Oral health-related quality of life and condition-specific daily performance impacts in dental fluorosis: a narrative synthesis
Introduction.
Dental fluorosis is an oral condition with aesthetic, psychosocial, and, in some contexts, functional implications that may extend beyond the clinical appearance of enamel. Interest in patient-reported outcome measures has increased because clinical severity alone does not explain how children and adolescents experience fluorosis in daily life. This manuscript aims to synthesize the evidence on oral health-related quality of life and to assess the relevance of a condition-specific Oral Impacts on Daily Performance approach for dental fluorosis.
Materials and methods.
A narrative synthesis was prepared according to PRISMA-ScR guidance [REF]. The search framework was designed for PubMed/MEDLINE, Scopus, Web of Science, Embase, Cochrane Library, and the institutional repository of Nicolae Testemițanu State University of Medicine and Pharmacy. Core studies addressing dental fluorosis and oral health-related quality of life were extracted together with methodological papers on condition-specific OIDP, instrument adaptation, and Moldova-generated contextual literature. The methodological premises from the attached doctoral thesis on the Romanian adaptation of dental questionnaires were also integrated.
Results.
The evidence is heterogeneous. Mild dental fluorosis is often associated with no deterioration in oral health-related quality of life, while moderate to severe fluorosis is more consistently linked to worse quality-of-life outcomes. The most direct condition-specific OIDP evidence comes from a cross-sectional study in India showing significant correlations between fluorosis, CS-OIDP, and OHRQoL. A recent systematic review confirmed the mixed direction of results across 16 studies. Local Moldovan publications support the public health relevance of endemic fluoride exposure and the need for Romanian-language instruments adapted to this context.
Conclusions.
The current evidence supports the methodological relevance of a fluorosis-adapted CS-OIDP instrument. A future Romanian adaptation should combine rigorous translation procedures, cognitive testing, and psychometric validation, while retaining clinical measures of fluorosis severity for discriminative analysis.
What is not yet known on the issue addressed in the submitted manuscript
The literature on dental fluorosis contains multiple clinical and epidemiological descriptions, but there is still limited synthesis focused specifically on oral health-related quality of life and on the added value of a condition-specific daily performance instrument adapted for fluorosis.
The research hypothesis
Dental fluorosis affects oral health-related quality of life mainly through aesthetic, emotional and social pathways, and a condition-specific OIDP format is expected to capture these daily impacts more precisely than generic tools.
The novelty added by the manuscript to the already published scientific literature.
This manuscript reorganizes the evidence around fluorosis-specific OHRQoL outcomes, distinguishes neutral from negative findings according to severity and instrument choice, and proposes a Moldova-oriented framework for the Romanian adaptation of a CS-OIDP version for dental fluorosis.
Introduction
Oral health-related quality of life (OHRQoL) is now interpreted as a patient-reported construct that complements clinical and epidemiological indicators by reflecting how oral conditions affect everyday life, well-being, and social functioning. Contemporary dentistry no longer relies exclusively on clinician-centered biomedical outcomes, because oral health problems may produce functional limitations, pain, dissatisfaction with appearance, and psychosocial distress that are best captured from the patient perspective [1, 2].
Dental fluorosis is a developmental condition caused by excessive fluoride exposure during enamel formation. Its clinical expression may range from faint opacities to marked staining and structural enamel defects, while its lived impact is shaped not only by severity, but also by social visibility, peer reaction, and the symbolic importance of dental appearance in childhood and adolescence [3, 4].
The available literature indicates that the relationship between dental fluorosis and OHRQoL is neither uniform nor linear. Mild fluorosis often shows little or no negative effect and may even be perceived as acceptable, whereas moderate and severe fluorosis are more likely to be associated with embarrassment, smiling avoidance, reduced social confidence, and worse quality-of-life scores [4-11].
Another unresolved issue is instrument choice. Generic OHRQoL tools are useful for broad comparisons, but condition-specific approaches are often better suited to detect restrictions linked to a visible single condition. Methodological studies on OIDP and recent reviews of cross-culturally adapted pediatric OHRQoL instruments support the logic of developing and validating a fluorosis-focused CS-OIDP version [12, 13]. At the same time, publications from the Republic of Moldova confirm that fluorosis remains relevant from clinical, medico-social, and public health perspectives, while the national evidence base on patient-perceived impact is still emerging [14-20].
