Fluorosis nutr-prob-final

1
Fluorosis – A Global
Nutritional Health Problem
Department of Food Science and Nutrition
College of Community and Applied Sciences,
Maharana Pratap University of Agriculture & Technology, Udaipur
Dr. (Mrs.) Renu Mogra
Professor
Dr. (Mrs.) Shashi Jain
Professor and Ex–Dean

Renu Mogra and Shashi Jain 2
Introduction:
Fluorosis is a crippling disease caused by
excess consumption of fluoride rich water
and food stuffs.
Disease affects all individuals irrespective
of age, sex and socio-economic status.
Characteristic features of the disease are
permanent deformity, joint pains, general
debility and misery.
Disease renders the person socially and
culturally crippled.

Renu Mogra and Shashi Jain
3
What is Fluorine?
Fluorine in the free state is a pale yellow gas
with pungent, irritating odour which on
cooling, condenses to liquid.
It is highly reactive and does not found in
elemental form in nature.
It has strong affinity to combine with other
elements to produce fluorides and represent
about 0.06 to 0.09% of the earth's crust (WHO,
1994)
In the food stuffs it is available in form of
fluoride.

GLOBAL SCENARIO ON FLUOROSIS
ENDEMICITY

5
INDIAN
SCENARIO
ON
FLUOROSIS
ENDEMICITY
70-100% districts affected
Endemicity not known

6
Endemicity of Fluorosis in Rajasthan

Renu Mogra and Shashi JainRenu Mogra and Shashi Jain 77
MAGNITUDE OF FLUOROSIS IN INDIA
 Roughly 66.62 million people are estimated to be at risk of fluorosis, of which 6 million
are children below the age of 14 years. The magnitude of problem in different states of
India is:
S.
No.
Name of the State
Districts
affected
S.
No.
Name of State
Districts
affected
1. Andhra Pradesh 16/23 10. Bihar 6/41
2. Gujarat 18/19 11. Tamil Nadu 8/29
3. Rajasthan 32/32 12. Uttar Pradesh 18/83
4. Karnataka 18/27 13. West Bengal 4/18
5. Orissa 18/32 14. Kerala 3/14
6. Punjab 14/17 15. Assam 2/23
7. Maharastra 10/32 16. Delhi 4 blocks/13
8. Madhya Pradesh 16/45 17. Jammu & Kashmir 1/14
9. Haryana 12/19

Sources of Fluoride (F) into the body
Ground
water
Cosmetics
Medicines
Working
area
Air
Industrial
wastes
Industrial
exposure
Food
SOURCES
OF
FLUORIDE
• Tooth powder
• Tooth paste
• Vitamin-supplements
• Mouth wash
• Chewing gum
• Irrigation with F rich
water
• Cereals
• Pulses
• Tea plants
• Marine fishes
• Fodder supplements

9
Entry of fluoride in ground water
Enrichment of 'F'
in carbonate
concentration
Dissolution by
water flowing
laterally
'F' rich
surface
water
Release of 'F' by
soil development
Rock with 'F'
bearing material
Possible precipitation of
CaF2 (Calcium Fluorite)
Dissolution of 'F' by
water draining the soil
'F' rich ground water
Selective scavenging of
'F' by plants
Fluoride in
ground water

Fluoride levels of groundwater in India
S.No. States Fluoride levels (mg/L)
1. Delhi (West) 0.1 – 16.0
2. Rajasthan 8.0 – 22.0
3. Karnataka 1.5 – 18.0
4. Uttar Pradesh 1.5 – 19.0
5. Madhya Pradesh 1.5 – 4.0
6. Maharastra 1.5 – 10.0
7. Haryana 1.5 – 4,578
8. Jammu and Kashmir 1.16 – 4.21

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Fluoride Content of Some Food Stuffs
Food Stuffs Fluoride Content (ppm)
Rich Sources:
Black Tea leaves 50-400
Green Tea leaves 400
Sea salt 14-20
Pulses 13-53
Sea foods 5-35
Betel nuts 4-12
Tobacco 10-40
Black rock salt 18
Food Stuffs
Fluoride
Content
(ppm)
Negligible sources:
Eggs 1.2
Chicken 1.4
Beef 2.0
Milk 0.07-0.2
Vegetables 0.1-0.2

