Prevalence of Dental Fluorosis Amongst Patients Attending the Tertiary Care Hospital, Peshawar, Pakistan.cdr

concentrations can weaken the skeletal system [2,3]. Overexposure to uoride can cause a sluggish, but progressive disease called uorosis [4], which is reduced by drinking milk. In many Asian countries, it is considered a major health threat [5]. Studies have shown little connection between uorosis and periodontal health, but there are some epidemiological studies reporting high levels of in ammation in uorosis areas as compared to nonuorosis areas [6]. Some studies do not show any A R T I C L E I N F O

relationship between uoride and periodontal health [7], whereas other studies show better periodontal health in high uoride areas [8]. Recent studies demonstrate that the presence of uoride ions reduces bacteria and microbes, which has an indirect effect on the periodontal status by reducing in ammation, similar to nutraceuticals, TGF-β (transforming growth factor-β), VEGF (vascular endothelial growth factor), and ADMA (asymmetric dimethylarginine). Having an adequate ionic level of uoride in saliva reduces enamel demineralization [9]. The WHO recommends that the uoride level is highest level must not surpass 1.5 mg/l to prevent bone and tooth issues. In dental uorosis, the uoride persistency affects both tooth appearance and formation. Mineralization and enamel development are disrupted both intracellularly and extracellularly by uorosis [10], and the presence of such lesions are linked to the consumption of substantial a m o u n t s o f u o r i d e w i t h i n t h e c r i t i c a l p h a s e (postsecretory or early maturation) when the actual growth of the tooth comes about. Microscopically, uorosis damages enamel by making it porous. In consequence, if there is a high level of uoride, the enamel will be more porous [11]. Porosity increases as the inter-crystalline space increases [12]. The structural arrangement of enamel crystals is normal but the inter-crystalline space is increasing [13]. These symptoms are associated with other systemic diseases according to many epidemiological studies [14]. The susceptibility and severity of dental uorosis varied from population to population. Genetic variations may play a role in this. A Matrix Metallo Protease (MMP20) gene variation was associated with the less severe phenotypes of dental uorosis in populations with high exposure to uoride in drinking water. Children can develop uorosis from infancy to the age of eight years, and they can experience aesthetic issues with their teeth from birth to six years of age. Premolars are typically more susceptible to the problem and sustain a greater amount of damage [15]. The clinical presentation of enamel uorosis is often characterized by white spots or lines on the tooth's surface, or by a white sheet of parchment. Food consumption has sometimes been associated with persistent uorosis, and brown stains can develop due to the absorption of extrinsic stains. Fluorosis, particularly at higher uoride doses accompanied by intrinsic stains, is also associated with discrete pitting. The severity and distribution of uorosis vary [16]. In mild cases, teeth that are in the posterior part of the mouth are less likely to need treatment, but in certain cases, especially those that are within the aesthetic limit, treatment is required. Treatment options include microabrasion technique and bleaching or resin covering, or full or partial coverage (veneer, full crown, etc.) [16]. There is still no clear evidence of any

