D. Dutta Consultant. NPPCF Govt. of West Bengal Office of the Chief Medical Officer of Health Bankura Pin-722101

1. Training Programme
on
Fluorosis Control Programme
Presented By
Dibyendu Dutta
Consultant
Fluorosis Control Programme
BANKURA
Mob. No- 8900336639

2. Fluorosis Control Programme : Importance
Importance of this Programme in this District
i) Fluorosis is a crippled disease. It makes immobilized the patient
day by day. Where as no exact mortality is found but its makes the
people crippled and some cases painful. With out mobility
people can not earn and life going unhealthy ,
stopped.
ii) Fluorosis is a chronic disease. Its affect the people slowly and makes
preliminary symptoms -> dental fluorosis -> skeletal fluorosis -> spinal
compression ->Crippled disorder. As it is due to make by slowly ingestion
of fluoride(more then 1.5 PPM) in drinking water , its severity is very
much higher.
iii) Affected people :
Bankura : 90,702.
Affected Village: 205
Affected Habitaion: 1005
Affected Tube well: 778
Fluoride range: up to 12.69 ppm water.

3. Fluorosis Control Programme : Status of West
Bengal

4. Fluorosis Control Programme : Status of
Bankura
 Persons suffers from Fluorosis in India : 6 Million
 (Dr. Raja Reddy , NIN ,
Hyderabad)
 Persons suffers from Fluorosis in West Bengal: 2.20 Lakh
 Persons Suffers from Fluorosis in Bankura: 90,742
 Current Status of Fluorosis In Bankura District

5. GIS Mapping of fluorosis endemic Block

6. Fluorosis Control Programme : Magnitude
of the problem
 West Bengal are worst affected from fluorosis. In Bankura
District Fluorosis Unit had already been find that :
 Water –fluoride level various from: 1.00 PPM – 12.69 PPM
(Machatora,Simlapal)
 Patient Blood-fluoride level: Sujit Gulimajhi 22/M
(Jamda,Simlapal)0.89 ppm Jenu Valgaum. Severe Dental
Fluorosis. Joint Pain and Back Pain.
Highest Urine fluoride level: Bulu Bedia ,Kamladanga
11.25 PPM .
In all these States, the drinking water has high fluoride content but the information
about the various food items and industrial emission having high fluoride level is not available.
 Permissible limit for fluoride, as per BIS, is 1 ppm in
drinking water.

8. Fluorosis Control Programme : Magnitude
of the problem

9. Dental fluorosis at Bankura District

10. Skeletal Fluorosis at Bankura District

11. Fluorosis Control Programme :
Surveillance Methodology and
Promotion of the Fluorosis
Control Programme

12. Assessment of the Problem
Under the National Programme for Prevention and Control
of Fluorosis, the district laboratory is established/
strengthened for confirmation of fluorosis cases, the
district cell under district nodal officer is created, staffed
with consultant and field investigators and funds are
provided for mobility support for undertaking community
based surveillance. The surveillance would also provide the
database for impact assessment of the programme. The
case definitions, sampling procedure and survey
methodology are as under:
(Dr. Pasha,National Consultant)

13. A : Case Definition
 Suspect Case:
 Dental Fluorosis:
Any case with a history of residing in an endemic area
along with one or both of the followings:
 Chalky white teeth
 yellow brown/dark brown bands

14. A : Case Definition
Skeletal Fluorosis
Any case with a history of residing in an
endemic area along with one or more of the
following:
 Severe pain and stiffness in neck and back bone.
(Patient has to turn the whole body towards that side
to see)
 Severe pain and stiffness in joints.
 Severe pain and rigidity in the hip region ( pelvic
girdle)
 Knock knee/ Bow leg
 Inability to squat
 Ugly gait and posture

15. A : Case Definition
Non skeletal Fluorosis
Any case with a history of residing in an
endemic area along with one or more of
the followings
 Gastro - intestinal problems: Consistent abdominal pain,
intermittent diarrhea/Constipation, blood in stool
 Neurological manifestations: Nervousness & depression,
tingling sensation in fingers and toes, excessive thirst and
tendency to urinate frequently (Polydipsia and polyuria)
 Muscular manifestations: Muscle weakness & stiffness, pain in
the muscle and loss of muscle power.

16. A : Case Definition
 Confirmed Case:
Any suspect case with one or more of the
followings:
 Any suspect case with high level of fluoride in urine
(>1ppm).
 Any suspect case with interossius membrane
calcification in the fore arm confirmed by X-ray.

