Systemic fluoride

SYSTEMIC FLUORIDE
By Dr. Lilavanti Vaghela
MDS in Pediatric and Preventive Dentistry

Content
• Introduction
• History
Types of systemic fluoride
Fluoride compounds and their concentration.
Water fluoridation
• Advantages and disadvantages.
• Feasibility in India (water fluoridation)
School water fluoridation. (Advantages and disadvantages).
Salt fluoridation
• Introduction
• Production and preparation
• Advantages and disadvantages
• Feasibility in India
• Limitations

Milk fluoridation
• Introduction
• Rationale of milk fluoridation.
• Planning a milk fluoridation programme.
Fluoride supplements and tablets
Antifluoride lobby
• Is fluoridation important?
• Reason to oppose fluoridation
• Fluoridation and law
• Controversy of fluoride
• Fluoride toxicity
• Conclusion
• References

Introduction
• Systemic fluorides provides a low concentration of fluoride to the teeth over a long
period of time.
• It circulates through the blood stream and is incorporated into developing teeth.
• After teeth erupt, fluoride contacts teeth directly through salivary secretions.
• Most systemic fluorides have a topical effect but their primary effect is systemic.
Essentials of public health dentistry, soben peter 5th edi

History of systemic fluoride
1800’s Fluoride
• Occurrence of fluoride in calcified tissues was already known
at the beginning of the 19th century.
• Magitot demonstrated the earliest reference relating fluoride
to dental caries in 1878.
5
Betul Kargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

• 1900’s Fluoride alerted researchers
• A series of events focused attention on the possible toxic effects
of fluoride on the dentition.
• The occurrence of disfigured teeth was reported in Naples, Italy
and this was believed to be due to a substance in water that
altered the calcification process.
• In the United Stated, it was also common to see the same in the
residents living in Colorado, Arizona, New Mexico and Texas.
6

• 1930’s Fluoride, something weird in water;
• Churchill, 1931 developed a method for determining the
concentration of fluoride in drinking water. He showed that
below 0.9 ppm fluoride in water no toxicity and no mottled
enamel is seen.
• Dean and McKay 1939 clearly illustrated that the epidemiology
of dental fluorosis, but clearly documented the reduction in
dental caries.
7

• 1939; to confirm the above hypothesis, epidemiological studies
were carries out in 4 Illinois cities. The cities were Galesberg
and Monmonth and nearby cities of Macomb and Quincy.
City F ppm in
water
No. of
children
% with no
dental caries
experience
DMF
permanent
teeth per
100 children
Galesburg 1.8 243 36.2 194
Monmouth 1.7 99 36.4 208
Macomb 0.2 63 14.3 368
Quincy 0.1 291 4.1 628
8

1940’s beginning of water fluoridation
• US Public Health Service teams conducted studies involving 21
cities selected on the basis of varying concentrations of fluoride
in the public water supplies.
No. cities
studied
No. of children
examined
Permanent
DMF teeth per
100 children
Fluoride
concentration
of public water
supply in ppm
11 3867 > 7 < 0.5
3 1140 4 0.5 to 0.9
4 1403 3 1.0 to 1.4
3 847 2.5 > 1.4
9

Grands Rapid-Muskegon
25th Jan 1945
• After 6 ½ years in July,1951 the caries experience of 6 and 15 years
old children residents of Grands Rapids was half that of Muskegon
Arnold et al, 1953
• Result after 15 years of fluoridation showed a dramatic caries
reduction of 50% i.e. in 15 years old children of Grands Rapids the
DMFT of 12.48 decreased to 6.22 in 1959
Arnold et al, 1962
10

Newburgh-Kingston study [1945-1955]
• Newburgh[NaF2]—river Hudson –Kingston
• David B Ast—chief of dental bureau-directed.
• Newburgh children –caries decline from 23.5 to 13.9 % after Fl.
• Confirmed the caries inhibitory property of Fluorides.
11

Age City Ppm of F
added
DMF teeth per 100
children with
permanent teeth
% reduction
6-9 years Newbrugh
Kingston
1 to 1.2
0
98.4
233.7
57.9
-
10-12
years
Newbrugh
Kingston
1 to 1.2
0
328.1
698.6
53
-
12

1950’s
An era of artificial water fluoridation started the world over and many
countries committed themselves to this programme in order to
reduce the increasing trends of dental caries in their communities.
14

Evanston –Oak park study [1946-1960]
• Drs. Blayney JR, Hill IN, Zimmerman –university of Chicago memorial dental clinic.
• Evanston children —43% reduction
[5.95 to 1.66 DMF]
• Oak park children —no change observed
15

Dutch study [Tiel-Culemborg]
1953-1969
• Backers Dirks 1961—11-15 yrs old children.
• Tiel –Fluoridated—1.1 ppm
• Culemborg ---0.10ppm control
• Fluoridation revealed not only a decrease in caries prevalence but also a 90% reduction
in mean number of extractions per child after a period of 16 years
16

New Zealand study
1954-1965
• Ludwig–Hastings conducted a retrospective study
• DMF of 10yr old
Reduction of 55%
1954 1964
5.48 2.46
17

1960’s WHO endorses the practice of water fluoridation
The WHO and the Pan American Health Organization endorsed the practice of
water fluoridation in 1964
18

1970’s
In the UK only about 3 million drink fluoridated water (6% of the population),
but over 100 million people (60% of the population) in the USA.
19

1980’s Around the world
• During the 80’s Germany, Spain, Yugoslavia, USSR, China and
Japan were far away from water fluoridation.
1990’s
• Water fluoridation was accepted in U.S, Australia, Brazil,
Canada, Hong Kong, Malaysia, UK, Singapore, Chile, New
Zealand, Israel, Columbia, Costa Rica, South Africa and Ireland in
the 1990’s.
20

2000’s
• The benefits from water fluoridation are considerably less today
than when the method was introduced, mainly because of the
increased exposure of fluoride from other sources.
• The differences in caries prevalence between fluoridated and non-
fluoridated areas have decreased.
• It should be concluded that water fluoridation needs be targeted
on high caries areas, which are normally also areas of social and
material deprivation.
21

1. Water Fluoridation
• Community Water Fluoridation
• School Water Fluoridation
2. Salt Fluoridation
3. Milk Fluoridation
4. Fluorides Tablets
Fluorides in CariesPrevention:Murray,
RuggGunn
TYPES OF SYSTEMIC FLUORIDE

FLUORIDES COMPOUNDS AND CONCENTRATIONS THAT ARE USUALLY
USED IN DIFFERENT SYSTEMIC FLUORIDES METHODS
FLUORIDES
METHODS
FLUORIDES
COMPOUNDS
CONCENTRATIONS
Water Fluoridation hydro fluorosilicate (FSA),
sodium
fluorosilicate, sodium
fluoride
0.7 - 1.2 mg/L
Salt Fluoridation potassium fluoride , sodium
fluoride
250-300 mg/kg
Milk Fluoridation Sodium fluoride or
disodium
monofluorophosphate
5 mg/L
Dietry Fluorides
Supplementation
sodium fluoride, acidulated
phosphate fluoride,
potassium
fluoride, calcium fluoride
0.25 – 1.0 mg/day
RuggGunn

CARIOSTATIC MECHANISM OF SYSTEMIC FLUORIDES
1. Rendering enamel more resistant to acid dissolution
2. Inhibition of bacterial enzyme systems
3. By reducing tendency of the enamel surface to absorb proteins
4. Modification in the size and shape of the tooth
Understanding dental caries by Gordon nikiforuk

Reducing enamel solubility
• Stabilization of the apatite lattice
• Fluoride fills inherent voids due to missing hydroxyl groups

Enzymatic Action
Fluoride ion has the ability to inhibit enzyme action
exerts a direct effect in plaque bacteria
• Higher levels of ionic fluoride (>32 ppm) are required to reduce acid production by plaque
(Jenkins, 1959)
• Revived by the important finding that fluoride is concentrated within plaque (Dawes et al, 1965)
which originates from the oral fluids rather than enamel.

➢The concentration of fluoride above 2 ppm in solution progressively decreases transport or
uptake of glucose into cells of oral streptococci
(Weiss et al., 1965, Schachtela et al., 1973)
➢Plaque has been depleted of its exogenous sugar supply, fluoride inhibits metabolism of
polysaccharides present in plaque thus indirectly interfering with acid production (Weiss et al.,
1965)

Surface Adsorption
• Fluoride incorporated in enamel substitution of hydroxyl ions altered the surface charge or free
energy and thus indirectly alters the deposition of pellicle and subsequent plaque formation.
(Erricsson et al, 1967)

Tooth Morphology
• Fluoride is believed to alter the tooth morphology i.e. reduction in the cusp height, fissure depth
and increase in the fissure width thus making teeth less susceptible to caries.
(Levius et al, 1969 and Assenden et al, 1974)

Systemic acquisition of fluoride
• Fluoride are incorporated pre-eruptively into enamel from tissue fluid during process of
mineralization

(weatherell et al,1977)
• The level of fluoride acquired is determined by concentration of fluoride in the plasma which, in
turn, is a function of the fluoride ingested in water, food or supplements.
• During the early stage of enamel formation, the f- concentration is relatively high but, surprisingly
the concentration falls as the tooth matures and acquires more mineral.
• Most of the fluoride is incorporated into the sound surface of enamel during the pre-eruptive
maturation stage when enamel undergoes rapid and more complete mineralization.

