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Fluorosis

Dr Soni RaniPGTDepartment Of Community MedicineKatihar Medical College

Presentation outline IntroductionPrevalence of fluorosis Causes and risk factors Mechanism of fluorosisSymptomsDiagnosis Prevention and Control

IntroductionFluorosisis a crippling disease resulted from deposition of fluorides in the hard and soft tissues of body. It is a public health problem caused by excess intake of fluoride through drinking water/food products/industrial pollutants over a long period. Ingestion of excess fluoride, most commonly in drinking-water affects the teeth and bones.

IntroductionIt results in major health disorders like dental fluorosis, skeletal fluorosis and non-skeletal fluorosis.

People exposed to large amounts of fluoride show dental effects much earlier than the skeletal effects.

Dental fluorosis affects children and discolors and disfigures the teeth.

IntroductionSkeletal fluorosis affects the bones and major joints of the body like neck, back bone, shoulder, hip and knee joints resulting in to severe pain, rigidity or stiffness in joints.

Severe forms of skeletal fluorosis results in marked disability.

IntroductionNon-skeletal forms of fluorosis are earlier manifestations, which develop long before the onset of typical changes in teeth and skeletal bones

these are seen as gastro-intestinal symptoms and may overlap with other diseases leading to misdiagnosis.

It affects men, women and children of all age groups.

Permissible level of fluoride in waterThe WHO has set the standard of fluoride in drinking water at 1.5 mg/l to be adopted by nations. According to guidelines of WHO, the climatic conditions, volume of water consumed and intake from other sources should be considered while setting nations standards. BIS( Bureau of Indian Standards) has fixed the upper limit at 1 mg/l.Level of 0.5 mg/l has been favored in 2000 AD by international workshop held in Thailand.

Prevalence- WorldFluorosis is worldwide in distribution and endemic at least in 25 countries. It has been reported from fluoride belts: One that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya.Another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan.

Prevalence- World

Prevalence-IndiaHigh levels of Fluoride were reported in 275 districts of 20 States of India (after bifurcation of Andhra Pradesh in 2014). Over 70-100% of districts are affected in the state of Rajasthan, Gujarat, Andhra Pradesh. 40-70% of districts are endemic in states of Paunjab, Haryana, Delhi, UP, Bihar, MP, Maharashtra, Karnataka and Tamil Nadu.10-40% districts are endemic in J&K, Assam, West Bengal, Odisha and Kerala.

Fluoride content ( Household)

CausesFluorosis is caused by excessive intake of fluorides from multiple sources such as in food, water, air (due to gaseous industrial waste), and excessive use of toothpaste.

However, drinking water is the most significant source.

CausesModerate-level chronic exposure (above 1.5 mg/litre of water - the WHO guideline value for fluoride in water) is more common.

Acute high-level exposure to fluoride is rare and usually due to accidental contamination of drinking-water or due to fires or explosions.

CausesFluoride in water is mostly of geological origin.

Water with high levels of fluoride content are mostly found at the foot of high mountains and in areas where geological deposits are collected in sea.

The drinking water fluoride so far detected in the country ranges from 0.2 to 48 mg/ liter.

Risk factorsSeveral of the ready to serve foods, beverages, snacks have high content of black rock salt (CaF2) or kala namak (which has 157ppm fluoride) and red rock salts.Tobacco or supari (aracanut) when they are chewed.Intake of certain drugs such as fluoroquinolone antibiotics, few anti-depressants, some anti-fungal drugs, cholesterol-lowering drugs, steroids and anti-inflammatory drugs, arthritis drugs, antacids, drugs for osteoporosis and otosclerosis can contribute to fluoride toxicity over time.

Risk factorsPerson with calcium deficiency or malnourished individuals appear to be more prone to develop dental and skeletal fluorosis.Fluoridated toothpastes: Indian studies have also shown that absorption of fluoride takes place within minutes after brushing the teeth with fluoridated toothpaste.Fluoridated beverages.