17. B - Sampling procedure
The information on fluorosis endemic areas along with
fluoride level in the drinking water sources is to be
obtained from Public Health Engineering Department
(PHED) of respective endemic states.
 Fluoride level in all the drinking water sources is to be
estimated by PHED.
 Based on the level of fluoride content, the villages will be
stratified in the following 3 strata as under:
Strata Fluoride Level
 I 1 - 3 ppm
II 3.1 – 5 ppm
III > 5 ppm

18. Sampling procedure
 For prevalence of fluorosis cases, 10% villages of each
strata will be selected randomly. If number of villages
is up to 20, then all the villages will be surveyed. If
number of villages is more than 20, then 10% of
villages from each strata (at least 20 villages in total)
will be surveyed.
 All the children in the age group of 6 to 11 years from
the primary school (3rd to 5th standard) in the
selected villages of the district will be surveyed for
prevalence of dental fluorosis.
 Survey for skeletal and non-skeletal fluorosis cases
would also be carried out in 20 households of
randomly selected villages of the district where dental
fluorosis is prevalent in school children.

19. C - Survey Methodology
 Details of survey for dental fluorosis in school children
will be collected on predesigned proforma and for skeletal
and non-skeletal fluorosis cases in villages would be
conducted by trained investigators.
 The information on demographic profile, dietary intake,
drinking water source and clinical manifestations of
fluorosis in the suspected member (s) of the family will be
collected in the predesigned format.
 Urine samples from fluorosis suspected cases will be
collected for confirmation.
 The suspected cases would be confirmed for interossius
membrane calcification in the fore arm by X-ray and
fluoride level in urine (>1ppm).

20. Survey Methodology
Analysis of urine sample
Sample Collection:
 15 ml of spot urine sample of the suspected cases
will be collected in 25ml of plastic screw capped
bottles.
 Put 1 - 2 drops of toluene on urine samples to make
a complete layer as preservative.
 Each sample should be properly labeled with
number and relevant details.

21. Survey Methodology
 Transportation of samples:
 Urine samples should be sent to district laboratory
within a weeks time.
 Samples can be kept at room temperature at district
laboratory if not being analyzed immediately.
*Report should be sent to State Nodal officer
on the predesigned Performa with a copy to
Adviser (Nutrition), DGHS, New Delhi
(Dr. Pasha,National Consultant)

22. Guidelines for Training
Training in a programme is a key step for its successful
implementation.
A pool of trainers will be generated at state/ district level
to provide training of different category of health care
providers at different level.
1. Training of Trainers
2. Medical Officer
3. Laboratory Technicians
4. Paramedical
5. Training of Health Workers, ASHA and AWWs
6. Policy makers &
7. Advocacy PRIs & VHSC& Teachers

23. Guidelines for Comprehensive
Management of Fluorosis Cases
 Guidelines for Comprehensive Management
of Flurosis Cases are:
 Early Detection &
 Prompt Intervention

24. Comprehensive Management
Early Detection:-
 It includes physical and radiological examination. During physical
examination the cases are to be identified as suspected cases and
confirmed cases. The symptoms of the suspected cases are as
follows:-
 Dental changes – chalky white tooth with mottled appearance
 Pain & stiffness of peripheral joints
 Deformities of lower limb
 The confirmation of the cases shall be undertaken by following
methods:
 Physical examination
 Radiological examination
 X-ray of forearm (AP view)
 X-ray of most affected part (AP & lateral views)
 Laboratory tests
 Urine analysis for fluoride level
 Blood analysis for fluoride level
 Analysis of drinking water for fluoride level

25. Comprehensive Management
 Prompt Intervention
The Prompt Intervention is to be planned in the
following manner:
 Health education
 Preventive measures
 Treatment
 Rehabilitation

26. Media Plan for Prevention and Control of
Fluorosis
The IEC Plan covering awareness generation and to bring
behavioural communication changes at the community level in
affected districts are very important in order to prevent and
control fluorosis in the community. For this there is a need:
 to educate community about adverse health effects of drinking water
with high level of fluoride,
 to educate the community about the safe drinking water sources in
their habitation and rain water harvesting measures to be adopted.
 to educate about the benefits of Nutritional interventions.
 The district level media team would be entrusted with the job of
advocating with the various functionaries of the district including
community level workers namely, ASHA, AWW, school teachers,
Panchayats, etc.

