Fluorosis
Magnitude of Fluorosis
• Worldwide in distribution
• Endemic in 22 countries
• Asia
– India and China are worst affected
• Mexico in North and Argentina in Latin
America
• East and North Africa are also endemic
2
Fluorosis in
• India
Worst affected - Rajasthan and Gujarat in
North India and Andhra in South India.
• Moderately affected - Punjab, Haryana,
M.P. and Maharashtra.
• Mildly affected - T.N., W.B., U.P., Bihar and
Assam.
• Throughout India - fluorosis is essentially
Hydrofluorosis except in parts of Gujarat
and U.P. where industrial fluorosis also
seen.
• In worst affected states, maps have been
prepared of geographic pathology on the
basis of fluoride distribution in the drinking
water. 3
Agent
• Primarily it isFactors
Fluoride which is present in
drinking water
• In water is more than 1.5 mg per litre, it
is toxic to health
• pH in terms of alkalinity of water
promotes the absorption of Flouride
• Calcium in the diet reduces the
absorption
• Hard water rich in Calcium reduces the
toxxicity
• Fresh Fruits and Vit.C reduces the effect
of F
• Trace elements like Molubdenum 4
enhances the effect of F
Host
• In School goingFactors
children seen as Dental
fluorosis.
• In third and fourth decade of life seen as
Skeletal Fluorosis.
• Males suffer more than females.
• Migration influences the occurrence
depending on which way people migrate.
• Illiterates suffer more frequently in the
fluorotic belts.
• Where aluminum ores are mined, it is
seen as occupational health hazard.
5
Environmental
Factors
• High Annual Mean Temperature
• Low Rainfall
• Low humidity
• Rich Natural subsoil rocks
• Vegetables from high Flouride belts
• Fluoridated tooth paste particularly
when used by children
• Tropical climate
• Developing Countries
6
Magnitude in India
8
Sources of fluoride for human
exposure:
Main sources of
fluoride :
• Water
• Food
• Air
• Medicament
• Cosmetic
11
Permissible limit of fluoride in drinking
water prescribed by various
organizations
Name of the organization Desirable limit
(mg/L)
Bureau of Indian Standards 0.6-
(BIS) 1.2
Indian Council of Medical 1.
Research (ICMR) 0
The Committee on Public Health Engineering
1.0 Manual and Code of Practice, Government
of
World Health Organization 1.
India
(International Standards for 5
Drinking Water)
12
Factors Affecting Development
of Fluorosis:
• Concentration of fluoridein drinking
water (more than 1.5 mg/ L), food,
cosmetics etc.
• Low calciumand high alkalinity of
drinking water promotes the absorption
of F.
• Age
15
Clinical Picture of
Endemic
Fluorosis
• Dental Fluorosis in
Children
• Skeletal Fluorosis in
Adults
• Non Skeletal Fluorosis
16
Dental
Fluorosis
• Teeth become dull and yellow-white spots
appear & Gradually turn brown.
• In late stages the whole teeth become
black. Teeth may be pitted or perforated and
may even get chipped off.
• In endemic zones people lose their teeth at
an early age and may become edentate.
17
Dental Fluorosis
Type ScaleDescription
Wt
Normal 0 Enamel smooth,
Enamel glossy, pale
creamy white
translucency
Questionable Slight aberrations
0.5 from translucency
fluorosis occasional white fleck
with
or spots
Very mild Small, opaque,
fluorosis 1 paper- white areas
involving less than
25% of the
surfaces of the two
most affected
teeth; may acquire
brown stains in
adulthood 18
Type Wt Description
Mild 2 More extensive
fluorosis dull white
involving less that
opacities
50% of the
surfaces of the two
most affected teeth.
Moderate All enamel
3 surfaces affected;
fluorosis distinct brown
staining frequent
Severe 4 Teeth show
fluorosis marked hypoplasia,
attrition and pitting;
brown or black
staining widespread.
19
Timing of chronic daily fluoride ingestion and
the corresponding dental fluorosis pattern
Fluoride When Permanent Teeth Infected Dental
Intake Exposed Fluorosis
(mg/kg/day} Severity
< 0-3 Incisors, 1st mil
0.5 years Molars d
0.10- 0-3 incisors, 1st molars, and moderat
0.15 years tips of canines & e
premolars
> 0-3 all sever
0.15 years teeth e
< 3-6 Premolars, canines, mil
0.05 years 2nd molars d
20
Fluoride When Permanent Dental
Intake Exposed Teeth Infected Fluorosis
(mg/kg/day} Severity
0.10- 3-6 Premolars, moderat
0.15 years canines, 2nd e
molars
> 3-6 all sever
0.15 years teeth e
< 0-6 all mil
0.5 years teeth d
0.10 - 0-6 all moderat
0.15 years teeth e
> 0-6 all Sever
0.15 years teeth e
21
Dental Fluorosis Treatment
Tooth whitening - only for mild fluorosis cases.
Composite bonding- only for severe cases of
fluorosis
Porcelain veneers- they can provide excellent
cosmetic results.
22
Skeletal Fluorosis :
• Associated with lifetime daily
intake of 3.0 to 0.6 mg/ l or
more.
• When a concentration of 10
mg/ l is exceeded in drinking-
water , Crippling Fluorosis
can ensue and lead to
permanently disability.
