Changes in the fluoride-induced modulation of maturation stage ameloblasts of rats

The Rogdi knockout mouse is a model for Kohlschütter-Tönz syndrome

Kohlschütter-Tönz syndrome (KTS) is a rare autosomal recessive disorder characterized by severe intellectual disability, early-onset epileptic seizures, and amelogenesis imperfecta. Here, we present a novel Rogdi mutant mouse deleting exons 6-11- a mutation found in KTS patients disabling ROGDI function. This Rogdi-/- mutant model recapitulates most KTS symptoms. Mutants displayed pentylenetetrazol-induced seizures, confirming epilepsy susceptibility. Spontaneous locomotion and circadian activity tests demonstrate Rogdi mutant hyperactivity mirroring patient spasticity. Object recognition impairment indicates memory deficits. Rogdi-/- mutant enamel was markedly less mature. Scanning electron microscopy confirmed its hypomineralized/hypomature crystallization, as well as its low mineral content. Transcriptomic RNA sequencing of postnatal day 5 lower incisors showed downregulated enamel matrix proteins Enam, Amelx, and Ambn. Enamel crystallization appears highly pH-dependent, cycling between an acidic and neutral pH during enamel maturation. Rogdi-/- teeth exhibit no signs of cyclic dental acidification. Additionally, expression changes in Wdr72, Slc9a3r2, and Atp6v0c were identified as potential contributors to these tooth acidification abnormalities. These proteins interact through the acidifying V-ATPase complex. Here, we present the Rogdi-/- mutant as a novel model to partially decipher KTS pathophysiology. Rogdi-/- mutant defects in acidification might explain the unusual combination of enamel and rare neurological disease symptoms.

Single Nucleotide Polymorphisms and Dental Fluorosis: A Systematic Review

Genetic factors contribute to susceptibility and resistance to fluoride exposure. The aim of this systematic review was to identify alleles/genotypes of single nucleotide polymorphisms (SNPs) associated with dental fluorosis (DF) and to identify them as protective or risk factors. PubMed, ScienceDirect, Cochrane Library, Scopus and Web of Science were searched for articles; the last search was performed in August 2022. Human studies that analyzed the relationship between SNPs and DF published in English were included; systematic reviews and meta-analyses were excluded. Methodological quality was graded using the Joanna Briggs Institute checklist and risk of bias was assessed using the Cochrane Collaboration's tool. Eighteen articles were included, 44% of which showed high methodological quality and data from 5,625 participants aged 6 to 75 years were analyzed. The SNPs COL1A2, ESR2, DLX1, DLX2, AMBN, TUFT1, TFIP11, miRNA17, and SOD2 were considered risk factors, and ESR1, MMP20, and ENAM were considered protective factors. In conclusion, there are alleles and genotypes of different single nucleotide polymorphisms involved in increasing or decreasing the risk of developing dental fluorosis.

Fluoride exposure alters Ca2+ signaling and mitochondrial function in enamel cells

Fluoride ions are highly reactive, and their incorporation in forming dental enamel at low concentrations promotes mineralization. In contrast, excessive fluoride intake causes dental fluorosis, visually recognizable enamel defects that can increase the risk of caries. To investigate the molecular bases of dental fluorosis, we analyzed the effects of fluoride exposure in enamel cells to assess its impact on Ca2+ signaling. Primary enamel cells and an enamel cell line (LS8) exposed to fluoride showed decreased internal Ca2+ stores and store-operated Ca2+ entry (SOCE). RNA-sequencing analysis revealed changes in gene expression suggestive of endoplasmic reticulum (ER) stress in fluoride-treated LS8 cells. Fluoride exposure did not alter Ca2+ homeostasis or increase the expression of ER stress-associated genes in HEK-293 cells. In enamel cells, fluoride exposure affected the functioning of the ER-localized Ca2+ channel IP3R and the activity of the sarco-endoplasmic reticulum Ca2+-ATPase (SERCA) pump during Ca2+ refilling of the ER. Fluoride negatively affected mitochondrial respiration, elicited mitochondrial membrane depolarization, and disrupted mitochondrial morphology. Together, these data provide a potential mechanism underlying dental fluorosis.

No Change in Bicarbonate Transport but Tight-Junction Formation Is Delayed by Fluoride in a Novel Ameloblast Model

We have recently developed a novel in vitro model using HAT-7 rat ameloblast cells to functionally study epithelial ion transport during amelogenesis. Our present aims were to identify key transporters of bicarbonate in HAT-7 cells and also to examine the effects of fluoride exposure on vectorial bicarbonate transport, cell viability, and the development of transepithelial resistance. To obtain monolayers, the HAT-7 cells were cultured on Transwell permeable filters. We monitored transepithelial resistance (TER) as an indicator of tight junction formation and polarization. We evaluated intracellular pH changes by microfluorometry using the fluorescent indicator BCECF. Activities of ion transporters were tested by withdrawal of various ions from the bathing medium, by using transporter specific inhibitors, and by activation of transporters with forskolin and ATP. Cell survival was estimated by alamarBlue assay. Changes in gene expression were monitored by qPCR. We identified the activity of several ion transporters, NBCe1, NHE1, NKCC1, and AE2, which are involved in intracellular pH regulation and vectorial bicarbonate and chloride transport. Bicarbonate secretion by HAT-7 cells was not affected by acute fluoride exposure over a wide range of concentrations. However, tight-junction formation was inhibited by 1 mM fluoride, a concentration which did not substantially reduce cell viability, suggesting an effect of fluoride on paracellular permeability and tight-junction formation. Cell viability was only reduced by prolonged exposure to fluoride concentrations greater than 1 mM. In conclusion, cultured HAT-7 cells are functionally polarized and are able to transport bicarbonate ions from the basolateral to the apical fluid spaces. Exposure to 1 mM fluoride has little effect on bicarbonate secretion or cell viability but delays tight-junction formation, suggesting a novel mechanism that may contribute to dental fluorosis.

Importance of bicarbonate transport in pH control during amelogenesis - need for functional studies

Dental enamel, the hardest mammalian tissue, is produced by ameloblasts. Ameloblasts show many similarities to other transporting epithelia although their secretory product, the enamel matrix, is quite different. Ameloblasts direct the formation of hydroxyapatite crystals, which liberate large quantities of protons that then need to be buffered to allow mineralization to proceed. Buffering requires a tight pH regulation and secretion of bicarbonate by ameloblasts. Many investigations have used immunohistochemical and knockout studies to determine the effects of these genes on enamel formation, but up till recently very little functional data were available for mineral ion transport. To address this, we developed a novel 2D in vitro model using HAT-7 ameloblast cells. HAT-7 cells can be polarized and develop functional tight junctions. Furthermore, they are able to accumulate bicarbonate ions from the basolateral to the apical fluid spaces. We propose that in the future, the HAT-7 2D system along with similar cellular models will be useful to functionally model ion transport processes during amelogenesis. Additionally, we also suggest that similar approaches will allow a better understanding of the regulation of the cycling process in maturation-stage ameloblasts, and the pH sensory mechanisms, which are required to develop sound, healthy enamel.

DENTAL ENAMEL FORMATION AND IMPLICATIONS FOR ORAL HEALTH AND DISEASE

Dental enamel is the hardest and most mineralized tissue in extinct and extant vertebrate species and provides maximum durability that allows teeth to function as weapons and/or tools as well as for food processing. Enamel development and mineralization is an intricate process tightly regulated by cells of the enamel organ called ameloblasts. These heavily polarized cells form a monolayer around the developing enamel tissue and move as a single forming front in specified directions as they lay down a proteinaceous matrix that serves as a template for crystal growth. Ameloblasts maintain intercellular connections creating a semi-permeable barrier that at one end (basal/proximal) receives nutrients and ions from blood vessels, and at the opposite end (secretory/apical/distal) forms extracellular crystals within specified pH conditions. In this unique environment, ameloblasts orchestrate crystal growth via multiple cellular activities including modulating the transport of minerals and ions, pH regulation, proteolysis, and endocytosis. In many vertebrates, the bulk of the enamel tissue volume is first formed and subsequently mineralized by these same cells as they retransform their morphology and function. Cell death by apoptosis and regression are the fates of many ameloblasts following enamel maturation, and what cells remain of the enamel organ are shed during tooth eruption, or are incorporated into the tooth's epithelial attachment to the oral gingiva. In this review, we examine key aspects of dental enamel formation, from its developmental genesis to the ever-increasing wealth of data on the mechanisms mediating ionic transport, as well as the clinical outcomes resulting from abnormal ameloblast function.