Risk factorsFluoride-rich foods such as tea, ocean fish, gelatin, skin of chicken, fluoridated salt, food contaminated with post-harvest fumigants (e.g. sulfuryl fluoride) and pesticides (e.g. sodium aluminium fluoride, Na3AlF6, which may be used on grapes).Fluoride from any other environmental sources, including cigarette smoke and industrial pollution.Others involved with power, welding, water fluoridation plants, refrigeration, rust removal, oil refining, plastics, pharmaceuticals, tooth-paste, chemicals, and automobiles.

Risk factorsFluorosis, in its severe forms, is mostly restricted to a particular climate zone in the world -- the areas with semi-arid tropical conditions. In these areas, the consumption of drinking water is high and the population is more vulnerable to the disease as compared to their counterparts in colder areas with low consumption of water, though the fluoride content of water in both the areas may be the same.

Risk factorsDiets rich in fat have been reported to increase deposition of fluoride in bones.Dental fluorosis can only occur if the fluoride exposure is during the first years of life while the teeth are forming.In China, fluoride toxicity occurs with: brick tea and food contaminated with fluoride during drying of chilies and corn with coal briquettes.

Mechanism of fluorosisOnce fluoride enters the body either through the blood vessels in the mouth or through the gastrointestinal route, it reaches the various organs and tissues in the body.

Fluoride (F) being an electronegative element, having a negative charge is attracted by positively charged ions like calcium (Ca++).

Mechanism of FluorosisBone and tooth having highest amount of calcium in the body, attract the maximum amount of fluoride and is deposited as calcium fluorapatite crystals.

At the same time, from certain areas in the bone and tooth, the unbound calcium is lost.

Symptoms It is not necessary that all symptoms are present at the same time. The severity and duration, (which is often episodic), depend on Persons age, nutritional status, environment, kidney function, amount of fluoride ingested, genetic background, tendency to allergies, andother factors such as hardness of the water due to presence of calcium and magnesium.

Dental fluorosis:

Clinical dental fluorosis is evident by staining and pitting of the teeth. In more severe cases all the enamel may be damaged.Ingestion of fluoride after six years of age will not cause dental fluorosis. The teeth could be chalky white and may have white, yellow, brown or black spots or streaks on the enamel surface. Discoloration is away from the gums and bilaterally symmetrical.

Skeletal fluorosis: The early symptoms of skeletal fluorosis, include stiffness and pain in the joints. In severe cases, the bone structure may change and ligaments may calcify, with resulting impairment of muscles and pain. Constriction of vertebral canal and intervertebral foramen exerts pressure on nerves, blood vessels leading to paralysis and pain.

Non skeletal fluorosisGastrointestinal symptoms: Abdominal pain, excessive saliva, nausea and vomiting are seen after acute high-level exposure to fluoride.Neurological manifestation: Nervousness and depression, tingling sensation in fingers and toes, excessive thirst and tendency to urinateMuscular manifestations: Muscle weakness & stiffness, pain in the muscle and loss of muscle power, inability to carry out normal routine activities.

Non skeletal fluorosisAllergic manifestation: Skin rashes, Perivascular inflammation: pinkish red or bluish red spot, round or oval shape on the skin that fade and clear up within 7-10 days.Low haemoglobin levels:Fluoride accumulates on the erythrocyte (red blood cells) membrane, which in turn looses calcium content.The membrane which is deficient in calcium content is pliable and is thrown into folds. The shape of erythrocytes is changed. Such RBCs are called echinocytes, and found in circulation. This would lead to low haemoglobin levels in patients chronically ill due to fluoride toxicity.

Non skeletal fluorosisEffects on foetus: Fluoride can also damage a foetus, if the mother consumes water/food with high concentrations of fluoride during pregnancy/breast feeding. Abortions, still births and children with birth defects are common in endemic areas.Urinary tract manifestationsUrine may be much less in volume; yellow-red in colour and itching in the region may occur.Ligaments and blood vessel calcification:A unique feature of the disease is soft tissues like ligaments, blood vessels tend to harden and calcify and the blood vessels may be blocked.