M E T H O D S
The study comprised of 2,433 participants in Peshawar, Pakistan who were seeking the dental care unit of Khyber Teaching Hospital from January 2021 to December 2021. Patient consent was obtained in written form by the operator. During the course of 12 months, multiple dentists performed examinations. Through the use of a uniform index and by using patients sample reexamined by numerous dentists, we standardized and calibrated the learning and examination procedures among the examiners. Additionally, a month after, the same patients were reassessed by a similar dentist, who was previously examined to ascertain reliability. During a questionnaire, patients submitted demographic information including their names, ages, genders, social security numbers, and water source. Keeping in view the standard guidelines of infection control, for evaluation, we use a mouth mirror, all recordings were collected in natural daylight. To assess dental uorosis, we used the revised Dean's Fluorosis Index [17]. i.
An unaffected tooth appears to have translucent enamel, and a smooth, glossy surface. This type of tooth is white or pale in color. ii.
Questionable. The enamel in this instance shows some changes from that discussed above. Occasionally, a white spot or eck may be visible on the enamel. It was designed to apply in cases where "de nitive determination of mild uorosis was not justi ed and a classi cation of unaffected was not justi ed." iii.
Very mild. "On some tooth surfaces, small opaque paper-white areas are visible, but they do not cover more than 25% of the tooth surface." iv.
Mild: "This white opaque area is more extensive than 50% of the surface but is not as extensive as a smear." v.
Moderate: White opaque patches cover 50% of the surface. vi.
Severe: The entire enamel of the tooth is affected. A discrete or con uent pit can be seen in this category. The statistical analyses were done using SPSS 26 (Chicago, IL, USA), a statistical package for social science. Additionally, the study employed descriptive statistics to signi cant relationship between dental caries, uoride and uorosis in patients. This area requires further investigation. Fluoride concentration is not monitored in the drinking water in Pakistan, where the issue is prevalent. This study is aimed at observing the uorosis incidence among Pakistan residents and comparing the results with those of previous studies conducted in the alike and surrounding regions to ensure or deny the motif that occurred in recent years with elevated uoride consumption in toothpaste, food and fertilizers etc. Peshawar, Pakistan and the distribution of uorosis by gender, source of drinking water, as well as the effect of these factors on its extent and in uence. It isn't surprising that uorosis is on the rise with the increase of the contents in drinking water. Furthermore, uorosis rates were high in optimal areas. Despite this nding, the incidence of uorosis was similar in this study to research in Mexico and America, showing an increase in uorosis incidence [18]. The water source in this area has not undergone any major improvements. The number stood at 80% in 1989, according to Fraysse et al. That is a signi cant difference from the results documented in the study under discussion. Based on data from other South Asian countries, in the current study the uorosis incidence variate apparently. According to Rugg-Gunn et al., a study conducted on in Riyadh revealed 83% enamel mottling among participants [19]. Among Saudi Arabian school children, Akpata et al. found a result of 90% [20]. When looking at uoride de cient areas in Kuwait, Vigild et al. revealed a 6% prevalence [21]. That is signi cantly lower than the results of this study. There is an endemic of dental uorosis in Sudan. The problem persists regardless of the level of uoride in the area. A study conducted by Ibrahim, et al. found that results for low areas ranged from 91% to 100%, while results for high ones were 100% [22]. A difference in prevalence may be due to different diagnostic criteria, sampling methods, or quantities of uoride consumed from different sources. It appears that uorosis is on the rise today compared to the period between the 1940s and 2010s [23]. When it comes to climate changes and seasons, temperature variation has an impact on severity. Whenever the temperature reaches a high point, that is also when the water intake rises [24]. If temperatures rise to a mean of 23°C, children may also drink more water. The simplest way to handle temperature extremes is to consume water, as it is inexperienced and readily available, unlike other solutions. The consumption of substances by children may be in uenced by this aspect. Fluorosis severity and prevalence are impacted by this factor signi cantly. Fluorides are released as solids and gases in industrial zones. Particles are formed when they are in solid form, while gases are produced when they are in the gaseous state. The respiratory system of humans can eventually be affected by plants' uoride particles on its surface or by plants that have absorbed it as a gas. The majorities of Pakistanis are poor and belong to lowerincome groups. In liquids, after water the children mostly consume tea and they consume it in large quantities. Children will consume more uoride if this is the case. According to Fraysse, the high mean temperature of the study was related to the 80% result, as it caused an increase in water intake and therefore supplement the

R E S U L T S
Out of 2,433 participants, 982(40.4%) were males and 1,451(59.6% were females. The prevalence of Fluorosis was 982 (40.4%), and the majority of these were males 414/982 (42.1%) as compared to females 568/1451 (39.14%) (Table1). The prevalence of uorosis is highest among individuals aged 11-20 years 874/982 (89%) while only two individuals aged over 40 years had dental uorosis (Table 2). Fluorosis can also affect people who drink water from various sources. Fluorosis is signi cantly more common in those who drink tap water 568 (56.9%), whereas people who drink treated or other sources of water were 2 (1.2%) ( Table. 3). Moreover, depending on the location, 620 (63.1%) individuals were found with localized uorosis while 362 (36.9%) were found with generalized one ( This study evaluated the incidence of uorosis in      [25]. Adding tea to a child's diet on a daily basis can add up to 2.7 milligrams of uoride to their diet. Studies have shown that females are more vulnerable to uorosis than males. Additionally, uorosis is most prevalent among 12-to 20-year-olds [26]. In addition to causing enamel pitting and porosity, uorosis alters tooth surfaces, causing germs to adhere, resulting in gingival in ammation, and the formation of hyper-cementosis in roots can hamper scaling and root planning [27]. By reducing bacteria growth and gingival in ammation, optimal uoride levels have a positive impact on periodontal health . Patients with dental uorosis can be well aware of its cosmetic effects according to severity and location. Many studies regarding treatment for edentulous teeth still have some controversy with alternatives ranging from conservative measures (like micro-abrasion and bleaching) to non-conservative measures (like veneers and full crowns). Finally, there are alternatives (like resin coatings) or even no treatment at all for patients with mild cases or when the affected teeth are away from the aesthetic zone [29].

C O N C L U S I O N
It is concluded that the prevalence of uorosis in Pakistan must be monitored continuously, and its sources must be investigated further. Fluoride intake is primarily caused by drinking water, but we must also consider other sources like toothpaste and industrial wastes and pollution. To reduce the effects on dental and periodontal health, uorosis prevention education and community awareness are essential.