Reduced Protein Expression of the Na+/Ca2++K+-Exchanger (SLC24A4) in Apical Plasma Membranes of Maturation Ameloblasts of Fluorotic Mice

Exposure of forming enamel to fluoride results into formation of hypomineralized enamel. We tested whether enamel hypomineralization was caused by lower expression of the NCKX4/SLC24A4 Ca²⁺-transporter by ameloblasts. Three commercial antibodies against NCKX4 were tested on enamel organs of wild-type and Nckx4-null mice, one of which (a mouse monoclonal) was specific. This antibody gave a prominent staining of the apical plasma membranes of maturation ameloblasts, starting at early maturation. The layer of immuno-positive ameloblasts contained narrow gaps without immunostaining or with reduced staining. In fluorotic mouse incisors, the quantity of NCKX4 protein in ameloblasts as assessed by western blotting was not different from that in non-fluorotic ameloblasts. However, immunostaining of the apical plasma membranes of fluorotic ameloblasts was strongly reduced or absent suggesting that trafficking of NCKX4 to the apical membrane was strongly reduced. Exposure to fluoride may reduce NCKX4-mediated transport of Ca²⁺ by maturation stage ameloblasts which delays ameloblast modulation and reduces enamel mineralization.

Buffering of protons released by mineral formation during amelogenesis in mice

Regulation of pH by ameloblasts during amelogenesis is critical for enamel mineralization. We examined the effects of reduced bicarbonate secretion and the presence or absence of amelogenins on ameloblast modulation and enamel mineralization. To that end, the composition of fluorotic and non-fluorotic enamel of several different mouse mutants, including enamel of cystic fibrosis transmembrane conductance regulator-deficient (Cftr null), anion exchanger-2-deficient (Ae2a,b null), and amelogenin-deficient (Amelx null) mice, was determined by quantitative X-ray microanalysis. Correlation analysis was carried out to compare the effects of changes in the levels of sulfated-matrix (S) and chlorine (Cl; for bicarbonate secretion) on mineralization and modulation. The chloride (Cl^- ) levels in forming enamel determined the ability of ameloblasts to modulate, remove matrix, and mineralize enamel. In general, the lower the Cl^- content, the stronger the negative effects. In Amelx-null mice, modulation was essentially normal and the calcium content was reduced least. Retention of amelogenins in enamel of kallikrein-4-deficient (Klk4-null) mice resulted in decreased mineralization and reduced the length of the first acid modulation band without changing the total length of all acidic bands. These data suggest that buffering by bicarbonates is critical for modulation, matrix removal and enamel mineralization. Amelogenins also act as a buffer but are not critical for modulation.

Appropriate real-time PCR reference genes for fluoride treatment studies performed in vitro or in vivo

OBJECTIVE

Quantitative real-time PCR (qPCR) is routinely performed for experiments designed to identify the molecular mechanisms involved in the pathogenesis of dental fluorosis. Expression of reference gene(s) is expected to remain unchanged in fluoride-treated cells or in rodents relative to the corresponding untreated controls. The aim of this study was to select optimal reference genes for fluoride experiments performed in vitro and in vivo.

DESIGN

Five candidate genes were evaluated: B2m, Eef1a1, Gapdh, Hprt and Tbp. For in vitro experiments, LS8 cells derived from mouse enamel organ were treated with 0, 1, 3 and/or 5mM sodium fluoride (NaF) for 6 or 18 h followed by RNA isolation. For in vivo experiments, six-week old rats were treated with 0 or 100 ppm fluoride as NaF for six weeks at which time RNA was isolated from enamel organs. RNA from cells and enamel organs were reverse-transcribed and stability of gene expression for the candidate reference genes was evaluated by qPCR in treated versus non-treated samples.

RESULTS

The most stably expressed genes in vitro according to geNorm were B2m and Tbp, and according to Normfinder were Hprt and Gapdh. The most stable genes in vivo were Eef1a1 and Gapdh. Expression of Ddit3, a gene previously shown to be induced by fluoride, was demonstrated to be accurately calculated only when using an optimal reference gene.

CONCLUSIONS

This study identifies suitable reference genes for relative quantification of gene expression by qPCR after fluoride treatment both in cultured cells and in the rodent enamel organ.

Ameloblast Modulation and Transport of Cl⁻, Na⁺, and K⁺ during Amelogenesis

Ameloblasts express transmembrane proteins for transport of mineral ions and regulation of pH in the enamel space. Two major transporters recently identified in ameloblasts are the Na(+)K(+)-dependent calcium transporter NCKX4 and the Na(+)-dependent HPO4 (2-) (Pi) cotransporter NaPi-2b. To regulate pH, ameloblasts express anion exchanger 2 (Ae2a,b), chloride channel Cftr, and amelogenins that can bind protons. Exposure to fluoride or null mutation of Cftr, Ae2a,b, or Amelx each results in formation of hypomineralized enamel. We hypothesized that enamel hypomineralization associated with disturbed pH regulation results from reduced ion transport by NCKX4 and NaPi-2b. This was tested by correlation analyses among the levels of Ca, Pi, Cl, Na, and K in forming enamel of mice with null mutation of Cftr, Ae2a,b, and Amelx, according to quantitative x-ray electron probe microanalysis. Immunohistochemistry, polymerase chain reaction analysis, and Western blotting confirmed the presence of apical NaPi-2b and Nckx4 in maturation-stage ameloblasts. In wild-type mice, K levels in enamel were negatively correlated with Ca and Cl but less negatively or even positively in fluorotic enamel. Na did not correlate with P or Ca in enamel of wild-type mice but showed strong positive correlation in fluorotic and nonfluorotic Ae2a,b- and Cftr-null enamel. In hypomineralizing enamel of all models tested, 1) Cl(-) was strongly reduced; 2) K(+) and Na(+) accumulated (Na(+) not in Amelx-null enamel); and 3) modulation was delayed or blocked. These results suggest that a Na(+)K(+)-dependent calcium transporter (likely NCKX4) and a Na(+)-dependent Pi transporter (potentially NaPi-2b) located in ruffle-ended ameloblasts operate in a coordinated way with the pH-regulating machinery to transport Ca(2+), Pi, and bicarbonate into maturation-stage enamel. Acidification and/or associated physicochemical/electrochemical changes in ion levels in enamel fluid near the apical ameloblast membrane may reduce the transport activity of mineral transporters, which results in hypomineralization.

Composition of mineralizing incisor enamel in cystic fibrosis transmembrane conductance regulator-deficient mice

Formation of crystals in the enamel space releases protons that need to be buffered to sustain mineral accretion. We hypothesized that apical cystic fibrosis transmembrane conductance regulator (CFTR) in maturation ameloblasts transduces chloride into forming enamel as a critical step to secrete bicarbonates. We tested this by determining the calcium, chloride, and fluoride levels in developing enamel of Cftr-null mice by quantitative electron probe microanalysis. Maturation-stage enamel from Cftr-null mice contained less chloride and calcium than did wild-type enamel, was more acidic when stained with pH dyes ex vivo, and formed no fluorescent modulation bands after in vivo injection of the mice with calcein. To acidify the enamel further we exposed Cftr-null mice to fluoride in drinking water to stimulate proton release during formation of hypermineralized lines. In Cftr-deficient mice, fluoride further lowered enamel calcium without further reducing chloride levels. The data support the view that apical CFTR in maturation ameloblasts tranduces chloride into developing enamel as part of the machinery to buffer protons released during mineral accretion.