Materials and methods
This paper is prepared as a narrative synthesis. The aim is to identify which published studies most directly inform the measurement of dental fluorosis through OHRQoL and condition-specific daily performance constructs, in support of a future Moldova-oriented adaptation and validation study. The analysis compares direct fluorosis studies, methodological papers on condition-specific OIDP, and context-setting publications from the Republic of Moldova.
The systematic search matrix included PubMed/MEDLINE, Scopus, Web of Science, Embase, Cochrane Library, and the institutional repository of Nicolae Testemițanu State University of Medicine and Pharmacy. In the present version, the exact export-based counts for initial hits, duplicate removal, and final selection remain to be completed during live database execution. Only studies and abstracts available through public servers were retained for the citable core, in line with the journal guide.
Full texts were examined with emphasis on study design, target population, sample size, type of OHRQoL instrument, relevance for fluorosis-specific impacts, and potential usefulness for cultural adaptation. The conceptual framework for OHRQoL and the methodological logic of translation, cultural adaptation, and psychometric validation of oral-health questionnaires were drawn from Gribenco [2].
For the direct evidence table, the following fields were extracted: disease, study design, authors and year, sample size, statistical significance, overall working judgment of study quality, magnitude of effect, absolute risk reduction, number needed to treat, and comments. Because the included studies were observational or review designs rather than treatment trials, absolute risk reduction and number needed to treat were recorded as not applicable.
Results
The direct evidence base was dominated by cross-sectional studies in schoolchildren and adolescents living in endemic or naturally fluoridated areas. Overall, the pattern was severity-dependent and instrument-dependent. Mild fluorosis frequently showed little or no detrimental effect on OHRQoL, whereas moderate to severe fluorosis more often correlated with worse aesthetic, psychosocial, and social-functioning outcomes [5-11].
Table 1. Search strategy and study selection matrix | |||||
Database | Selective search strategy | Initial results | Duplicates removed | Selected records | Final included studies |
PubMed /MEDLINE | "dental fluorosis" AND ("oral health-related quality of life" OR OHRQoL OR OIDP OR "Oral Impacts on Daily Performance" OR CS-OIDP) | 12 | 3 | 8 | 5 |
Scopus | TITLE-ABS-KEY("dental fluorosis" AND ("oral health-related quality of life" OR OHRQoL OR OIDP OR "Oral Impact on Daily Performance" OR CS-OIDP)) | Author verification | Author verification | 7 | 4 |
Web of Science | TS=("dental fluorosis" AND ("oral health-related quality of life" OR OHRQoL OR OIDP OR "Oral Impact on Daily Performance" OR CS-OIDP)) | Author verification | Author verification | 6 | 3 |
Embase | ('dental fluorosis'/exp OR 'dental fluorosis') AND ('oral health related quality of life' OR ohrqol OR oidp OR 'oral impact on daily performance' OR 'condition specific oral impact on daily performance') | Author verification | Author verification | 5 | 2 |
Cochrane Library | "dental fluorosis" AND (OHRQoL OR OIDP OR "oral health-related quality of life") | 1 | 0 | 1 | 0 |
Nicolae Testemițanu University | dental fluorosis AND (quality of life OR OHRQoL OR OIDP OR impact on quality of life) | 6 | 1 | 5 | 4 |
Total | Working matrix updated on 08 Apr 2026 | 19 + author verification fields | 4 + author verification fields | 32 | 18 |
Note: The matrix reports a working execution status updated in April 2026. Numeric values labeled "Author verification" require final confirmation in the native interfaces of subscription databases before submission. | |||||
Table 2. Evidence table for Dental Fluorosis, OHRQoL and CS-OIDP | ||||||
Study design | Author, year | N | Statistically significant? | Study quality | Magnitude of effect | Comments |
Systematic review | Montanher et al., 2024 | 16 studies / 16,314 participants | Mixed | Moderate | Global effect mixed; overall negative tendency | Nine studies reported negative association, six no significant association, and one positive association. Major heterogeneity in design, fluorosis thresholds, and OHRQoL tools. |
Cross-sectional | Do and Spencer, 2007 | ≈677 | Yes | Moderate | Small favorable effect for mild fluorosis | Mild fluorosis (TF 2) was associated with better child and parental OHRQoL in multivariable models. |
Cross-sectional | Onoriobe et al., 2014 | 5,484 examined | No | Moderate to good | Null or very small effect | Fluorosis did not reach statistical or minimal important difference thresholds; caries had a clearer negative impact. |
Cross-sectional | Garcia-Perez et al., 2017 | 524 | Yes | Moderate | Moderate negative effect | In children aged 11-12 years, moderate/severe fluorosis (TFI ≥4) was associated with deterioration of OHRQoL. |
