This document discusses endemic skeletal fluorosis, a disease caused by excessive fluoride ingestion. It provides statistics on the prevalence of fluorosis in India, with over 66 million people living in endemic areas and 6 million Indians crippled by the disease. Key points include: - Fluoride levels were measured in groundwater sources across India, with levels above 1.5 ppm in many rural areas. - Dietary sources of fluoride intake include crops grown in endemic areas as well as foods like tea. Estimates of daily fluoride intake in some villages exceeded recommended limits. - Symptoms of fluorosis include skeletal and joint problems that can become crippling. Studies also found impaired kidney function in many cases. -

1. Endemic Skeletal Fluorosis
Understanding the disease -
Ways to contain it
D. Raja Reddy
Hyderabad

2. Endemic Skeletal
Fluorosis
Fluorosis is a disease caused by excessive
ingestion of fluoride through water, food or
both.
This disease is widely prevalent in our country.

3. Incidence of skeletal fluorosis
• 275 districts out of 626 in the country are
affected by fluorosis.
• 66 million people are living in the endemic
areas who are at risk of contacting fluorosis.
• 6 million Indians are known to be crippled
because of fluorosis.
• Hence Fluorosis is a major public health
problem in India and it is also a problem in
25 other countries around the world

4. The Incidence of Endemic Skeletal Fluorosis
• 1974: 25-30 million people at risk and half a
million are crippled.
• 1999 (UNICEF): 201 districts affected and
60 million at risk. 6 million people crippled.
• 2009(Ministry of health and family welfare): 275
districts are affected and 66 million people are at
risk in endemic areas.
6 millions are crippled.

5. It is important for us to know about the
sources of fluorides, their metabolism in
human body and the factors governing
the development of fluorosis in endemic
areas of our country so that effective
measures can be undertaken to contain
this disease.

6. Fluoride Metabolism
• Fluorine is a halogen which is most electro negative
and highly reactive element and hence it does not
occur in free form in nature.
• This element combines readily with other elements to
form fluorides which are widely distributed in nature.
• Fluorides are the 13th commonest element in the
earth’s crust and are present in some amounts in
everything we eat and drink.

7. • Cristiani & Gautier coined the term fluorosis in 1925.
• Fluorosis in humans was first mentioned as
an occupational disease by Feil in 1930.
• This was substantiated in 1932 when Moller and
Gudjonsson of Netherlands published about Skeletal
fluorosis in cryolite miners.
• In 1937 Shortt et al described the cases of endemic
skeletal Fluorosis from India which also contained its
neurological manifestations.

8. What are the sources of fluorides
• Waters: Ground & surface waters: 90% of rural areas
depend on ground waters and more than 50% of
them have high amounts of fluorides more than 1.5
ppm. All cities get water from perennial rivers having
optimum amounts of fluorides around 0.3 - 0.4ppm.
Hence fluorosis has become a rural problem.
• Beverages: Tea is exceptionally rich in fluorides
• Foods: Crops cultivated in endemic areas with
ground waters having high amounts of fluorides
leads to cereals and vegetables containing large
amounts of fluorides

9. Fluoride levels in ground waters in different states
of India
-----------------------------------------
Assam(2)-1.6-23.4;A.P.(17)-0.4-29.0;Bihar(8)-0.2-
14.0;Delhi(4)-0.9-32.46;Gujarat(All except Dhang)-
1.5-13.0;Haryana(12)-0.23-48.0;J&K(1)-0.5-
4.21;Karnataka(14)-0.2-7.79;Kerala(3)-0.2-
5.40;Maharashtra(10)-0.11-10.0;M.P.(10)-1.5-
4.20;Orissa(3)-0.60-9.20;Punjab(13)-0.4-
42.5;Rajasthan(All32)-0.1-10.0;Tamil Nadu(8)-0.1-
7.0;U.P.(7)-0.2-25.0;West Bengal(4)-1.1-14.47;

10. Fluorides
What are the beneficial uses of fluorides.
• Fluorides reduce the incidence of dental decay
and caries. These are very cost effective and
hence water supplies are fluoridated having less
than optimum amounts of fluorides.
• Another advantage of fluorides is that the
incidence of senile osteoporosis is much less in
areas having optimum amounts of fluorides.

