collected over 30 years, all for the training of as many dentists as possible. Our goal is for everyone to observe them, study them in detail, and learn from them.

My passionate interest and admiration for Dental Fluorosis began approximately 35 years ago when I was an undergraduate student at the Faculty of Dentistry at the Central University of Venezuela (U.C.V.). It was a chance encounter, almost insignificant, where I did not gain much information at the time.

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ABOUT THE

AUTHORS I then began to seek out where to read and whom to learn from about this topic. At the same time, I graduated as a dentist and began my teaching career at the Department of Operative Dentistry at my alma mater. As I delved into this new universe, the little I knew about Dental Fluorosis lingered in my mind, and I did not believe what many told me—that it had no solution and was not worth my time, that it did not generate income.

This belief became almost a creed for a long time and still persists among perhaps millions of professionals around the world. I knocked on countless doors over the years, asked those I considered competent, left notes, sent messages, and insisted whenever I could and had the opportunity within my teaching schedule.

Eventually, I realized that I had to solve it on my own, and with much difficulty, I embarked on this wonderful phase of growth that has brought me to this digital present, so distant and different from that past.

Dentistry has allowed me to enjoy several life passions, such as photography, reading, science, and technology, among others. The first has been a continuous learning experience from the days of film development to the arrival of the first computers at my dental school, which I immediately understood were here to stay.

Alongside photography, I needed to develop in that area.

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ABOUT THE

AUTHORS I began teaching photography at the School of Architecture and, after two years, started collaborating on the same topic at the School of Medicine at my beloved U.C.V. It was then that Dr. Castor Velázquez, head of the prosthetics postgraduate program at my school, learned of my journey and asked me to focus on clinical photography in that program. With the support of Dr. Oscar Quirós, an orthodontist and visionary from that past era, I continued to develop in these diverse areas of the profession and university teaching. In my department, I became acquainted with tooth whitening, and under the guidance of my professor and colleague, Dr. Iván Alfonzo, I delved into what I now call "a super treatment."

This may be part of a future book on proposed treatments for Dental Fluorosis.

Like any new path of which I was not entirely aware, this one was not without its ups and downs—marked ups and downs, along with countless obstacles both within my mind and around my life.

At that time, the world and dentistry were changing enormously.

The vision and concepts in cariology seemed to enter their golden era (finally), and enamel development defects emerged as the next big challenge, especially if we were discussing minimally invasive dentistry.

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ABOUT THE

AUTHORS

Photography, almost overnight, transitioned from analog to digital, and we had to adapt and migrate to the new technology, understanding that new and unknown paths were opening up. Thus, I began documenting every patient who came to the university under my supervision as a teacher, and in private practice as well. Over approximately 30 years, and without fully realizing it, I accumulated a vast number of photographs of patients with Dental Fluorosis and explored the science behind this significant problem and other enamel defects such as Molar Incisor Hypomineralization (MIH) and Amelogenesis Imperfecta, among others.

Alfredo Natera

Any path in life must be filled with cultural flexibility to perceive all its nuances. For this reason, we feel that this Atlas is a reward for the constant effort printed on every page and photograph it contains.

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FROM THE

CVIC FLUOROSIS INSTITUTE As we delved into books and scientific articles, we encountered the need to establish order and achieve organization as a natural course to continue, long before we regretted not having done so at the right time. Thus, the idea of creating an institute that would represent us and define our objectives was born. We needed a name that was more than just a clinic or a service; we aimed to create a concept that would accompany us in our identity as clinical dentists. We applied a methodical approach, and in 2007, the Venezuelan Center for Clinical Research for the Treatment of Dental Fluorosis and Enamel Development Defects (CVIC FLUOROSIS) was established, with its own capital and registered intellectual property.

But, most importantly, the patients to whom we dedicated our work were not in my city. They were spread across the country, so I had to travel extensively to find them, meet them, document their hidden smiles, and earn their trust to demonstrate what we could do, all while having clear objectives and investing many resources to achieve them.

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FROM THE

CVIC FLUOROSIS INSTITUTE With a suitcase full of photographic equipment, I set out to document every patient I could, even in streets and schools, as happened in San Timoteo, accompanied by pediatric dentist Gusmelia Fuenmayor, and in many states, towns, and cities across my country. Over time, this adventure took me to countries such as Ecuador, the Dominican Republic, Mexico, Colombia, Peru, Morocco, Curacao, Spain, France, and others. At times, we gained recognition from some institutions and even received funding to continue our study and data collection, which we continue to present in scientific articles published in indexed Latin American journals, other European countries, and books like this fabulous Atlas. We also experienced periods where we could do nothing due to a lack of resources, but at those times, we simply kept moving forward.

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FROM THE

WATER WELLS AND THE CHILDREN

It is very important to show photos of two wells with high levels of fluoride in their water. The first well is located in the city of Vigirima, Carabobo state, Venezuela. It stands solitary, proud, and threatening. Few suspect what its vital waters conceal. This significant photograph was taken by Dr. Rosa Rojas.

The second well is called Puerto Rico and is located in the municipality of San Timoteo, in the southern part of Zulia state, Venezuela. For me, it was a dreadful experience to be in front of this grim structure, responsible for so many people with Dental Fluorosis in the area.

