Thanks to Dr. Khandare the great indian scientist

1. FLUOROSIS: AN OVER VIEW
Dr. Arjun L. Khandare
Scientist E (Deputy Director)
National Institute of Nutrition (ICMR)
Hydreabad
National Programme for Prevention and Control of
Fluorosis

2.  Fluorosis is a slow, progressive and crippling malady
affecting most of the organs in the body where flouride
in drinking water is > 1.0ppm.
 More than 90% of rural drinking water supply
programmes are based on ground water available,
which is being overexploited for agriculture, causing a
high influx of fluoride into water.
 Endemic fluorosis has been steadily increasing ever
since the disease was discovered in India during the
1930s .
Introduction

3. Magnitude of the problem
Global scenario
Fluorosis is public health problem in 25 countries around the world.(DARK
AREAS)

4. Arunachal
Pradesh
Kerala
21
Tamil Nadu
28
Karnataka
67
Andhra Pradesh
70
Maharashtra
31
Madhya Pradesh
36
Orissa
56
West Bengal
22
Gujarat
95
Rajastha
n
100.0
Punjab
82Haryana
63
Delhi
31
Uttar Pradesh
22
Sikkim
Nagaland
Manipur
MizoramTripura
Himachal Pradesh
Jammu &
Kashmir
7
Bihar
15
Assam
9
Andaman
Nicobar
70-100 % Districts affected
40-70 % Districts affected
10-40 % Districts affected
<10% Districts affected
Endemicity not known
Source:A Treatise on Fluorosis by Dr. A.K. Susheela
 No of affected
District 204 (21
States /UT)
 people affected, 62
million ( 6 million
children)
 Causative factor,
excess consumption
of fluoride through
drinking water
(>1.0ppm) and diet.
Problem in India

5. • Initial symptoms : Headache, constipation, vague body
pains, backache, joint rigidity & general weakness.
• These were followed by multiple joint pains, mostly in
the feet, knees, and back.
• Difficulty in walking
• Limitation of joint movement. Inability to close the fist
• Spinal stiffness and kyphosis developed in a few
patients.
• Flexion of spine
• Neurological complication
Clinical symptoms

7. Types of fluorosis

8. Fluorosis
Dental Skeletal Non skeletal

9. Dental fluorosis
Normal:
The enamel surface is smooth,
glossy and usually a pale creamy
white in color.
Mild: The white opacity of the
enamel of the teeth is more
extensive, but covers less than
50% of the tooth surface .

10. Moderate:The enamel surface of the
teeth shows marked wear and tear with
brown stain and is frequently a disfiguring
feature .
Severe: The enamel surface is badly
affected and hypoplasia is so marked
that the general form of the tooth may
be affected. There are pitted/worn
out areas and widespread brownish
discoloration with the teeth often
having a corroded appearance.

11. Skeletal Fluorosis
Identification

12. 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 chin
with the chest. A fluorotic
subject would not be able
to do so, if there is pain or
stiffness in the neck.

13. STRETCH TEST: The
individual is made to stretch
the arms sideways, fold the
arm and try to touch the back
of the head. If there is pain or
stiffness in the shoulder joint
and backbone, the exercise will
be difficult, suggesting
possibility of fluorosis
Confirmation with X-ray
Ossified Interosseous
Membrane

14. Types of skeletal fluorosis - I
 Genu valgum,
 Genu varum,
 Anterioposterior bowing of tibia (Saber
tibia),
 Scoliosis,
 Paraplegia are severe forms of skeletal
fluorosis

15. Recent NIN study conducted in Bihar
Children of 2-3 year were affected with sever forms of crippling bone deformities
Children affected from fluorosis

16. Skeletal fluorosis in Assam

18. Genu valgum (KNOCK KNEES)
Legs are bowed inwards in the
standing position. The bowing
usually occurs at or around the
knee, and when standing with
knees together, the feet are far
apart.
Genu Varum
Legs are bowed outwards in the
standing position. The bowing
usually occurs at or around the
knee. When standing with the
feet together, the knees remains
far apart.
Types of skeletal fluorosis - II

19. Kyphosis: – Forward bending of
spine. Fixed and rigid thoracic
cage as well as spinal cord
compression occur
Anterioposterior
bowing of tibia
Types of skeletal fluorosis - III

20. Types of skeletal fluorosis - IV
Paraplegia: Spinal
cord compression due
to osteosclerosis with
paraplegia as a result
of endemic skeletal
fluorosis

21.  Tingling sensation in fingers and toes
 Excessive thirst
 Polydypsia and polyurea
 Nervousness & Depression
NON SKELETAL MANIFESTATIONS

22. NIN Research
(1995 – TO DATE)

23. Effect of nutrition adequacy on severity of endemic fluorisis
No of Mild Moderate Severe
cases %
Nutrition adequate 290 91 8 1
Nutrition 300 11 56 33
Inadequate

24. Incidence of Metabolic Bone Disease Accompanying
Endemic Skeletal Fluorosis
(Radiological Survey)

25. Beneficial effect of tamarind ingestion
on fluoride toxicity
Control fluoride Fluoride + Tamarind

26. Studies in humans

30. Fluorosis Mitigation : Strategies

32. Fluoride detection in drinking water
(Field testing kit)
Demonstration of fluoride testing by kit method (Color
development)

33. HOUSEHOLD LEVEL BONE CHAR DEFLUORIDATOR
This is very simple and
inexpensive method conceived by
staff of ICOH and WHO
Bore well water with 3.8 ppm
fluoride after passing through this
defluoridator reduced to 0.18 ppm
The pipe is 75 cm feet long and 90
cm diameter with 1kg Bone Char
activated by heating

34. Community Based Bone Char Defluoridator
Inauguration of Community Bone Char
Defluoridator at endemic village of Nalgonda
District

35. Community Based Bone Char Defluoridator at
Khudabakshpalli, Nalgonda, AP.

36. 1.Roof catchment
2.Gutters
3.Downpipe and first flush
pipe
5.Filter unit
4.Storage tank
The roof catchments are relatively cleaner when compared to the ground level
catchments
Built and maintained by the local communities.
Available at their door steps with least cost
1
4
3
5
2
Rain Water Harvesting Asbestos roof

37. 1. Rubble
(Lowest)
2. Coarse Sand
3. Charcoal
4. Thick Sand
5. Pebbles
(Topmost)
The Filter Unit is a Cement container filled with filter media below - upwards.
The Filter Unit removes the debris and dirt from water that enters the tank.
Direct sunlight exposure is avoided to prevent formation of algae and
breeding of mosquitoes.
5400 lits. of storage water is sufficient for a family of 5 members, for 6
months ( 5 lit / person/ day)

38. Rain Water Harvesting: Slab House

39. Surgical Intervention

41. Fluoride meter

42. Measurement of fluoride
Requirement
• Fluoride meter with ION selective electrode
• TISAB (total ionic strength adjustment buffer) -For masking
other chemicals present in solution and making fluoride
available for measurement
• Different types of TISAB – different samples
Water/urine- TISAB-I
Serum- TISAB –II
• Standards –to calibrate fluoride meter. Range depends on
type of sample.

43. Procedure
1.Sample preparation-
5ml of TISAB + 5 ml of sample
(water/ diluted urine/ diluted serum/ other samples)
2. Calibration
3.Expression-
Concentration of fluoride is expressed in ppm (parts
per million/ mg per ml/ µg per L)