Other types of fluorosisHydrofluorosis

Industrial fluorosis

Neighborhood fluorosis

DiagnosisAll the substances containing fluoride should be avoided during diagnosis.

If the symptoms are caused by fluoride, they should diminish markedly within a week and largely disappear within several weeks.

Gastrointestinal symptoms settle within 15 days.

(Physical tests for detection of skeletal fluorosis in endemic areas)Coin test

Chin test

Stretch test

Coin test The subject is asked to lift a coin from the floor without bending the knee.

A person with skeletal fluorosis would not be able to lift the coin without flexing the large joints of lower extremity (unable to bend without bending knee, test is present in other disease also).

Chin test/ Stretch test 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, he/she is unable to bend the neck-touching the chest with chin is not possible.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 touch the back of the head.

RadiographsX-ray would reveal increased girth, thickening and density of bone, ligaments calcified.Maximum ill effects of fluoride are detected in the neck, spine, knee, pelvic and shoulder joints. It also affects small joints of the hands and feet.

SA/GAG test(Sialic acid / Glycosaminoglycan test)The SA/GAG test is for early detection/diagnosIs of fluoride toxicity.

The value of SA/GAG will be reduced in fluorosis and will be significantly elevated in ankylosing spondylitis.

The SA/GAG value shows no significant change in arthritis, osteoporosis and spondylosis.

Estimation of Fluoride contentDrinking water- 1.0 ppm (parts per million) is considered as the permissible upper limit for fluoride content in drinking water.

Blood (serum):The serum fluoride levels may or may not be informative as fluoride in circulation never maintains a steady state; it is diverted to other tissues; absorbed by tissues and excreted.

Estimation of Fluoride contentUrine(24 hrs collection if possible): The urinary fluoride level is more useful compared to the blood fluoride level.

If the subject has been ingesting food, water, drugs or any other substance contaminated with fluoride, urinary fluoride is bound to be high.

History taking is an important task in the diagnosis).

Haemoglobin estimation:for detection of anaemia.

PreventionFluorosis can be prevented by avoiding excessive intake of fluoride by individuals / community.Excessive fluoride intake and its adverse effects can be minimized or prevented by adapting following measures:by using alternative water sources,by defluoridation of water,by improving the nutritional status of population/individuals at risk.

Alternative water resourcessurface water, rainwater, and low fluoride ground water:Surface water: If surface water is used for drinking purposes particular caution is required, since it is often contaminated with biological and chemical pollutants. Surface water should be used after proper disinfection with simple and low cost method such as sand filtration, ultra violate disinfection; chlorination (may be adequate in some places but not all places.)

Alternative water resourcesRainwater: It is usually cleaner and low cost simple source, but problem is for large storage of water and large reservoir in the communities and households.Low fluoride ground water- fluoride content can vary in wells in the same area, depending on the geological structure of the aquifer and the depth at which water is drawn. Deepening tube wells and digging new wells in another site may be helpful. Fluoride is unevenly distributed in ground water both vertically and horizontally.

Defluoridation of waterUse of safe drinking water with safe fluoride levels is the preferred option for the prevention of fluorosis; however access to safe water in fluorosis endemic areas is limited.

The de-fluoridation (removing excessive fluoride from drinking water) is the only solution; this can be done by different methods:

Defluoriditation Of waterChemical Adsorption Ionic Separation Alum Coagulant ( Nalgonda Tech)Electrolyte defluoridation

Chemical precipitationAlum coagulation/Flocculation:The Nalgonda technology (named after Nalgonda in Andhra Pradesh, India, where first community de-fluoridation plant was set up) is based on the principle of flocculation. This technique was developed by the National Environmental Engineering Research Institute (NEERI), Nagpur, India.Raw water is mixed with aluminum sulphate (alum: hydrate aluminum salt)), lime or sodium carbonate (1/20th of alum, as process is best carried out under alkaline conditions) and bleaching powder (3 mg/l, is added to disinfect the water).This Technique is suitable for community and house hold levels.