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Requirement of fluoride for different age
groups (Food and Nutrition Board, USA)
S.
No.
Age Group
Requirement
per day
(mg/day)
Safe limit
(mg/day)
1. Infants (<1 yrs.) 0.5 1.0
2. Children (1-5 yrs.) 1.5 2.5
3.
Adolescents
(12-18 yrs.)
2.0 2.5
4. Adults 2.5 4.0

Fluoride Essentiality V/s ToxicityFluoride Essentiality V/s Toxicity
• Fluoride is essential for bone mineralization and
enamel formation. It is also known as double
edged sword as:
– Consumption of water containing low levels of fluoride
(< 1 ppm) leads to dental caries.
– Consumption of water containing high levels of fluoride
(> 1.5 ppm) are associated with acute or chronic
fluorosis, manifesting itself as dental, skeletal or non-
skeletal fluorosis.
• Acute toxicity results from a single massive dose of
fluoride.
• Chronic toxicity occurs due to cumulative effect of
consuming excess fluoride for several years.

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Fluoride content of drinking water and
effect on body
Fluoride in drinking
water (ppm)
Effects
Less than 1.5
No effect and may
prevent dental carries
1.5 to 3.0 Dental fluorosis
3.0 to 6.0 Skeletal fluorosis
More than 10
Changes in bones and
crippling occurs

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1. Dental Fluorosis
 Dental fluorosis occurs in children who are
exposed to high fluoride intake before the
complete mineralization of dentine. The
characteristic feature of dental fluorosis is
dental mottling.
 Structure of enamel is affected due to depletion
of calcium and accumulation of fluoride in the
matrix.

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Clinical Symptoms of Dental Fluorosis
1. Teeth become dull, loose natural shining
2. White yellow discoloration turns brown
3. Horizontal brown streaks or spots on the enamel surface
 Brown streaks at the tip of teeth indicate that the child
has been exposed to high fluoride up to the age of 2
years.
 Brown streaks in the middle of teeth indicate that child
has been exposed to high fluoride up to the age of 2-4
years.
 Brown streaks in the upper part of teeth denote that the
child has been exposed to high fluoride from the age of 4
to 6 years and more.
1. Teeth become black, pitted or perforated and may even
chipped off.
2. Loss of teeth at an early age.

17
Chalky white discoloration
White marble like appearance,
Pits and perforation on enamel surface
Discoloration seen on the enamel surface
(Yellow, Brown, Black) either as spots
or horizontal streaks away from the gums.
DENTAL
FLUOROSIS
1
3
2
4

Classification of dental flurosis
(WHO, 1971)
 Grade-I: White opacities or
lack of luster on enamel
 Grade-II: Well
developed pits on
enamel
 Grade-III: Distant
brown staining enamel

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2. Skeletal Fluorosis
 Skeletal fluorosis include muscular – skeletal
dysfunction, arthritis, fixed flexion deformities,
restricted movements of joints and stiffness of
spine. Apart from this biochemical, hormonal
and pathological changes also takes place.
There are three stages of skeletal fluorosis

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 Stage-I:
 Generally found in young adults.
 Relatively asymptomatic mean patients
remain unaware about the occurrence of
disease in body.
 Patients experience / vague pain in small
joints of hands and feet, knee and spinal
joints

21
Stage-II:
Due to deposition of Fluoride in and around the
bones, patient feels:
• Stiffness of spine
• Limitation in movement
Fluorosed Normal
NormalFluorosed
a- Two segments
of the vertebral
column from
human
fluorosed &
normal
showing
constriction of
intervertebral
foramen
b- Two vertebrae
(from normal &
fluorosed human
subjects)
showing
narrowing of the
vertebral canal &
increase in the
size of the body
of the vertebrae

22
Stage-III
• Difficulty in movement
• Unable to bend down wards and
backwards
• Rigidity of neck
• Paralysis
• Crippling deformities of bone
like kyphosis, scoliosis, flexion
deformity, paraplegia,
quadriplegia, osteophytes.

Bio-chemical changes
1. Changes in blood
 Increase in plasma fluoride
 Increase in serum alkaline phosphatase
1. Changes in bone matrix
 Increase in bone mass and bone density
 Decrease in collagen content.
 Decrease hydroxylation of proline and
lysine in bone collagen.

