2. ENDEMIC FLUOROSIS
Presented by
Dr.Sachin Shekde
JR1.
DEPT OF COMMUNITY MEDICINE
GMC,LATUR
Guided by
Dr.Balaji Ukarande
Assist. Professor
2
3. CONTENTS
• 1.Introduction of fluorine and fluorides.
• 2.Worldwide distribution of endemic fluorosis.
• 3.Fluorosis in India.
• 4.Sources of fluoride.
• 5.Definition of fluorosis.
• 6.Types of fluorosis.
• 7.Prevention and control of fluorosis.
• 8.Defluoridation.
• 9.Goals of NPPCF.
• 10.Guidelines of MoHFW.
• 11.Summary.
• 12.References.
4. INTRODUCTION
• Fluorine is the 13th most abundant naturally occurring
element in the Earth’s crust.
• It is the lightest member of the halogens.
• It is the most electronegative and reactive of all the
elements and as a result, elemental fluorine does not
occur in nature but found as a fluoride mineral
complexes.
• Fluorine is more reactive than chlorine> bromine>
iodine.
4
5. • Fluorine is essential for mineralization of
bones & formation of dental enamels
• 96% of fluoride of body found in bones &
teeth.
• Normally small amount of fluoride is
required (0.5 to 0.8 mg/lit) in drinking
water.
6. • Fluorine is often called as two-edged
sword.
• Prolonged ingestion of fluoride through
drinking water in excess of the daily
requirement is associated with dental and
skeletal Fluorosis.
• Similarly, inadequate intake of fluoride in
drinking water is associated with dental
caries.
7. • World Health Organization (WHO) has set the
upper limit of fluoride concentration in
drinking water at 1.5 mg/l .
• The Bureau of Indian Standards, has
therefore, laid down Indian standards as 1.2
mg/l as maximum permissible limit of fluoride
with further remarks as “lesser the better” .
• Intake of fluoride higher than the optimum
level is the main reason for dental and
skeletal fluorosis .
8. Permissible limit of fluoride in drinking
water
Name of organisation Desirable limit (mg/L)
Bureau of Indian Standards (BIS) 0.6-1.2
Indian Council of Medical
Research (ICMR) 1.0
The Committee on Public Health
Engineering Manual and Code
of Practice, Government of
India
1.0
World Health Organization
(International Standards for
Drinking Water)
1.5
9. • Fluorosis is an important public health problem in
24 countries, including India, which lies in the
geographical fluoride belt that extends from Turkey
to China and Japan through Iraq, Iran and
Afghanistan .
• Of the 85 million tons of fluoride deposits on the
earth’s crust, 12 million are found in India . Hence
it is natural that fluoride contamination is
widespread, intensive and alarming in India.
10. WORLDWIDE DISTRIBUTION
• Worldwide in distribution.
• Endemic in 22 countries.
• Asia and in Asia,India and China are worst
affected.
• Mexico in North and Argentina in Latin
America.
• East and North Africa are also endemic.
12. FLUOROSIS IN INDIA
• Endemic fluorosis is prevalent in India since 1937 .
• It has been estimated that the total population
consuming drinking water containing elevated
levels of fluoride is over 66 million .
• Endemic fluorosis resulting from high fluoride
concentration in groundwater is a public health
problem in India .
13. • The available data suggest that 15 States
in India are endemic for fluorosis (fluoride
level in drinking water >1.5 (mg/l) .
• about 62 million people in India suffer from
dental, skeletal and non-skeletal fluorosis.
• Out of these; 6 million are children below
the age of 14 years .
14. • Throughout India fluorosis is essentially
Hydrofluorosis except in parts of Gujarat and
U.P. where industrial fluorosis is also seen.
• In worst affected states, maps have been
prepared of geographic pathology on the
basis of fluoride distribution in the drinking
water.
18. • Rajasthan and Gujarat in North India and
Andhra in South India are worst affected.
• Punjab, Haryana, M.P. and Maharashtra are
moderately affected.
• T.N.,W.B.,U.P.,Bihar and Assam are mildly
affected.