Enamel maturation: a brief background with implications for some enamel dysplasias

The maturation stage of enamel development begins once the final tissue thickness has been laid down. Maturation includes an initial transitional pre-stage during which morphology and function of the enamel organ cells change. When this is complete, maturation proper begins. Fully functional maturation stage cells are concerned with final proteolytic degradation and removal of secretory matrix components which are replaced by tissue fluid. Crystals, initiated during the secretory stage, then grow replacing the tissue fluid. Crystals grow in both width and thickness until crystals abut each other occupying most of the tissue volume i.e. full maturation. If this is not complete at eruption, a further post eruptive maturation can occur via mineral ions from the saliva. During maturation calcium and phosphate enter the tissue to facilitate crystal growth. Whether transport is entirely active or not is unclear. Ion transport is also not unidirectional and phosphate, for example, can diffuse out again especially during transition and early maturation. Fluoride and magnesium, selectively taken up at this stage can also diffuse both in an out of the tissue. Crystal growth can be compromised by excessive fluoride and by ingress of other exogenous molecules such as albumin and tetracycline. This may be exacerbated by the relatively long duration of this stage, 10 days or so in a rat incisor and up to several years in human teeth rendering this stage particularly vulnerable to ingress of foreign materials, incompletely mature enamel being the result.

Fluorosed mouse ameloblasts have increased SATB1 retention and Gαq activity

Dental fluorosis is characterized by subsurface hypomineralization and increased porosity of enamel, associated with a delay in the removal of enamel matrix proteins. To investigate the effects of fluoride on ameloblasts, A/J mice were given 50 ppm sodium fluoride in drinking water for four weeks, resulting serum fluoride levels of 4.5 µM, a four-fold increase over control mice with no fluoride added to drinking water. MicroCT analyses showed delayed and incomplete mineralization of fluorosed incisor enamel as compared to control enamel. A microarray analysis of secretory and maturation stage ameloblasts microdissected from control and fluorosed mouse incisors showed that genes clustered with Mmp20 appeared to be less downregulated in maturation stage ameloblasts of fluorosed incisors as compared to control maturation ameloblasts. One of these Mmp20 co-regulated genes was the global chromatin organizer, special AT-rich sequence-binding protein-1 (SATB1). Immunohistochemical analysis showed increased SATB1 protein present in fluorosed ameloblasts compared to controls. In vitro, exposure of human ameloblast-lineage cells to micromolar levels of both NaF and AlF₃ led to a significantly increase in SATB1 protein content, but not levels of Satb1 mRNA, suggesting a fluoride-induced mechanism protecting SABT1 from degradation. Consistent with this possibility, we used immunohistochemistry and Western blot to show that fluoride exposed ameloblasts had increased phosphorylated PKCα both in vivo and in vitro. This kinase is known to phosphorylate SATB1, and phosphorylation is known to protect SATB1 from degradation by caspase-6. In addition, production of cellular diacylglycerol (DAG) was significantly increased in fluorosed ameloblasts, suggesting that the increased phosphorylation of SATB1 may be related to an effect of fluoride to enhance Gαq activity of secretory ameloblasts.

Stress response pathways in ameloblasts: implications for amelogenesis and dental fluorosis

Human enamel development of the permanent teeth takes place during childhood and stresses encountered during this period can have lasting effects on the appearance and structural integrity of the enamel. One of the most common examples of this is the development of dental fluorosis after childhood exposure to excess fluoride, an elemental agent used to increase enamel hardness and prevent dental caries. Currently the molecular mechanism responsible for dental fluorosis remains unknown; however, recent work suggests dental fluorosis may be the result of activated stress response pathways in ameloblasts during the development of permanent teeth. Using fluorosis as an example, the role of stress response pathways during enamel maturation is discussed.

Barrier formation: potential molecular mechanism of enamel fluorosis

Enamel fluorosis is an irreversible structural enamel defect following exposure to supraoptimal levels of fluoride during amelogenesis. We hypothesized that fluorosis is associated with excess release of protons during formation of hypermineralized lines in the mineralizing enamel matrix. We tested this concept by analyzing fluorotic enamel defects in wild-type mice and mice deficient in anion exchanger-2a,b (Ae2a,b), a transmembrane protein in maturation ameloblasts that exchanges extracellular Cl(-) for bicarbonate. Defects were more pronounced in fluorotic Ae2a,b (-/-) mice than in fluorotic heterozygous or wild-type mice. Phenotypes included a hypermineralized surface, extensive subsurface hypomineralization, and multiple hypermineralized lines in deeper enamel. Mineral content decreased in all fluoride-exposed and Ae2a,b(-/-) mice and was strongly correlated with Cl(-). Exposure of enamel surfaces underlying maturation-stage ameloblasts to pH indicator dyes suggested the presence of diffusion barriers in fluorotic enamel. These results support the concept that fluoride stimulates hypermineralization at the mineralization front. This causes increased release of protons, which ameloblasts respond to by secreting more bicarbonates at the expense of Cl(-) levels in enamel. The fluoride-induced hypermineralized lines may form barriers that impede diffusion of proteins and mineral ions into the subsurface layers, thereby delaying biomineralization and causing retention of enamel matrix proteins.

Enamel pits in hamster molars, formed by a single high fluoride dose, are associated with a perturbation of transitional stage ameloblasts

Excessive intake of fluoride (F) by young children results in the formation of enamel subsurface porosities and pits, called enamel fluorosis. In this study, we used a single high dose of F administered to hamster pups to determine the stage of ameloblasts most affected by F and whether pit formation was related to F-related sub-ameloblastic cyst formation. Hamster pups received a single subcutaneous injection of either 20 mg or 40 mg NaF/kg body weight, were sacrificed 24 h later, and the number of cysts formed in the first molars were counted. Other pups were sacrificed 8 days after F injection, when the first molars had just erupted, to score for enamel defects. All F-injected pups formed enamel defects in the upper half of the cusps in a dose-dependent way. After injection of 20 mg NaF/kg, an average of 2.5 white spots per molar was found but no pits. At 40 mg NaF/kg, almost 4.5 spots per molar were counted as well as 2 pits per molar. The defects in erupted enamel were located in the upper half of the cusps, sites where cysts had formed at the transition stage of ameloblast differentiation. These results suggest that transitional ameloblasts, located between secretory- and maturation-stage ameloblasts, are most sensitive to the effects of a single high dose of F. F-induced cysts formed earlier at the pre-secretory stage were not correlated to either white spots or enamel pits, suggesting that damaged ameloblasts overlying a F-induced cyst regenerate and continue to form enamel.

Fluoride incorporation into apatite crystals delays amelogenin hydrolysis

Enamel fluorosis has been related to an increase in the amount of amelogenin in fluorosed enamel compared with normal enamel in the maturation stage. In this study we tested the hypothesis that fluoride incorporated into carbonated apatite alters amelogenin hydrolysis. Recombinant human amelogenin (rh174) was allowed to bind to 0.15 mg of carbonated hydroxyapatite (CAP) or to fluoride-containing carbonated hydroxyapatite (F-CAP) synthesized to contain 100, 1,000, or 4,000 ppm F(-). After 3 h of digestion with recombinant human matrix metalloproteinase 20 (MMP20) or kallikrein-related peptidase 4 (KLK4), bound protein was characterized by reverse-phase high-performance liquid chromatography (HPLC). Proteolytic fragments of amelogenin formed after 24h of digestion with MMP20 of KLK 4 were identified by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The hydrolysis, by both MMP20 and KLK4, of amelogenin bound to F100-CAP was significantly reduced in a dose-dependent manner compared with the hydrolysis of amelogenin bound to CAP. After 24 h of hydrolysis, a similar number of MMP20 cleavage sites was found for amelogenin bound to CAP and amelogenin bound to F100-CAP; however, 24 fewer KLK4 cleavage sites were identified for amelogenin bound to F100-CAP than for amelogenin bound to CAP. These results suggest that the reduced hydrolysis of amelogenins in fluorosed enamel may be partially caused by the increased fluoride content in fluoride-containing apatite, contributing to the hypomineralized enamel matrix phenotype observed in fluorosed enamel.