Cross-sectional | Shyam et al., 2020 | 2,200 | No for global score | Moderate | Null/minimal effect | Mild dental fluorosis did not affect OHRQoL among schoolchildren in endemic fluoride areas of Haryana. |
Cross-sectional | Varshney et al., 2022 | 200 | Yes | Moderate | Moderate negative effect on daily performance | Most directly relevant CS-OIDP study. Mean CS-OIDP in high-fluoride area was 39.85, with a significant correlation between fluorosis, CS-OIDP, and OHRQoL. |
Cross-sectional | Thilakarathne et al., 2023 | 989 | Mixed | Moderate | Selective negative effect | No global association with OHRQoL, but significant associations with pain, irritability/frustration, and teasing by peers. |
Note: ARR = absolute risk reduction; NNT = number needed to treat; NA = not applicable because the included studies were observational or reviews. | ||||||
The recent systematic review by Montanher et al. summarized 16 studies with 16,314 participants and confirmed marked heterogeneity in both the direction and magnitude of findings. This heterogeneity appears to reflect differences in severity thresholds, age groups, coexisting caries, cultural interpretations of dental appearance, and instrument choice [11].
The direct evidence table shows that the strongest negative signals come from studies involving moderate and severe fluorosis, especially when outcome domains include smiling, socialization, school activities, and aesthetic dissatisfaction. The most directly relevant CS-OIDP evidence currently available comes from Varshney et al., whose study in Indian schoolchildren linked fluorosis severity to both CS-OIDP and broader OHRQoL outcomes [9].
For instrument adaptation, methodological literature is equally important. Hvaring et al. demonstrated that condition-specific OIDP has superior discriminative ability compared with the generic version in adolescents with a defined oral condition, while Gusmao et al. highlighted the need for structured translation, cultural adaptation, and psychometric testing of pediatric OHRQoL instruments [12, 13]. Table 3 summarizes the most useful methodological and Moldova-linked contextual publications for the next drafting stage.
Table 3. Supporting methodological and contextual sources for fluorosis-focused CS-OIDP adaptation | ||
Source | Type | Contribution to the current manuscript |
Hvaring et al., 2014 | Methodological study | Condition-specific OIDP had stronger discriminative ability than generic OIDP in adolescents with a defined oral condition, supporting the logic of fluorosis-focused CS-OIDP adaptation. |
Gusmao et al., 2024 (PMID 38341559) | Systematic review | Reviewed the reliability and validity of cross-culturally adapted pediatric OHRQoL instruments and emphasized structured adaptation and psychometric testing before local implementation. |
Gribenco, 2023 | Doctoral thesis / methodological framework | Provides a Moldovan conceptual basis for OHRQoL and a practical translation-adaptation-validation workflow that can inform Romanian CS-OIDP development. |
Stepco, 2009 | Doctoral thesis | Classical Moldovan fluorosis source on complex treatment methods, useful for local historical and clinical framing of endemic fluorosis. |
Spinei, 2001 | Doctoral thesis | Early Moldovan thesis on contemporary dental care for children with fluorosis; useful for local historical context. |
Stepco and Ferdohleb, 2017 | Moldova-based medico-social study | Documents endemic exposure, community fluorosis index, and medico-social dimensions of fluorosis in children from an endemic area. |
Kurpanov et al., 2023 | Conference abstract | Frames dental fluorosis through public health and quality-of-life perspectives in Moldova. |
Casico and Spinei, 2023 | Conference abstract | Addresses the impact of dental fluorosis on children’s quality of life in a Moldova-related publication. |
Tonofa et al., 2024 | Conference abstract | Extends the Moldovan discussion to dental fluorosis in the primary dentition. |
Stepco et al., 2025 | Springer conference chapter | Links the aesthetic perception of dental fluorosis with oral-health-related quality of life and is directly relevant for future discussion and citation. |
Bivol et al., 2026 | Moldova-based cross-sectional study | Examines population knowledge regarding the role of fluoride in drinking water and oral health in the Republic of Moldova and strengthens the public health rationale for fluorosis-related communication, prevention, and instrument adaptation. |
Discussion
The present synthesis supports a pragmatic interpretation of the literature. Dental fluorosis should not be treated as if it has a single uniform impact on quality of life. The severity of the enamel defect, its visibility, the social meaning of appearance, and the properties of the instrument used all influence the observed result. This explains why older and recent studies alike can yield neutral, mixed, or clearly negative findings [4-11].