13. Col. Henry Edward Shortt, FRS, CIE (1887-1987) -
Doctor, Soldier, Scientist & Shikari-A remarkable
person.
• Endemic skeletal fluorosis: Clinical and radiological study.
• Kala Azar - caused by fleas-medical treatment with Stibamine
reduced mortality from 90% death rate to 90% cure rate.
• Discovered the missing links in malarial parasite cycle. Ross
discovered the malarial parasite.

14. Endemic Fluorosis in the
Madras Presidency
Shortt, H.E. et al 1937
Kidney efficiency tests
• Filteration rate : Below normal limit in six cases out of ten
• Blood urea clearance : In all the cases the figures were
below the normal lower limit
• Blood urea
• Creatinine
Result
• Kidney function in the majority of the cases is impaired
Abnormal in majority of cases}

17. Concentration or dose of fluoride Effect (WHO 1970)
1 PPM water Dental caries reduction
2 PPM water Dental fluorosis
5 PPM No Osteosclerosis
8 PPM water 10% Osteosclerosis
20-80 mg / day water or food Crippling skeletal fluorosis
50 PPM water or food Thyroid changes
100 PPM water or food Growth retardation
125 PPM water or food Kidney changes
2.5 - 5 gm acute dose Death

20. Podili, Darsi and Kanigiri Regions
(1937 & 1940,1941 studies)
• Incidence of fluorosis is highest because of
high atmospheric temperatures in summer
reaching upto 115-116 F.
• Farm laborers are more affected.
• More severe in individuals whose diet is
deficient in calories and Vitamin C.
• People with kidney disease suffer more.

21. Daver, M.B. Occurrence of fluorosis in endemic forms in
Hyderabad State - Indian Med. Gaz. 80, 332-336, 1945.
Siddiqui, A.H. Fluorosis in Nalgonda District,
Hyderabad - Deccan - Brit. Med. J. 2,
1408-1413, 1955.
Krishnamachari K.A.V.R., Krishnaswamy K.,-
Genu Valgum and osteoporosis in an area of
endemic fluorosis - Lancet 2, 877-879, 1973.

24. Nalgonda Reports (1945,1955,1973)
• Disease severe in laborers than those involved in sedentary occupations.
• Nutrition does play a role in the incidence.
• Diets of the region are very poor in calcium intake. Averaged about
300 mg in adults.
• High levels of fluoride in water supplies attributed to low levels of calcium in
soils and rocks (Netherland study).
• Genu valgum appeared in 1970’s which was not present in 1940s
and 1950.
• Bore wells, use of fertilizers and pesticides, sale of vegetables and dairy
products. Increase in fluoride intake and further deterioration of nutrition
appear to be the main culprits.

26. Sl.No. Sample Fluoride (ppm)
01 Rice 60
02 Brinjal 120
03 Bean (Bobbarulu) 120
04 Cucumber 80
05 Little gourd 160
06 Chillies (Powder) 60
07 Wheat 100
09 Turmeric 240
10 Millet (Jowar) 30
12 Bean (Chikkudu) 180
14 Gingerly 40
15 Tamarind 60
16 Green Gram 80
17 Millet (Sajjalu) 60

27. Amount of Fluoride in daily diet in endemic
villages, which consisted of 450 grams of Rice,
110 grams of pulses, 200 grams of jowar,
200 grams of vegetables, 20 grams of oil
and 1200 ml of water (in milligrams)

28. Village Fluoride in Milligrams
Naibai (2.0 - 6.2 PPM) 75.76
Yellareddyguda (2.6 - 10.0) 54.66
Yedavalli (4.4 - 7.5) 62.20
Note: In brackets are given fluoride levels in water
samples of the villages. Fluoride through water was
less than 20% to the total daily intake of fluoride.