• Primary teeth have a shorter period of enamel maturation and therefor acquire less f- than
permanent teeth.
• The small difference in the concentration of f- between permanent teeth have also been
explained by the difference in maturation time between teeth.
• A gradient concentration, with decreasing concentration towards the DEJ, exists in unerupted as
well as erupted teeth in fluoridated and non fluoridated area.

Acquisition of f- in enamel

(Sakae and hirai,1982 )
• While most f- is aquired during the pre-eruptive development of teeth it is important to recognize
that a significant amount of the mineral component of enamel is acquired as a result of post
eruptive maturation.

Fluoride and hidden caries (occult caries)
• A popular belief has been that occult caries have resulted from the widespread
use of fluoride.
• “fluoride bombs” or “fluoride syndrome.
• This theory hypothesizes that fluoride helps in remineralization and decreases
the progress of the caries in the pit and fissure areas of enamel, but the
cavitation continues in the dentin part with the intact enamel surface at the top
of the carious lesion
Management of occult caries induced large periapical lesion N. B. Nagaveni, Shruti Virupaxi, P. Poornima, V. V. Subba Reddy 2015

• One study stated that occult caries is found to be with very low caries scores
because of increased fluoride exposure.
• However, there is a contradictory statement about fluoride and occult caries in a
study done in Nederland, which compared the prevalence of occult caries.
• The study observed 31% decreases in the prevalence of occult caries in the
fluoridated city. This was found in contrast to the hypothesis of “fluoride bomb,”
suggesting that fluoride has a minimal role in the pathogenesis of occult caries.
Management of occult caries induced large periapical lesion N. B. Nagaveni, Shruti Virupaxi, P. Poornima, V. V. Subba Reddy 2015

Water fluoridation
• Water fluoridation remains the cornerstone of any sound caries prevention program.
• It does not only the most effective means of reducing caries, but remains the most cost effective,
cost saving, convenient, and reliable method of providing the benefits of fluoride to the general
population because it does not depend on individual compliance.
Fluorides And Dental caries – A Compendium. By Dr. Amrit Tewari.

definition
• Controlled adjustment of the concentration of fluoride in a
communal water supply so as to achieve maximum caries
reduction& a clinically insignificant level of fluorosis.
• Upward adjustment of the concentration of fluoride ion in a
public water supply in such a way that the concentration of
fluoride ion in the water can be constantly maintained at 1
ppm by weight to prevent dental caries with min possibility of
causing dental fluorosis.
RuggGunn

Water Fluoridation
• Epidemiological surveys of 1930s conducted by T.H. Dean studied the
dental caries experience of children, residents of 21 cities of USA ; fluoride
in their drinking water ranging from 0.6 to 6ppm
• Results reaffirmed the hypothesis of McKay
There was an inverse relationship between incidence of very mild mottling
and dental caries.
• Continued systematic endeavours of Dean finally established the optimal
threshold of fluoride- 1ppm in drinking water, the level at which it led to
maximum reduction in caries with only sporadic instances of mild fluorosis
of no aesthetic significance

Relative safety of water fluoridation
• Leone et al ,1954 conducted a comprehensive medical examination of the
residents of Bartlet Texas, who for 15 years drank water with 8 ppm of
fluoride and compared the results with residents of Cameron, Texas, who
drank water having 0.4 ppm revealing no unusual cases of arthritis, bone
fracture, exostosis, or hypertropic bone changes.
• Weidman et al 1963 reported no radiographic evidence of skeletal
abnormality in persons consuming water supply containing upto 4 ppm of F
throughout their lives.
40

• In 1978 WHO reaffirmed its support for fluoridation.
• Thus it is evident that optimal levels of fluoride-1 ppm in drinking water is
physiologically and medically absolutely safe in addition to being useful for dental
caries prevention.

OPTIMUM LEVELS OF FLUORIDE
Ppm F = 0.34/ E
E= -0.038+0.0062×t in F
E= estimated daily water intake in
children in oz/lb body weight
t= mean maximum daily air
Temperature in
Degree Fahrenheit.
Annual average
max daily air temp
(F)
Optimal
fluoride
40.0-53.7
53.8- 58.3
58.4-63.8
63.9-70.6
70.7-79.2
79.3-90.5
1.2
1.1
1.0
0.9
0.8
0.7
• Optimum recommended fluoride
levels varies with climate because
water consumption increases in
warmer climates.
• Cold climate- 1.2ppm
• Hot climate – 0.7ppm
• Moderate climate – 1ppm

• The first community fluoridation program in the U.S. began in 1945 in
Grand Rapids, Michigan, and resulted in 50-60% lower tooth decay rates
in children consuming optimally adjusted fluoridated water compared to
children consuming fluoride-deficient water.
• Since that time, many studies on safety and efficacy have been published,
making fluoridation of public drinking water one of the most widely
studied public health measures in history.
RuggGunn

MATERIALS USED IN WATER FLUORIDATION
• Three types of fluoride equipments
1. Dry feeder
2. Solution feeder
3. Saturation methods
Constant monitoring is required once the water is fluoridated to maintain the constant
level of fluoride i.e., 0.8 to 1.2 ppm.

Compounds used in water fluoridation
Fluorospar
-CaF2 is the main ingredient, 85-98%
- normal consumption >500,000 tons/year
Sodium fluoride
-White, odorless, free flowing- powder or mixture of various sized particles.
-Manufactured from HF, a byproduct of fluorospar
-Expensive
Silicofluorides
-Byproduct of purification of phosphate rocks.
RuggGunn

-Sodium silicofluoride
-Hydrofluosilicic acid is the raw material.
-Solutions are corrosive.
Hydrofluosilicic acid
-More expensive than silicofluorides on account of transportation.
Ammonium silicofluoride
-Neutralizing fluosilicic acid with aqueous ammonia or ammonia in gaseous form.
-Desirable where ammonia is used to form chloramines with chloride.

Dry feeder
• Principle : NaF or silicofluoride in form of powder is introduced with aid of automatic mechanism
Factors limiting utilization:
• Need for care in handling F.
• Obstruction of pipes.
• Compaction of F while stocked at humid temp.
Recommodation:
• Medium sized town
• 3.8million l/day

• Solution feeder
Principle: Volumetric pump permitting addition of hydrofluosilicic acid in proportion with water
treated.
Factors limiting utilization
• Resistant to attack by hydrofluosilicic acid.
• Necessitates construction in polyvinyl chloride.
• Imprecision in determining volume for small quantities.
• Recommendation:
• Medium sized & large sized >7.6million l/day

Saturator system
• Principle: 4% saturated sol of NaF is produced and injected at the desired concentration at the
water distribution source with the aid of pump.
Factors limiting utilization
• High hard water level
• Need to clean gravel bed
Recommendations
• Suitable for Small towns
• <3.8million l/day

Venturi flouridator system
• It is non electrical system which was developed by J.N. Leo
• It is activated by the flow of water in the main water line.
• The tank containing the f- is made of a clear acrylic thermoplastic and this enables the operator to
make a visual inspection of the level of chemical, in order to replenish it.
• Adavantage
• Simple to install
• Cost effectiveness
• No possibility of accidental overdose

Saturation suspension cone
• Developed in Brazil by Water & Sewage Authorities of state of Rio Grande do Sul.
• Consists of an upside down cone charged with a bag of sodium silico fluoride
through which a constant flow of water percolates.

Types of equipment for water fluoridation
Saturator
system
Dry feeder Solution feeder
Principle
4% saturated sol
of NaF is
produced and
injected
NaF or
silicofluoride in
form of powder is
introduced with aid
of automatic
mechanism
Volumetric pump
permitting addition of
hydrofluosilicic acid in
proportion with water
treated.
Factors
limiting
utilization
High hard water
level
Need to clean
gravel bed
Need for care in
handling F.
Obstruction of
pipes.
Compaction of F
while stocked at
humid temp.
Resistant to attack by
hydrofluosilicic acid.
Necessitates
construction in polyvinyl
chloride.
Imprecision in
determining volume for
small quantities.
Recommendations
Small towns
<3.8million l/day
Medium sized town
3.8million l/day
Medium sized & large
sized >7.6million l/day

Feasibility in india
• Increasing prevalence of dental caries and dentist population ratio is only
1:80,000 and lack of preventive awareness of oral disease, community water
fluoridation appears to be most effective.
• But the only short coming in that it can be implemented only in areas which
have central pipeline supply which constitutes only 30% of population.