Many times, the local population managed to disconnect it from the community water supply, but the "authorities" would reconnect it, creating a dichotomy between having water for basic life needs and suffering from Dental Fluorosis, which all the inhabitants of numerous towns and cities in Venezuela are well acquainted with, or experiencing the terrible scarcity of this vital liquid.

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FROM THE

WATER WELLS AND THE CHILDREN

These photographs are just two of the thousands of wells distributed throughout my country and the world, which is why I believe that as a profession, we must take a step forward in a collective struggle for the oral health of all our fellow beings. Allowing this and much more contradicts our dental essence.

The first photograph of children is from a school in the same area where the Puerto Rico well is located. I must point out that more than 80% of all schoolchildren present Dental Fluorosis in varying levels of severity, meaning eight hundred out of every thousand children, and this is just one of many afflictions of our childhood. The following photograph shows a group of children waiting to be seen at one of the many care sessions we conducted in Venezuela, sponsored by various commercial dental product brands.

These last two photographs are perhaps the most important in the Atlas. Our duty is to protect their innocence at all times, remembering that they represent the future of every country.

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Water wells in Vigirima Carabobo State Venezuela

PHOTOGRAPH BY DDS ROSA ROJAS

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Water wells Puerto Rico San Timoteo South of Lake Maracaibo Zulia State. Venezuela

PHOTOGRAPH BY DDS ALFREDO NATERA

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School in San Timoteo South of Lake Maracaibo Zulia State. Venezuela PHOTOGRAPH BY DDS ALFREDO NATERA

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Care of children with Dental fluorosis Materán Group Consultation Valencia. Carabobo State Venezuela PHOTOGRAPH BY DDS ALFREDO NATERA

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ON THE

OBJECTIVES OF THE ATLAS The idea of presenting this pathway for the identification, diagnosis, and classification of Dental Fluorosis stems from addressing misconceptions and gaps in information. These misconceptions suggest that Dental Fluorosis is a form of hypoplasia or that many white spots or other enamel development defects are similar.

In 2011 and 2018, Drs. Roberto Espinosa Fernández, Roberto Valencia Hitte, and Israel Ceja Andrade published the 1st and 2nd editions of a fantastic book titled "Dental Fluorosis: Etiology, Diagnosis, and Treatment," which provides guidance for Latin America and the world and is highly recommended reading for all.

Each of these defects has clinical characteristics that, in the mind of an expert, distinguish it from other defects, provided the expert has the patient's medical history, necessary supplementary examinations, and the correct knowledge.

From this source, we took the reference for the "average annual fluoride intake in PPM and its relation to Dean's classification and the TF index" (Stanley L.: 1968. Dean 1934. Thylstrup A. and Fejerskov O. 1978). We have also included the two most widely used classifications. The first was proposed by Dr. Henry Trendley Dean in the early 1930s, ninety years ago, and the second, proposed by Anders Thylstrup and Ole Fejerskov (TF), during the 1970s. These classifications have been faithfully translated and shown in detail, both in texts and accompanied by images designed to complement Dean's classification and the TF index, with a large number of high-quality clinical photographs.

It is already quite challenging in many clinical cases to achieve an accurate diagnosis without making mistakes at this crucial stage, which could lead to incorrect treatments. This is why we recognize "the gaps" because we have seen the significant impact that books and scientific articles can have in this globalized world where valuable information increasingly has the power to "change lives."

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ON THE

OBJECTIVES OF THE ATLAS Thus, we have designed this Atlas where multiple clinical photographs can be observed and detailed, allowing comparison with the characteristics of patients. Although it is inconsistent with logic to rely solely on photographs to achieve an accurate diagnosis, this aspect of the information will be addressed in the following book on this same topic.

While clinical reasoning is a difficult concept to explain theoretically, it is used daily by all health professionals, even though they do not often think about it, as it happens very naturally.

In conclusion, we present this work for a better understanding of Dental Fluorosis with the hope of contributing in the right direction.

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Bibliography THYLSTRUP AND FEJERSKOV, 1978. AS REPRODUCED IN “HEALTH EFFECTS OF INGESTED FLUORIDE” NATIONAL ACADEMY OF SCIENCES, 1993. PP. 171.

DEAN H. CLASSIFICATION OF MOTTLED ENAMEL DIAGNOSIS. J. AM. DENTAL ASSN. 1934 AUG; 21:14211426.

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ON

CLINICAL PHOTOGRAPHS Each photograph is a treasure for us. They capture smiles that convey embarrassment and an unknown inner world of each person, which I have tried to reveal in some cases.

In dental practice, we always think that we need to connect in some way with our patients and their feelings, which are not observable but are crucial. Photography allows us that connection. When I carefully review the images on a television or computer screen and plan the next steps, I can hear their voices and better understand their needs.

Another goal of this Atlas is to share our work, our clinical photography, and our fascination with Dental Fluorosis, its magnetic attraction, and its terrible impact on patients, as well as our limited understanding of this very complex health and life issue.

All the photography presented in this Atlas was taken over many years.