23
Stages: Skeletal
Fluorosis
Preclinical Stage: the patient feels no symptoms but
changes have taken place in the body
• Biochemical abnormalities occur in the blood and in
bone composition
• Histological changes can be observed in the bone in
biopsies
Early clinical stage:
• Pains in the bones and joints
• Sensations of burning, pricking, and tingling in the limbs
• Muscle weakness
• Chronic fatigue;
• Gastrointestinal disorders and reduced appetite.
• Changes in the pelvis and spinal column can be
detected on x-rays. 24
Second clinical stage:
• Constant pains in the bones, ligaments begin to
calcify.
• Osteoporosis may occur in the long bones,
and early symptoms of osteosclerosis
• Bony spurs may appear on the limb bones,
especially around the knee, the elbow, & on
the surface of tibia and ulna.
Advanced skeletal fluorosis (Crippling Skeletal
Fluorosis):
• Extremities become weak and moving the
joints is difficult.
• The vertebrae partially fuse together,
crippling the patient.
25
Tests for Skeletal Fluorosis
• Coin Test: The subject is asked to lift a coin from the
floor without bending the knee. A fluorotic subject
would not be able to lift the coin without flexing the
large joints of lower extremity.
• Chin Test: The subject is asked to touch the anterior
wall of the chest with the chin. If there is pain or
stiffness in the neck, it indicates the presence of
Fluorosis.
• Stretch Test: The individual is made to stretch
the arm sideways, fold at elbow and touch the back of
the head. When there is pain and stiffness, it would
not be possible to reach to the occiput indicating
presence of Fluorosis. 26
Non Skeletal
Fluorosis
1. Neurological Manifestations
• Nervousness & Depression
• Tingling sensation in
fingers and toes
• Excessive thirst and
tendency to urinate
• Frequently (Polydypsia
and polyurea)
• Control by brain appears
to be adversely affected.
• Muscular manifestations
27
2. Muscular manifestations
• Muscle Weakness & stiffness
• Pain in the muscle and
loss of muscle power
3. Urinary tract
manifestations
• Urine may be much less in
volume
• Yellow red in colour
• Itching in the region of
axilla
28
4. Allergic manifestation
• Skin rashes
• Perivascular inflammation.
• Pinkish red or bluish red
spot, round or oval shape on
the skin that fade and clear
up within7-10 days.
29
5. Gastro - intestinal problem
• Acute abdominal pain
• Diarrhoea
• Constipation
• Blood in Stool
• Bloated feeling (Gas)
• Tenderness in Stomach
• Feeling of nausea
6. Red Blood cells
• Formation of
echinocytes.
• Anaemia.
30
De-fluoridation:
-At Household Level
-At Commercial
Level
31
• De-fluoridation is the process of removal of
excess fluoride from water.
• WHO has identified and evaluated the most
promising de-fluoridation methods :
Bone charcoal
Contact precipitation based on the addition of
calcium and phosphate compounds
Nalgonda Technique
Activated alumina
32
At Household
Level
33
Nalgonda Technology:
Water Treatment
• De-fluoridation using Nalgonda technology
(Adapted from RDNDWM, 1993)
• Raw water mixed with aluminium sulphate (alum),
lime or sodium carbonate (1/20th of alum) and
bleaching powder (3 mg/l).
• Stir water slowly for 10-20 minutes and allow to settle
for nearly one hour. Supernatant is withdrawn.
Discard the sludge.
34
These Do NOT Remove Fluoride
• Boiling Water :This will concentrate the
fluoride rather than reduce it.
• Freezing Water: Freezing water does not
affect the concentration of fluoride.
35
Food
Supplements
40
Food for ameliorating fluoride effects
:
Calcium:
Milk, (2) dahi, (3) jaggery (4) green leafy vegetables, (5) til
seed, (6)
cheese, (7) kamal kakdi, (8) arbi, (9) Chulai ki sag, (10)
jeera, (11) drumsticks and the leaves, (12) soya products
(13) broccoli etc.
Iron:
Beet root (2) apple (3) raw and ripe banana (4) brinjal
etc.
Vitamin C:
Vegetable oil, (2) nuts (almond, peanut), (3) whole grain
cereals, (4) green vegetables, (5) dries beans etc.
Vegetables and fruits rich in antioxidants:
Papaya, (2) carrot, (3) pumpkin, (4) spinach and other 41
leafy vegetables, (5) garlic, (6) spring onion, (8) chilly,
• Fluoride Rich Dental Products:
– Fluoridated toothpaste
– Mouth rinse
– Varnish and
– Sodium fluoride tablets
43
Other ways to remove Fluoride
• Reverse Osmosis Filtration
• Activated Alumina De-fluoridation Filter:
Used in locales where fluorosis is prevalent,
expensive and require frequent replacement
• Using harvested rainwater for drinking
46
Case
Case 1: studies
Patient: a doctor specialized in surgery;
unable to stand long hours and operate on
patients due to back pain. Pain killer was
providing only temporary relief.
Reason for the health problem: high fluoride in
drinking water which the patient was not
aware of as fluoride does not change colour,
taste or odour. On confirmation of Fluorosis
to, the interventions provided relief and
recovery from the ailment.
51
Thank You
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