NBCe1 in mouse and human ameloblasts may be indirectly regulated by fluoride

Enamel biomineralization results in a release of protons into the enamel matrix, causing an acidification of the local microenvironment. This acidification, which may be enhanced by more rapid mineral deposition in the presence of fluoride, must be neutralized by the overlying ameloblasts. The electrogenic sodium bicarbonate co-transporter NBCe1 has been localized in mouse ameloblasts, and has been proposed to have a role in matrix pH regulation. In this study, transcript analysis by PCR showed NBCe1-A present in human ameloblasts, whereas mouse ameloblasts expressed NBCe1-B. In situ hybridization and qPCR in mouse and fetal human incisors showed that NBCe1 mRNA was up-regulated as ameloblasts differentiated. Ingestion of 50 ppm fluoride resulted in an up-regulation of NBCe1 mRNA in maturation-stage mouse ameloblasts in vivo, as compared with controls. NBCe1 expression was up-regulated by low pH, but not by fluoride, in human ameloblast-lineage cells in vitro. The up-regulation of NBCe1 in vivo as enamel maturation and mineralization progressed provides evidence that NBCe1 participates in pH modulation during enamel formation. Up-regulation of NBCe1 in fluorosed maturation ameloblasts in vivo, with no effect of fluoride in vitro, supports the hypothesis that fluoride-enhanced mineral deposition results in acidification of the mineralizing enamel matrix.

Fluorosis in rats exposed to oscillating chronic fluoride doses

Considering that blood fluoride concentration varies according to fluoride exposure and that dental fluorosis is related to the amount of enamel formed under a given fluoride dose, the present study investigated whether the fluorosis produced by an oscillating chronic fluoride dose would be similar to that caused by exposure to a constant dose, representing the mean of the oscillation during a given time. Rats received during 78 days water with fluoride concentrations of 0, 12.5, 25 or 37.5 microg F/mL, or oscillating concentrations of 12.5 and 37.5 microg F/mL every 72 h (mean exposure=25 microg F/mL). The concentrations of fluoride in the plasma, femur and incisors of the rats were determined at the end of the experimental period. Also, the enamel dental fluorosis index was determined in the incisors using a quantitative method developed by our research group named Dental Fluorosis by Image Analysis (DFIA). Fluoride concentrations in plasma, femur and teeth, and DFIA increased linearly for constant fluoride concentrations in water (p<0.0001, r values=0.87-0.98). The results of the oscillating group and the groups receiving 25 microg F/mL did not differ significantly (p>0.05). The findings of this study suggest that in animals chronically exposed to symmetrically oscillating fluoride doses, the resulting dental fluorosis reflects the metabolic effect of the mean of the oscillating doses.

The impact of fluoride on ameloblasts and the mechanisms of enamel fluorosis

Intake of excess amounts of fluoride during tooth development cause enamel fluorosis, a developmental disturbance that makes enamel more porous. In mild fluorosis, there are white opaque striations across the enamel surface, whereas in more severe cases, the porous regions increase in size, with enamel pitting, and secondary discoloration of the enamel surface. The effects of fluoride on enamel formation suggest that fluoride affects the enamel-forming cells, the ameloblasts. Studies investigating the effects of fluoride on ameloblasts and the mechanisms of fluorosis are based on in vitro cultures as well as animal models. The use of these model systems requires a biologically relevant fluoride dose, and must be carefully interpreted in relation to human tooth formation. Based on these studies, we propose that fluoride can directly affect the ameloblasts, particularly at high fluoride levels, while at lower fluoride levels, the ameloblasts may respond to local effects of fluoride on the mineralizing matrix. A new working model is presented, focused on the assumption that fluoride increases the rate of mineral formation, resulting in a greater release of protons into the forming enamel matrix.

JNK/c-Jun signaling pathway mediates the fluoride-induced down-regulation of MMP-20 in vitro

Delayed removal of amelogenins, which are initially hydrolyzed by matrix metalloproteinase MMP-20, is a characteristic of enamel fluorosis. In this study, we investigated the regulation of MMP-20 and possible effects of fluoride on MMP-20 expression in human ameloblast lineage cells. Protein expression and signaling pathways of human ameloblast lineage cells, exposed to 10 muM fluoride, were compared to control cells without fluoride exposure. The role of activator protein-1 in MMP-20 regulation was analyzed by DNA-protein affinity precipitation and luciferase reporter gene assays. MMP-20 protein levels in human ameloblast lineage cells decreased in the presence of fluoride, while amelogenin and TIMP-2 were not altered. Fluoride also decreased the transcription of a luciferase reporter gene driven by the MMP-20 promoter. Down-regulation of MMP-20 by fluoride was related to suppression of JNK/c-Jun phosphorylation. In contrast, the JNK activator elevated the expression of MMP-20. Three c-Jun binding sites on the MMP-20 promoter were identified for the first time, and were occupied by c-Jun as MMP-20 was induced. Deletion of any one of AP-1 binding sites on the MMP-20 promoter significantly reduced the transcription of downstream luciferase reporter. These in vitro findings suggest that c-Jun is a key regulatory element for MMP-20 expression, and human ameloblast lineage cells can respond to fluoride by down-regulating MMP-20 transcription through the JNK/c-Jun signaling pathway.

Micromolar fluoride alters ameloblast lineage cells in vitro

Fluorosed enamel is caused by exposure to fluoride during tooth formation. The objective of this study was to determine whether epithelial ameloblast-lineage cells, derived from the human enamel organ, are directly affected by micromolar concentrations of fluoride. Cells were cultured in the presence of fluoride, and proliferation was measured by BrdU incorporation. The effect of 0, 10, or 20 microM fluoride on apoptosis was determined by the flow cytometry apoptotic index. The effects of fluoride on gene expression were investigated by SuperArray microarray analysis and real-time PCR. Fluoride had a biphasic effect on cell proliferation, with enhanced proliferation at 16 microM, and reduced proliferation at greater than 1 mM F. Flow cytometry showed that both 10 microM and 20 microM NaF significantly increased the apoptotic index of ameloblast-lineage cells. There was no general effect of fluoride on gene expression. These results indicate multiple effects of micromolar fluoride on ameloblast-lineage cells.

The dentin sialoprotein (DSP) expression in rat tooth germs following fluoride treatment: An immunohistochemical study

Fluoride is known to alter expression of dentin matrix proteins and affect their posttranslational modifications.

OBJECTIVE

The objective of our study was to examine dentin sialoprotein (DSP) expression in the early and late bell stages of development of the first molar tooth germs in rats treated with fluoride.

DESIGN AND METHODS

Pregnant dumps were divided into three groups. They were fed a standard diet and from the fifth day of pregnancy, each group received either tap water (with trace amounts of fluoride), tap water with a low concentration of fluoride, or tap water with a high concentration of fluoride. Changes in DSP expression and distribution were visualized by immunohistochemistry.

RESULTS

Immunoreactivity for DSP was detected in the cervical regions of the early bell stage in tooth germs of the 1-day-old animals. The earliest reaction was visible in the control group and the group supplemented with the low fluoride concentration (F(L)) but not in the group supplemented with the high fluoride concentration (F(H)). In early bell stages across all experimental groups, the immunoreactivity to DSP was observed in the cusp tip regions and was localized to preameloblasts, young and mature odontoblasts, dental pulp cells, predentin, and dentin. Generally, more intense positive staining for DSP was detected in animals supplemented with the high fluoride concentration. In the late bell stage found in the 4-day-old control group and the group supplemented with the low fluoride concentration, immunoreactivity for DSP was less intense compared with younger animals. However, immunoreactivity was greater in the group treated with the high dose of fluoride. In this group, the positive immunostaining for DSP, especially in young ameloblasts, was prolonged and relatively strong.

CONCLUSIONS

Fluoride supplementation causes changes in the developmental pattern of DSP expression and its distribution in rat tooth germs.

