This document discusses fluorosis, which is caused by prolonged consumption of drinking water containing excessive fluoride. It begins by providing background on fluoride, its sources, and recommended levels. It then describes the signs and symptoms of dental and skeletal fluorosis. Laboratory tests for detecting fluoride levels are also outlined. The bulk of the document details India's National Programme for Prevention and Control of Fluorosis. It describes the objectives, strategies, and assistance provided to states. Activities are outlined at the community, CHC, district, state and central levels. Prevention, treatment, and health education approaches are summarized. Finally, it discusses adequate sampling methodology and references used.

1. D R R A V I P R A K A S H
J U N I O R R E S I D E N T - 1
D E P T . O F C O M M U N I T Y M E D I C I N E
K A T I H A R M E D I C A L C O L L E G E , K A T I H A R
National Programme for Prevention and
Control of Fluorosis

2. Introduction..
Fluorine-
 Most abundant element in nature.
 Never found in gaseous form.
 Highly reactive, always present in fluoride form.
 Essential for mineralisation of bones and formation of dental enamel.
 Main source are drinking water and food.
 Recommended fluoride level (as per BIS ) = 1 mg/litre i.e. 1 ppm (in
drinking water)
 Available in – black tea, black salt, supari, tinned food, fruit juices, sea
fish, cheese .

3.  “Double Edged Sword” – prolong consumption of drinking water more
than 1 mg/litre causes dental and skeletal fluorosis and inadequate
intake (less than 0.5mg/L) causes dental caries.
 Indicator of dental caries in Community – “DMF-Index” (D= decayed,
M= mottled, F= fallen)
 Fluorosis – endemic in India, High levels of Fluoride were reported in
230 districts of 20 States (after bifurcation of Andhra Pradesh in 2014) .
The population at risk as per population in habitations with high fluoride
is 11.7 million as on 1.4.2014 ( data from MDWS). It affects men,
women and children of all age groups.
 High risk group – children, elderly people, pregnant & lactating
mothers, patient with renal and cardiovascular diseases.

4. Geographical distributions

5. Risk factors: Terms
 Dramatic increase in
population and
industrialization & shortage
of drinking water supply
 Lack of awareness
 Undernutrition
 Use of toothpaste having
excess fluoride
 Food habits
 Skeletal fluorosis
 Dental fluorosis
 Non-skeletal fluorosis
 Hydrofluorosis
 Food-borne fluorosis
 Industrial fluorosis
 Neighbourhood fluorosis

6. Dental fluorosis Skeletal fluorosis
 Loss of shiny appearance on
teeth
 Appearance of chalky-white
patches(mottling)
 Patches later become
brownish/black
 Appearance of corroded teeth
in severe cases.
 Commonly seen over Incisors
and Molar teeth (not over
deciduous teeth)
 Calcification of tendons &
ligaments.
 Pain in joint of extremities and
later pain & stiffness of back.
 Radiological changes shows
Exostosis and calcification in
tendons & ligaments.
Sign & Symptoms

9. Dental fluorosis Skeletal fluorosis

10. Changes in skeletal fluorosis

12. Lab investigation
 High level of fluoride in drinking water, blood, urine.
 Anaemia with change in RBC structures.
 X-ray shows increased girth, thickness and density of bones.
Fluoride testing-
 Calorimetric
 Photometric
 Ion-selective method (most accurate)

13. Defluoridation (Nalgonda technique)

15. National Programmes for prevention and control
 Under ministry of health and family welfare
 New health initiative during 11th Five Year Plan, initiated in 2008-09 and is
being expanded in a phased manner. 100 districts of 17 States were covered
during 11th Plan,
 further 11 districts were taken up during 2013-15 (over 19 States) and
additional 84 new districts are to be taken up during the remaining period of
12th Plan.
 100 % centrally approved.
Aim- To prevent and control fluorosis cases in the country.
Objectives-
 To collect the baseline survey data for starting the project.
 To manage the cases of fluorosis comprehensively in the selected area.
 Capacity building for prevention, diagnosis and management of fluorosis
cases.