India does not need water fluoridation; An Illusion
• India already has a high concentration of fluoride in drinking water and as such does not
need any communal water fluoridation.
• Rama Subramanian et al 1979; revealed that only about 5% of the population live in high
fluoride areas or known endemic fluoride belts eg. Bhatinda belt in Punjab, Etawah area
in UP, Anantpur and Guntakal areas in Andra Pradesh, etc.
• Only about 3% of the population lives in optimal fluoride areas and the rest about 90%
of the population consumes water, deficient of fluoride.
• About 66% are using water with fluoride contents less than 0.5ppm which are well
below the optimum fluoride levels required for protection against dental caries.

Fluoride status - India
• 15 out of 29 states and 7 union territories are endemic.
• Andhra Pradesh, Gujarat, Rajasthan -70-100% districts affected
• Bihar, Punjab, Haryana, Karnataka, Maharashtra, Madhya Pradesh, Tamil Nadu, Uttar
Pradesh, some parts of Delhi -40-70% districts affected
• Uttaranchal, Jharkhand, Chhattisgarh, Assam, Kerala, Orissa, West Bengal, Jammu &
Kashmir -10-40% districts affected.
Place State Fluoride level
Rajauli Bihar 8 ppm
Nalgonda Andhra Pradesh 10-12 ppm
Kolar Karnataka 2.8- 4.3
Unnao Uttar Pradesh 2.9 to 7.0

Fluoride status - India
Fluoride level States
>4.0 ppm Punjab, Haryana, Rajasthan, Gujarat,
Madhya Pradesh, Andhra Pradesh,
Tamil Nadu
4- 8 ppm Gujarat (Kutch, West Jamnagar)
Madhya Pradesh (Chandi, Betul)
>5.0 ppm Andhra Pradesh (Ananthpur,
Karimnagar, Krishna districts)

INDIA
• Economic aspect of water fluoridation is quite obvious and the per capita cost shall be about
Rs0.25 per individual per year & the caries reduction of 50%.
• Cost to benefit ratio works out to be 1:160 i.e., for every Rs0.25 spent on water fluoridation , each
person shall save Rs40.

ADVANTAGES OF WATER FLUORIDATION
• Large number of people are benefited.
• Consumption is regular
• Fluoridated drinking water not only acts systemically
• During tooth formation to make dental enamel more
resistant to dental decay,but also has topical effect
through the release in saliva after ingestion.
• Fluoridation of community water is the least expensive way to provide
fluoride to a large group of people.

DISADVANTAGES OF WATER FLUORIDATION
• Interfere with human rights
• Other modes are not considered
• Common source of water supply may not be present.

Water fluoridation and child dental health
• In deciduous dentition
• Tank and storvick in 1964, USA examined 134 children aged 1-6yr, born and brought up in
corvallis (1 ppm F- in drinking water) and 114 children of similar age from Albany (f- free).
• Result showed that , for each age group, caries experience was lower in Corvallis than in Albany
• The mean caries rate was 56% lower in the f- area than in non f- area

• The effect of water fluoridation in reducing dental caries in the deciduous dentition should not be
underestimated.
• A reduction in the caries experience of the deciduous teeth is most important factor when the
need for dental treatment in a community is considered.
• In addition, it has important psychological and social benefits in that far fewer children in a
fluoride area are exposed to the unfortunate sequelae of untreated dental caries – pain, sepsis,
extraction of teeth etc.

Indian JDent Res.1993 RELATIONSHIP BETWEEN CARIES,WATER FLUORIDE LEVEL
AND SOCIOECONOMICCLASSIN15-YEAR-OLD INDIAN SCHOOL CHILDREN.
RahmatullaM1, WyneAH.
Thepurpose of this studywasto determinethe relation betweencaries experience,
water fluoride level andsocioeconomicclassamongthe
15-year-old schoolchildren of Tamilnadu.Thestudy children were stratified on the basisof
water fluoridelevel andsocioeconomic(SE)class.
Therewasahighly significant difference in the cariousexperienceof
15-year-old children from low fluoride (LF)areasin relation tothe SEclass, the low SEclass
havingthe highestcariesexperience.Thedifference between cariesexperienceof 15-year-
old children from LFandHFareas wasnot statistically significant. Thepresent study has
indicated towards the needof provisionof morevigorous preventive efforts in lower SE cla
ss childrenin both the urban andrural population.

Harding MA, O'Mullane
DM, 2003
Cho HJ et al,2014
Water fluoridation is an effective safe means of
preventing dental caries, reaching all populations,
irrespective of the presence of other dental services
The systemic effect of fluoride intake through water
fluoridation could be important for the prevention of
dental caries.

ActaMed Acad.2013Nov;42(2):131-9.
WATERFLUORIDATION AND ORALHEAL
TH.
HardingMA,O'MullaneDM.
Water fluoridation isaneffective safemeansof preventing dental caries,
reachingall populations, irrespective of the presenceof other dental
services. Regularmonitoring of dental cariesandfluorosis is essential
particularly with the life long challengewhich dental cariespresents.

CommunityDent OralEpidemiol. 2014 SYSTEMIC EFFECT OF WA
TER
FLUORIDATION ON DENTAL CARIES PREVALENCE.
ChoHJ1,JinBH,ParkDY
,JungSH,LeeHS,PaikDI,BaeKH.
Theaimof this studywasto evaluatethe systemiceffect of water fluoridation
on dental cariesprevalenceandexperienceinCheongju, SouthKorea,where
water fluoridation ceased7yearspreviously.
CONCLUSIONS:
While 6-year-oldchildren who hadnot ingested fluoridated water showedhigher
dft in theWF-ceasedareathanin the non-WFarea,11-year-old children in the WF-
ceasedareawho had ingested fluoridated water for approximately 4yearsafter
birth showedsignificantlylower DMFTthan those in the non-WFarea.This suggests
that thesystemiceffect of fluoride intakethroughwater fluoridation couldbe
important for the preventionof dental caries.

SCHOOL WATER FLUORIDATION
• School water fluoridation is one of the possible areas to be explored. This programme helps in
limiting caries in school children who are the prime concern.
• It is the suitable alternative where water fluoridation is not feasible.
• The amount of fluoride added In school drinking water should be greater than normal because
children have to stay in the school for a short period of time and to compensate for holidays and
vacations.
HISTORY
• This procedure was first started in 1954 in St. Thomas V.S Virgin islands by US public health
service division.
RuggGunn

• The current recommended regimen for school water fluoridation is adding 4.5 times
more fluoride .
• There has been around 25 to 40 % decrease in dental caries with this program.
• Simple fluoridators particularly that employ the venturi system are most suitable
,because they require almost no maintenance and can be utilized effectively in small
instalments of small or medium sized schools.
ADVANTAGES
• good results in reducing caries.
• Minimal equipment .
• Not expensive.

DISADVANTAGES
• Children do not receive the benefit until they go to school.
• Not all children go to the school in poor countries and towns and villages.
• Amount of amount water drunk can’t be regulated.

• Young and Elliot, 1966
➢ Apatite is a hexagonal crystal with two equal axis,
120° apart and a third axis perpendicular to these
two.
➢In order to maintain symmetry, hydroxyl ions must
be located on side of the calcium plane as often as
on the other.
➢To avoid this steric interference one of the
hydroxyl ions gets exterminated creating a void or
reversal points.

• This isomorphic replacement possible due to similarity of ions.
• The number of reversal points cannot be large or there would be no tendency of
hydroxyapatite to be stable.
• If all the hydroxyapatite were to get converted to fluorapatite the amount of
fluoride present in the enamel would have been 38000 ppm in comparison 1000
to 2000 ppm in its outermost surface.

• According to Jain Min Sim at al in 2011
• He did feasibility study on f- in drinking water in mehsana,Gujarat
• Average concentration of f- is >1.5ppm

• According to R.K.Verma,2014
• He publishes one report for ground water in Gandhinagar district, Gujarat
• He mentioned minimum f- conc in water 1.25ppm
maximum f- conc in water 2.65ppm
GROUND WATER BROCHURE GANDHINAGAR DISTRICT GUJARAT ,2014

• According to Fawaz at al in 2015
• Title – status of water fluoride- An update from the Asian contries
• He stated that in india Out of a total of 609 districts, 220 districts are known to
have high fluoride levels in ground water.
• It is also argued that India already has a high concentration of fluoride in drinking
water and does not need any community water fluoridation.
Dr. Fawaz Pullishery, et al. STATUS OF WATER FLUORIDATION STATUS OF WATER FLUORIDATION STATUS OF WATER
FLUORIDATION STATUS OF WATER FLUORIDATION-- AN UPDATE FROM AN UPDATE FROM AN UPDATE FROM AN UPDATE
FROM THE ASIAN COUNTRIES ,2015

• However, only 6% of the population lives in high fluoride areas or known endemic
fluoride belts. About 3% of the population lives in optimal fluoride areas and rest
about 90% of population consumes water deficient in fluoride.
Dr. Fawaz Pullishery, et al. STATUS OF WATER FLUORIDATION STATUS OF WATER FLUORIDATION STATUS OF
WATER FLUORIDATION STATUS OF WATER FLUORIDATION-- AN UPDATE FROM AN UPDATE FROM AN UPDATE
FROM AN UPDATE FROM THE ASIAN COUNTRIES ,2015

• Acco to Meththika Vithanage ,2015
• Of the 85 million tons of fluoride deposits on the earth’s crust, 12 million tons are found
in India.
• About 50 % of the ground-water in Delhi exceeds the maximum permissible limit for
fluoride in drinking water
• Fluoride content was higher in deeper aquifers of Maharashtra (Madhnure et al.
2007)which was due to long residence time than shallow groundwater.
Fluoride in the environment: sources, distribution and defluoridation,Meththika Vithanage,2015

• According to shakir Ali Khan,
May 2019
S. Ali, et al. Groundwater for Sustainable Development 9 (2019) 100224

• According to one
project – Shodhganga
OCCURRENCE OF FLUORIDE IN GUJARAT,shodhganga,2014
Chapter-8

OCCURRENCE OF FLUORIDE IN GUJARAT,shodhganga,2014
Chapter-8

SALT FLUORIDATION
• Salt fluoridation is a controlled addition of fluoride ,usually sodium or
potassium fluoride ,during the manufacture of salt for human consumption.
HISTORY
• First fluoridated salt was introduced by WESPI in Switzerland 1948.it has
been on sale in Switzerland since 1955.
• Experiments have been conducted with concentration of fluoride in salt
ranging from 90 mg of fluoride per kg. salt to 200 -350 mg/kg .