We aimed to gather as much graphic information as possible, and we always had that goal in mind. The evolution of photographic equipment and technology, the variations in our own knowledge, the use of different techniques, general conditions, and the wide variety of patients have all contributed to where we are today, where we understood what needed to be done.

The photography we do every day in the clinic is quick and requires great dedication and effort. This must be well understood. Therefore, to complete the collection and selection of all the photographs, we had to wait for an event led by Dr. María Alejandra Celis, where we obtained some spectacular photographs of patients with Dental Fluorosis TF 8 and 9 (severe). This was like the cherry on top of a spectacular ice cream, as obtaining patient consent and coordinating the photographic logistics and quality was not easy and deserves to be praised for its dedication, interest, and friendship.

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ON

CLINICAL PHOTOGRAPHS The importance of photographic documentation of everything we do and everyone we see in the dental clinic is so great that even the last case displayed in TF2 unfortunately combines Dental Fluorosis with Molar Incisor Hypomineralization (MIH), a situation worthy of a more in-depth and detailed study.

Dr. Alan Mighell, Researcher and Dean of the Faculty of Dentistry at the University of Leeds in England, reported a clinical case in a scientific article of a patient with Amelogenesis Imperfecta and Dental Fluorosis.

This again highlights how important clinical dental photography is and how complex diagnosing and understanding enamel development defects can be.

The learning curve for clinical dental photography techniques is long and sometimes steep due to its theory and application. However, I prefer simplicity and usually avoid complicating photographic shots, although I confess there was a time when I deviated from this principle.

Nevertheless, this is not the case with what we present in this Atlas.

The setup used for our photographic equipment is as follows: Shutter Speed: 1/100 Sensitivity or ISO: 100 Lens: 100mm Macro, f/2.8, with manual focus.

Lens Opening: f/22-f/32 White Balance set to flash.

Twin Flash for anterior areas.

Ring Flash for posterior areas.

Plastic dental retractors.

Contrastors.

No diffusers, softboxes, or other light modifiers were used, as these tend to obscure many details of the subject. The macro lens projects and reduces the image rather than enlarging it.

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ON

CLINICAL PHOTOGRAPHS Regarding photography, I would like to address two questions posed by a dentist and great photographer named Carlos Ayala during an excellent course I took in Madrid, Spain, in October 2022. These questions, related to Dentistry and macro or clinical dental photography, are presented and answered as follows:

When you combine our long learning curve in each area with photographic technology, you will likely need to delve deeper into defining a protocol and sequence for documenting clinical cases. In other words, you need to integrate dentistry, time, vision, science, and patience.

Where are we headed with photography?

Photography evolves with new techniques, forms, and elements to capture images with light that we strive to remember in great detail. It’s not just about picking up the camera and shooting; we must “compose and create the photograph” to document as much as possible everything we encounter and do daily.

I believe the path has no visible horizon. It is not only about learning to use this fabulous tool, which evolves faster than our understanding of it, but also about understanding Dental Fluorosis, the dimension of the problem, and the expanding scope of our knowledge in dentistry.

Our profession requires many accessories and instruments, both to receive and help patients and to learn, evolve, and build knowledge

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ON

CLINICAL PHOTOGRAPHS Is macro photography hyper-realistic?

Definitely, YES. Dr. Ayala answered this perfectly, saying, “It makes the ugly look horrible.”

That’s why it is the most suitable for showing details, curves, shadows, anatomies, imperfections, and surfaces against the light, such as in the cover and back cover photographs—essentially, “teeth, smiles, and lives with Dental Fluorosis.”

Macro photography reveals the perfection of nature, even if it is ugly. This is why what we do with our hands is very imperfect and cannot compare to nature. Of course, each person has their own perspective on the same object.

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ABOUT THE

CANINE PHOTOGRAPHS At the beginning of the Atlas, just before diving into the classification systems, you can find photographs of a canine with Dental Fluorosis. It is quite curious to have this particular tooth intact in my hands. I don’t remember when, where, or how I obtained it, so I always say that it simply “came to me.”

I have taken multiple photographs of this tooth, and it is essential to include these in the Atlas.

In these photographs, we can observe the canine from all four anatomical surfaces and, at the same time, the damage caused by Dental Fluorosis on the enamel. I decided to display them to invite anyone interested in observing and studying Dental Fluorosis to learn as much as possible from them.

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Dean H. Classification of Mottled Enamel Diagnosis. J. Am. Dental Assn. 1934 Aug; 21:1421- 1426.

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DENTAL FLUOROSIS

DEAN´S CLASSIFICATION A.- Normal B.- Questionable C.- Very mild D.- Moderate E.- Severe

Dean H. Classification of Mottled Enamel Diagnosis. J. Am. Dental Assn.

1934 Aug; 21:1421-1426

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DEAN´S CLASSIFICATION NORMAL: The enamel presents the usual translucent semivitriform type of structure. The surface is smooth and glossy and usually of a pale creamy white color. In addition to those showing normal calcification, for purposes of classification, there is also included under this heading all persons showing hypoplasia other than mottling of the enamel.

QUESTIONABLE: “Teeth” show slight aberrations in the translucency of normal enamel, ranging from a few white flecks to occasional white spots, 1 to 2 mm. in diameter. In such areas, the following method of differential diagnosis is followed: First, no attempt is made to diagnose these small white spots or minute white fleckings as the earliest signs of mottling of the enamel by examination of the person per se.