Chemical precipitationAt household level a bucket of water (20 liters) is mixed with alum, lime and bleaching ( doses of alum and lime are determined after assessing the fluoride content and alkalinity of water) and left for coagulation and settling of the flocks at the bottom of bucket for at least one hour. The treated water is withdrawn through a tap 5 cm above the bottom of the bucket, safely above the sludge level. Store the water for the drinking purposes in another bucket and discard the sludge.

Chemical precipitationElectrolyte defluoridation:Solar Energy Based Electrolytic Plants are installed by NEERI in few endemic areas of fluorosis. In this process when direct current is passed through the aluminum electrodes in water (containing excessive fluoride),Active species of hydroxide of aluminum are produced;which adsorb the fluoride ions present in the water resulting in the formation of the sludge and treated water (which is used for drinking).Dried sludge can be disposed in the land filling or may be used in brick making.

AdsorptionThis 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 is also suitable for both community and household levels.Once adsorbent become saturated with fluoride ions filter is backwashed with a mild acid or alkali solution, as the backwashing material is rich in fluoride, it should be disposed off carefully so that not re contaminating nearby ground water.

Ionic separationReverse Osmosis FiltrationElectrodialysis

Better nutritionmeasures to improve nutritional status (intake of calcium and vitamin C, iron, antioxidants) of affected population particularly children are an effective supplement to technical solutions mentioned above.

Mothers in affected areas should be encouraged to breastfeed since breast milk is usually low in fluoride.

Caution..!Following procedures do not remove fluoride:

Boiling water: will concentrate fluoride content rather than removing it.

Freezing water: does not affect concentration of fluoride

Activated carbon:filters do not remove fluorides.

Program for prevention and control of fluorosis

The Rajiv Gandhi National Drinking Water Mission started by Ministry of Rural Development worked for control of fluorosis through its awareness campaign from 1987- 1993, (coordinated by Fluorosis Control Cell at the All India Institute of Medical Sciences, Delhi) had a limited coverage. In 2008-09, Ministry of Health and Family Welfare, Government of India launched a National Programme for Prevention and Control of Fluorosis (NPPCF) with the aim for prevention, diagnosis and management of fluorosis in endemic areas.

National Programme for Prevention and Control of Fluorosis (NPPCF)Ministry of Health and Family Welfare, Government of India during 11thfive year plan started the programme with the Goal of prevent and control fluorosis in the country. Programme ( 100% centrally sponsered) is 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) Additional 84 new districts are to be taken up during the remaining period of 12th Plan.

Objectives of NPPCFTo collect, assess, and use the baseline survey data of department of drinking water supply for starting the project.

Comprehensive management of fluorosis in selected areas.

Capacity building for prevention, diagnosis and management of fluorosis cases.

Strategy for NPPCFSurveillance of fluorosis in the community;Capacity building (human resource) in the form of training and manpower support;Establishment of diagnostic facilities in the medical hospitals;Management of fluorosis cases including treatment surgery, rehabilitation;Health education for prevention and control of fluorosis.

Guideline for surveillance of Fluorosis in communityCase definition

Sampling Procedure

Survey Methodology

Case definition Suspect case:Dental fluorosis (in Children)Any case with a history of residing in an endemic area along with one or both of the followingChalky white teeth/ white spot on white enamel surface.Transverse yellow, brown/black bands or spots on enamel surface ( Discoloration away from the gums and bilaterally symmetrical.)

Case definition Skeletal fluorosisAny case with a history of residing in an area with fluoride above 1.0mg/l along with one or more following health complaints- Severe pain and stiffness in neck, back bone (lumber region) , shoulder, knee and hip region. Pain may commence either in 1 or 2 or more joints. Patient has restricted mobility of cervical/lumber spine and to turn the whole body towards the side to see.