• Initial clinical trial of 90 mg/kg fluoride salt showed 20- 25 % of reduction of
dental caries.
• In 1967 Muhleman showed the safe dose of fluoridated salt, that 300 mg/kg
yields 1.5 mg fluoride/5 gm of salt.
• Tooth from Hungary, after 8 years of salt fluoridates at the level of 250 mg
fluoride /kg reported 35-58% of caries reduction
RuggGunn

PRODUCTION AND PREPARATION OF FLUORIDATED SALT
• For effective caries prevention, fluoride must be present in ionic form when salt
(sodium chloride) is dissolved in water .
• Fluoride is added to salt by spraying concentrated solutions of sodium fluoride or
potassium fluoride.
• Premixed granules of NaF and CaF2 with PO4 are added to common salt.
RuggGunn

ADVANTAGES
• Fluoridated salt is safe.
• Theoretically fluoridated salt prevents dental caries by both systemic as well topical
action.
• It does not require community water supply as in case of water fluoridation.
• It permits individual to accept it or reject it.
• Low cost
• Fluoridated salt and iodized salt can be made available to the population.

DISADVANTAGES
• No precise control over indicated consumption, since salt
intake varies greatly among people.
• Less sodium (Na) intake to help control hypertension.
RuggGunn

FEASIBILITY IN INDIA
• Salt fluoridation appears to be a viable and feasible method of
fluoride ingestion systemically because its distribution can be
easily monitored as the supply can be effectively controlled
especially for those areas which do not need supplemental
fluorides.
• Moreover ,individual monitoring is not required as the levels
are so adjusted so as to provide optimum levels of fluoride
keeping in view the fact that on an average an individual
consumes 5-8 gms of salt per day.
RuggGunn

• Also salt is freely available and is used on a large scale all over the
country by majority of the population of various ethnic and regional
groups.
• Regarding the acceptability of the population it shall be readily
accepted as the addition of fluoride to salt does not alter its colour
as in case of salt iodization.
RuggGunn

LIMITATIONS
1. Large variations in salt intake in different groups of people .fluoridated salt
consumption is lowest when the need for fluorides is greatest – in early years
of life.
2. The amount of fluoridated salt ingested may decrease with increasing
consumption of processed foods .
3. Difficulties arise when there are multiple drinking water sources which have a
naturally optimal or excessive fluoride concentration.
4. It requires refined salt produced with modern technology and a high level of
technical expertise.
5. The current view data high salt intake may contribute to hypertension.
RuggGunn

• Milk fluoridation is the addition of a measured quantity of fluoride to bottled or
packaged milk to be drunk by children.
HISTORY
• It was introduced by Zeigler ,a paediatrician, who started the first project with
fluoridated milk in Swiss city of Winterthur in 1953.
• In 1971, Dr. Edgar borrow established the Borrow foundation (formally the
Borrow dental milk foundation) in England, with the aim of promoting the use
of milk as a vehicle for fluoride for the benefit of children’s oral health.
• The first community based milk fluoridation scheme was introduced in 1988, in
Bulgaria, under the international milk fluoridation program.
MILK FLUORIDATION

RATIONALE OF MILK FLUORIDATION
• The nutritional value of milk has been well documented .
• Milk is often available to children through school and nutritional programs and
the use of such distribution systems can provide a convenient and cost efficient
vehicle.
• Virtually all forms of milk products are suitable for fluoridation and the process is
relatively simple.
• Milk fluoridation can be targeted at those communities in greatest need.
RuggGunn

• Research has been demonstrated the effectiveness of fluoridated milk in
preventing dental disease .
• The bioavailability of fluoride is not reduced by milk.
• Fluoridated milk keeps a permanently low level of ionized fluoride within
the oral cavity ,promoting remineralisation. This topical mechanism
contributes to the caries preventive effect of fluoridated milk.
RuggGunn

COMPOUNDS USED FOR MILK FLUORIDATION
• Calcium fluoride
• Sodium fluoride
• Disodium monofluorophosphate
• Disodium silicofluoride
RuggGunn

FEASIBILITY IN INDIA
➢Though theoretically milk fluoridation is advantageous, in addition
being the staple food for children and its consumption can be
confined to groups who need it most, that practically speaking that
this scheme /method does not seem to be viable and feasible
because of :
RuggGunn

• In INDIA, majority of children population living in rural and urban areas cannot
afford milk daily.
• Central milk supply system does not exist in India.
• Variation of intake and quantity of milk is another which cannot be controlled
since it depends upon the socio-economic religious and ethnic factors.
RuggGunn

DENTAL CARIES AND FLUORIDE LEVELS IN WATER AND MILK IN 13-15YEAR OLD
ADOLESCENT POPULATION IN DAKSHINA KANNADA DISTRICT, INDIA
Mithra N. Hegde,2013
• The range of fluoride levels in waters samples was 0.01 to 0.17 ppm and that of
milk samples was 0.176 to 1.38 ppm.
• There was no much difference in fluoride levels of different milk sources.
• Hence association between DMFT and milk fluoride levels was not statistically
significant

FLUORIDE SUPPLEMENTS
• Fluoride supplements are available in different forms such as fluoride tablets
,drops , lozenges.
• Fluoride tablets, drops and lozenges are not available over the counter but
prescribed by the dentist or paediatrician to individual patients or as a part of
school or home based preventive dentistry program.
RuggGunn

Fluoride tablets- a dual approach in prevention of dental caries
• Drinking water fluoridation is the most effective mass preventive method against dental
caries.
• However, large population groups are unable to benefit from this measures.
• In some countries there are lack of financial and technical resources for water
fluoridation.

• Fluoridated salt, milk and f- tablets have long attracted interest as potential vehicle for
fluoride which might serve for systemic and topical use as an alternative to f- drinking
water.
• F- tablets provide systemic effect before mineralization of primary and permanent
dentition is completed and topical effect thereafter.

Effect of f- tablets in deciduous teeth
• Majority of the studies investigating the cariostatic effectiveness of f- in deciduous teeth
and reduction ranging from 50-80% when f- administration in the form of tablets was
started before 2 yrs of age and continued for a minimum 3-4 yrs.
• Hoskova ( 1968) found deft reduction of 93% when f- tablets were started prenatally and
54% reduction when tablets were given since birth.
• Hennon (1971) reported 78% defs reduction, 3 yrs after ingestion of f- tablets since birth.

• The American Center for Disease Control (CDC) also has published in 2001
recommendations for using fluoride to prevent and control dental caries. They concluded
that the quality of evidence to support use of fluoride supplements by children aged less
than 6 years was low.
• Hasson et al., in 2008, examined evidence regarding the effectiveness of fluoride
supplements in preventing caries and their association with dental fluorosis. They
concluded that “there is weak and inconsistent evidence that the use of fluoride
supplements prevents dental caries in primary teeth.”

• Stephanie Tubert-Jeannin (2011) reported that the effectiveness of fluoride supplements
in preventing tooth decay in young children (less than 6 years of age) with deciduous
teeth.

Effect of f- tablets on permanent teeth
• Studies starting supplements after the age of 3yrs do not measure optimum effects since
many teeth had already been calcified and erupted prior to f- ingestion.
• Naf 2.2mg – 1 mg f-
1.1mg – 0.5mg f-
0.55mg – 0.25 mg f-
• Naf tablets with vitamin combination are also available.

F- tablets: as dental public health measures in rural india.
• Because of non availability of distilled water, f- mouth rinses can not be prepared and
stored in large quantities.
• F- tablets have been found to be easiest vehicle for the preparation of daily fluoride
mouth rinses for home use for with 10mg Naf tab got manufactured

• A dual rule of f- tablets in the prevention of dental caries both in topical form ( for mouth
rinse and chewing) as well as in systemic form make them an imp means for dental caries
prevention at mass level especially in the rural communities.

