This document discusses fluorosis, a condition caused by excessive fluoride intake that affects teeth, bones, and soft tissues. It is a public health problem in several countries including India. The most common cause is ingestion of drinking water with high fluoride levels. Clinically, it can cause skeletal fluorosis, dental fluorosis, and other soft tissue effects. Skeletal fluorosis results in brittle bones that are prone to fractures, and spinal manifestations can include fusion of vertebrae. Dental fluorosis causes mottling of tooth enamel. Diagnosis involves testing urine and serum fluoride levels along with radiological exams. Treatment focuses on preventing further fluoride intake by drinking defluoridated water and calcium supplements. Surgical intervention may

1. FLUOROSIS
DR PRATIK DHABALIA
RESIDENT IN ORTHOPEDICS
Dr DY Patil Hospital, Navi Mumbai

2. INTRODUCTION
• Most abundant element in nature
• 96% of fluoride in human body is present in bones and teeth.
• Helps in normal mineralization of bones and formation of dental
enamel.
• Fluorosis is a cosmetic condition affecting teeth, bones and soft
tissues.

3. EPIDEMIOLOGY
• Public health problem in 24 countries, including india.
• 5 geographical belts
• India and china
are most affected countries

4. • In india, most affected states are
Andhra Pradesh, Gujarat,
Rajasthan.

5. ETIOLOGY
1. Most common cause is ingestion of drinking water containing high
fluoride levels. (bore wells)
2. Use of fluoridated dental products like toothpaste or mouth rinse.
Children tend to swallow it.
3. Ingestion of food contaminated by coal dust, which are cooked in
chulhas.
4. Inhalation by industrial workers.
5. Ingestion of fruit juices, soft drinks and sea food.
5. Drugs – 5FU, NaF, Fluoxetin, FQ

6. RDA
• WHO – 0.5 to 1.0 mg/L
• Sources:
Rock salt
Salted snacks (peanuts, Channa)
Pickles
Preserved fruit juices
Soft drinks
Sea Food

7. CLINICAL MANIFESTATIONS
• Mainly affects 12-15 years of age
• Clinically can be divided into three types
1. Skeletal fluorosis
2. Dental fluorosis
3. Soft tissue and other manifestations

8. Skeletal Fluorosis
• The fluoride incorporation into the bone hydroxyapatite,
altering the size and structure of its crystals.
• The fluoroapatite formed decreases the mechanical
competence of the bone, resulting in abnormal structure and
poor quality of bone, with increased risks for fractures.
• Rickets, osteomalacia, secondary hyperparathyrodism and
regional osteoporosis are often associated with skeletal
fluorosis.
• The bone diseases and deformities are more severe and
complex in patients with dietary calcium and vitamin-D
deficiencies.

9. • Causes brittle bones which increases chances of pathological
fractures.
• Causes ossification of ligaments and cartilage which leads to stiffness
• Impairment of joint mobility
• Deformity of bones

10. Spinal manifestations
• Spinal deformities – fusion of vertebrae, radiculopathy, LCS, OPLL, “Poker
back” spine (kyphosis) is a late manifestation of skeletal fluorosis wherein
the entire spine becomes one continuous column of bone
• Mechanical compression of the spinal cord and nerve roots resulting from
the osteophytes - reduction of the antero-posterior diameter of the spinal
canal and intervertebral foramina, sclerosed vertebral column and ossified
ligaments. The cervical cord is affected earlier than the dorsal cord.
• The progressive cervical radiculomyelopathy of fluorosis is characterized by
marked wasting and atrophy of the small muscles of the hands, spastic
paraparesis or quadriparesis often in flexion.

17. Dental fluorosis
• Asymptomatic: Few white flecks of enamel to occasional white spots
• Very mild: Small opaque white area which is scattered over less
surface area.
• Mild: White opaque areas on surface up to 50% of area.
• Moderate: More than 50% of surface area of white opaque
• Severe: Almost all enamel surface is affected.
• Dental fluorosis is also called as mottling of the tooth enamel, due to
excess fluoride during the tooth development.