Instrument sensitivity is a central issue. Generic OHRQoL tools are valuable for broad comparisons, but they may dilute impacts when the central complaint is condition-specific and socially visible. The logic of CS-OIDP is particularly relevant here because it attributes impairment to a defined condition and links that condition to concrete daily performances. For dental fluorosis, such a model is likely to be more informative than a generic score alone when the primary burden concerns smiling, self-image, peer interaction, or social participation [9, 12].
The attached Moldovan thesis by Gribenco is useful even though it did not validate OIDP itself. It offers a local conceptual justification for patient-reported oral-health measures and a practical workflow for translation and cultural adaptation, including expert review, back-translation, pilot testing, and psychometric validation. These elements can be transferred methodologically to a Romanian CS-OIDP version adapted for dental fluorosis [2].
The Moldova-related publications included here should be interpreted as contextual anchors rather than a completed body of validation evidence. They document endemic fluorosis, medico-social characteristics, public health framing, quality-of-life concerns, and recent attempts to discuss aesthetic perception and primary dentition. Together, they justify rather than replace a formal adaptation and validation study [14-20].
A recent Moldova-based cross-sectional publication in Akademos on population knowledge regarding the role of fluoride in drinking water and oral health further strengthens the public health rationale for fluorosis-related communication and preventive action in the Republic of Moldova [21].
This draft has limitations. It is a narrative synthesis rather than a completed systematic review, the formal database execution and deduplication counts are still pending, and some Moldova-related items are conference abstracts rather than full analytical papers. Nevertheless, the manuscript is sufficiently structured to support the next step: author revision, completion of the live search counts, and preparation of a Romanian fluorosis-focused CS-OIDP adaptation protocol.
Conclusions
The best available evidence indicates that moderate and severe dental fluorosis are more likely than mild fluorosis to impair oral health-related quality of life, especially in aesthetic, psychosocial, and social-performance domains. A condition-specific OIDP approach is methodologically justified for dental fluorosis because it is better suited to capture condition-linked restrictions in daily life than a broad generic measure alone. For the Republic of Moldova, the next priority is to complement endemic fluorosis descriptions with a culturally adapted and psychometrically validated Romanian CS-OIDP version for research, public health, and clinical use.
Competing interests
None declared
Authors’ contributions
Conception and design of the work – IT, AF, EC, IS, SS, LS, ES. Drafting the article – AF, EC, LS. Reviewing the article for important intellectual content – LS, ES, EC, AF. All authors critically reviewed the work and approved the final version of the manuscript.
Acknowledgements and funding
No external funding.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Authors’ ORCID IDs:
Irina Tonofa – https://orcid.org/0009-0000-1654-5206
Alina Ferdohleb – https://orcid.org/0000-0003-1344-5466
Elena Ciobanu – https://orcid.org/0000-0002-8969-922X
Iurie Spinei – https://orcid.org/ 0000-0002-7072-9652
Silvia Stratulat – https://orcid.org/ 0000-0003-0985-307X
Larisa Spinei – https://orcid.org/ 0000-0002-5370-9801
Elena Stepco – https://orcid.org/0000-0001-8167-1997
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