• Correct dosage is based on the concentration of fluoride in drinking
water, age and weight of the child and other available fluoride.
• Not more than 1 milligram of fluoride should be ingested each day from
all available systemic sources.

INDICATIONS FOR USE
• In areas where there are no central supplies, where the fluoride
concentration of well-water is low and where parental motivation is
very high.
• As an interim measure in these communities with a central water
system that have not yet implemented community water
fluoridation.
• In areas where water fluoridation or salt fluoridation schemes cannot
be implemented.
• In families where there is high degree of mobility involving frequent
changes in the place of work and residence and where parents wish
to ensure daily fluoride supplementation themselves.
RuggGunn

PRECAUTIONS
• Accidental ingestion of fluoride supplements can cause stomach upset.
• No more than 2.2 mg sodium fluoride tablet should be dispensed at one time.
• There is no risk of dental fluorosis if the proper regime is followed.
• However, fluoride supplements when ingested prior to tooth eruption are a risk
factor for dental fluorosis.
RuggGunn

• Is fluoridation important?
• Reason to oppose fluoridation
• ethics
• Fluoridation and law
111

Introduction
• Fluorides are added to a number of consumer products, such as
toothpastes, mouth-rinses and gels, in order to try to reduce tooth
decay in children.
112
Barbier O. (2010) Molecular mechanisms of fluoride toxicity. Chemico-Biological
Interactions. 188: 319–333.

• On the question of risks, some dental and medical authorities
have some how managed to convey the incorrect impression that,
apart from strengthening teeth, fluoride is inert in the human
body and is therefore harmless.
• The biochemistry and physiology of fluoride in the human body
contradicts this notion. Not only is fluoride incorporated into
teeth, but also into bone and many soft tissues.
113

‘is fluoridation important ???’
• Fluoride is not an essential nutrient. No disease has ever been
linked to a fluoride deficiency. Humans can have perfectly good
teeth without fluoride.
“Fluoride is the only chemical added to water for the
purpose of medical treatment”
• All other water treatment chemicals are added to improve the
water's quality or safety, which fluoride does not do.
114

• Fluoride is not an essential nutrient (National Research Council
[NRC]; Institute of Medicine [IOM].
• No disease has ever been linked to a fluoride deficiency. It has
never been shown that ingested fluoride is needed to produce
decay free teeth.
• Not a single biological process has been shown to require
fluoride. On the contrary there is extensive evidence that fluoride
can interfere with many important biological processes. 115

• Only eight countries in the world have more than 50% of their
populations drinking artificially fluoridated water (Australia,
Colombia, Ireland, Israel, Malaysia, New Zealand, Singapore,
and the USA).
116
Barbier O. (2010) Molecular mechanisms of fluoride toxicity.
Chemico-Biological Interactions. 188: 319–333.

Fluoridation is unethical
• Informed consent is standard practice for all medication, and
one of the key reasons why most of Western Europe has ruled
against fluoridation.
• Compulsory mass medication
• With water fluoridation we are allowing governments to do to
whole communities (forcing people to take a medicine
irrespective of their consent) what individual doctors cannot do
to individual patients.
117

Fluoridation's role in the decline of tooth decay is in serious doubt
• The largest survey ever conducted in the US (over 39,000
children from 84 communities) by the National Institute of Dental
Research showed little difference in tooth decay among children
in fluoridated and non-fluoridated communities.
• According to NIDR researchers, the study result was not shown
to be statistically significant.
118
Lawrence G, Bammer G, Chapman S: 'Sending the wrong signal': analysis of print media. Aust N Z J Public Health 2000, 24:254-264.

Fluoridation's role in the decline of tooth decay is in serious doubt
• The largest survey ever conducted in the US (over 39,000
children from 84 communities) by the National Institute of Dental
Research showed little difference in tooth decay among children
in fluoridated and non-fluoridated communities.
• According to NIDR researchers, the study result was not shown
to be statistically significant.
119

The dose cannot be controlled
• Once fluoride is put in the water it is impossible to control the
dose each individual receives because people drink different
amounts of water.
• Being able to control the dose a patient receives is critical.
• Some people (e.g., manual laborers, athletes, diabetics, and
people with kidney disease) drink substantially more water than
others.
120

Tooth decay does not go up when fluoridation is stopped
• Where fluoridation has been discontinued in communities from
Canada, the former East Germany, Cuba and Finland, dental
decay has not increased but has generally continued to decrease
(Maupomé 2001; Kunzel 2000; Seppa 2000).
121
Slade GD, Spencer AJ, Davies MJ, Stewart JF: Caries experience among children in fluoridated
Townsville and unfluoridated Brisbane. Aust N Z J Public Health 2009, 20:623-629

NIH-funded study on individual fluoride ingestion and tooth decay
failed to find a significant correlation
• A multi-million dollar, U.S. National Institutes of Health (NIH) -
(Warren 2009) found no relation between tooth decay and the
amount of fluoride ingested by children.
• This is the first time that tooth decay has been investigated as a
function of individual exposure as opposed to mere residence in
a fluoridated community.
122

The Centers for Disease Control
The mechanisms of fluoride’s benefits are mainly TOPICAL and
not SYSTEMIC. Thus, you don't have to swallow fluoride to
protect teeth.
• As the benefits of fluoride (if any exist) are topical, and the risks
are systemic, it makes more sense, for those who want to take the
risks, to deliver the fluoride directly to the tooth in the form of
toothpaste.
123

People now receive fluoride from many other sources besides water
• Fluoridated water is not the only way people are exposed to
fluoride. Other sources of fluoride include food and beverages
processed with fluoridated water (Heilman 1999), fluoridated
dental products (Levy 1999), mechanically deboned meat (Fein
2001), tea (Levy 1999) and on food (Burgstahler 1997).
• It is now widely acknowledged that exposure to non-water
sources of fluoride has significantly increased since the water
fluoridation program first began (NRC 2006).
124
Connet P. 50 reason to oppose fluoridation.

There has never been a single randomized clinical trial to
demonstrate fluoridation's effectiveness
• Despite the fact that fluoride has been added to community water
supplies for over 60 years, "there have been no randomized trials
of water fluoridation" (Cheng 2007).
• The U.S. Food and Drug Administration (FDA) continues to
classify fluoride as an "unapproved new drug."
125

Report of “The York Review”
• A systematic review of public water fluoridation.
• This was the 1st systematic review based on search of 25
electronic database world wide with inclusion of 214 studies on
the subject of water fluoridation and rigorous search of the
published and unpublished literature of human epidemiological
studies. (McDonagh 2000)
126

• Body of evidence available on the efficacy and safety of water
fluoridation was of lower quantity and quality.
• Fluoride of drinking water supplies reduces caries prevalence,
but is associated with dental fluorosis.
• Balance of evidence did not show an association between any
fracture and water fluoride.
127
Conclusions of York rivew

Overall limitations of “york review”
• Very few studies followed the same individuals longitudinally.
• Lack of analysis of confounding variables.
• Failure to undertake appropriate statistical analysis.
• Despite discontinuation of water fluoridation, no increase in
the caries tooth decay was seen, but has actually decreased
Canada, former East Germany, Cuba and Finland.
128

There is no margin of safety for several health effects
• No one can deny that high natural levels of fluoride damage health.
Millions of people in India and China have had their health
compromised by fluoride.
• The real argument is about whether there is an adequate margin of
safety between the doses that have been shown to cause harm in
published studies and the total dose people receive consuming
uncontrolled amounts of fluoridated water and non-water sources of
fluoride.
129

• Fluoride accumulates in the body
• Children are being over-exposed to fluoride

The highest doses of fluoride are going to bottle-fed babies
• Because infant exposure to fluoridated water has been repeatedly found to be a
major risk factor for developing dental fluorosis later in life, a number of dental
researchers have recommended that parents of newborns not use fluoridated
water when reconstituting formula (Brothwell 2003; Marshall 2004).
• Even the American Dental Association (ADA), the most ardent institutional
proponent of fluoridation, distributed a November 6, 2006 email alert to its
members recommending that parents be advised that formula should be made
with "low or no-fluoride water.”
131

The level in mothers' milk is very low
• The level of fluoride in mother's milk is remarkably low (0.004
ppm, NRC, 2006).
• This means that a bottle-fed baby consuming fluoridated water
(0.6 – 1.2 ppm) can get up to 300 times more fluoride than a
breast-fed baby.
• There are no benefits, only risks, for infants ingesting this high
level of fluoride at such an early age
132

• Fluoride may damage GI tract
• Fluoride may effect the growth
• Fluoride may damage the brain
• Fluoride may lower IQ
• Fluoride affects the pineal gland
• Fluoride affects thyroid function
• Fluoride damages bone
• Fluoride causes arthritic symptoms
• Fluoride may increase hip fractures in the
elderly
• Fluoride may cause reproductive problems
Bernhardt M, Sprague B: The poisonmongers. In The tooth robbers Edited by: Barrett S, Rovin S. Philadelphia: GF
Stickley; 1980:1-8.
Dooland CA: Repeating is believing: an investigation of the illusory truth effect. In PhD Thesis State University of New
York at Albany, Psychology; 1999.