Effects of sodium fluoride on the actin cytoskeleton of murine ameloblasts

Fluoride is associated with a decrease in the incidence of dental caries, but excess fluoride can lead to enamel fluorosis, a defect that occurs during tooth enamel formation. In fibroblasts, the Arhgap gene encodes a RhoGAP, which regulates the small G protein designated RhoA. Fluoride treatment of fibroblasts inactivates RhoGAP, thereby activating RhoA, which leads to elevation of filamentous actin (F-actin). Since RhoA is a molecular switch, our hypothesis is that in ameloblasts, fluoride may alter the cytoskeleton through interference with the Rho signaling pathway. Our objective was to measure the effects of sodium fluoride on F-actin using tooth organ culture and confocal microscopy. The results indicated that cellular responses to fluoride include elevation of F-actin in ameloblasts. It was concluded from immunohistochemistry, RT-PCR and confocal approaches that the components of the Rho pathway are present in ameloblasts, and that the response to fluoride involves the Rho/ROCK pathway.

Tooth quality in dental fluorosis genetic and environmental factors

Dental fluorosis (DF) affects the appearance and structure of tooth enamel and can occur following ingestion of excess fluoride during critical periods of amelogenesis. This tooth malformation may, depending on its severity, influence enamel and dentin microhardness and dentin mineralization. Poor correlation between tooth fluoride (F) concentration and DF severity was shown in some studies, but even when a correlation was present, tooth fluoride concentration explained very little of DF severity. This fact calls into question the generally accepted hypothesis that the main factor responsible for DF severity is tooth fluoride concentration. It has been shown previously that genetic factors (susceptibility to DF) play an important role in DF severity although DF severity relates to individual susceptibility to fluoride exposure (genetics), tooth fluoride concentration relates to fluoride ingestion (environmental). The objective of this study was to investigate the correlation between tooth fluoride concentration, DF severity, and tooth mechanical and materials properties. Three strains of mice (previously shown to have different susceptibility to DF) at weaning were treated with four different levels of F in their water (0, 25, 50, and 100 ppm) for 6 weeks. Mice teeth were tested for fluoride by instrumental neutron activation analysis (INAA), DF severity determined by quantitative light-induced fluorescence [QLF], and tooth quality (enamel and dentin microhardness and dentin mineralization). Tooth fluoride concentration (environment factor) correlated positively with DF severity (QLF) (rs=0.608), fluoride treatment group (rs=0.952). However, tooth fluoride concentration correlated negatively with enamel microhardness (rs=-0.587), dentin microhardness (rs=-0.268) and dentin mineralization (rs=-0.245). Dental fluorosis (genetic factor) severity (QLF) correlated positively with fluoride treatment (rs=0.608) and tooth fluoride concentration (rs=0.583). DF severity correlated negatively with enamel microhardness (rs=-0.564) and dentin microhardness (rs=-0.356). Genetic factors (DF severity) and the environmental factor (fluoride concentration in tooth structure) have similar influence on tooth biomechanical properties, whereas only the environmental factor has an influence on tooth material property (mineralization).

Dental fluorosis: chemistry and biology

This review aims at discussing the pathogenesis of enamel fluorosis in relation to a putative linkage among ameloblastic activities, secreted enamel matrix proteins and multiple proteases, growing enamel crystals, and fluid composition, including calcium and fluoride ions. Fluoride is the most important caries-preventive agent in dentistry. In the last two decades, increasing fluoride exposure in various forms and vehicles is most likely the explanation for an increase in the prevalence of mild-to-moderate forms of dental fluorosis in many communities, not the least in those in which controlled water fluoridation has been established. The effects of fluoride on enamel formation causing dental fluorosis in man are cumulative, rather than requiring a specific threshold dose, depending on the total fluoride intake from all sources and the duration of fluoride exposure. Enamel mineralization is highly sensitive to free fluoride ions, which uniquely promote the hydrolysis of acidic precursors such as octacalcium phosphate and precipitation of fluoridated apatite crystals. Once fluoride is incorporated into enamel crystals, the ion likely affects the subsequent mineralization process by reducing the solubility of the mineral and thereby modulating the ionic composition in the fluid surrounding the mineral. In the light of evidence obtained in human and animal studies, it is now most likely that enamel hypomineralization in fluorotic teeth is due predominantly to the aberrant effects of excess fluoride on the rates at which matrix proteins break down and/or the rates at which the by-products from this degradation are withdrawn from the maturing enamel. Any interference with enamel matrix removal could yield retarding effects on the accompanying crystal growth through the maturation stages, resulting in different magnitudes of enamel porosity at the time of tooth eruption. Currently, there is no direct proof that fluoride at micromolar levels affects proliferation and differentiation of enamel organ cells. Fluoride does not seem to affect the production and secretion of enamel matrix proteins and proteases within the dose range causing dental fluorosis in man. Most likely, the fluoride uptake interferes, indirectly, with the protease activities by decreasing free Ca(2+) concentration in the mineralizing milieu. The Ca(2+)-mediated regulation of protease activities is consistent with the in situ observations that (a) enzymatic cleavages of the amelogenins take place only at slow rates through the secretory phase with the limited calcium transport and that, (b) under normal amelogenesis, the amelogenin degradation appears to be accelerated during the transitional and early maturation stages with the increased calcium transport. Since the predominant cariostatic effect of fluoride is not due to its uptake by the enamel during tooth development, it is possible to obtain extensive caries reduction without a concomitant risk of dental fluorosis. Further efforts and research are needed to settle the currently uncertain issues, e.g., the incidence, prevalence, and causes of dental or skeletal fluorosis in relation to all sources of fluoride and the appropriate dose levels and timing of fluoride exposure for prevention and control of dental fluorosis and caries.

Mechanism and timing of fluoride effects on developing enamel

Fluoride appears to specifically interact with mineralizing tissues, causing an alteration of the mineralization process. In enamel, fluorosis results in a subsurface hypomineralization. This hypomineralized enamel appears to be directly related to a delay in the removal of amelogenins at the early-maturation stage of enamel formation. The specific cause for this delay is not known, although existing evidence points to reduced proteolytic activity of proteinases that hydrolyze amelogenin. This delay in hydrolysis of amelogenins could be due to a direct effect of fluoride on proteinase secretion or proteolytic activity, or to a reduced effectiveness of the proteinase due to other changes in the protein or mineral of the fluorosed enamel matrix. The formation of dental fluorosis is highly dependent on the dose, duration, and timing of fluoride exposure. The early-maturation stage of enamel formation appears to be particularly sensitive to the effects of fluoride on enamel formation. Although the risk of enamel fluorosis is minimal with exposure only during the secretory stage, this risk is greatest when exposure occurs in both secretory and maturation stages of enamel formation. The risk of fluorosis appears to be best related to the total cumulative fluoride exposure to the developing dentition.

Biological mechanisms of dental fluorosis relevant to the use of fluoride supplements

Fluorosis occurs when fluoride interacts with mineralizing tissues, causing alterations in the mineralization process. In dental enamel, fluorosis causes subsurface hypomineralizations or porosity, which extend toward the dentinal-enamel junction as severity increases. This subsurface porosity is most likely caused by a delay in the hydrolysis and removal of enamel proteins, particularly amelogenins, as the enamel matures. This delay could be due to the direct effect of fluoride on the ameloblasts or to an interaction of fluoride with the proteins or proteinases in the mineralizing matrix. The specific mechanisms by which fluoride causes the changes leading to enamel fluorosis are not well defined; though the early-maturation stage of enamel formation appears to be particularly sensitive to fluoride exposure. The development of fluorosis is highly dependent on the dose, duration, and timing of fluoride exposure. The risk of enamel fluorosis is lowest when exposure takes place only during the secretory stage, but highest when exposure occurs in both secretory and maturation stages. The incidence of dental fluorosis is best correlated with the total cumulative fluoride exposure to the developing dentition. Fluoride supplements can contribute to the total fluoride exposure of children, and if the total fluoride exposure to the developing teeth is excessive, fluorosis will result.

