MOTTLING OF ENAMEL IN

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The presence of mottled teeth in the inhabitants of Mecca, Saudi Arabia, is described here. This is the first report on fluorosis in this area and the author discusses the various factors involved.

1 The presence of mottled teeth in the inhabitants of Mecca, Saudi Arabia, is described here. This is the first report on fluorosis in this area and the author discusses the various factors involved. MOTTLING OF ENAMEL IN MECCA AND THE ARABIAN PENINSULA-A SURVEY AND RESEARCH STUDY CARRIED OUT IN Mohamed D. El Tannir, B.Ch.D. (Cairo) M.S.D. SAUDI ARABIA IN in Cairo, Egypt, the author noticed mottled enamel in a group of patients who came from Mecca in Saudi Arabia. This symptom of fluorine toxicosis had not been reported before in Africa and Asia except in Morocco, Tunisia. and South Africa. In March, the author was summoned to Saudi Arabia where he had the opportunity to inv-estigate the problem. Mecca and Its Water Supply In a narrow valley in the Arabian Peninsula. not far from the Red Sea, lies one of the most ancient and holy cities in the world, Mecca. At the center of MIecca lies the Kaaba, the house of worship. traditionally built by Abraham in the 16th century, B.C. A few yards from the Kaaba lies the Zamzam well, the first and most ancient of the water sources in Mlecca. Inhabitants of Mecca, up to the days of the famous Kalif Haroun-al-Rasheed, used to drink mainly from one canal supplied by the Zaafaran spring (apart from Zamzam, Towa, Ossman, and some other wells). That spring consisted of five branches, Honein, Mishash. Ghowirat, Thokba, and Zaafaran. Towards the end of the 8th century, Queen Zobeida, the wife of Haroun-al- Rasheed came from Baghdad on a pilgrimage. Appreciating the difficulties encountered by the pilgrims, Zobeida introduced a new source of water from a well, 30 meters in depth, located at Mount Kara, 25 kilometers from Mecca. The water passes through the "Nuaman" on its way to Arafa Mountain, the meeting place of pilgrims, ending in "Habs el Jinn," a suburb of Mecca, in a channel built of stone; sometimes at ground level, and at others, cutting through the mountain. This was introduced to Mecca in open canals, and connected with the Zaafaran source. In the year 1950 the Royal Family conducted the water of a new spring, 55 kilometers from Mecca, to the Holy City, to satisfy the increasing demand for an adequate water supply. This was given the name of "Aziziah" after the later King Abdul Aziz Al-Saud. Methods of Analysis The following data were obtained: name of the person examined; age, sex, nationality; place of birth; water source; place of childhood; social class (A, B, and C); extent of mottling (brown, yellow, white, and mottling-free); ex- JANUARY,

2 tent of caries (severe, moderate, mild, and sound). The DMF (decayed, missing, filled) system was not used since filled and missing teeth were remarkably rare. The investigation included examination of all 115 patients in King's Hospital at Zaher, 33 inpatients in Mecca Maternity Hospital, and 46 outpatients in Ajiad Hospital. In the "Missions Preparatory School" (a secondary high school) 196 were examined, comprising all the students in a number of classrooms chosen at random. The same was done with 146 students in Rahmaniah Primary School. Similarly, 37 private cases and 12 persons living in the suburbs of Mecca, but using the same drinking water were also examined. In all, 570 persons were examined. Those examined came from all classes and included both sexes. Nine samples from the different original sources of water in Mecca and the surrounding area were collected. Samples of the mixed water drunk by the inhabitants inside Mecca were also collected. These samples were sent directly to the Chemical Laboratory in Jedda. The estimation of fluorides in the samples obtained, however, was not accurately carried out due to certain deficiencies in the equipment of the laboratory. The report only indicated the presence of fluorine "in traces" in the mixed water of Mecca. However, an official printed report of water analyses carried out in 1936 was found,' and it showed Figure 1-Upper incisors showing brown Figure 2-Shows brown mottling and deand yellow mottling, longitudinal brown pressions. Chalky white lines are seen streaks and certain areas showing de- on the upper central incisors. pressions. The lower incisors and canines showing white chalky patches. Note the gums. A B IC Figure 3-Spectrogram (flame) showing: A, normal enamel, B, mottled enamel and C, normal enamel to which manganese was added. The three white dots between B and C, around 26, indicate the manganese lines in both. 46 VOL. 49, NO. 1. A.J.P.H.

MOTTLED TEETH the water to contain (in parts per million ): Zobeida Zamzam Zaafaran Fluorine 2 1.5? Iron 0.06 0.15 0.