Fluoride may leach lead from pipes, brass fittings and soldered joints
• Maas et al (2007) have shown that fluoridating agents in combination
with chlorinating agents such as chloroamine increase the leaching of
lead from brass fittings used in plumbing.
• While proponents may argue about the neurotoxic effects of low levels
of fluoride there is no argument that lead at very low levels lowers IQ in
children.
134

No health agency in fluoridated countries is monitoring fluoride exposure
or side effects
• No regular measurements are being made of the levels of fluoride in
urine, blood, bones, hair, or nails of either the general population or
sensitive subparts of the population (e.g., individuals with kidney
disease).
135

Many scientists oppose fluoridation
• Today, as more and more scientists, doctors, dentists and other
professionals, read the primary literature for themselves, rather
than relying on self-serving statements from the ADA and the
CDC
• As of July 2011, over 3700 professionals have signed a statement
calling for an end to water fluoridation worldwide.
137

FLUORIDATION AND THE LAW
▪ Fluoridation is not simply a health issue, it is a political one. The
decision to implement fluoridation must ultimately come from
public authorities, who are usually responsive to political
pressure.
Mandatory legislation:
▪ Legislation making fluoridation of public water supplies
compulsory under government policy.

Enabling legislation:
▪ It empowers health authorities or local governments to institute community water
fluoridation.
▪ While such legislation does not automatically lead to fluoridation of water
supplies, it opens the way for national or local health officials to act on the matter

• In 1987, the Government of India launched a Technology Mission on Safe
Drinking Water (Rajiv Gandhi National Drinking Water Mission) for ensuring
provision of safe drinking water to rural population.
• Under this programme, the Ministry of Rural Areas and Employment, Which is
the nodal Ministry for providing safe water, has laid emphasis on water quality
through removal of excess fluoride, arsenic and other pollutants in water.

Conclusion
• It is important that public health officials are aware of these tactics
so that they can better counter their negative effect.

• When used appropriately, fluoride is a safe and effective agent that can be
used to prevent dental caries.
• Systemic fluorides help in circulating fluorides in the blood stream and is
incorporated into developing teeth. But still systemic fluorides are yet not
widespread in India, therefore to ensure additional gains in oral health
practices fluoride toothpastes should be used widely.

Sources of f-
• Fluoride is the thirteenth most abundant element in the Earth's crust.
• It rarely occurs as the element but normally is found as the fluoride ion or as a
number of inorganic and organic fluorides.
• It occurs in varying concentrations in rocks, soil, water, air, plants and animals
both naturally and as a consequence of human activity such as agricultural or
industrial processes.
Ayyasamy Pdukkadu Munusamy et al Adv. Appl. Sci. Res., 2014, 5(2):173-185

Principal source of human fluoride ingestion is water
• Present in nearly all ground water
• Derived from plants, marine animals and even dust particles
• Tea
• Certain types of fishes, dried salmon-84.5 ppm
• Potatoes-6.4 ppm
Essentials of public health dentistry by soben peter, 5th edi

DIETARY ITEMS FOR FLUORIDE CONTENT (Tandon and Thomas 2000)
Items Dry wt. of substance (g)
Fluoride (ppm) in dry
wt. of substance
Fluoride in 100 g
sample(micrograms
)
Vegetables
group
Beans 2.50 2.38 59
Tomato 1.80 1.56 28
Brinjal (local) 2.70 2.21 60
Cucumber 1.40 0.98 14
Ladies finger 1.03 0.86 9
Green chillies 1.30 1.14 15
Pumpkin 1.10 0.54 6

Fruits
Dry wt. of
substance (g)
Fluoride (ppm) in dry wt. of
substance
Fluoride in 100 g
sample(micrograms)
Orange 0.86 31.0 9
Pineapple 1.40 1.03 14
Green grapes 1.04 0.55 6
Banana 2.46 0.39 10
Apple 1.30 0.32 4
Guava 1.70 0.43 7
DIETARY ITEMS FOR FLUORIDE CONTENT (Tandon and Thomas 2000
)

Animal
foods
Dry wt. of substance
(g)
Fluoride (ppm) in dry
wt. of substance
Fluoride in 100 g
sample(microgra
ms)
Chicken 4.60 0.92 42
Whole egg 4.10 4.62 189
Pork 3.80 1.17 45
Mutton 2.20 1.80 40
Sea foods
Fresh water
fish
2.10 0.58 12
Dried sea
fish
8.20 165.44 135.70

• Dry tea leaves-97 ppm of fluoride
• Both green and black tea contain fluoride, although green tea contains twice the
amount of f- than black.

Average fluoride content of tea
Brand of tea
Quantity of tea
and sugar used
tea without milk
content in 1 cup
tea with milk
(200ml)
Approx.
fluoride
with milk &
sugar
(Fluoride content in ppm) (micro gms)
CTC tea leaves 1 tsp 1.710 1.54 200
Commercial tea
(Brooke
Bond, Lipton green
label,
Taj Mahal)
1 tsp 1.00-1.19 0.928-1.11 190-222

• Buffaloes milk-0.499 ppm
• Human breast milk has low fluoride content, less than 0.02mg/L
• The fluoride content in cow’s milk is reported to be 0.02-0.05 mg/L
Covis J,Hargreaves JA.Fluoride intake from beverage consumption. Community Dent Oral Epiemiol 1988;16:11-15

• The f- concentration in various foods reflects the f- conc in the water used in food
processing.
• Mineral water usually contains considerably higher conc. From1.5-7ppm, dependind on
the geological location of the sourses.
• Water, naturally or artificially fluoridated, is the most imp single sourse of f-
• When 1liter of fluoridated water containing 1ppm f- is consumed, most of the f- is
absorbed, whereas only 1/3 to ½ of f- in foods is assimilated.

Fluoride drops
• Fluoride drops are prescribed to prevent cavities in primary and permanent teeth while
the teeth are in formation stage.
• Drops are often recommended for children who live in areas where the water supply is
not fortiﬁed with ﬂuoride.
All About Fluoride Drops for Infants | Colgate® Oral Care

Dispensing Fluoride Drops
• To prescribe a fluoride supplement, a dentist or doctor must first find out the amount of
fluoride present in a child's drinking water.
• Fluoride ion concentration is measured in parts per million for both drinking water and
supplemental dosage, but drops will usually be pre-mixed and measured in milligrams
[Acc to ADA]
• fluoride drops can be given to a child with or without food, and sometimes diluted with
water or juice.

• Most pharmacists recommend a baby or toddler wait two hours after medication is taken
to eat, drink or take other medications.
• If an excess amount is ingested it could cause stomach pain , indigestion or diarrhea
(National Centers for Poison Control.)

Sodium f- drops
• Sodium Fluoride Drops 0.5 mg/mL
• Other Ingredients: Glycerin, purified water, xylitol, propylene glycol, natural flavor,
sucralose, methyl paraben, propyl paraben.
Sodium Fluoride Drops 0.5 mg/mL, Sancilio & Company Inc, march 2018

• While prescription fluoride is proven to be effective in decreasing cavities, it’s also
important to practice good oral hygiene with child.
• Parents should Start consulting a dentist when baby is around 6 months old or as soon
as their first tooth erupts.

Feasibility of water fluoridation
COST-EFFECTIVENESS
Following estimates are required for conducting a cost-effectiveness analysis of CWF:
(Capital Costs Fluoridation schemes require capital expenditure to)
• Establish a plant and equipment
• Consultant engineering fees
• To replace and upgrade those facilities when necessary.
Operating Costs (Annual running costs)
• Fluoride materials
• Labor
• Maintenance
Rathore, et al.: Cost-Effectiveness of Community Water Fluoridation International Journal of Scientific Study | July
2015 | Vol 3 | Issue 4

Factors reported to influence the per capita cost include:
• Size of the community (the larger the population reached, the lower the per capita cost)
• The level of tooth decay in population
• Age and treatment of the water treatment works
• Number of fluoride injection points in the water supply system
• Amount and type of system feeder and monitoring equipment used
• Amount and type of fluoride chemical used, its price, and its cost of transportation and
storage
• Expertise of personnel at the water plant.
2015 | Vol 3 | Issue 4

2015 | Vol 3 | Issue 4

Definition
• Downward adjustment of concentration of fluoride ion in public water supply in such a
way,that the concentration of fluoride in water ismaintained constantly at 1ppm
OR
• It isthe process of removing excess fluoride present in drinking water supplyin order to
prevent dental fluorosis or more severe disability.

Defluoridation of water
• Several methods have been suggested
i. Based upon ion exchange process or adsorption and
ii. Based upon addition of chemicals to water during treatment.
In India, the first work on defluoridation was done by the National Environmental
Engineering Research Institute (NEERI) at Nagpur in 1961.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavar Renuka, krishnappa Pushpanjali.