Morphometry and autoradiography of altered rat enamel protein processing due to chronic exposure to fluoride

Female Sprague-Dawley rats had 6 weeks of 0 (control), 75 or 100 parts/10(6) sodium fluoride in their drinking water. Whole mandibular incisors were removed, fixed, demineralized and sections prepared for light-microscopic morphometric analysis of dose-related alterations in enamel protein retention. Other rats given 0 and 75 parts/10(6) only (control and experimental groups) were used for autoradiographic evaluation of alterations in enamel protein removal 35S-methionine was applied directly over secretory ameloblasts at the end of the fifth week of fluoride exposure. Incisors were removed either 5 or 7 days later and processed for autoradiographic analysis. The results indicated: (1) extended retention of enamel proteins in fluoride-exposed maturation enamel as well as reduced enamel protein synthesis and/or secretion in the secretory stage; (2) negative linear correlation between extended enamel protein retention and reduced enamel protein secretion among groups; and (3) repression of enamel protein removal. The data are also consistent with the concept that the fluoride effect is multifactorial.

Ameloblast cycling patterns as measured by fluorochrome infiltration of rat incisor enamel

Rapid modulation of maturation ameloblasts between smooth-ended and ruffle-ended forms may play an important part in the development of normal dental enamel. Previous studies of modulation rates relied upon measurements of stained or fluorescing bands on the enamel surface of whole incisors along with separate histological sections for cell-band dimensions. The present study utilized direct measurement of maturation-ameloblast bands and fluorescing regions of underlying enamel in the same histological sections, which increased the accuracy and ease with which modulation rates could be determined. Rats were injected with calcein at various times before killing and preparation of survey midsagittal sections of the lower incisors. The lengths of bands of smooth-ended ameloblasts and underlying fluorescing regions of enamel were measured throughout the maturation zone. Modulation rates were found to range from 238 microns/h (early maturation) to 91 microns/h (late maturation). Calcein diffused into enamel to varying degrees depending upon the location within the maturation stage. This new approach of direct measurement greatly facilitates the investigation of ameloblast modulation and provides additional insights into progressive structural changes in enamel during maturation.

Dental fluorosis: its use as a biomarker

Several epidemiological studies, beginning with those of Dean and co-workers in the 1940's, clearly demonstrate the relationship between dental fluorosis in humans and the level of fluoride in water supplies. These studies and others have shown that, in a population, there is a direct relationship among the degree of enamel fluorosis, plasma and bone fluoride levels, and the concentration of fluoride in drinking water. However, dental fluorosis is a reflection of fluoride exposure only during the time of enamel formation, somewhat limiting its use as a biomarker. In addition, the degree of fluorosis is dependent not only on the total fluoride dose, but also on the timing and duration of fluoride exposure. At the level of an individual response to fluoride exposure, factors such as body weight, activity level, nutritional factors, and the rate of skeletal growth and remodeling are also important. These variables, along with an individual variability in response to similar doses of fluoride, indicate that enamel fluorosis cannot be used as a biological marker of the level of fluoride exposure for an individual.

Strategies for improving the assessment of dental fluorosis: focus on chemical and biochemical aspects

In order to assess fluoride accumulation and effects in developing dental tissues, one must determine the concentration profile of fluoride in the tissue and to assess separately the labile (i.e., free ions in fluid and ions associated with organic matter) and stable (i.e., incorporated into apatite lattice) pools of fluoride. Free fluoride ions in the mineralizing milieu markedly affect the driving force for precipitation and, as a result, the nature of precipitating crystals. The fluoride incorporated into the crystalline lattice increases the stability of the formed mineral. Improvement in the understanding of the mechanism of dental fluorosis requires more comprehensive information about the effects of fluoride on the ionic composition of the fluid phase, the nature of the initially precipitating mineral(s), the interactions between crystals and matrix proteins, and the enzymatic degradation of the proteins. Recent observations relevant to the role of fluoride in enamel formation include: (1) that there are threshold concentrations of fluoride below which the precipitation and hydrolysis of thin-platy octacalcium phosphate is facilitated but beyond which de novo apatite precipitation prevails; (2) that the presence of fluoride in the mineralizing milieu most likely affects the steady-state concentrations of mineral lattice ions; (3) that incorporation of fluoride into the stable pool is retarded by the presence of matrix proteins, particularly amelogenins, which inhibit the growth of apatite crystals; (4) that increasing the degree of fluoridation of apatite crystals enhances the adsorption of amelogenins onto the crystal surface, and (5) that amelogenins pre-adsorbed onto apatite crystals are more resistant to enzymatic cleavages by trypsin (used as a prototype of amelogeninases).

Dental tissue effects of fluoride

It is now well-established that a linear relationship exists between fluoride dose and enamel fluorosis in human populations. With increasing severity, the subsurface enamel all along the tooth becomes increasingly porous (hypomineralized), and the lesion extends toward the inner enamel. In dentin, hypomineralization results in an enhancement of the incremental lines. After eruption, the more severe forms are subject to extensive mechanical breakdown of the surface. The continuum of fluoride-induced changes can best be classified by the TF index, which reflects, on an ordinal scale, the histopathological features and increases in enamel fluoride concentrations. Human and animal studies have shown that it is possible to develop dental fluorosis by exposure during enamel maturation alone. It is less apparent whether an effect of fluoride on the stage of enamel matrix secretion, alone, is able to produce changes in enamel similar to those described as dental fluorosis in man. The clinical concept of post-eruptive maturation of erupting sound human enamel, resulting in fluoride uptake, most likely reflects subclinical caries. Incorporation of fluoride into enamel is principally possible only as a result of concomitant enamel dissolution (caries lesion development). At higher fluoride concentrations, calcium-fluoride-like material may form, although the formation, identification, and dissolution of this compound are far from resolved. It is concluded that dental fluorosis is a sensitive way of recording past fluoride exposure because, so far, no other agent or condition in man is known to create changes within the dentition similar to those induced by fluoride. Since the predominant cariostatic effect of fluoride is not due to its uptake by the enamel during tooth development, it is possible to obtain extensive caries reductions without a concomitant risk of dental fluorosis.

Effects of chronic fluoride exposure on morphometric parameters defining the stages of amelogenesis and ameloblast modulation in rat incisors

The response of ameloblasts to long-term (6 weeks) exposure to 100 ppm fluoride was examined in continuously erupting mandibular incisors of female Sprague-Dawley rats as compared to control rats receiving a similar diet (Teklad L-356) but no sodium fluoride in their drinking water. After treatment, animals from both groups were perfused intravascularly with glutaraldehyde, and the incisors were removed and processed for light microscope morphometric analyses directly from 1 microns thick Epon sections. Other animals were injected intravenously with calcein (green fluorescence) followed 4 hours later by xylenol orange (red fluorescence) in order to reveal smooth-ended ameloblast modulation bands and thereby allow quantification of parameters related to the creation and movement of modulation waves within the maturation zone of these teeth. The results indicated that rat incisors expressed four major changes in normal amelogenesis which could be attributed to the chronic fluoride treatment. First, ameloblasts produced a thinner than normal enamel layer by the time they completed the secretory stage and entered the maturation stage of amelogenesis. Second, enamel organ cells within the maturation zone, especially those from the papillary layer, were shorter in height than normal. Third, ameloblasts related to maturing enamel in areas where it was partially soluble and/or fully soluble in EDTA modulated at a rate that was much slower than normal. In some locations ameloblasts remained ruffle-ended for as much as 30% longer than normal per cycle. This upset the usual pattern such that fewer total modulation cycles were completed per unit time by these ameloblasts. Fourth, enamel proteins were lost from the maturing enamel layer at a rate that was about 40% slower than normal. The data suggested that ameloblasts detected the delay in the extracellular breakdown and/or loss of enamel proteins and they responded by remaining ruffle-ended for longer intervals than usual (positive feedback).

Biological mechanisms of fluorosis and level and timing of systemic exposure to fluoride with respect to fluorosis

Enamel fluorosis can occur following either an acute or chronic exposure to fluoride during tooth formation. Fluorosed enamel is characterized by a retention of amelogenins in the early-maturation stage, and by the formation of a more porous enamel with a subsurface hypomineralization. The mechanisms by which fluoride affects enamel development include specific effects on both the ameloblasts and on the developing enamel matrix. Maturation-stage ameloblast modulation is more rapid in fluorosed enamel as compared with control enamel, and proteolytic activity in fluorosed early-maturation enamel is reduced as compared with controls. Secretory enamel appears to be more susceptible to the effects of fluoride following acute fluoride exposure, such as may occur with the use of fluoride supplements. However, both human and animal studies show that the transition/early-maturation stage of enamel formation is most susceptible to the effects of chronic fluoride ingestion at above-optimal levels of fluoride in drinking water.