19. • 70-100% districts are affected in Andhra
Pradesh, Gujarat and Rajasthan.
• 40-70% districts are affected in Bihar, National
Capital Territory of Delhi, Haryana, Jharkhand,
Karnataka, Maharashtra, Madhya Pradesh,
Orrisa, Tamil Nadu and Uttar Pradesh
• 10-40% districts are affected in Assam, Jammu
& Kashmir, Kerala, Chhattisgarh and West
Bengal. While the endemicity for the rest of
the states is not known.
22. Sources of Fluoride
• Contaminated ground
water is the main
source.
• Contaminated
drinking & cooking
water, agricultural &
food products, drugs
and industrial
emissions & pollutants
23. • The main source of fluoride in groundwater is
the rocks which are rich in fluoride.
• Most of the people affected by high fluoride
concentration in groundwater live in the tropical
countries where the per capita consumption of
water is more because of the prevailing climate.
24. Sources of fluoride for human
exposure
Main sources of fluoride :
• Water
• Food
• Air
• Medicament
• Cosmetic
26. AGENT FACTORS
• Primarily it is Fluoride which is present in
drinking water .
• when F in water is more than 1.5 mg per
litre, it is toxic to health .
• pH in terms of alkalinity of water promotes
the absorption of F .
27. • calcium in the diet reduces the absorption
of F .
• Hard water rich in Calcium reduces the F
toxicity .
• Fresh Fruits and Vit.C reduces the effect
of F .
• Trace elements like Molybdenum
enhances the effect of F .
28. Host Factors
• In School going children seen as dental
fluorosis.
• In third and fourth decade of life seen as
Skeletal Fluorosis.
• Males suffer more than females.
• Illiterates suffer more frequently in the
fluorotic belts.
29. Environmental Factors
• High Annual Mean Temperature.
• Low Rainfall.
• Low humidity.
• F rich Natural subsoil rocks.
• Vegetables from high F belts.
• Fluoridated tooth paste particularly when used
by children.
• Tropical climate.
• Developing Countries.
30. Fluoride Concentration (mg/l)
Fluoride ( mg/l) Source Effects
0.002 Air Effect on plants
1.00 Water Prevention of Dental
caries
>=2 Water Effect dental enamel
>=8 Water Effect Bones and
muscles
>50 Food, Water Changes in Thyroid
(>100 Food, Water Defective
development
>120 Food, Water Changes in Kidney
31.
32. What is Fluorosis ?
• Fluorosis is a major public health problem
caused by intake of excess amount of
fluorides over a long period resulting
permanent and irreversible damages.
33. • Fluorosis is a disease caused by deposition of
fluorides in the hard and soft tissues of the
body.
• It is not merely caused by excess intake of
fluoride but there are many other attributes
and variables which determine the onset of
fluorosis in human population.
• It is usually characterized by discoloration of
teeth and crippling disorders.
35. DENTAL FLUOROSIS
• Tooth enamel is principally made up of
hydroxyapatite (87%) which is crystalline calcium
phosphate .
• Fluoride which is more stable than hydroxyapatite
displaces the hydroxide ions from hydroxyapatite
to form fluoroapatite.
36. • Fluorosis of dental enamel occurs when excess
fluoride is ingested during the years of tooth
calcification essentially during the first 7 years
of life .
• It is characterised by "mottling" of dental
enamel, which has been reported at levels
above 1.5 mg/L intake.
37. • The teeth loose their shiny appearance and
chalk-white patches develop on them.
• This is the early sign of dental fluorosis.
• Later the white patches become yellow and
sometimes brown or black.
38. • In severe cases, loss of enamel gives the teeth
a corroded appearance. Mottling is best seen
on the incisors of the upper jaw.
• It is almost entirely confined to the permanent
teeth only during the period of formation.
• In endemic zones, people lose their teeth at
an early age and may become edentate.
39. • Several classifications have been proposed to
assess the severity of dental fluorosis.
• Dean’s based his classification on the clinical
appearance of the enamel, and it varied from
normal to severe.