Case definition Knock knee/ Bow leg ( in children and adolescents )Inability to squat ( in advance stage of skeletal fluorosis )Ugly gait and posture ( in advance stage of skeletal fluorosis )

Case definition Non skeletal fluorosis- Any case with history of residing in an endemic area along with one or more of the following health complaints-GASTROINTESTINAL PROBLEM- Consistent abdominal pain, intermittent diarrhea/ constipation, bloated feeling, nausea, loss of appetite.

Case definition Neurological manifestations- Nervousness and depression, tingling sensations in fingers and toes, excessive thirst and tendency to urinate frequently (polydipsia and polyuria) Muscular Manifestations- Muscle weakness and stiffness, pain in the muscle and loss of muscle power, unable to walk and work.

Confirmation of a caseAny suspected case with clinical history can be confirmed by following tests

Urine fluoride level ( >1 mg/dl)

X- Ray forearm- interosseous membrane calcification.

Serum fluoride level.

Sampling Procedures The information on fluorosis endemic area is obtained from public health engineering department. The survey is to be conducted by district officials of district programme cell ( Fluorosis).Based on level of fluoride content the villages can be identified in three categories-

Sampling Procedures StrataFluoride levelIUp to 1.0-3.0 ppm II3.1- 5.0 ppmIII>5.0 ppm

Sampling Procedures If the number of villages is up to 20, then all the villages will be surveyed. If the number of villages is more than 2o, then 10% of village from each stratum ( at least 20 villages in total) will be selected randomly and surveyed. In each of these villages, children aged 6-11 years from primary school are surveyed for Dental fluorosis.

Sampling Procedures In randomly selected 20 households of sample villages where dental fluorosis is prevalent in school children, survey is conducted for skeletal and non skeletal fluorosis.

The suspected case on survey are confirmed by X- Ray forearm and fluoride level in Urine (>1.0 g/dl).

Management Early Diagnosis-Suspected cases are confirmed by X-ray/ Urine /Serum/ drinking water fluoride level.The disease is easily preventable if diagnosed early and steps are taken to prevent intake of excess fluoride.Dental and skeletal fluorosis is irreversible and no treatment exists, the only remedy is prevention by keeping fluoride intake with in safe limits.

Treatment Medical treatment includes supplementation with vitamin C,D, antioxidants, calcium and treatment of malnutrition.Treatment of deformities includes conservative management through corrective plasters in children and provision of orthopedic appliances. Selected cases with knee deformity, cases with compressive myelopathy and those with pathological fractures need surgical intervention.

Treatment Dental fluorosis treatment:

tooth whitening for mild fluorosis cases

composit bonding

Porcelain veneers

Health EducationSensitizing the community with information on fluorosis, importance of drinking safe water and about healthy diet are important for prevention and control of fluorosis.

Water contaminated with fluoride more than 1ppm should not be consumed.

Health EducationHigh fluoride containing products viz., Supari, tobacco, black rock salt, red rock salt (Sindhi), Drugs and cosmetics like toothpaste, mouth rinses and any other products proven to have high fluoride should be avoided.

Intake of foods (rich in calcium, iron, vitamin c, other antioxidants), such as milk, curd, green leafy vegetables, fruits should be advocated.

Human Resource DevelopmentTo develop adequate human resource both in Health and Public Health Engineering Sectors.Special focus is laid on updating the information for medical personnel/doctors to recognize the disease. In a similar manner, the focus for public health engineering department/ integrated child development services (ICDS) and other departments is to practice early detection of endemic areas and proper water management.

Expected Outcome of NPPCF

Number of fluorosis cases managed and rehabilitated in the programme districts Capacity for laboratory testing for fluoride in water, urine to be developed. Trained health sector manpower in Government set up for measuring fluoride in urine and waterImprove information base for the community and all concerned in the programme districts.

References National programme for prevention and control of fluorosis, Revised guideline( 2014). Health and family welfare, Govt. Of India. Health policies and programmes in India, 15th edition, Dr. D K Taneja.Textbbok of Community Medicine, Preventive and social medicine, sunder lal/ Adarsh/ pankaj 5th edition. Parks Text Book Of Preventive & Social Medicine, 24th edition.