16. Strategy-
 Capacity building at different level of health care system
 Training
 Surveillance of fluorosis in community and school children
 Establishment of laboratories for early diagnosis in district
hospital/medical hospitals
 Management (treatment, surgery, rehabilitation )
 health education
 Survey of fluorosis by surveillance tool including case definition,
adequate sampling and survey methodology

17. Assistance provided to States-
 Strengthening manpower in endemic district by providing for :
 Consultant
 Laboratory Technician
 Field Investigators (3) for six months
 Purchase of equipment for lab including an Ion meter
 Training at various levels
 Health Education and Publicity
 Treatment including reconstructive surgery and rehabilitation

18. Programme activities
1. Community Diagnosis of Fluorosis village/block/cluster wise.
2. Facility mapping from prevention, health promotion, diagnostic facilities,
reconstructive surgery and medical rehabilitation point of view –
village/block/district wise.
3. Gap analysis in facilities and organization of physical and financial
support for bridging the gaps, as per strategies listed above.
4. Behavioral changes through appropriate IEC strategy .
5. All members having Fluorosis should be introduced to interventions and
monitored to improve health. 3 months later, health complaints and UFL
to be re-assessed.
6. Referrals for severe cases and their follow up

19. S.
No.
Level Activities
1. Community
(Village )
1. The consultant along with field personnel will assess the
entire endemic village and identify the persons suffering from
any form of fluorosis, so as to reach to provisional field based
diagnosis.
2. Awareness-cum-Training Programme for Medical Officers
of PHC/CHC and District Hospitals about general symptoms
of fluorosis and preventive management.Also for paramedical
workers, ICDS workers, PRI functionaries, teachers in the
community
3. Line listing of water sources, identify and colour code safe
sources to be introduced through the PHED. Intervention
activities to be introduced for fluorosis prevention.
Rehabilitative intervention, reconstructive surgery and
Referral system for what is not possible locally

20. S.
No.
Level Activities
4. Behavioural changes to be introduced through appropriate
IEC approach.
5. Inter-sectoral cooperation for interventions for Prevention and
Control of Fluorosiswith special emphasis on identification and
colour code of safe sources.
6. Selected interventions for prevention and health promotion to
be introduced, behavioural changes, supply of safe drinking
water. Monitoring and impact assessment are required.
7. Prevalence of fluorosis in a District to be recorded.
Management of Non-skeletal Fluorosis would be achieved in a
short span of time by introducing interventions.

21. S.
No
.
Level Activities
2. Community
Health
Centres
(CHCs)/
FRU
1. Similar activities to be introduced for CHC level staff and block
level functionaries.
2. Training Programme for Clinical examination and management
of fluorosis cases – Medical officers, Health personnel of CHCs.
3. Training-cum-Awareness Programme for BDC, ICDS staff and
Block level functionaries about different components of the
Programme for proper supervision and implementation.
4. Diagnostic tests of urine fluoride level and skeletal fluorosis
level assessment if facilities are available.
5. Monitoring the of village/PHC level activities
6. Referrals

22. S.
No.
Level Activities
3. District 1. Similar activities as the CHC level to be introduced at
District level.
2. Develop Fluorosis mapping of the district using water
fluoride estimation data and dental fluorosis survey in
school children
3. Detailed training Programme for Medical Officers &
Health Personnel for comprehensive management of
fluorosis cases to be drawn up and implemented.
4. Training-cum-Awareness Programme for DDC, ICDS
and education personnel on various components of the
programme .

23. S.
No.
Level Activities
5. Diagnostic support for dental, skeletal and non-
skeletal fluorosis to be established in a District.
6. Basic medical, surgical and rehabilitative activities for
cases diagnosed by district level specialists.
7. Monitoring.
8. Referral of difficult cases to near by Medical College
Hospital.
9. The CMO of the district will be the Nodal Officer for
NPPCF.