40. DENTAL FLUOROSIS SCALE
(Dean’s index)
• Normal Enamel (0): Enamel smooth, glossy,
pale creamy white translucency
• Questionable fluorosis (0.5): Slight
aberrations from translucency with
occasional white fleck or spots
• Very mild fluorosis (1) :Small, opaque, paper-white
areas involving less than 25% of the
surfaces of the two most affected teeth; may
acquire brown stains in adulthood
41. • Mild fluorosis (2) :More extensive dull white
opacities involving less that 50% of the
surfaces of the two most affected teeth
• Moderate fluorosis (3): All enamel surfaces
affected; distinct brown staining frequent
• Severe fluorosis (4): Teeth show marked
hypoplasia , attrition and pitting; brown or
black staining widespread.
46. • To determine the severity of dental
fluorosis as a public health problem, Dean
devised a method of calculating the
prevalence and degree of severity in a
community, which he termed the
community fluorosis index (CFI).
47. • The Community Fluorosis Index (CFI) is a way
of measuring the burden of dental fluorosis in
a population.
• Instead of just measuring the overall
prevalence of fluorosis (i.e., what percentage
of people have fluorosis ).
• The CFI is thus a measurement of both
prevalence and severity.
48. How the CFI Is Calculated ?
• The CFI is calculated based on the following
point scale for the different categories of
dental fluorosis (using the Dean Index):
• Questionable Fluorosis = 0.5 points
• Very Mild Fluorosis = 1 point
• Mild Fluorosis = 2 points
• Moderate Fluorosis = 3 points
• Severe Fluorosis = 4 points
49. • When the CFI was <0.4, Dean’s considered it of
little or no public health concern.
• while indices between 0.4 and 0.6 were
borderline, and the removal of excess fluoride
was indicated when the CFI was >0.6.
• Hence, a CFI of 0.6 sets the upper limit of fluoride
concentration for aesthetic reasons. Dean's index
is based upon the clinical appearance only.
50. SKELETAL FLUOROSIS
• Associated with lifetime daily intake of 3.0 to 6.0 mg/l
or more.
• It affects young as well as old.
• The symptoms include severe pain and stiffness in
the backbone,joints and/or rigidity in hip bones.
51. Common Causes of skeletal Fluorosis
• Fluoridated Water for Kidney Patients
• Excessive Tea Consumption
• High-Fluoride Well Water (more likely to be a
factor among deep wells)
• Industrial Fluoride Exposure
• Fluorinated Pharmaceuticals (Voriconazole &
Niflumic Acid)
• Indoor coal burning (a common practice in
China).
52. SKELETAL FLUOROSIS
• When a concentration of 10 mg/L is exceeded, crippling
fluorosis can ensue. lt leads to permanent disability.
• X-ray examinations of the bones reveals thickening and
high density of bones.
• In some patients with calcium deficiency osteomalacia
type changes are seen.
• Constriction of vertebral canal and intervertebral foramen
- pressure on nerves leads to paralysis.
53. • There may be sclerosis of spine, pelvis and
limbs. The ligaments of spine may be calcified,
producing a ‘poker back’.
• The tendinous insertion of muscles may be
ossified, producing the characteristic ‘rose
thorn’ shadow in the X-Ray.
53
54. Stages: Skeletal Fluorosis
Preclinical Stage :
• the patient feels no symptoms
• but changes have taken place in the body
• Biochemical abnormalities occur in the blood
and in bone composition
• Histological changes can be observed in the
bone in biopsies
55. Second clinical stage
• Constant pains in the bones, ligaments begin
to calcify.
• Osteoporosis may occur in the long bones,
and
• early symptoms of osteosclerosis Bony spurs
may appear on the limb bones, especially
around the knee, the elbow, & on the surface
of tibia and ulna.
56. Advanced skeletal fluorosis
• Extremities become weak and moving the
joints is difficult.
• The vertebrae partially fuse together, crippling
the patient.