3 MOTTLED TEETH the water to contain (in parts per million ): Zobeida Zamzam Zaafaran Fluorine 2 1.5? Iron MNIanganese Nil Nil Nil Zamzam is occasionally used for drinking water, while Zobeida has been the main source for drinking water for hundreds of years until the provision of the water from the new Aziziah source in Findings (Data) 1. The total number of the inhabitants of NMecca was estimated in 1954 to be between 300,000 and 350,000 (no accurate census was carried out). 2. The total number examined was 570, of whom 68 were females. 3. The people examined represent different classes (ranging from princes to the poorest classes), as well as different ages and nationalities living in Mecca. 4. Permanent teeth were more affected with mottling than the deciduous ones. (This was also apparent in cases where both dentitions were retained.) The finding might be attributed to the fact that fluids reaching the infant during pregnancy are filtered through the placenta. Infants in Mecca are breast fed. The mother's milk, which naturally contains a good amount of calcium, is also not expected to contain the same high concentration of fluorine. This is a point Table 1 A-Caries among the inhabitants of Mecca Moderate Caries- Their Advanced Their and Mild Their Inhabitants Total free Per cent Caries Per cent Caries Percentage Birth and childhood in Mecca Other inhabitants Total Inhabitants showing fluorosis Fluorosis-free inhabitants Total B-Standard of caries in Saudi Arabia As measured among the inhabitants of Mecca who were born outside it and spent childhood up to the age of 13 years outside it Mloderate Caries- Their Advanced Their and Mild Their Inhabitants Total free Per cent Caries Per cent Caries Percentage Showing fluorosis Fluorosis-free Total JANUARY,

Table 2-Mottling among the inhabitants of Mecca AMore Range Than One of Age Mottling- Brown Yellowv White Kind of Years Total Free Mottling Mottling Mottling Mottling 1.

4 Table 2-Mottling among the inhabitants of Mecca AMore Range Than One of Age Mottling- Brown Yellowv White Kind of Years Total Free Mottling Mottling Mottling Mottling 1. Ajiad Hospital (children outpatients) 2. Rahmaniah School Missions Preparatory School Private cases Mecca Maternity Hospital Zaher Hospital Mecca Suburbs Total Percentage 9.7% 17.8% 19.5', 23.5% 100% 29.5% 70.5% worth further investigation. In addition, infants have a low drinking water intake. Mottling in deciduous teeth is mostly of the white-patches type, suggesting the milder condition of fluorosis. Milder cases in deciduous teeth showed only slight loss of translucency of the teeth (Table 3). 5. Few cases showed manifestations in all the teeth, but mostly the incisors were very clearly affected; upper central incisors more than laterals, and the maxillary incisors more than the mandibular incisors, labial more than lingual. In cases where all the teeth were affected, incisors usually showed brown manifestations, something rare in molars. The latter usually showed white patches or lines (suggesting an effect of light, especially in producing the brown coloration). 6. Discolorations were either deep brown, yellow, or chalky white patches. In some cases the chalky white discoloration appeared as successive lines (Figure 2) Outer glaze was present in most cases. Some cases, however. showed loss of glaze, others showed marked irregularity in surface, sometimes showing some depressions over the surface (incisors Figure 1, and canines and premolars Figure 2). The glazed surface of enamel does not encourage the suggestions that foodstuffs and saliva may have any role in the creation of colors met with in mottled teeth. 8. No gross malformation was observed. 9. No abnormal attrition was observed. 10. Of the total number of cases 23.5 per cent had more than one kind of patch (Table 2). Sometimes they were at different levels. The white was usually near the incisive margin of the incisors. But in many cases different colors were at the same horizontal level. excluding the possibility of difference in the period of calcification, i.e., brown, vellow, and white patches could be formed at the same time and under the same condi- VOL. 49, NO. 1, A.J.P.H.

5 MOTTLED TEETH tions. This suggests a role of the ameloblasts, and the presence of a selective action. Longitudinal brown streaks were present in some cases penetrating zones of different colors (Figure 1). 11. It was very evident in these studies that the consistency of teeth affected by fluorosis is softer than the nonfluorosed teeth. They are friable, more easily excavated and very quickly drilled. These findings should be explored further. 12. The percentage of mottling among the inhabitants of Mecca (Table 2) (2 ppm of fluorine in water) amounted to 70.5 per cent of the total. Among the inhabitants who were born in Mecca and spent their childhood there, the percentage amounted to 90.8 per cent in adults and 48 per cent in children (deciduous teeth) (Table 3). This may be compared with an examination carried out in Salida, Colo.,2 where fluorides were present (2 ppm) in drinking water. Cases presenting fluorosis amounted to 90.3 per cent of the total. Brown stained teeth represented 9.7 per cent of the total inhabitants of Mecca, or 13.5 per cent of cases showing fluorosis (55 cases out of 402) (Table 2); this may be compared with 4.1 per cent in Salida (14 out of 338 cases affected). 13. The percentage of caries-free persons among the total inhabitants of Mecca, was 62.6 per cent (Table 1 A). This is to be compared with 55.7 per cent caries-free among the inhabitants who were born and lived their childhood outside MIecca, and did not show fluorosis. The latter figure could be considered as standard for Saudi Arabia. There is, therefore, an improvement in the ratio of 62.6:55.7, i.e., 100:89. (Table 1) 14. Sixty-two per cent of the inhabitants of Mecca were free of periodontal disease compared to 42 per cent free of periodontal disease in inhabitants who were born and spent their childhood outside it and showed no fluorosis (the Table 3-Mottling among inhabitants born in Mecca and spending their childhood there Adults Children Range (Permanent Dentition) (Deciduous Dentition) of Age Mottling- Mottling- Years Total Free Mottled Total Free Mottled 1. Ajiad Hospital (children outpatient) Rahmaniah School Missions Preparatory School Private cases Mecca Maternity Hospital Zaher Hospital Total Percentage 100% 90.8%c 1005% 48% Children less than two years in age are six in all, of whom three per cent. had mottled enamel, i.e., 50 JANUARY,