Dean H. Classification of Mottled Enamel Diagnosis. J. Am. Dental Assn. 1934 Aug; 21:1421-1426

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DEAN´S CLASSIFICATION VERY MILD: The white, opaque areas on the surfaces of the teeth involve at least half of the tooth surface. The surfaces of molars, bicuspids, and cuspids subject to attrition show thin white layers worn off and the bluish shades of underlying normal enamel. Faint brown stains are sometimes apparent, generally on the upper incisors.

MODERATE: No change is observed in the form of the tooth, but generally all of the tooth surfaces are involved.

Surfaces subject to attrition are definitely marked. Minute pitting is often present, generally on the labial and buccal surfaces. Brown stain is frequently a disfiguring complication. It must be remembered that the incidence of brown stain varies greatly in different endemic areas, and many cases of white opaque mottled enamel, without brown stain, are classified as “moderate” and listed in this category.

Dean H. Classification of Mottled Enamel Diagnosis. J. Am. Dental Assn. 1934 Aug; 21:1421-1426

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DEAN´S CLASSIFICATION MODERATE: Macroscopically, a greater depth of enamel appears to be involved. A smoky white appearance is often noted. Pitting is more frequent and generally observed on all the tooth surfaces. Brown stain, if present, is generally deeper in hue and involves more of the affected tooth surfaces.

SEVERE: The hypoplasia is so marked that the form of the teeth is a t times affected, the condition often being manifest in older children as a mild pathologic incisal-occlusal abrasion. The pits are deeper and often confluent.

Stains are widespread and range from a chocolate brown to almost black in some cases. Under this classification, I include the type of case which McKay has referred to as the “corrosion” type of mottled enamel.

Dean H. Classification of Mottled Enamel Diagnosis. J. Am. Dental Assn. 1934 Aug; 21:1421-1426

49

Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes.

Community Dent Oral Epidemiol. 1978 Nov 6(6):315-28

50

THYLSTRUP & FEJERSKOV INDEX (TF) VALUE 0: Normal translucency of enamel remains after prolonged air-drying.

VALUE 1: Narrow white lines corresponding to the perikymata.

VALUE 2: Smooth surfaces: More pronounced lines of opacity that follow the perikymata. Occasionally confluence of adjacent lines.

Occlusal surfaces: Scattered areas of opacity <2 mm in diameter and pronounced opacity of cuspal ridges.

VALUE 3: Smooth surfaces: Merging and irregular cloudy areas of opacity. Accentuated drawing of perikymata often visible between opacities.

Occlusal surfaces: Confluent areas of marked opacity. Worn areas appear almost normal but usually circumscribed by a rim of opaque enamel.

VALUE 4: Smooth surfaces: The entire surface exhibits marked opacity or appears chalky white. Parts of surface exposed to attrition appear less affected.

Occlusal surfaces: Entire surface exhibits marked opacity. Attrition is often pronounced shortly after eruption.

Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes.

Community Dent Oral Epidemiol. 1978 Nov 6(6):315-28

51

THYLSTRUP & FEJERSKOV INDEX (TF) VALUE 5: Smooth surfaces and occlusal surfaces: Entire surface displays marked opacity with focal loss of outermost enamel (pits) <2 mm in diameter.

VALUE 6: Smooth surfaces: Pits are regularly arranged in horizontal bands <2 mm in vertical extension.

Occlusal surfaces: Confluent areas <3 mm in diameter exhibit loss of enamel. Marked attrition.

VALUE 7: Smooth surfaces: Loss of outermost enamel in irregular areas involving <1/2 of entire surface.

Occlusal surfaces: Changes in the morphology caused by merging pits and marked attrition.

VALUE 8: Smooth and occlusal surfaces: Loss of outermost enamel involving >1/2 of surface.

VALUE 9: Smooth and occlusal surfaces: Loss of main part of enamel with change in anatomic appearance of surface. Cervical rim of almost unafffected enamel is often noted.

Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes.

Community Dent Oral Epidemiol. 1978 Nov 6(6):315-28

52

53

COMPARISON OF DEAN´´S CLASSIFICATION AND TF INDEX

TF0 Dean: normal

TF1 Dean: questionable

TF2 Dean: very mild

TF3 Dean: moderate

TF4 Dean: moderate

TF5 Dean: severe

TF6 Dean: severe

TF7 Dean: severe

TF8 Dean: severe

TF9 Dean: severe

54

Clinical cases TF0 Dean: normal 55

TF0: Normal translucency of enamel remains after prolonged air-drying.

Dean: normal The enamel presents the usual translucent semivitriform type of structure.

The surface is smooth and glossy and usually of a pale creamy white color.

In addition to those showing normal calcification, for purposes of classification, there is also included under this heading all persons showing hypoplasia other than mottling of the enamel.

Average annual fluoride intake: 0.7 ppm

56

Clinical case #1 57

TF0 Dean: normal

58

TF0 Dean: normal

59

TF0 Dean: normal

60

Clinical case #2 61

TF0 Dean: normal

62

Clinical case #3 63

TF0 Dean: normal

64

TF0 Dean: normal

65

TF0 Dean: normal

66

Clinical cases TF1 Dean: questionable 67

TF1: Narrow white lines corresponding to the perikymata.