57. A VICTIM OF SKELETAL FLUOROSIS
WITH STIFFNESS OF NECK AND SPINE
62. GENU VALGUM
• A new form of fluorosis characterised by genu
valgum and osteoporosis of the lower limbs has
been reported in recent years in some districts of
Andhra Pradesh and Tamil Nadu.
• The syndrome was observed among people whose
staple was sorghum (jowar).
64. TESTS FOR SKELETAL FLUOROSIS
• COIN TEST: The subject is asked to lift a coin
from the floor without bending the knee. A
fluorotic subject would not be able to lift the
coin without flexing the large joints of lower
extremity.
• CHIN TEST: The subject is asked to touch the
anterior wall of the chest with the chin. If there
is pain or stiffness in the neck, it indicates the
presence of fluorosis.
65. • STRETCH TEST:
The individual is made to stretch the arm
sideways fold at elbow and touch the back of the
head. When there is pain and stiffness, it would
not be possible to reach to the occiput indicating
presence of Fluorosis.
66. NON-SKELETAL FLUOROSIS
• There are convincing evidence of involvement
of skeletal muscles, erythrocytes, G-I mucosa,
ligaments and spermatozoa on consuming more
than optimal intake of fluorides.
• Detection of Fluorosis at early stage is possible
by understanding the soft tissue manifestation.
67. • In the fluorosed muscles,actin and myosin
filaments are destroyed and mitochondria lose
their structural integrity thereby providing
evidence of depletion of muscle energy.
68. • The erythrocyte membrane loses its calcium
content in presence of high fluoride.
• Non-ulcer dyspeptic complaints are manifested by
consuming high F in water and food.
• Infertility due to oligospermia and azoospermia is
commonly seen in fluorotic belts.
68
69. Non Skeletal fluorosis
Neurological Manifestations
1. Nervousness & Depression
2. Tingling sensation in fingers and toes
3. Excessive thirst and tendency to urinate Frequently
( Polydypsia and polyurea )
4. Control by brain appears to be adversely affected.
70. 2. Muscular manifestations
• Muscle Weakness & stiffness
• Pain in the muscle and loss of muscle power
3. Urinary tract manifestations
• Urine may be much less in volume Yellow red in
colour
71. • 3. Allergic manifestation
Skin rashes
Perivascular inflammation.
Pinkish red or bluish red spot, round or
oval shape on the skin that fade and clear up
within7-10 days.
72. 5. Gastro - intestinal problem
• Acute abdominal pain
• Diarrhoea
• Constipation
• Blood in Stool
• Bloated feeling (Gas)
• Tenderness in Stomach
• Feeling of nausea
73. PREVENTION AND CONTROL
• Flurosis Can be prevented or minimized..
by using alternative water sources.
• by removing excessive fluoride from drinking
water.
• by improving the nutritional status of
populations at risk.
74. Alternative water sources
• These include surface water, rainwater, and low-fluoride
groundwater.
• Surface water : Surface water should not be used
for drinking without treatment and disinfection.
75. Rainwater
• Rainwater is usually a much cleaner water
source and may provide a low-cost simple
solution.
• The problem, however, is limited storage
capacity in communities or households.
• Large storage reservoirs are needed because
annual rainfall is extremely uneven in tropical
and subtropical regions. Such reservoirs are
expensive to build and require large amounts of
space.
76. • Low-fluoride groundwater:
• Fluoride content can vary greatly in wells in the
same area, depending on the geological
structure of the aquifer and the depth at which
water is drawn.
• The fact that fluoride is unevenly distributed in
ground water, both vertically and horizontally,
means that every well has to be tested
individually for fluoride in areas endemic for
fluorosis:
77. DE-FLUORIDATION
• “De-fluoridation is the process of removal of
excess fluoride from water.”
• The defluoridation methods are divided into
three basic types depending upon the mode
of action :
78. • Based on kind of chemical reaction with
fluoride: Nalgonda technique .
• Based on adsorption process: Bone charcoal,
processed bone, tricalcium phosphate,
activated carbons, activated magnesia,
tamarind gel, serpentine, activated alumina,
plant materials .