29. …Dirishavancha Village

32. Estimation of Trace Elements in Drinking Water
Supplies of Podili, Darsi and Kanigiri Areas of
Andhra Pradesh
Estimation of trace elements in drinking water
supplies of three endemic fluorotic villages of Andhra
Pradesh - Vagella, Yellareddyguda and Yadavalli

33. Methodology
• Fluoride = Ion selective electrode
• Nitrate = Ultraviolet spectrometry
• T.D.S = Conductivity
• Ca & Mg = EDTA titration
• 60 trace elements = ICPMS technique
(Inductively coupled plasma
mass spectrometry)

34. Total Dissolved Solids mg/l 500
Total Hardness mg/l as Ca Co3 300
Fluoride mg/l 1.0
Nitrate mg/l 45
Calcium mg/l 75
Magnesium mg/l 30
Cadmium mg/l 0.01
Chromium mg/l 0.05
Drinking Water - Desirable Limit
Bureau of Indian Standards &
Central Public Engineering Organisation

35. Fluoride, Nitrate and TDS values
S.No. Fluoride (ppm)* Nitrate (ppm)** TDS (ppm)***
1 1.52 28 1302
2 0.95 5 315
3 0.75 5 339
4 0.3 5 294
5 1.61 2 774
6 1.05 144 1086
7 0.81 5 255
8 0.64 47 1272
9 0.36 12 306
10 2.75 210 2172
11 0.44 8 378
12 1.06 21 447
13 0.62 57 834
14 2.4 3 564
15 1.42 48 291
16 4.4 93 936
17 1.56 17 732
18 1.64 57 552
Mean 1.3489 42.6111 713.8333
SD 1.0154 56.1763 500.2407
*Acceptable level of fluoride in drinking water is 0.5 ppm for a tropical country like India
** Acceptable level of Nitrate in drinking water is 50 ppm
***Acceptable value of TDS in drinking water 500 ppm

36. S.No Li V Cr Fe Cu Zn Ga Se Sr Ba U B Mo Sb
1 3.8 172 2.6 80 12.6 56 3.4 9.2 418 60.6 15 524 38 1.14
2 3 14.726 2.3 109 55.1 181 2.52 2.12 330 41.7 1.44 101 2.8 0.82
3 3 18.01 4.57 122 80.4 180 2.18 4.51 306 36.8 1.45 100 2.1 0.52
4 3 17.5 1 99.5 5 5 2.51 1.99 285 42.4 1.47 102 2 2.53
5 18.9 74.4 14.3 312 226 223 17.8 6.79 1894 471 5.5 326 3.01 0.7
6 30.4 11.4 6.2 704 5.6 388 7.6 4.8 1204 214 3.6 212 2.2 1.06
7 3 14.1 4.3 112 5 5 2.44 2.66 328 40.6 1.44 106 2.5 0.96
8 54.2 7.35 13.2 513 6.15 10.76 6.34 4.89 1070 175 4.57 413 3.23 1.13
9 8.11 20.8 5.32 138 15.3 53.9 2.75 1.82 628 54.7 1.22 103 2 0.6
10 66 19.8 4.86 442 5 6.9 1.92 9.33 1866 37.2 13.2 687 39 0.6
11 3.27 21 1.04 112 5 5.88 3.73 5.46 306 102 1.58 102 2 0.66
12 5.59 12.7 6.66 85.4 77 175 2.66 2.86 698 44.5 2.67 143 2.18 0.73
13 19.8 24.57 14.09 268 5 85 11.79 4.86 1655 317 11.1 254 2 0.9
14 21.23 6.66 2.99 299 5 131 2.27 1.79 397 40.8 6.78 128 8.45 0.61
15 18.5 4.27 6.34 246 5 12.7 0.62 1.69 383 11.4 2.46 72.4 4.11 0.67
16 31.8 14 20.36 80 5 80.2 0.31 8.84 207 5.61 15.54 493 4.56 0.36
17 29.05 16.21 17.85 108 5 38.4 1.04 2.69 88.2 16.96 9.81 366 18 0.73
18 21.83 6.72 9.18 206 5 151 2.4 2.02 410 40.8 7.01 129 8.8 0.82
Min 3 4.27 1 80 5 5 0.31 1.69 88.2 5.61 1.22 72.4 2 0.36
Max 66 172 20.36 704 226 388 17.8 9.33 1894 471 15.54 687 39 2.53
Mean 19.13 26.45 7.62 224.21 29.34 99.37 4.12 4.35 692.95 97.39 5.88 242.3 8.16 0.86
Median 18.7 15.468 5.76 130 5 68.1 2.515 3.685 403.5 42.05 4.085 136 2.905 0.73
SD 18.24 39.36 5.87 175.45 55.157 102.85 4.38 2.65 585.29 123.37 4.98 183.87 11.73 0.466
7 158 155
List of extremely high trace elements
*All the trace element values in ppb.