Dean: questionable “Teeth” show slight aberrations in the translucency of normal enamel, ranging from a few white flecks to occasional white spots, 1 to 2 mm. in diameter. In such areas, the following method of differential diagnosis is followed: First, no attempt is made to diagnose these small white spots or minute white fleckings as the earliest signs of mottling of the enamel by examination of the person per se.

Average annual fluoride intake: 1.0 ppm

68

Clinical case #1 69

TF1 Dean: questionable

70

TF1 Dean: questionable

71

TF1 Dean: questionable

72

TF1 Dean: questionable

73

TF1 Dean: questionable

74

Clinical case #2 75

TF1 Dean: questionable

76

TF1 Dean: questionable

77

TF1 Dean: questionable

78

Clinical case #3 79

TF1 Dean: questionable

80

TF1 Dean: questionable

81

TF1 Dean: questionable

82

TF1 Dean: questionable

83

Clinical case #4 85

TF1 Dean: questionable

86

Clinical case #5 87

TF1 Dean: questionable

88

Clinical cases TF2 Dean: very mild 89

TF2: Smooth surfaces: More pronounced lines of opacity that follow the perikymata. Occasionally confluence of adjacent lines.

Occlusal surfaces: Scattered areas of opacity <2 mm in diameter and pronounced opacity of cuspal ridges.

Dean: very mild The white, opaque areas on the surfaces of the teeth involve at least half of the tooth surface. The surfaces of molars, bicuspids, and cuspids subject to attrition show thin white layers worn off and the bluish shades of underlying normal enamel. Faint brown stains are sometimes apparent, generally on the upper incisors.

Average annual fluoride intake: 1.3 ppm 90

Clinical case #1 91

TF2 Dean: very mild

92

TF2 Dean: very mild

93

TF2 Dean: very mild

94

Clinical case #2 95

TF2 Dean: very mild

96

TF2 Dean: very mild

97

TF2 Dean: very mild

98

TF2 Dean: very mild

99

TF2 Dean: very mild

100

TF2 Dean: very mild

101

TF2 Dean: very mild

102

TF2 Dean: very mild

103

Clinical case #3 105

TF2 Dean: very mild

106

TF2 Dean: very mild

107

TF2 Dean: very mild

108

TF2 Dean: very mild

109

Clinical case #4 111

TF2 Dean: very mild

112

TF2 Dean: very mild

113

TF2 Dean: very mild

114

Clinical case #5 115

TF2 Dean: very mild

116

Clinical case #6 117

TF2 Dean: very mild

118

TF2 Dean: very mild

119

TF2 Dean: very mild

120

TF2 Dean: very mild

121

Clinical case #7 123

TF2 Dean: very mild

124

TF2 Dean: very mild

125

TF2 Dean: very mild

126

TF2 Dean: very mild

127

Clinical case #8 129

TF2 Dean: very mild

130

TF2 Dean: very mild

131

Clinical case #9 133

TF2 Dean: very mild

134

TF2 Dean: very mild

135

Clinical case #10 137

TF2 Dean: very mild

138

TF2 Dean: very mild

139

Clinical case #11 141

TF2 Dean: very mild

142

TF2 Dean: very mild

143

TF2 Dean: very mild

144

TF2 Dean: very mild

145

Clinical case #12 147

TF2 Dean: very mild

148

Clinical case #13 149

TF2 Dean: very mild

150

TF2 Dean: very mild

151

Clinical case #14 153

TF2 Dean: very mild

154

TF2 Dean: very mild

155

TF2 Dean: very mild

156

TF2 Dean: very mild

157

Clinical case #15 DENTAL FLUOROSIS AND MOLAR INCISOR HYPOMINERALIZATION 159

TF2 Dean: very mild

160

TF2 Dean: very mild

161

TF2 Dean: very mild

162

TF2 Dean: very mild

163

TF2 Dean: very mild

164

Clinical cases TF3 Dean: moderate 165

TF3: Smooth surfaces: Merging and irregular cloudy areas of opacity. Accentuated drawing of perikymata often visible between opacities.

Occlusal surfaces: Confluent areas of marked opacity. Worn areas appear almost normal but usually circumscribed by a rim of opaque enamel.

Dean: moderate No change is observed in the form of the tooth, but generally all of the tooth surfaces are involved. Surfaces subject to attrition are definitely marked. Minute pitting is often present, generally on the labial and buccal surfaces. Brown stain is frequently a disfiguring complication. It must be remembered that the incidence of brown stain varies greatly in different endemic areas, and many cases of white opaque mottled enamel, without brown stain, are classified as “moderate” and listed in this category.