• Based on ion-exchange process: Anion/Cation
exchange resins
79. • Filtration:
• Reverse Osmosis Filtration
• Activated Alumina Defluoridation Filter
• Distillation Filtration
• There are basically two approaches for
treating water supplies to remove fluoride:
• Flocculation
• adsorption.
80. Flocculation
• National Environmental Engineering Research Institute
(NEERI), Nagpur has evolved an economical and simple
method for removal of fluoride which is referred as
NalgondaTechnique.
• Nalgonda Technique involves addition of Aluminium
salts, lime and bleaching powder followed by rapid
mixing, flocculation, sedimentation, filtration and
disinfection.
81. NALGONDA Technique
Water Treatment
• water mixed with aluminium sulphate (alum), lime or
sodium carbonate ( 1/20 th of alum) and bleaching
powder ( 3 mg/l) .
• Stir water slowly for 10-20 minutes and allow to
settle for nearly one hour.
• Supernatant is withdrawn.
• Discard the sludge.
82.
83.
84.
85. Adsorption
• The other approach is to filter water down
through a column packed with a strong
adsorbent, such as activated alumina (Al2O3),
activated charcoal, or ion exchange resins.
• This method, too, is suitable for both
community and household use.
86. Better nutrition:
• adequate calcium intake is clearly associated
with a reduced risk of dental fluorosis.
• Vitamin C may also safeguard against the risk.
88. Fluoride Containing Items to be avoided
• Drugs
• Antidepressants viz, Citalopram, Escitalopram, Paraxetine
and Prozac .
• Antiinfective drugs viz.Fluoroquinolones (Ciprofloxacin,
Moxifloxacin, and Gatifloxacin).
• Anti-cholesterol drugs require fluorinated intermediates for
their synthesis viz. Atorvastatin and Fluvastatin.
• Sodium fluoride by itself is also prescribed for Otosclerosis
and Osteoporosis.
• Homeopathy drugs also contain fluoride.
89. Fluoride Containing Items to be avoided
Industrial Emission / Occupational Exposure
• Hydrofluoric acid, fumes and fluoride dust
from industries.
• Working with Lasers (laser equipment)
• Working in Libraries, Archives where sodium
fluoride sprayed to save books from insects.
90. Steps to Reduce Fluoride
• Avoid Fluoride Rich Food Substances
• Black tea and Lemon tea (tea with milk is
safe);
• Black rock salt ( kala namak );
• Black rock salt lased pickles, Garam masala ,
salty snacks, Chaat and Chaat masala Canned
fruit juices
• Chewing of tobacco Supari ( arccanut ) and
“ Hajmola ” and other “ Churan ” containing
rock salt.
92. GOAL OF NPPCF
• Goal of National Programme for
Prevention and Control of Fluorosis
(NPPCF):
To prevent and control fluorosis cases
in the country.
93. Objectives of NPPCF
• To collect & use baseline survey data of
fluorosis.
• Comprehensive management of fluorosis in
endemic areas.
• Capacity building for prevention, diagnosis &
management of fluorosis cases.
94. Mitigation of Fluorosis
• Closing contaminated water source.
• Arranging alternative safe water source.
• Rain & surface water harvesting for agriculture &
household.
• Supply of pipeline river water from water treatment
plant.
95. Mitigation of Fluorosis
• Enhanced surveillance, early detection, proper treatment &
rehabilitation Training of field level health personnel.
• Capacity building of District Hospitals & Medical Colleges.
• Laboratory support development in District Hospitals &
Medical Colleges.
• Health education, dietary counseling & nutrition.
• Dietary supplementation of calcium, vitamin C, D3 & iron
96. GUIDELINES FOR COMPREHENSIVE
MANAGEMENT OF FLUOROSIS CASES
• Early Detection –
a) Dental Changes
b) Pain & Stiffness of peripheral joints
c) Deformities of lower limb
• Prompt Intervention –
a) Health Education
b) Preventive Measures
c) Treatment
d) Rehabilitation
97. DISTRICT LEVEL ACTIVITIES
• Training of MO for Management of Cases.
