This presentation contains problem statement, reason of fluorosis, endemic areas, management and national program for fluorosis in India.

1. Dr Soni Rani
PGT
Department Of Community Medicine
Katihar Medical College

2. Presentation outline
1. Introduction
2. Prevalence of fluorosis
3. Causes and risk factors
4. Mechanism of fluorosis
5. Symptoms
6. Diagnosis
7. Prevention and Control

3. Introduction
 Fluorosis is 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.

4. Introduction
 It 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.

5. Introduction
 Skeletal 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.

6. Introduction
 Non-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.

7. Permissible level of fluoride in
water
 The 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.

8. Prevalence- World

10. Fluoride content ( Household)
≤ 1.0 ppm
61%
1.01 to 1.5 ppm
13%
≥1.5ppm
26%

11. Causes
 Fluorosis 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.

12. Causes
 Moderate-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.

13. Causes
 Fluoride 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.

14. Risk factors
 Several 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.

15. Risk factors
 Person 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.

16. Risk factors
 Fluoride-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.

17. Risk factors
 Fluorosis, 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.

18. Risk factors
 Diets 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.

19. Mechanism of fluorosis
 Once 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++).

20. Mechanism of Fluorosis
 Bone 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.

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

22. 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.

23. 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.

24. Non skeletal fluorosis
 Gastrointestinal 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 urinate
 Muscular manifestations: Muscle weakness &
stiffness, pain in the muscle and loss of muscle power,
inability to carry out normal routine activities.

25. Non skeletal fluorosis
 Allergic 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.

26. Non skeletal fluorosis
 Effects 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 manifestations Urine 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.

27. Other types of fluorosis
 Hydrofluorosis
 Industrial fluorosis
 Neighborhood fluorosis

28. Diagnosis
 All 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.

29. (Physical tests for detection of
skeletal fluorosis in endemic areas)
1. Coin test
2. Chin test
3. Stretch test

30. 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).

31. 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.

32. Radiographs
 X-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.

33. 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.

34. Estimation of Fluoride content
 Drinking 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.

35. Estimation of Fluoride content
 Urine (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.

36. Prevention
 Fluorosis 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:
A. by using alternative water sources,
B. by defluoridation of water,
C. by improving the nutritional status of
population/individuals at risk.

37. Alternative water resources
 surface 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.)

38. Alternative water resources
 Rainwater: 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.

39. Defluoridation of water
 Use 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:

40. Defluoriditation Of water
Chemical Adsorption
Ionic
Separation
Alum Coagulant (
Nalgonda Tech)
Electrolyte
defluoridation

41. Chemical precipitation
 Alum 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.

42. Chemical precipitation
 At 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.

43. Chemical precipitation
 Electrolyte 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.

44. Adsorption
 This 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.

45. Ionic separation
 Reverse Osmosis Filtration
 Electrodialysis

46. Better nutrition
 measures 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.

47. 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.

49.  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.

50. National Programme for Prevention and
Control of Fluorosis (NPPCF)
 Ministry of Health and Family Welfare, Government of
India during 11th five 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.

51. Objectives of NPPCF
 To 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.

52. Strategy for NPPCF
 Surveillance 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.

53. Guideline for surveillance of Fluorosis in
community
 Case definition
 Sampling Procedure
 Survey Methodology

54. Case definition
1. Suspect case:
 Dental fluorosis (in Children)
 Any case with a history of residing in an endemic
area along with one or both of the following
 Chalky 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.)

55. Case definition
Skeletal fluorosis
 Any case with a history of residing in an area with
fluoride above 1.0mg/l along with one or more
following health complaints-
1. 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.

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

57. 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-
1. GASTROINTESTINAL PROBLEM-
 Consistent abdominal pain, intermittent
diarrhea/ constipation, bloated feeling, nausea,
loss of appetite.

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

59. Confirmation of a case
 Any 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.

60. 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-

61. Sampling Procedures
Strata Fluoride level
I Up to 1.0-3.0 ppm
II 3.1- 5.0 ppm
III >5.0 ppm

62. 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.

63. 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).

64. 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.

65. 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.

66. Treatment
Dental fluorosis treatment:
 tooth whitening for mild fluorosis cases
 composit bonding
 Porcelain veneers

67. Health Education
 Sensitizing 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.

68. Health Education
 High 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.

69. Human Resource Development
 To 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.

70. Expected Outcome of NPPCF
A. Number of fluorosis cases managed and
rehabilitated in the programme districts
B. Capacity for laboratory testing for fluoride in water,
urine to be developed.
C. Trained health sector manpower in Government set
up for measuring fluoride in urine and water
D. Improve information base for the community and all
concerned in the programme districts.

71. 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.