24
Bio-chemical changes
3. Changes in bone composition
 Decreased citrate and carbonate
concentration.
 Increase in fluoride levels.
4. Changes in urine
 Increased excretion of fluoride while
excretion of total hydroxyproline remains
unchanged.

25
Hormonal changes
 Increase in parathyroid hormone
leading to osteosclerosis
 Decreased levels of T3 and T4 in
thyroid gland.
 Growth hormone and vitamin D
metabolites in plasma remains
unchanged

26
Pathological changes
 Stomach and bowel disorder
 Myocardial damage
 Calcification of soft tissue
 Neurological disturbances

27
Physical tests to detect skeletal fluorosis
TEST- I
Normal, healthy individual can bend his
body and touch the floor / toes
Flourotic person is unable to bend his
body without folding knees

28
TEST-II
Normal, healthy individual can touch the
chest with the chin
Flourotic person is unable to bend the
neck – touching the chest with the chin
not possible

29
TEST - III
normal, healthy individual can stretch
the hands, fold he arms and touch the
back of the head
Flourotic person is unable to stretch the
hands, fold the arms and touch the back
of the head

30
3. Non-skeletal fluorosis
Non skeletal fluorosis involves:
 Skeletal muscle
 Erythrocytes
 GIT mucosa
 Ligaments
 Kidney
 Liver
 Adrenal gland and
 Reproductive organs.

31
Effect on muscle:
• Loss of muscle
energy and inability
to carry out normal
routine activities.
• Accumulation of
fluoride on the
erythrocyte
membrane.
• RBC attain the
shape of an amoeba
Red Blood Cells in Human Flurosed individual
Scanning electron micrograph showing a normal red blood cell with a smooth
membrane (). An echinocyte with wavy membrane denoting loss of
calcicum (∆). An echinocyte with prominent projections is also seen.

Effect on GIT
Nausea
Vomiting
Loss of appetite
Pain in stomach
Gas formation
Constipation / diarrhea.
Anaemia,
Headache

33
Effects on reproduction
– Male infertility with abnormality in sperm
– Still births & repeated abortions.
a- Normal Sperm
C- Multiple & coiled tail of human sperm from an
individual consuming fluoride contaminated water
b- Abnormal double headed human sperm from an
b- Abnormal head and mid piece of human sperm from an

Neurological effects
 Tingling, nervousness, depression
 Excessive thirst
 Tendency to urinate more frequently
 Allergic reactions

Prevention of fluorosis
 Consume a diet rich in calcium,
protein, vitamin C, Vitamin E and
antioxidants.
 Consume safe defluoridated
water.

Renu Mogra and Shashi JainRenu Mogra and Shashi Jain
3636
Proteins, calcium richProteins, calcium rich
foods:foods:
Pulses, milk, paneer, til, cuminPulses, milk, paneer, til, cumin
seedseed
Consume more of protein and calciumConsume more of protein and calcium
rich food:rich food:

2. Consume more of vitamin C rich foods2. Consume more of vitamin C rich foods
Vitamin C richVitamin C rich
foodsfoods
Amla, guava, lemon, orange, tomato,Amla, guava, lemon, orange, tomato,
coriander leaves, green chilies.coriander leaves, green chilies.

38
3. Consume more of vitamin E rich foods.
Vitamin E rich foods Vegetable oil, nuts, whole grain cereal,
green vegetable, dried beans

4. Consume more of antioxidants
Antioxidants
Rich sources
Garlic, ginger, white onion, carrot, papaya,
pumpkin, sweet potato

40
D
o
n
't
C
o
n
s
u
m
e
Betelnut Tobacco
F lu o r id a te d
T o o th P a s te
Gutkha

41
Defluoridation of water
STEEL FILTER PLASTIC FILTER EARTHEN POT FILTER
1. Activated Alumina (AA) filter:
Types:

42
1. Pour 15 liter of
water in AA
Filter system
and leave for
one hour.
2. Collect the
filtered water
in pot.
3. Keep water
pot at a safe
place
4. Take out
water with
the help of
mug having
handle.
Techniques

43
1. Pour 40 lit. water
in a container in a
container & add
alum & calcium
carbonate solution
2. Stir with a
plastic stick
for 15 minutes
3. Close the
container &
leave for
one hour
4. After one hour,
take out water
from tap and
collect in an
earthen pot. Drain
the remaining
dirty water.
2. Domestic Defluoridation