Table 4-Periodontal diseases among the inhabitants of Mecca Disease- Severely Moderate and Inhabitants Total Free Percentage Affected Mild Cases All examined 570 355 62 44 171 Standard for

6 Table 4-Periodontal diseases among the inhabitants of Mecca Disease- Severely Moderate and Inhabitants Total Free Percentage Affected Mild Cases All examined Standard for periodontal diseases in Saudi Arabia as estimated by condition among inhabitants born and spending childhood outside Mecca Perio. Disease- Severely Moderate and Total Free Percentage Affected Mild Cases Those showing fluorosis Those fluorosis-free standard) (Table 4). Freedom from gingival diseases clearly decreased with advancing age. 15. Signs of mottling were present in certain inhabitants who were born in the Arabian Peninsula outside Mecca and spent their childhood in their native lands up to the age of 13 years (minimum'). These came from: A-Saudi Arabia: 1. Hejaz-one case each from Rabegh and Yonboh 2. Nejd-two cases from Hail, and one each from Shakra and Dorma 3. Assir-two cases from Bani Shehr, and one each from Shemran and Nejran B-Hadramouth: One case each from Habban, Bijan, Yafih, Haliy, Ghorfah and Daouhan C-Yemen: Four cases from Taa-iz (two of whom came from its suburbs, most probably the same drinking water source) Three from Heraz One each from Zabeid and Sanhaa. Discussion of Findings Mottled enamel as seen in Mecca consists of discoloration of the enamel, which sometimes reaches the dentin. The morphology of the teeth and jaws was otherwise normal. Discoloration appeared as patches of brown, light yellow, or chalky white, usually under a glazed surface of enamel. The patches were definite areas, although the borders were not sharp, but quickly diffused away. The chalky white patches appear (under the glazed surface of the enamel) to lose completely their semi-transulcency. This is not exactly the case with the brown or yellow colorations, where translucency is maintained. (Figure 1). The white discoloration was described in different references as lines, yet in the cases examined in Mecca, it was found that most of the cases showed the white discoloration in patches similar to the brown and yellow ones. Some cases showed definite successive lines of this chalky white appearance (Figure 2). It may be suggested that the white color indicates a milder condition of fluorosis than the yellow or brown. The possibility was considered that the reason for this is the increase in the amount of drinking water consumed in the hot summer, and the lesser amount drunk in the pleasant winter weather in Mecca. This, however, so VOL. 49, NO. 1. A.J.P.H.

MOTTLED TEETH did not give a satisfactory explanation, since normal, brown and white patches alternating horizontally were found at the same period of calcification.

The following facts seem to support this hypothesis. 1. Sporadic cases of mottled teeth occur in districts where an excess of fluorine in drinking water is not known to occur. 2.