Average annual fluoride intake: 1.5 ppm

166

Clinical case #1 167

TF3 Dean: moderate

168

TF3 Dean: moderate

169

TF3 Dean: moderate

170

TF3 Dean: moderate

171

Clinical case #2 POSTERIOR TEETH WITH DENTAL FLUOROSIS 173

TF3 Dean: moderate

174

Clinical case #3 175

TF3 Dean: moderate

176

TF3 Dean: moderate

177

TF3 Dean: moderate

178

TF3 Dean: moderate

179

Clinical case #4 181

TF3 Dean: moderate

182

TF3 Dean: moderate

183

TF3 Dean: moderate

184

TF3 Dean: moderate

185

Clinical case #5 187

TF3 Dean: moderate

188

TF3 Dean: moderate

189

TF3 Dean: moderate

190

TF3 Dean: moderate

191

Clinical case #6 DENTAL FLUOROSIS AND DEMARCATED OPACITIES 193

TF3 Dean: moderate

194

TF3 Dean: moderate

195

TF3 Dean: moderate

196

TF3 Dean: moderate

197

TF3 Dean: moderate

198

Clinical case #7 199

TF3 Dean: moderate

200

Clinical case #8 201

TF3 Dean: moderate

202

Clinical case #9 203

TF3 Dean: moderate

204

Clinical case #10 205

TF3 Dean: moderate

206

TF3 Dean: moderate

207

TF3 Dean: moderate

208

TF3 Dean: moderate

209

TF3 Dean: moderate

210

TF3 Dean: moderate

211

Clinical case #11 213

TF3 Dean: moderate

214

TF3 Dean: moderate

215

TF3 Dean: moderate

216

Clinical case #12 217

TF3 Dean: moderate

218

Clinical case #13 219

TF3 Dean: moderate

220

Clinical case #14 POSTERIOR TEETH WITH DENTAL FLUOROSIS 221

TF3 Dean: moderate

222

Clinical case #15 POSTERIOR TEETH WITH DENTAL FLUOROSIS 223

TF3 Dean: moderate

224

Clinical case #16 225

TF3 Dean: moderate

226

TF3 Dean: moderate

227

TF3 Dean: moderate

228

Clinical case #17 229

TF3 Dean: moderate

230

TF3 Dean: moderate

231

TF3 Dean: moderate

232

Clinical cases TF4 Dean: moderate 233

TF4: Smooth surfaces: The entire surface exhibits marked opacity or appears chalky white. Parts of surface exposed to attrition appear less affected.

Occlusal surfaces: Entire surface exhibits marked opacity. Attrition is often pronounced shortly after eruption.

Dean: moderate No change is observed in the form of the tooth, but generally all of the tooth surfaces are involved. Surfaces subject to attrition are definitely marked. Minute pitting is often present, generally on the labial and buccal surfaces. Brown stain is frequently a disfiguring complication. It must be remembered that the incidence of brown stain varies greatly in different endemic areas, and many cases of white opaque mottled enamel, without brown stain, are classified as “moderate” and listed in this category.

Average annual fluoride intake: 2.0 ppm

234

Clinical case #1 235

TF4 Dean: moderate

236

TF4 Dean: moderate

237

TF4 Dean: moderate

238

TF4 Dean: moderate

239

TF4 Dean: moderate

240

Clinical case #2 241

TF4 Dean: moderate

242

TF4 Dean: moderate

243

TF4 Dean: moderate

244

TF4 Dean: moderate

245

Clinical case #3 247

TF4 Dean: moderate

248

TF4 Dean: moderate

249

TF4 Dean: moderate

250

TF4 Dean: moderate

251

TF4 Dean: moderate

252

Clinical case #4 253

TF4 Dean: moderate

254

TF4 Dean: moderate

255

TF4 Dean: moderate

256

TF4 Dean: moderate

257

Clinical case #5 259

TF4 Dean: moderate

260

Clinical case #7 261

TF4 Dean: moderate

262

TF4 Dean: moderate

263

TF4 Dean: moderate

264

Clinical case #8 265

TF4 Dean: moderate

266

Clinical case #9 267

TF4 Dean: moderate

268

TF4 Dean: moderate

269

TF4 Dean: moderate

270

TF4 Dean: moderate

271

TF4 Dean: moderate

272

TF4 Dean: moderate

273

Clinical case #10 275

TF4 Dean: moderate

276

TF4 Dean: moderate

277

Clinical case #11 279

TF4 Dean: moderate

280

TF4 Dean: moderate

281

TF4 Dean: moderate

282

TF4 Dean: moderate

283

Clinical case #12 285

TF4 Dean: moderate

286

TF4 Dean: moderate

287

TF4 Dean: moderate

288

Clinical case #13 289

TF4 Dean: moderate

290

TF4 Dean: moderate

291

TF4 Dean: moderate

292

TF4 Dean: moderate

293

TF4 Dean: moderate

294

Clinical case #14 295

TF4 Dean: moderate

296

TF4 Dean: moderate

297

TF4 Dean: moderate

298

TF4 Dean: moderate

299

Clinical case #15 301

TF4 Dean: moderate

302

TF4 Dean: moderate

303

Clinical case #16 305

TF4 Dean: moderate

306

TF4 Dean: moderate

307

TF4 Dean: moderate

308

TF4 Dean: moderate

309

Clinical case #18 311

TF4 Dean: moderate

312

TF4 Dean: moderate

313

TF4 Dean: moderate

314

TF4 Dean: moderate

315

Clinical cases TF5 Dean: severe 317

TF5: Smooth surfaces and occlusal surfaces: Entire surface displays marked opacity with focal loss of outermost enamel (pits) <2 mm in diameter.