Deflouridation
technique
Ion exchange
Precipitation
Electro
chemical
Reverse
osmosis
Adsorption

Adsorption technique of defluoridation
• This technique functions on the adsorption of fluoride ions onto
the surface of an active agent.
• Activated alumina, activated carbon and bone char were among
the highly tested absorbing agents.
❖Activated Alumina
❖Bone char
❖Brick piece column
❖Mud pot

Activated Alumina
▪ Application of domestic defluoridation plant, based on activated
alumina, was launched by UNICEF in rural India
▪ The disadvantages with activated alumina are; Adsorption of
fluoride is possible only at specific pH range, needing pre-and post-
pH adjustment of water.
▪ Frequent activation of Alumina is needed, which make the
technique expensive.

❖Bone char (calcium phosphate exchange)
▪ the process of Defluoridation by bone char as the ion exchange and
adsorption between fluoride in the solution.
▪ The efficacy of the plant depends upon temperature and pH of raw
water; duration for which the bone-char is in contact with raw
water.
▪ It is a highly economic technique with a defluoridation percentage
of 62 to 66

❖Bone char (calcium phosphate
exchange)
▪ Disadvantage :
✓The bone char harbors
bacteria and hence
unhygienic.
✓It is a technique sensitive
procedure,
✓the use of bone-char
may invite cultural and
religious objections

❖Brick pieces column
▪ The basic principle of functioning of Brick piece column is the
same as that of activated alumina.
▪ The soil used for brick manufacturing contains Aluminium oxide.
❖Mud pot
▪ The fluoride removal capacity will vary with respect to the
alumina content
▪ The major advantages of mud pots are they are economic and
readily acceptable for the rural communities .

❖Natural adsorbents
▪ Many natural adsorbents from various trees were tried as defluoridation
agents.
▪ Seeds of the Drumstick tree, roots of Vetiver grass and Tamarind seeds were
few among them.
▪ Researchers at “M. S. Swaminathan Research Foundation‟ (MSSRF) had
shown drumstick seeds to have remarkable defluoridation efficiency, which
was higher than that of activated alumina.

Defluoridation by Ion-Exchange technique
• Synthetic chemicals,

Cation Exchange Resins
These are commercially produced resins which are expensive and uneconomical in most circumstances
a) Defluoron 1 : sulphonated raw dust + 2 % alum solution.
b) Carbion: Used on sodium & hydrogen cycles
c) Magnesia: It removed the excess fluoride but pH of treated water was beyond
10 and its correction by -acidification
-recarbonation.
d) Defluoron 2: 1)developed in 1968
2)to over come the problem of defluoron
3) sulphonated coal + aluminium solution.

• The two major drawbacks of Ion-exchange and adsorption techniques are:
❑There is often difficult to arrange where there is no piped water system
supply.
❑ gradual exhaustion of the active agent is not easily detected.

Defluoridation by Precipitation technique
• Precipitation methods are based on the addition of chemicals
(coagulants and coagulant aids) and the subsequent
precipitation of a sparingly soluble fluoride salt as insoluble
fluorapatite
• The best example for this technique is the famous
Nalgonda technique of defluoridation.

Nalgonda technique
• National Environmental Engineering Research Institute (NEERI), Nagpur
has evolved an economical and simple method for removal of fluoride
which is referred to as “Nalgonda Technique” ( in 1974 and reported by
bulushu in 1988)

• Involves addition of readily available chemicals
• sodium aluminate or lime + bleaching powder + filter alum to the fluoride water
followed by
• flocculation>sedimentation > filtration.
• Useful-a) domestic and
b) community water supplies.

Domestic defluoridation filters
❖Stainless steel candle filters adopting Nalgonda technique
❖Consists of water filters of any size and make fitted with candle filters and an
additional mixing device

STEPS IN NALGONDA TECHNIQUE

Mechanism
• The unit holds 22 litres of water, which is filled into the upper
chamber.
❖Rapid mix:
▪ Rapid mixing is an operation by which the coagulant is rapidly and
uniformly dispersed through out a single or multiple phase system.
▪ It is rapidly mixed for a period of 30 to 60 sec with speed of 10 to 20
rpm so that the coagulant is rapidly and uniformly dispersed.
▪ This help in the formation of micro flocs and result in proper utilization
of chemical coagulant.

❖Flocculation :
▪ It is the 2nd stage of the formation of settable particles(flocs)
from destabilized colloidal size particles.
▪ It is achieved by gentle and prolonged mixing for a period of 10
to 15 min with the speed of 2 to 4 rpm.

❖Sedimentation
▪ It is the separation from the water by gravitational setting of
suspended particles that are heavier than water.
▪ Factors that affect sedimentation are:
a) Size,shape,density and nature of particles
b) Viscosity,density and temperature of water.
c) Surface over flow rate.
d) Velocity of flow.
e) Effective depth of settling zone.

❖Filtration:
▪ It is the process of separating suspended and colloidal impurities from
water by passes through a porous media.
▪ The flocculated water is allowed to settle and filter through fullers
earth candle overnight.
▪ Treated water will be available for drinking and cooking with desire
level of fluoride.

• Absence of acceptable, alternate low fluoride source within transportable
distance.
• Total dissolved solids below 1500 mg/l.
• Total hardness is below 600 mg/l.
• Raw water fluorides ranging from 1.5 - 20 mgF/l.
Indication of Nalgonda Technique

Advantages of Nalgonda technique
• Regeneration of media is not required.
• No handling of caustic acids and alkalies.
• The chemicals required are readily available and are used in conventional
municipal water treatment.
• Adaptable to domestic use.
• Economical
• Simplicity - design ,construction,operation and maintainence.

• Can be used to treat water in large quantities for community usage.
• Highly efficient removal of fluorides from high levels to desirable levels.
• Little wastage of water and least disposal problem.
• mimimum mechanical and electrical equipment.
• No energy except muscles power for domestic equipment.
• Local semi-skilled workers can be readily employed.

• Simultaneous removal of color, odor, turbidity, bacteria and organic
contaminants.
• Normally, associated alkalinity ensures fluoride removal efficiency.
• Provides de-fluoridated water of uniform acceptable quality.

Disadvantages of Nalgonda technique
• Desalination may be necessary when the total dissolved solids exceed 1500
mg/l.
• Hardness of the raw water in the range of 200 mg/l to 600 mg/l requires
precipitation softening and beyond 600 mg/l becomes a cause for rejection or
adoption of desalination.
• Generation of higher quantity of sludge compared to electrochemical
defluoridation
• The large amount of alum needed to remove fluoride.

Maintenance of Nalgonda filters
• The package plant installed on hand pump scheme costing Rs
1.6 lakh to serve 250 population.
• To serve population of 250, 50 stainless steel filters are
required and the cost of 50 filters is approx. Rs 35000.
• The main advantage will be its low cost of investment and low
cost of maintainence.

Modifications for Nalgonda technique.
INCLUSION CRITERIA
Poly Aluminium Chloride:
It is evident that for higher
concentrations of fluoride,
the removal efficiency of
fluoride is higher with Poly
Aluminium Chloride (PAC)
when compared with
Alum.
Poly Aluminium Hydroxy
Sulphate(PAHS):
A polymeric aluminum
compound, poly-
aluminium-hydroxy-
sulphate(PAHS) is found to
require less flocculation
time and settling time.

Other techniques of defluoridation
physical methods that are tested for defluoridation of water.
• Though they are effective in removing fluoride salts from water, there are certain
disadvantages that limit their usage on a large scale.
Reverse
osmosis
Electrolysis
and electro
dialysis

❖Reverse Osmosis
▪ In reverse osmosis, the hydraulic pressure is exerted on one side
of the semi permeable membrane which forces the water across
the membrane leaving the salts behind.

❖ Electro dialysis
-Membranes allow the ions to pass but not the water.
-The driving force is an electric current which carries the ions through the membranes
-Highly energy intensive
-Expensive.
-Both processes are very complicated

❖Defluoridation by electrolysis:
▪ The basic principle of the process is the adsorption of fluoride
with freshly precipitated aluminum hydroxide, which is
generated by the anodic dissolution of aluminum or its alloys
in an electro chemical cell.
❑Advantages :
• Does not require addition of chemicals.
• No need to pre & post-treatments .
• Low volume of sludge.

• Units can be designed for any capacity.
• Units are designed for specific locations & fluoride content of water. But can be operated
with varying fluoride concentrations by slightly altering the operating parameters.
• The electrochemical reactor occupies less floor space.
• Operator friendly
• Requires less electric energy (0.3 to 0.6kwh/1000 lts)

Current status of defluoridation in India.
• UNICEF has worked closely with the Government and other partners in defluoridation
programmes in India, where excessive fluoride has been known for many years to exist in
much of the nation's groundwater.
• Government of India launched a massive programme, namely „Technology Mission on
Safe Drinking Water‟ in 1986 wit the goal of providing potable water to the people living
in rural India.

• UNICEF's focus in the Indian programme has been on strengthening the systems for
monitoring water quality, facilitating water treatment by households, and advocating
alternative water supplies when necessary.
• Under national drinking water scheme of Govt. of India, 16 villages belonging to
Siddhpur, Kheralu, Visnagar, Patan, Chanasma and Kadi talukas of Mehsana district,
Gujarat were provided with defluoridation plants at the cost of Rs. 106 lakh.
• However, due to high cost of (approximately Rs1.5 lakh/year) maintenance and
repairing, most of the plants are nonfunctional.