44
3. Nalgonda Technique at Community Level
• Nalgonda technique is a combination of rapid mixing, chemical
interaction, flourlation, sedimentation, filtration, disinfection and
sludge concentration
• Rapid mixing involves mixing of alkali, aluminum salts and
bleaching powder with water.
• Flocs are formed due to chemical reaction between fluorides and
aluminum salts.
• Addition of alkali hydrolyze the aluminum salts and bleaching
powder disinfect the treated water.
• Flocs along with fluorides, turbidity, bacteria and other impurities
are sedimentation and filtered through the filters
• Filtered water is used for consumptions.

45
Layout plan of Nalgonda Technique

46
Merits of Nalgonda Technique
• No regeneration of media
• No handling of caustic acids and alkalis
• Adaptable to domestic use also.
• Simple design, operation and
maintenance efficient removal of fluorides.
• Removal of colour, odour, turbidity,
bacteria and organic contaminates.
• Sludge generated is convertible to alum.

Remove the cap
from the test tube
and wash it with
sample water.
Transfer water
sample upto 50ml.
mark
Transfer Ziroconyl
Alzarine Red till
52.5ml. mark.
Recap the test
tube
Gently mix the solution
by titling the test tube.
While doing so keep
one finger over the cap
FLUORIDE TESTING IN WATER USING JALTARA KIT
1 2
3

One Hour allow
the solution to
develop colour
for an hour
along with the
cap
After one hour
remove the cap.
Compare the
colour with
standard colour
chart looking from
the top of the test
tube
One hour
Standard Colour comparion Chart for Fluoride (in mg/l)
Fluoride
4
5

49
 Testing of Fluroide in Water Using Fluoride Meter
 Material Required:
 Standard fluoride solution
 Colour reagent
 Plastic beaker
 Pipettes (0.1, 1.0, 10.0 ml. markings)
 Calibration:
 Take 18 ml. distilled water in a plastic beaker
 Add 2 ml. of colour reagent.
 Mix thoroughly.
 Transfer 1 ml of the solution to a measuring cuvette.
 Follow instructions given for blank adjustment
 Transfer back the solution form cuvette tot he same beaker.
Fluoride meter

50
 Accurately add 0.1 ml. standard fluoride solution (100 ul.
auto pipette or 0.1 ml. pipette is recommended for
accuracy)
 Thorough mixing after the addition of the standard
solution is essential for accuracy.
 Follow the instruction manual for calibration.
 Measuring fluoride Concentration:
 Take 5 ml sample + 4ml distilled water in a plastic beaker.
 Add 1 ml of colour reagent and mix thoroughly.
 Transfer a portion of a above sample to the cuvette.
 Follow the instruction given in the manual for fluoride
measurement.
 Meter will display the fluoride concentration in mg/I (ppm)

51
References
 WHO monograph series No. 59 Fluriodes and Human Health, (1970).
 Nanda, R.S. (1972). Fluoride content of North Indian Foods. Ind. J. Med. res. 60:
1470-1482.
 Takamori, T. (1971) Recent studies on fluorosis. Fluoride: 4: 154-166.
 Susheela, A.K. (1992) Defluoridation of drinking water. Merits and alternative
technologies. NFI Bulletin 13(3): 6-8, 1992.
 Susheela, A.K. (2001). A Treatise on Fluorosis. Fluorosis Research and Rural
Development foundation, New Delhi.
 Jain, S. (2002). Estimation of Fluoride in Water Foodstuff. A training report.
Organized by AICRP-FN, College of Home Science, Udaiupr from Jan 29 to Feb1,
2002, P. 1-12.
 Gyani, A.K., Vaish, A.K. and Vaish, P. (1999). Proceedings of National Seminar on
Environment an Health, DST, Jaipur and UNICEF, New Delhi.
 Bamji, M.S., Rao, N.P. and Reddy, V. (1999). Fluorosis. In: Textbook of Human
Nutrition. Oxford and IBH publishing Co. Pvt. Ltd. New Delhi, P. 424-442.
 I yenger, L. and Luckachen, G.G.(1999). Defluoridation Methods, Proceeding of
National Seminar on Environment and health, P. 79-86.

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