The fluorosis risk index: a method for investigating risk factors

The fluorosis risk index (FRI), a new index developed for use in analytical epidemiologic studies, is designed to permit a more accurate identification of associations between age-specific exposures to fluoride sources and the development of enamel fluorosis. The FRI divides the enamel surfaces of the permanent dentition into two developmentally related groups of surface zones, designated either as having begun formation during the first year of life (classification I) or during the third through sixth years of life (classification II). Data from the first use of this index in a population-based case-control study are given to illustrate the high reliability of the index, its validity, and its unique utility for the identification of risk factors of enamel fluorosis.

Relationship of total fluoride intake to beneficial effects and enamel fluorosis

Recent studies indicate that the prevalence of very mild to moderate dental fluorosis, as classified by Dean, has increased relative to that found in earlier investigations. To date, fluoridated water, fluoride supplements, the diet, fluoride dentifrices, and other topical fluoride applications have been identified as sources of systemic fluoride. Recent evidence suggests that there is a strong association between mild to moderate enamel fluorosis and the use of fluoride supplements during early childhood, and that the presently recommended supplementation schedule for U.S. children above the age of 2 years may be too high. Evidence also suggests that there is a strong association between fluoride dentifrice use during early childhood and enamel fluorosis in fluoridated populations. These findings support the need for a careful review of existing supplementation schedules and early oral hygiene practices. There is a pressing need for additional analytical epidemiological studies to confirm existing findings and to determine whether other fluoride sources may be associated with enamel fluorosis. Further, since exposure to combinations of individual risk factors has been shown to carry more than merely an additive increase in the risk of fluorosis, these studies must be multifactorial in design. There is also a need for more fluorosis prevalence and severity data to be gathered, so that the development of enamel fluorosis as a public health problem can be assessed, and so that the success of measures implemented to maximize efficacy while minimizing unwanted side-effects can be monitored.

Nature and mechanisms of dental fluorosis in animals

Recent studies of dental fluorosis in animals have been reviewed. The aim was to describe studies which have provided information which may be relevant to explaining the mechanisms involved in human dental fluorosis. Studies on rats, sheep, and pigs have provided details of dosage regimens which produce lesions which resemble those described in human fluorosis. In the pig and rat, the plasma fluoride concentrations associated with these dental lesions are of the same order of magnitude as those which may occur in man. Three different kinds of studies in different species have shown that fluoride affects processes occurring during enamel maturation. One study on rats has indicated that fluoride may reduce matrix removal during maturation by an effect on enamel proteases. Many studies have demonstrated accumulation of fluoride in secretory enamel and that fluoride concentrations in maturation enamel are lower than in secretory enamel. This phenomenon had previously been explained by the binding of fluoride to enamel proteins, but recent studies indicate that such binding does not occur. The hypothesis that enamel fluorosis might be caused by general effects of fluoride on calcium metabolism has not been supported by more recent studies. It was concluded that, although the mechanisms involved in dental fluorosis remain obscure, recent animal studies do seem to have provided new information which may prove to be important for our understanding of mechanisms whereby fluoride causes dental fluorosis in man.

The effect of fluoride on the developing mineralized tissues

The work described considers the effects on calcified tissues of those concentrations of fluoride which are not overtly cyto-toxic, i.e., in the general region of up to 1-2 mumol/L. Plasma fluoride concentrations or those of the cellular environment are considered rather than dietary levels. The effect of fluoride ion on specific stages of tooth and bone development is discussed. Little effect has been observed on the modulation of gene expression as far as odontogenesis is concerned, although there is evidence that fluoride could be osteogenic in both embryonic and adult tissues. Expression of extracellular matrix protein genes seems not to be impaired, but subtle changes detected in the enamel matrix could be due to selective alterations in amino-acid uptake or interference with subsequent protein processing. This could also be due to an extension of the secretory period without concomitant changes in post-secretory matrix processing. Removal of matrix is apparently impaired, with concomitant incomplete maturation. While existing mineral phases can be affected, it is more likely that matrix and or mineral-matrix interaction is the site of action. Explant studies suggest that the effect may be reversible. Inhibition of proteolysis during enamel maturation may account for the reported inhibition of enamel crystal growth. This is supported by the finding that the normally incomplete maturation of porcine enamel is associated with a somewhat greater residual protein content. The use of animal models in the investigation of enamel dysplasia (fluoride-induced or otherwise) should therefore be viewed with caution.

Banding patterns in rat incisor enamel stained by histochemical complexing methods for calcium

A characteristic banding pattern can be visualized at the surface of the rat incisor in the maturation zone of amelogenesis by staining with glyoxal bis(2-hydroxyanil) (GBHA). Other banding patterns can be obtained with certain histological and fluorochrome stains and by radioautography following 45Ca injection. In this study, several histochemical reagents known to complex with different states of calcium were used to stain the surface of enamel. Rat incisors were quickly dissected and immediately immersed in solutions containing the following calcium-binding reagents: arsenazo III, calmagite, murexide, N,N-naphthaloylhydroxylamine, and calcein. Routinely, one contralateral lower incisor from each pair was counterstained with GBHA in order to relate each of the staining patterns to the banded distribution of maturation ameloblasts that is reflected by the characteristic GBHA staining pattern in the enamel. Each of the reagents used in this study demonstrated a staining pattern consisting of a series of broad bands running transversely and obliquely across the enamel. In all cases, the dyes stained predominantly that enamel associated with ruffle-ended ameloblasts, i.e. enamel left unstained by GBHA. Some of the reagents also stained enamel in the secretion zone. The appearance and distribution of the staining patterns reflect the banded distribution of maturation ameloblasts and appear to be controlled on a time scale related to the rapid modulation of these cells.

Proton microprobe determination of fluorine profiles in the enamel and dentine of erupting incisors from sheep given low and high daily doses of fluoride

Developmental defects in incisors were induced by daily oral ingestion of sodium fluoride solutions. Teeth extracted at eruption from sheep that had been subjected to four different fluoride regimens--0.2 or 0.5 mg F/kg body weight daily for 6 months, 2 or 6 mg F/kg body weight daily for 21 days--were analysed for fluorine by gamma emission using a proton microprobe. Calcium and zinc profiles were also measured using proton-induced X-ray emission. Diffuse opacities, similar in appearance to mild human fluorosis, were produced by the first two regimens, whereas the last two produced hypoplastic lesions. Different distributions of fluoride were found in the unerupted enamel and dentine, and these patterns reflected variations in both the duration and concentration of the fluoride dose used to induce the fluorotic lesions.

The Ca, Pi, F, and proline content of developing bovine enamel under GBHA-stained and unstained bands

The surface enamel of fetal bovine teeth was stained with GBHA to indicate the position of bands of smooth-ended and ruffle-ended ameloblasts relative to the developing enamel. The boundaries of the bands were scored, under a dissecting microscope, and the bulk enamel under each band was collected. The enamel samples were assayed for Ca, Pi, F, and proline. The amount of Ca and Pi in the enamel increased in successive bands and seemed unrelated to the overlying ameloblast cell type. The loss of proline seemed unrelated to cell type. The fluoride content of enamel increased by approximately 50% in the first stained band immediately adjacent to the secretory zone. The F level returned to secretory values in the succeeding unstained band. Thus, only changes in the F level of developing enamel appeared to be related to GBHA staining patterns.