7 MOTTLED TEETH did not give a satisfactory explanation, since normal, brown and white patches alternating horizontally were found at the same period of calcification. The discoloration could be attributed, however, to a certain imbalance during calcification, provoked by the presence of fluorine, without the latter being the direct cause of the color. The following facts seem to support this hypothesis. 1. Sporadic cases of mottled teeth occur in districts where an excess of fluorine in drinking water is not known to occur. 2. According to the chemical analysis carried out by Bowes and Murray,4 the mottled teeth of the inhabitants of Maldon contain per cent fluorine in the enamel and per cent in the dentin. Had fluorine been the direct cause of mottling, the dentin should have shown the manifestation more clearly. This was not the case, since mottling usually attacks enamel, and sometimes extends to the dentin. It has been suggested by Ockerse and Wasserstein,5 that the stain in mottling is caused by the presence of manganese compounds in the enamel, almost excluding the possibility of the stain being related to iron which was advocated by Bowes and Murray.4 They also expressed their suspicions that foodstuffs and saliva are causal factors. A reference was also made to a black stain in severely mottled enamel. No reference was made to the presence or percentage of fluorine in the drinking water supply of the area where specimens were taken. Nor was it shown whether drinking water was a possible source of the manganese in question. This possibility of the stain being due to the presence of manganese was investigated, although its absence from the drinking water of Mecca was not very encouraging. Spectrographic examinations of one specimen of mottled enamel (from Mlecca) and of normal enamel (from Cairo), gave favorable results with the work done by Ockerse and Wasserstein. The manganese lines ( A, A, A) (Figure 3) were quite apparent in the spectrogram of the mottled tooth B, and undetectable in the spectrogram of the normal tooth A. Spectrogram C showed normal enamel from Cairo to which manganese was added for comparison. Conclusions 1. Fluorosis has been found in the Middle East in Mecca and probably it occurs in some other parts of the Arabian Peninsula. 2. Fluorine in water again was associated with resistance to caries; per cent of the people of Mecca, who vere born and spent their childhood there, were caries-free (Table 1 A). The percentage of the caries-free (fluorosisfree) was 55.7 per cent among the inhabitants who were born outside Mecca and spent their childhood, up to the age of 13 years in their native villages or towns (which was considered to be a standard for the condition) (Table 1 B). The ratio is therefore 65:55.7 or 100: It was found that the percentage of caries-iree people among the inhabitants showing signs of fluorosis was 61.5 per cent of their total, and those cariesfree showing no signs of fluorosis were 65.4 per cent of their total (Table 1 A). 4. Two ppm of fluorine in water caused the teeth of 90.8 per cent of adults, and 18 per cent of children to be affected by mottling (Table 3). This is not far from the results of Day' which showed the incidence to be per cent and per cent, respectively. 5. The incidence of colors found in mottling could be attributed to a process provoked by the presence of fluorine during calcification, without this being the direct cause of the color. The effect of light is a probability which might be taken into consideration as a factor in the evolution of mottling, since the JANUARY,

8 teeth and the tooth surfaces which were more exposed to light showed more severe mottling. 6. Manganese seems to be a probable cause of the brown coloration of mottled enamel, since it proved to be present in different specimens of teeth affected by mottling. Fluorine seems to exercise a 'fixing" action in that respect. ACKNOWLEDGMEN-TS-The author wishes to express his gratitude to His Royal Highness Prince Abdulla El Faisal, Minister of Interior, Saudi Arabia, who made this work possible; and to the Alinistries of Public Health and Education, Saudi Arabia, for their kind cooperation. REFERENCES 1. Rashid, H. H. Full Analysis of Water Collected from Mecca. Water Analysis Department, Ministry of Pvblic 2. Health, Cairo, Egypt, Frisch, John G. Fluoride Effects on Dental Decay. 3. J. Wisconsin Dent. Soc. 24: (Nov.), Collyer, J. F., and Sprawvson, Evelyn. Dental Surgery and Pathology. Newv York, N. Y.: Longmans, Green, , p. 65. Bosses, J. H.. and Murray, M. M. A Chemical Ststdy of "'Mottled Teeth" from Maldon, Essex. Brit. Dent. J. 60:556, Ockerse, T., and Wasserstein, B. Stain in Mottled Enamel. J. Am. Dent. A. 50:535 (May), Day, C. D. M. Chronic Endemic Flioorosie in Northern Indiia. Brit. D)ent. J. 68:409, Dr. Mohamed D. El Tannir resides in Cairo, Egypt, U.A.R. (6 (A) Talaat Harb Street). "Resuscitafion of Newborn" Manual Now Ready A manual oin "Resuscitation of the Newborn" has been prepared by the Committee on Fetus and Newborn of the American Academy of Pediatrics. Cooperating in its preparation were representatives of the American College of Obstetricians and Gynecologists; American Hospital Association; American Public Health Association, Section on Maternal and Child Health; and American Society of Anesthesiologists. Edwin M. Gold, M.D., senior obstetric consultant. New York City Health Department, was the APHA section representative to the committee. He is also chairman of the Section's Committee on Resuscitation of the Newborn, each member of which reviewed the manual before publication. The final document has been endorsed by these four organizations and in addition by the American Academy of General Practice, the Section on Pediatrics; and the Committee on Maternal and Child Care of the American Medical Association; the American Nurses' Association; and the National League for Nursing. The printing and make-up of the 24-page pamphlet. made possible by the Mead, Johnson Company, is an excellent illustration of the art of printing. The manual is being distributed by the Academy to the members of the four cooperating societies. It is available on request from the American Academy of Pediatrics Hinman Ave., Evanston, Ill. 52 VOL. 49, NO. 1. A.J.P.H.

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