37. S.No
Yellareddyguda
Nitrate TDS F Ca Mg
1 106 1350 8.85 60 50
2 29 954 7.25 50 45
3 16 363 1.45 50 15
4 120 1092 4.25 50 30
5 235 1914 3.05 120 50
6 358 2544 3.45 95 85
7 156 1806 3.6 75 70
8 8 960 5.1 35 50
9 128 1944 8.75 60 80
10 15 1206 5.75 45 30
Total 1171.00 14133.00 51.50 640.00 505.00
Min 8.00 363.00 1.45 35.00 15.00
Max 358.00 2544.00 8.85 120.00 85.00
Mean 117.10 1413.30 5.15 64.00 50.50
SD 112.55 635.51 2.49 25.91 22.54

39. 10.008.006.004.002.000.00
F
40
30
20
10
0
Frequency
Mean =2.0089
Std. Dev. =2.28876
N =94
F
Fluoride Levels in Water Supplies of
Endemic Areas of AP

40. 10000.008000.006000.004000.002000.000.00
Sr
40
30
20
10
0
Frequency
Mean =1591.2371
Std. Dev. =1670.01876
N =94
Sr
Strontium Levels in Water Supplies of
Endemic Areas of AP

41. Hanumantha Puram Village
in Prakasam
F : 0.9 - 1.7 ppm
TDS : 640 - 1500 ppm
NO3 : 50 - 890 ppm
Sr : 2487.73 - 9931.74 ppb
•
•
•
•

42. PH: 7.6 - 8.3, F: 0.3 - 1.5 ppm, Nitrates: 10 - 140 ppm,
TDS: 380 - 790 ppm, Uranium: 5.20 - 14.39 ppb,
Chromium: 6.35 - 31-98 ppb, Cadmium: 0.01 - <0.01 ppb
PH 8.3, TDS 530, Nit 10, Fluorides 1.5

43. • 7 out of 18 water samples are good for
drinking in Prakasam District
• 4 out of 30 water samples were good for
drinking in Nalgonda and Chittoor Districts

44. National Symposium on Fluorosis
Hyderabad - October, 3-5,1974
Proceedings Published in 1977.
Geological survey of India

49. 96 - 99% of fluoride resides
in the skeleton. Fluorides
have an affinity to calcium
phosphate moiety of bones.
Rest in soft tissues

56. Neurological Sequelae of Fluorosis
• Mechanical in nature
• Radiculopathy due to compression of spinal
nerves.
• Myelopathy due to compression of spinal cord.
• Radiculo-myelopathy is common.
• Associated with evidence of dental fluorosis and
/or restriction of spine movements in endemic
area is diagnostic.
• Confirmation by X-rays and urinary and serum
fluoride level estimation.

67. Role of Magnesium
• Magnesium has a peculiar relationship with fluoride. Mg
forms 0.05% of body weight and it is essential. Mg helps in
elimination of fluoride from the body by competing with Ca.
• Fluorosis incidence is less in villages where the water
content of Mg is high.
• Daily requirement of Mg is 350-500 mg.
• Intravenous magnesium oxide and hydroxide injection
increases urinary fluoride excretion in fluorotic dogs.

68. Role of Vitamin C
• Pandit’s studies in endemic areas of fluorosis of
Prakasam district proved that incidence of fluorosis
was high in individuals whose diet was poor in vitamin
C content. Daily requirement of vitamin C is 40 mg.
• How this vitamin affects fluoride metabolism is not
known at present.