Dean: severe The hypoplasia is so marked that the form of the teeth is a t times affected, the condition often being manifest in older children as a mild pathologic incisal-occlusal abrasion. The pits are deeper and often confluent. Stains are widespread and range from a chocolate brown to almost black in some cases. Under this classification, I include the type of case which McKay has referred to as the “corrosion” type of mottled enamel.

Average annual fluoride intake: > 3.9 ppm

318

Clinical case #1 319

TF5 Dean: severe

320

TF5 Dean: severe

321

TF5 Dean: severe

322

TF5 Dean: severe

323

Clinical case #2 325

TF5 Dean: severe

326

TF5 Dean: severe

327

Clinical case #3 329

TF5 Dean: severe

330

TF5 Dean: severe

331

Clinical case #4 333

TF5 Dean: severe

334

Clinical case #5 335

TF5 Dean: severe

336

TF5 Dean: severe

337

TF5 Dean: severe

338

Clinical case #6 339

TF5 Dean: severe

340

TF5 Dean: severe

341

Clinical case #7 343

TF5 Dean: severe

344

Clinical case #8 345

TF5 Dean: severe

346

Clinical case #9 347

TF5 Dean: severe

348

TF5 Dean: severe

349

TF5 Dean: severe

350

Clinical case #10 351

TF5 Dean: severe

352

TF5 Dean: severe

353

Clinical case #11 355

TF5 Dean: severe

356

TF5 Dean: severe

357

TF5 Dean: severe

358

Clinical cases TF6 Dean: severe 359

TF6: Smooth surfaces: Pits are regularly arranged in horizontal bands <2 mm in vertical extension.

Occlusal surfaces: Confluent areas <3 mm in diameter exhibit loss of enamel.

Marked attrition.

Dean: severe The hypoplasia is so marked that the form of the teeth is a t times affected, the condition often being manifest in older children as a mild pathologic incisal-occlusal abrasion. The pits are deeper and often confluent. Stains are widespread and range from a chocolate brown to almost black in some cases. Under this classification, I include the type of case which McKay has referred to as the “corrosion” type of mottled enamel.

Average annual fluoride intake: > 3.9 ppm

360

Clinical case #1 361

TF6 Dean: severe

362

TF6 Dean: severe

363

TF6 Dean: severe

364

TF6 Dean: severe

365

Clinical case #2 367

TF6 Dean: severe

368

TF6 Dean: severe

369

TF6 Dean: severe

370

TF6 Dean: severe

371

Clinical case #3 373

TF6 Dean: severe

374

TF6 Dean: severe

375

Clinical case #4 377

TF6 Dean: severe

378

TF6 Dean: severe

379

Clinical case #5 381

TF6 Dean: severe

382

TF6 Dean: severe

383

Clinical case #6 385

TF6 Dean: severe

386

Clinical case #7 387

TF6 Dean: severe

388

TF6 Dean: severe

389

TF6 Dean: severe

390

TF6 Dean: severe

391

TF6 Dean: severe

392

Clinical case #8 393

TF6 Dean: severe

394

TF6 Dean: severe

395

TF6 Dean: severe

396

DENTAL FLUOROSIS IN PRIMARY SECOND MOLARS AND PERMANENT FIRST MOLARS

397

TF6 Dean: severe

98

Clinical case #9 399

TF6 Dean: severe

400

TF6 Dean: severe

401

DENTAL FLUOROSIS IN PRIMARY SECOND MOLARS AND PERMANENT FIRST MOLARS

402

TF6 Dean: severe

403

Clinical cases TF7 Dean: severe 405

TF7: Smooth surfaces: Loss of outermost enamel in irregular areas involving <1/2 of entire surface.

Occlusal surfaces: Changes in the morphology caused by merging pits and marked attrition.

Dean: severe The hypoplasia is so marked that the form of the teeth is a t times affected, the condition often being manifest in older children as a mild pathologic incisal-occlusal abrasion. The pits are deeper and often confluent. Stains are widespread and range from a chocolate brown to almost black in some cases. Under this classification, I include the type of case which McKay has referred to as the “corrosion” type of mottled enamel.

Average annual fluoride intake: > 3.9 ppm

406

Clinical case #1 407

TF7 Dean: severe

408

TF7 Dean: severe

409

TF7 Dean: severe

410

TF7 Dean: severe

411

Clinical case #2 413

TF7 Dean: severe

414

TF7 Dean: severe

415

TF7 Dean: severe

416

TF7 Dean: severe

417

TF7 Dean: severe

418

Clinical case #3 419

TF7 Dean: severe

420

TF7 Dean: severe

421

TF7 Dean: severe

422

TF7 Dean: severe

423

TF7 Dean: severe

424

TF7 Dean: severe

425

Clinical case #4 427

TF7 Dean: severe

428

TF7 Dean: severe

429

TF7 Dean: severe

430

TF7 Dean: severe

431

TF7 Dean: severe

432

TF7 Dean: severe

433

TF7 Dean: severe

434

Clinical case #5 435

TF7 Dean: severe

436

TF7 Dean: severe

437

TF7 Dean: severe

438

TF7 Dean: severe

439

Clinical case #6 441

TF7 Dean: severe

442

TF7 Dean: severe

443

TF7 Dean: severe

444

DENTAL FLUOROSIS IN PRIMARY SECOND MOLARS AND PERMANENT FIRST MOLARS

445

TF7 Dean: severe

446

Clinical case #7 447

TF7 Dean: severe

448

TF7 Dean: severe

449

TF7 Dean: severe

450

TF7 Dean: severe

451

Clinical cases TF8 Dean: severe 453

TF8: Smooth and occlusal surfaces: Loss of outermost enamel involving >1/2 of surface.