20. Other manifestations
• Thyroid – Hypothyroidism
• Renal – Nephrolithiasis
• Cardiac – Arrhythmias and IHD
• Muscular – Weakness and wasting

21. INVESTIGATIONS
Skeletal Fluorosis should be strongly suspected in any person with
features of stiffness, rigidity, restricted movements at the spine and
joints, bone and joint pains and who has been residing continuously for
>6 months in endemic area.

22. Serological
• CBC – Anemia,
• ESR and CRP raised
• Alkaline phosphatase and fluoride levels are elevated.
• Serum parathyroid hormone levels are always raised as a
compensatory mechanism to maintain extracellular ionised
calcium equilibrium consequent to decreased solubility and
reactivity of fluoroapatite crystals, fluoride induced
osteomalacia and dietary calcium deficiency
• Plasma calcium, magnesium and phosphorus remain normal

23. • Urine fluorides: They are the best indicator of fluoride intake. There is
a linear relation between urinary fluoride levels and fluoride intake.
• 24 h samples of urine are more reliable than random or morning
samples.
• In cases of skeletal fluorosis, values will be >0.4 ppm.
• Serum fluoride levels: Normal values in non-endemic regions range
from 0.002 to 0.008 mg/dl. Patients with skeletal fluorosis show high
levels up to 0.02–0.19 mg/dl.
• Bone fluoride estimation, bone biopsy and scintigraphic studies may
help to support the diagnosis of skeletal fluorosis.

24. Radiological
• The earliest radiological findings appear within six months of
continuous exposure to high intakes of fluoride and include
• periosteal and endosteal reactions
• coarse axial trabeculations
• osteopenia in the metaphyseal regions
• Sclerosis and modelling abnormalities of the epiphyses

25. • The most pronounced changes are seen in the vertebral column with
marked osteosclerosis and irregular osteophyte formation resulting in
beak-like lipping and a chalky-white ground-glass appearance.[6]
Calcification of the interosseous membrane of the forearm is a
radiographic sign of fluorosis.[3]

26. • Pulmonary function tests: Due to involvement of the rib cage,
fluorosis causes restrictive lung disease
• Computed tomography: This can help to visualise alterations in spinal
canal, indentations of epidural space and calcified ligaments..
• Magnetic resonance imaging: Spinal cord changes due to prolonged
compression and secondary vascular compromise.

27. MANAGEMENT
Medical:
• In many cases, fluorosis is so mild that no treatment is needed. Only
withholding the intake of fluorine reverses the disease.

28. • Prevention:
The use of more than 100 m deep bore water supply is able to
provide water with fluoride less than 1mg/L, low alkalinity and
normal or high normal calcium contents and this could play a
master role in the control of endemic fluorosis.
Drinking defluoridated water. It is recently suggested that drinking of
defluoridated water from the ″calcium amended-hydroxyapatite″
defluoridation method may help in the fluorosis reversal.

29. Calcium is the strongest antagonist of fluoride toxicity.
Adequate intakes of calcium to maintain the positive calcium
balance to counteract the toxic effects of fluoride is therefore
essential for the population residing in endemic fluorosis villages.
Avoiding intake of fluoridated water, seafood, pickles, high salt
diet, preserved juices.
Cautious use of dental products like toothpaste and mouth rinse.

30. Supplements –
• Vit C
• Vit D
• Calcium

31. Surgical
• In few cases with deformities, especially children, corrective plasters
and orthotics can be used.
• In cases with pathological fractures, severe spinal deformity, cervical
myelopathy surgical intervention maybe required.

32. • The appearance of teeth affected by moderate-to-severe fluorosis can
be significantly improved by a variety of techniques. Most of them are
aimed at masking the stains.
• Such techniques may include:
• Tooth whitening and other procedures to remove surface stains
• Bonding which coats the tooth with a hard resin that bonds to the
enamel
• Crowns
• Veeners (which are custom-made shells)