69. • Biological effects of fluoride intoxication are related to the
total amount of fluoride ingested, whatever the source be
it food, water or both. The factors, which govern the
development of fluorosis, are:
– The prevalence of high levels of fluoride intake.
– Continued exposure to fluoride.
– Strenuous manual labor.
– Poor nutrition especially deficient intake of calcium,
magnesium and vit. C.
– Impaired renal function due to disease.
– Presence abnormal amounts of trace elements like
Uranium, Strontium that may aggravate fluoride toxicity.

72. Main sources of Fluoride
• Drinking water
• Staple foods grown
in these regions
• Tea & sea foods

73. Millennium development goals to be achieved by 2015
• Halving poverty and halving the population of people
without access to safe drinking water

74. Defluoridation Plants
• Based on Nalgonda technique-lime and alum
method.
• Addition of aluminum salts, lime and bleaching
power followed rapid mixing, flocculation,
sedimentation, filtration and disinfection.
• None of the 29 plants installed in Nalgonda
district are working.

76. Domestic Defluoridation Units
• Based on filtration of fluoride rich water with
PAC granules (Activated Alumina).
• Specific safe water yield depends upon the
amount of activated alumina and its depth.
Decrease in yield with decrease in AA depth
and cycles of use (IIT Kanpur). DDU
design is very important.

77. …Domestic Defluoridation Units
• 850 rupees needed for every 3months of use.
• Aluminum compounds are being incriminated in the
causation of Alzheimer’s disease. Raising the PH
is the one way to lessen the amount of AL but
Defluoridating property diminishes with increase
in PH, which is best at 6.5.

78. Alleviation of Endemic Fluorosis - Action Plan
AP Villages (28,123)
Towns 210
Check the teeth of school children
Brown / Yellow pigmentation
Non-Fluorotic Fluorotic
Low endemicity (only have
dental fluorosis)
Milk to children to prevent
valgus deformities
High Endemicity have
• Genu valgum
• Skeletal
• Crippling
Investigations
• Fluoride estimation of all water sources
• Trace Element estimation of all water sources
• Estimate the contribution of water and food to the total
daily intake of fluoride
Predominantly water borne -
supply water containing optimum
fluoride levels
Predominantly Food related- in
addition supply water for
cultivation

80. Optimum Fluoride Level in
Drinking Water Supplies
• Srikantia, S.G., Permissible levels of fluoride in drinking
water. Proceedings of the symposium on fluorosis
October 1974. Indian Academy of Geoscience,
Hyderabad, India 1977. P.407-409.
• ICMR & WHO - 1.5 PPM
• The WHO noted that setting a national standard for
fluoride it is particularly important to consider the
climatic conditions, water intake and intake of
fluoride from other sources such as food

82. General Name Telugu Calcium Magnesium Vitamin-C
Equivalent Name (in Mg/100gm of the food source)
Ragi Ragulu 344 -- --
Agathi Avisagu 1130 -- 169
Amaranth Thotakura 530-800 4.2 179
Colacasia leaves Chama Aaku 1546 12.8 --
Curry leaves Karvepaku, Curry Pattha 836 -- --
Poppy feed Ghasalu, Khus Khus 1584 9.9 --
Jagary Gur / Bellum 1638 -- --
Gingelly seeds Nuuvulu / Til 1450 5.2 --
Jowar Jonalu -- 171 --
Cummin Jeera Jeelakara 1080 475 --
Amla Usrikaya -- -- 600
Green chilly Hari Mirch -- -- 111

84. Summary
• Fluorosis is a major public health problem in our country
affecting millions of people in 20 odd states and hence the
central government should take it up as Fluorosis control or
eradication programme.
• ICMR should fix 0.5 PPM of fluoride as a permissible safe
upper limit of fluoride in drinking water supplies in our country.
• Every fluoride affected village must be provided with safe
drinking water preferably from perennial river nearby and
stop wasting money on erecting defluoridation plants.

85. Thank you