Dean: severe The hypoplasia is so marked that the form of the teeth is a t times affected, the condition often being manifest in older children as a mild pathologic incisal-occlusal abrasion. The pits are deeper and often confluent. Stains are widespread and range from a chocolate brown to almost black in some cases. Under this classification, I include the type of case which McKay has referred to as the “corrosion” type of mottled enamel.

Average annual fluoride intake: > 3.9 ppm

454

Clinical case #1 455

TF8 Dean: severe

456

TF8 Dean: severe

457

TF8 Dean: severe

458

TF8 Dean: severe

459

Clinical case #2 461

TF8 Dean: severe

462

TF8 Dean: severe

463

TF8 Dean: severe

464

TF8 Dean: severe

465

TF8 Dean: severe

466

TF8 Dean: severe

467

Clinical case #3 469

TF8 Dean: severe

470

TF8 Dean: severe

471

DENTAL FLUOROSIS IN PRIMARY SECOND MOLARS AND PERMANENT FIRST MOLARS

472

TF8 Dean: severe

473

Clinical cases TF9 Dean: severe 475

TF9: Smooth and occlusal surfaces: Loss of main part of enamel with change in anatomic appearance of surface. Cervical rim of almost unafffected enamel is often noted.

Dean: severe The hypoplasia is so marked that the form of the teeth is a t times affected, the condition often being manifest in older children as a mild pathologic incisal-occlusal abrasion. The pits are deeper and often confluent. Stains are widespread and range from a chocolate brown to almost black in some cases. Under this classification, I include the type of case which McKay has referred to as the “corrosion” type of mottled enamel.

Average annual fluoride intake: > 3.9 ppm

476

Clinical case #1 477

TF9 Dean: severe

478

TF9 Dean: severe

479

TF9 Dean: severe

480

TF9 Dean: severe

481

TF9 Dean: severe

482

Clinical case #2 483

TF9 Dean: severe

484

TF9 Dean: severe

485

TF9 Dean: severe

486

TF9 Dean: severe

487

TF9 Dean: severe

488

TF9 Dean: severe

489

TF9 Dean: severe

490

TF9 Dean: severe

491

REGARDING

THE PHOTOGRAPHS ON THE TWO BACK COVERS The photographs on the back cover depict Dental Fluorosis TF7 (severe), and both were taken using the same backlighting technique. The photographer's position was diagonal and in front of the patient, allowing almost an in-depth view, palpating the loss of enamel continuity, micromorphology, and other characteristics of the enamel tissue. This approach allows us to hypothesize that the deep pigmented tissue might be dentin, though it is not. This perception could possibly result from incorrect identification and diagnosis, inadequate oral hygiene, and the consumption of highly chromogenic foods, pigments that become embedded in the spaces and irregularities of the tissue.

It is important to reiterate that both photographs exhibit Dental Fluorosis TF7 (severe), and they do not display identical characteristics. Each stage has a bandwidth or gray areas in which cases like these can exist, underscoring the importance of this Atlas and the extensive photographic evidence provided to the readers.

494

495

496

ON THE

CONCLUSION OF THE ATLAS As I have previously expressed, my goal with this Atlas is to contribute to science, dentistry, and progress, and to raise awareness about Dental Fluorosis because “this type of enamel developmental disorder is not invisible to millions of people suffering from it worldwide.” We, as dentists, are responsible for identifying, diagnosing, and providing solutions to a very complex problem—both personally and socio-economically, as well as environmentally. I have often observed a lack of understanding of enamel developmental disorders, and Dental Fluorosis is one of the most prevalent alterations.

Where are we headed with Dental Fluorosis?

We have a single path and direction with Dental Fluorosis: we are moving decisively towards the future. We will continue working, studying, demonstrating, publishing, and allowing our minds to progress, always based on scientific evidence. This is just the beginning, undoubtedly, and we are already advancing to the next steps. Therefore, I affirm that as long as I continue researching, investigating, and learning, I will remain motivated and happy with my life.

I firmly believe that results are achieved through people, by being motivated to read, analyze, learn, and improve to stand out. Excellence in training for many professionals on the identification, diagnosis, and classification of Dental Fluorosis and various enamel developmental defects, with institutional certification and proper calibration, should be the next goal for those who believe in this path of science and health. In this way, I think this Atlas will be defined by the utility it provides to many dental professionals.

497

And finally, I want to extend an invitation to every observer, researcher, clinician, student, future dentist, dental professional, and all health personnel: to walk together, starting today, “towards a modern and responsible dentistry.”

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