The macroscopic and scanning electron-microscopic appearance and microhardness of the enamel, and the related histological changes in the enamel organ of erupting sheep incisors resulting from a prolonged low daily dose of fluoride

The hypothesis that diffuse opacities in enamel result from a chronic, mild disturbance to ameloblast activities was tested using fluoride. Three sheep (HF) were dosed orally with 0.5, and 3 (LF) with 0.2 mg fluoride/kg body weight daily for 6 months. A control sheep (C) received no additional fluoride. The 7 sheep were killed at or close to the time of emergence of their permanent central incisors. One tooth from each sheep was sectioned longitudinally. The enamel related to the secretory (S) and maturation (M) phases of ameloblast activity at the start of fluoride dosing was determined from a tetracycline marker. The pattern of mineralization of the outer 150 micron of the cut labial enamel was assessed using microhardness testing. The SEM appearance of the acid-etched outer enamel was compared in S and M zones in 5 teeth. The enamel of the C tooth was translucent. Diffuse opacities, similar in appearance to human fluorosis, were present in all fluoride-treated teeth. Hardness values in the outer 70 micron of the enamel decreased as the fluoride dose increased and, in the HF teeth, were lower in the S zone than in the M zone. Fluoride given during the M phase induced a surface hypomineralization which increased in degree and depth when fluoride was also given during the S phase. The SEM appearance of M and S enamel was similar in 2 LF and 1 HF teeth but, in the other HF tooth, S enamel but not M enamel had a disordered prism structure and loosely-packed crystals in an abnormal organic matrix. Histological examination revealed that ameloblasts remained in only 4 of the 7 teeth and that their regression and the formation of the cementum adjacent only to the labial enamel were progressing abnormally.

Demonstration by staining and radioautography of cyclical distributions of protein at the enamel surface in rat incisors

Staining patterns in the enamel during the maturation stage of amelogenesis reflect the banded distribution of ruffle-ended and smooth-ended ameloblasts. This study investigated the possibility that proteins at the enamel surface may be distributed cyclically according to cyclical changes in ameloblast morphology. Dissected lower rat incisors were wiped free of their enamel organs and immediately immersed in fixative containing one of the following heavy metal and histological stains: uranyl acetate, lead citrate, Coomassie blue, alcian blue and ruthenium red. Other animals were injected with [35S]methionine to label newly-formed enamel proteins. Their incisors were dissected, the enamel organs were wiped from the enamel surface, and the teeth were processed as whole mounts for radioautography. Teeth stained by heavy metals were also viewed by back-scattered electron imaging. The in-situ staining revealed that proteins were distributed in bands and stripes across maturing enamel. Radioautography revealed that the proteins in the stripes were newly-synthesized and secreted into the enamel by certain maturation ameloblasts. We conclude that the enamel organ expresses cyclical activity in part through secretion of proteins.

Cyclic induction and rapid movement of sequential waves of new smooth-ended ameloblast modulation bands in rat incisors as visualized by polychrome fluorescent labeling and GBHA-staining of maturing enamel

The movement of smooth-ended ameloblast modulation bands was studied in continuously erupting Tincisors of male Wistar rats, with fluorochromes such as calcein (green), xylenol orange (red), tetracycline (yellow), and calcein blue (turquoise) used to label maturing enamel intensely at sites delimiting the location of smooth-ended ameloblasts at the time of injection. Hence, a fluorescent label of one color was injected to establish a reference position at time "0" followed by one or more fluorescent labels of different colors, or by in vitro enamel staining with glyoxal bis(2-hydroxyanil)(GBHA), at various times after the initial injection. For example, rats injected with calcein followed by xylenol orange at 10 min or two, four, six, or 12 hr later showed zero, 367, 888, 1259, and 2833 μm incisal movement, respectively, of the red bands relative to companion green fluorescent bands in the mandibular incisors. If one takes into account the eruption rate for these teeth (27.1 μm per hr), these data were indicative of a coordinated, wave-like movement of smooth-ended ameloblast modulation bands incisally along the length of the tooth at a mean rate of 243 μm per hr. Measurements and graphic plots of the distribution of smooth-ended ameloblast bands in histological sections and in GBHA-stained teeth revealed not only that such bands were positioned at all possible locations along the length of the maturation zone within a group of different teeth, but also that the average interband distance equaled about 2100 μm in the apical part of the maturation zone. Hence, new modulation waves appear to arise near the region of post-secretory transition and travel along the ameloblast layer toward the gingival margin about once every 8.5 hours. This suggests that a given cohort of ameloblasts may modulate as frequently as three times a day and complete a minimum of 45 modulation cycles by the end of enamel maturation.

Studies on the changes in developing enamel caused by ingestion of high levels of fluoride in the rat

Exposure to chronic high levels of fluoride results in the formation of fluorosed enamel. Although enamel may be more susceptible to fluorotic effects at certain stages of development, fluoride at sufficiently high levels may affect enamel at all stages of formation. Careful study of the changes in enamel caused by chronic fluoride ingestion is needed to understand more fully the mechanisms involved in the formation of fluorotic enamel. This paper discusses the various studies we have completed to define the changes, in developing enamel of the rat incisor, caused by long-term ingestion of fluoride in drinking water. Fluoride has been found to inhibit secretion of enamel proteins. Changes in the maturation stage of enamel formation include the retention of amelogenin proteins during early maturation. The various mechanisms which have been investigated in the formation of fluorosed enamel include a direct effect of fluoride on the enamel organ, and specific interactions of fluoride with the extracellular enamel matrix. Although the same amount of protease appears to be secreted in fluorosed and control enamel, a delay in the digestion of amelogenin protein occurs. This suggests that fluoride may directly or indirectly inhibit the protease present in fluorosed enamel to slow the proteolysis of amelogenins.

A comparative study of disturbed mineralization of rat incisor enamel induced by strontium and fluoride administration

The disturbed pattern of mineralization of developing enamel of the rat incisor after the oral administration of SrCl2 and NaF was investigated in an attempt to disclose possible mechanisms which might not be readily detectable under normal conditions, but which may control the progressive mineralization of developing enamel, especially during the maturation stage. Undemineralized ground sections of upper incisors were examined by contact microradiography, tetracycline labeling, and electron microprobe analysis. It was clear that Sr and F disturb the pattern of mineralization during the maturation stage in a characteristic fashion. Sr inhibits the early stage of maturation in which mineralization progresses from the surface toward the middle layer, whereas F accelerates the same stage prominently. At the late stage of maturation, the pattern of hypomineralization is different in the enamel of Sr- and F-treated rats. Mineralization in the inner and innermost layers of the Sr-treated rats and that in the outer layer of the F-treated rats ceases earlier than that in the controls, although the enamel is still hypomineralized.

At the latest stage of maturation, Fe penetrates more deeply into the hypomineralized enamel of the Sr- and F-treated rats, because of the higher porosity of the matrix.

These results suggest that the maturation stage is not a simple, continuous process, but rather is composed of substages (phases) which have different control mechanisms and in which mineralization progresses in different modes and rates.

Cyclic localization of actin and its relationship to junctional complexes in maturation ameloblasts of the rat incisor

The patterns of fluorescence associated with maturation ameloblasts of mandibular incisors labeled with 7-nitrobenz-2-oxa-1,3-diazole-phallacidin (NBD-phallacidin) for the detection of F-actin were investigated in normal and fluoride-treated rats. In normal rats, bands of smooth-ended ameloblasts (SA) exhibited intense fluorescence at their proximal ends only. Bands of ruffle-ended ameloblasts (RA) exhibited strong fluorescence at their distal ends as well as at their proximal ends. Regional differences in degree of intensity within the bands and between bands were displayed. In the apical part of the RA bands the proximal fluorescence was intense; it then decreased in an incisal direction; and it finally was absent close to the adjacent SA band. The incisal extension of strong proximal fluorescence in RA bands was short in early maturation and long in late maturation. The fluorescence pattern at both ends of the ameloblasts was cyclically repeated throughout the region of ameloblast modulation corresponding to the numbers of SA bands. In rats receiving 113 ppm fluoride in their drinking water for 2 months the number of fluorescence and ameloblast modulation cycles was reduced equally indicating that the cyclic F-actin localization is a phenomenon related to ameloblast modulation. Electron microscopy revealed that areas of strong fluorescence contained filament bundles, presumably actin filaments, in relation to continuous junctions occluding the interameloblast spaces. Areas of weak or no fluorescence were related to discontinuous macular junctions. The results suggest that the changes in F-actin distribution correlate well with junctional complex development, and therefore, possible functions related to the intermeloblast spaces within the RA bands may be redistributed as the ameloblasts are carried incisally by the erupting incisor.