• Training of Dist staff, ICDS & Educational Personnel.
• Fully Equipped Lab.
• Diagnostic support for all kinds of Fluorosis.
• Monitoring.
• Basic medical, surgical & rehabilitative activities for
diagnosed cases by dist level specialist.
• Referral of difficult cases to near by Medical College.
98. COMMUNITY
(VILLAGE LEVEL ACTIVITIES)
• Provisional community diagnosis
• Verification of Community Diagnosis by PHC
Doctors.
• Line listing of sources reduction activity,
Reconstructive Surgery Cases, Rehabilitative
Intervention activities, local action & referral.
• Appropriate IEC.
• Inter-sectoral Co-operation.
• Measures for prevention and health promotion.
99. ACTIVITIES UNDER NPPCF CELL
• IEC material Development.
• Suggestions for abandoning Fluoride affected
drinking water sources.
• Urine analysis going on of suspected cases in
affected villages.
• Training Programme.
• Fluorosis confirmatory diagnosis camp at RH in
respective blocks.
100. To do…
• Cooperation & coordination of all- District
Health Officer, District Health Lab, Water
quality department, Village panchayat, Taluka
Health Officers, Medical Officers, Paramedical
staff to prevent this irreversible diseases by
detection, diagnosis, referral and
management of affected community people.
101. LATUR DISTRICT SCENARIO
• 2005-06 Report found 21 fluoride
contaminated sources.
• All sources has alternates available at present
& are below 1.5 ppm.
• 2012-2013 Chemical water analysis campaign
at District health lab revealed - Out of 3373
Samples tested, 17samples have fluoride level
>1.5 ppm
• Ahmadpur = 6, Nilanga=1, Renapur=2, Udgir=8
103. TAKE HOME MESSAGES
• Fluorosis is preventable disorder
• Fluorosis is not an infectious disease and it’s
clinical effects are seen after a long period of high
fluoride consumption.
• Checking drinking water source is essential for
good general health and proper development
• Dietary management is easiest and cost effective
way for Fluorosis cases to reduce fluoride level.
• Dental fluorosis is easy to detect & helps us to arrest
the further skeletal effects with interventions.
• Health Education & promotion are important at
community level.
104. THESE METHODS DO NOT REMOVE
FLUORIDE
• Boiling Water :This will concentrate the
fluoride rather than reduce it.
• Freezing Water: Freezing water does not affect
the concentration of fluoride.
105. SUMMARY
• Fluorosis is a public health problem caused by
excess intake of fluroide >1.0 ppm through
drinking water/food products/industrial
pollutants over a period of time.
• It is permanent and irreversible harmful
disease effect on the health of an individual
and the community,which in turn has an
impact on growth, development, economy
and manpower of the country.
105
106. • There has been remarkable increase in the
incidence of fluorosis in the entire country.
• There is no effetive treatment for the fluroide
related disorders, prevention and control is
the most effective measures for the same.
106
107. Please Save water and Use it
Appropriately for us and our next
generations
109. references
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96
• 2) J. Kishore National Health Programmes of India 10th edition p-586-87
• 3) I J Res Dev Health, April 2013vol.1(2)(ijrdh) by Arlappa N et al .(www.IJRdh.com)
• 4) The National Medical Journal of India vol.12 no 3 ,1999 by S.P.S Teotia . Dept of
medicine ,L.L.R.M medical college , Meerut. U.P
• 5)Susheela A.K. Fluorosis : India scenario : A treatise on fluorosis . Fluorosis research
and rural development foundation : New Delhi India.
• 6) Journal of Chemical and Pharmaceutical Research 2009,1(1):31-37. by Tiwari et. al.
• 7) http://article novapublishers.com /catalouge/product_info php? Product id-15895.
• 8) Guidelines for surveillance of fluorosis in community by dept. of health and family
welfare, Govt of India, 2012-2013.
• 9) Indian journal of Paediatrics. Sept 2013: 80(9)713-715 by A.K. Susheela.
• 10)Textbook of public health and community medicine.A.F.M.College.pune P.768-
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