24. S. No. Level Activities
4. State 1. Programme Planning, execution of programme
activities, monitoring, mid-term evaluation and reporting to
the Centre (GOI) through the State Nodal officer.
2. Receipt and disbursement of allocation.
3. Utilization certificate processing and physical progress
to be submitted to the Centre (GOI) as per proforma.
4. Assisting Central Team in follow-up activities.
5. The SNO to regularly monitor the progress in the
districts

25. S.
No.
Level Activities
5. Centre 1. Programme Development, Programme Planning &
implementation through States/UTs.
2. Fund management and release to the States/UTs
3. Supervision, Monitoring and impact assessment.
4. Performance reviews

26. Suspected case
Dental fluorosis in children:
 H/O residing in an endemic areas plus either one or both (chalky
white teeth, transverse yellow or brown band on teeth)
Skeletal fluorosis:
 H/O residing in an endemic area with fluoride level more than 1 ppm plus
one or more of the following (pain & stiffness in neck, back bone, shoulder,
knee & hip region, knock-knees or bow legs, inability to squat)
Non-skeletal fluorosis:
 H/O residing in an endemic area plus one or more symptom (pain
abdomen, intermittent diarrhoea, constipation, anorexia, nausea, muscle
weakness & stiffness, pain in muscle, inability to walk, nervousness and
depression, tingling sensations, polydipsia, polyuria)

27. Confirmation of cases
 Any suspected case with high level of fluoride in urine (more than 1 ppm)
 Any suspected case with calcification of interosseous membrane in the
forearm, confirmed by x-ray
 Any suspected case with kidney ailment, serum fluoride need to be tested,
besides urine fluoride.
Sample Collection (Urine and Water) :
1. 30ml of spot urine sample of the suspected cases will be collected in a
plastic screw capped bottles (not glass bottles).
2. Put 1 - 2 drops of toluene (AR grade) on urine samples to make a complete
layer.
3. Each sample should be properly labeled with number and relevant details.
4. Similarly 30 ml water sample will also be collected from the source and not
from any container in the kitchen.

28. Adequate sampling:
by stratified sampling procedure
Survey methodology:
 School survey & Community survey
Strata Fluoride level
I 1.0 - 3.0 ppm
II 3.1 - 5.0 ppm
III More than 5.0 ppm

29. Prevention & Control:
 Defluoridation of water
 Rainwater harvesting
 Restrict intake of fluoride rich items ( tobacco, supari, black tea,
lemon tea, black/rock salt, fluoridated toothpastes &
mouthwashes.)
Treatment:
 Supplementation with vit C & D, antioxidants, calcium
 Deformity reduction, Rehabilitation, Physiotherapy

33. Rajiv Gandhi National Drinking Water
Mission(RGNDWM)
 A Second generation Programme (1991-92)
Guidelines for fluoride control:
 To identify and label any potable source SAFE and educate the
population to conserve/use the source for drinking & cooking only
 To tap safe low fluoride aquifers
 To arrange for blending of water from different sources to obtain
adequate quantities of safe water and to supply this potable mixture
through designated safe standposts
 To provide piped water supply schemes through distant sources
 Rainwater harvesting technique used to mitigate fluorosis
 To provide community treatment plants to remove excess of fluoride

34.  UNICEF and DANIDA working with GOI to strengthening the district
water quality laboratories, development of activated alumina(AA).
 DANIDA also supporting Rural Drinking Water Supply and Sanitation
Project (RDWSSP) in Karnataka.

35. Slogans for Prevention and Control of
Fluorosis
a) Peele dant, haddi jam, yeh hay pani mey fluoride ka
kam.
b) Doodh, dahi, hari sabzi khao, fluorosis se mukti
pao.
c) Peeney ke pani mey fluoride hay jahan, fluorosis
hay vahan.
d) Peeney ke pani ki janch karo, apenko fluorosis se
bachao.

38. References
 Park’s Text book of Preventive & Social Medicine.
 Community medicine with Recent advances by A.H.Suryakantha
 Textbook of Community Medicine by Sunder Lal, Adarsh, Pankaj.
 Government of India. Annual Report. New Delhi; Ministry of Health
and Family Welfare. GOI; 2003
 PIB. Antyodaya Anna Yojna . (2013). Press Information Bureau,
Government of India, New Delhi. [online] Available from
http://pib.nic.in/newsite/efeatures.aspx?relid=95141
 MoHFW. National Programm for Prevention and Control of Fluorosis,
Revised Guidelines (2014). Ministry of Health and Family Welfare,
Government of India, New Delhi.

39. Thank you….