• Other plants are,
• Dharoi Reservoir Dependent Scheme:
371 villages belonging to Kheralu, Sidhpur, Visnagar and Patan taluka will be provided with
the 68.86 MLD of water under group water supply scheme, at an estimated cost of Rs. 140
Crore.
• Sabarmati River Dependent Scheme:
109 villages from Vijapur Taluka will be provided with water drawn from Sabarmati river at
an estimated cost of Rs. 36 Crore

• Narmada Canal Dependent Scheme:
• 111 villages belonging to Chanasma Taluka, 118 villages belonging to Kadi Taluka and a
large number of villages belonging to Sami and Harij taluka will be provided with the
water from Narmada main canal by constructing necessary storage tanks and filtration
plants.
• The experience of villagers with several existing regional water supply schemes is,
however, not very satisfactory for two reasons;
(i) the water supply is generally erratic and
(ii) the water supply scheme is not under the control of the village community

Toxicity of Fluorides
• Fluorides are extensively used in the practice of Dentistry to reduce the
incidence of Dental caries.
• Used in excessive quantities, F. can produce toxic and even lethal outcome when
ingested, inhaled or absorbed in to the body.
• safety tolerated dose (STD) – 8-16mg of f- /kg body wt
• Certainly lethal dose (CLD) – 32-64mg of f- /kg body wt
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

Toxicity of Fluoride
Acute Toxicity Chronic toxicity
Asinglelarge dose
2.5- 5 mg
Dental fluorosis
2- 8 ppm
(0yearto 10year)
Skeletal fluorosis
More than 8ppm for 10- 20yrsof
any age
More than optimum level
for longer duration

Symptoms of Fluoride Toxicity
Fluoride acts in Four general ways
1) When f Salts contact with moist skin or mucous membrane, Hydrofluoric acid
forms cause chemical burn.
2) It is generally protoplasmic poison that acts to inhibit enzyme system.
3) It binds calcium that is needed for nerve action.
4) Ahyperkalemia occurs that contribute to cardio toxicity.

• Following ingestion of Fluoride, nausea and vomiting can occur. It is due
to Production of Hydrofluoric acid in the acid environment of stomach,
causes irritation of the stomach wall.
Local or general signs of muscle tetany ensure due to the drop of
blood calcium.
This can be accompanied by abdominal cramps and pain.
• Finally, hypocalcemia and hyperkalemia intensity results in either
coma, convulsions or cardiac arrhythmia's.

FLUOROSIS
• Anon-reversible, disease weakening skeletal structures caused byhigh levelof
fluorides in water.
• skeletal fluorosis
• Dental fluorosis

Skeletal Fluorosis
• Awater fluoride levelover 8ppm
• Characterized by
– Increased x-raydensity of trabecular bone (spine, pelvis)
– Increased thickness of long bone cortices due to endosteal and periosteal
apposition
• In more advanced cases
– Calcification of ligaments
→Ankylosing spondylitis

Skeletal Fluorosis
• Other effects are-
– Gastric complaints
– Osteo sclerosis
– Exostosis of long bones, vertebrae, jawbones, & other
flat bones.
Misdiagnosed as Rheumatoid or Osteo Arthritis

Skeletal Fluorosis
Early cases— vague pain in small joints, knee and
joints of spine
Later cases--- stiffness of spine &
limitation of movement
Advanced cases---KYPHOSIS— difficulty in walkingpartly
due to stiffness & partly due to
neurological lesions

Dental Fluorosis
• Definitions
1. Hypo-mineralization of tooth enamel or dentin bythe long continued
ingestion of excessive amounts of fluorides during tooth development
-Dean 1934
2. Aspecific disturbance of tooth formation caused byexcessiveintake of fluoride
during formation period of dentition
- Murray 1986

Dental Fluorosis
3. Disturbance in tooth enamel formation caused by fluoride being present in
tissue fluid over aprolonged period during tooth development
-fejerskov 1988
4. Permanent hypo mineralization of enamel characterized bygreater surface
and subsurface porosity than in normal enamel,resulting from excessfluoride
reaching the developing tooth during developmental stages
- fejerskov 1990

Possible mechanism of dental fluorosis
• Inhibit Protein synthesis and reduce secretory enamel (reducesamino
acid uptake)
• In Mineralization:
– Irreversibly affects the existingmineralizing matrix, (more rapid
deposition and disruption of crystal growth)
– Interferes with deposition of crystals in new matrix
– reduce the availableionic calcium, resulting in reduced
proteolytic activity

• Interferes Protein removal from the matrix
– Amelogenin is hydrolyzed and removed from the matrix
– Adose dependent delayin hydrolysis and removal of
amelogenin is caused by fluorides
delaygrowth of enamel crystals
tooth erupts with incompletely mineralized enamel

Distribution of fluorosis in permanent dentition
• Posterior teeth are more affected than anterior in
both maxilla and mandible
• Fluorosis occurs symmetrically within the arch
• Premolar>2nd molar>max incisor>canine>1st molar> mandibular
incisors

Distribution of fluorosis in primary dentition
• Exhibit less fluorosis than their permanent successors, but distribution within
the dentition follows similar pattern
• Assessment of fluorosis is difficult in primary dentition because:
– Thinner enamel-→ more whitish appearance
– Incremental lines of retzius is often lacking or less pronounced than permanent
teeth

• Reasons for less appearance of fluorosis in primary dentition:
– Placenta as selective barrier
– Most of calcification of primary teeth occurs before birth
– Duration of enamel maturation is shorter
– Thinner enamel

Post eruptive changes in dental fluorosis
• Changes are determined by degree of subsurface porosity
• Pitting occurs shortly after eruption depending on initial hypo-mineralization
• Verysusceptible to enhanced attrition

• Porous enamel maytake up stains
– The shape usuallyfollows the position of upper lip
– Continuous drying out of max incisors in combination with
immediate exposure of these teeth to anysort of staining from
food makes them particularly susceptible to discoloration

• the severityof fluorosis:-
(i) Fluoride concentration in drinking water,
(ii) Period of exposure,
(iii) Climatic factors (for example Temperature),
(iv)Fluoride ingestion through other sources,
Nutritional status,
(v) Chemical constituent of drinking water other
than fluoride, and
(vi)Occupation.

Classification systems of fluorosis
• Dean’s index:
– Trendly H. Dean in 1934
– Initially this index categorized dental fluorosis on a seven point
ordinal scale :-
Normal, questionable, very mild, mild, moderate, moderately
severe, severe
– In 1939 Dean combined moderately severe and severe as only
severe and thus modified it into 6 point scale

Criteria of scoring:-
0 – Normal – enamel represents usual translucent
semivitriform, surface is smooth, glossy&pale creamy white color
1 – Questionable – slight aberrations from the translucency ranging
from white flecks to occasional
white spots

2 – VeryMild– small opaque paper white area scattered
irregularly over the tooth showing no more than 1-2mm of
white opacity
3 – Mild – white opaque areas in the enamel are more extensive but
do not involve as much as 50% of the tooth

4 – Moderate – allenamel surface are affected & surfaces
subjected to attrition show marked wear, brown stains are frequently
a disfiguring feature
5 – Severe – allenamel surface are affected &surface hypoplasia is so
marked that the general form of the tooth maybe altered . discrete
or confluent pitting . Brown stains are widespread &givea
corroded appearance

• Community fluorosis index:-
Trendly H Dean In
1935– criteria
Normal 0
Questionable 0.5
Very mild 1
Mild 2
Moderate 3
Severe 4

In 1942 – Community index of dental fluorosis
sum of ( no. of individuals x statistical wt)
CFI
no. of individuals examined

In 1946 – Public Health significance of CFI score
0.0 – 0.4 – Negative
0.4 – 0.5 – Borderline
o.5 – 1.0 – Slight
1.0 – 2.0 – Medium
2.0 – 3.0 – Marked
3.0 – 4.0 – Very marked

Differential diagnosis
characteristics Dental fluorosis Enamel opacities
Area affected allsurfaces, often enhanced on or near tips
of cusps or incisal edges
Usually centered in smooth surface
of limited extent
Lesion shape Line shading in pencil sketch which follow
incremental lines OR cloudy appearance
OR snow capping at cusp tips
Round or oval
Demarcation Diffuse distribution of varying intensity Clearly differentiated
Color Paper white ,frosted appearance, stain at
time of eruption
Creamy yellowto dark reddish
orange at the time of eruption
Teeth affected Alwayshomologous teeth. Premolars &
2nd molars mostly affected
Labial surface of single tooth,
mostly incisors

Effective treatment of dental fluorosis
• Bleaching
• Crown
• Veneers & laminates
• Composite restorations

Prevention of fluorosis
1. Change the source of drinking water to the water containing
optimum amount of fluorides
2. Defluoridation

Systemic fluoride

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