27. IEC Plan for Preventionand Control of
Fluorosis

29. Do’s and Don’ts in relation to Nutrition
intervention in fluorosis

Do’s Don’ts
Calcium rich food Black tea
Milk, Milk products Black/Rock salt
Green leafy vegetable Tobacco
Supari
Fluoridated tooth paste
Vitamin C rich food
Citrus fruits
Green leafy vegetables
Iron rich food
Green leafy vegetables
Guava, Banana, Brinjal

31. Programme Stacture and its Overview (NPPCF, Bnakura)
The Adviser (Nutrition) The District Consultant
MH&FW.New Delhi.India (NPPCF.Bankura)
The National Consultant(NPPCF) The District Lab Tech
(NPPCF)
The DHS
SH&FW. W.B.
Field Workers
The Add. DHS(PH&CD) (NPPCF)
SH&FW. Swasthya Bhaban. Kol-91.
W.B.
The Dy.DHS(PH&CD)
and
The ADHS(MPHWS) & SPO (NPPCF)Swasthya Bhaban. Kol-91. W.B.
The CMOH
and District Programme Officer. (NPPCF)
The Dy. CMOH-II
and District Nodal Officer(NPPCF)

32. Performance and duties done by District Fluorosis Control
Unit.Bankura.
• Successful implementation of this National
Programme
• Monitoring the programme by consulting all its
The District Consultant Stake-Holders/Concern Persons under direct
control of District Programme officers/District
Nodal Officers.
• Management and safe operating of Lab.
Instrument.
The District Lab Tech • Make ready report , Testing of Collected sample and as
necessary he should also visit the endemic village for blood
collection under supervision of his consultant and direct
control od district officers.
• Field Survey , sample collection and make ready
report.
• Make data-entry of patient line listing (As per state
Field Investigators needed)
• This National Programme will be successful if all district
programme holders wants.

33. Promotion of the Programme
1. Involvement should be made of Block level
2. BPHN/PHN supervise the screening of fluorosis cases and collection
of sample made by ANM staffs and ASHA at grass-root level.
3. Sample should be sent to District Lab. for testing.
4. Block Data Entry Operator should Collect the data / report and make
compile report to sent at District.
5. District should compile the report from blocks and sent to state
authority. And also arrange screening camp + Sample collection +
Drug Distribution + IEC Camp etc.
6. District fluorosis unit also maintain the overall programme under
direct control of District Programme Officer and District Nodal
Officer
7. District Programme Officer and District Nodal Officer supervise the
all programme.

34. THANK YOU

35. Table of Content: PART-A
1. Current Status of Fluorosis in World View
2. Current Status of fluorosis in India
3. Current Status of Fluorosis in West Bengal
4. Current Status of Fluorosis in Bankura.
4.1 Data Sheet of fluorosis endemicity
4.2 GIS Mapping of fluorosis endemic Block
5. Availability of fluoride-free water scheme by District
administration
6. Programme Overview (NPPCF, Bnakura)
7.Performance and duties done by District Fluorosis Control
Unit.Bankura.

36. 1. Current Status of Fluorosis in World View
Fluorosis is public health problem in 25 countries around the world.(DARK
AREAS)

37. 2. Current Status of fluorosis in India
Jammu &
Kashmir
7
 No of affected
Himachal Pradesh Arunachal District 204 (21
Punjab
Delhi Pradesh States /UT)
82
Haryana
31
63
Rajastha Sikkim
n
Uttar Pradesh
22
Assam
Nagaland  people affected, 62
Bihar 9
100.0
Gujarat 15
Manipur
Tripura Mizoram
million ( 6 million
Madhya Pradesh children)
95
36 West Bengal
Orissa 22
Maharashtra
31
56
70-100 % Districts affected
 Causative factor,
Andhra Pradesh
40-70 % Districts affected
excess consumption
Karnataka 70
67 10-40 % Districts affected of fluoride through
<10% Districts affected drinking water
Tamil Nadu Endemicity not known (>1.0ppm) and diet.
28
Kerala Andaman
21 Nicobar
Source:A Treatise on Fluorosis by Dr. A.K. Susheela

38. . Current Status of Fluorosis in West Bengal

39. 4.0 Current Status of Fluorosis in Bankura.

40. endemicity
 Persons suffers from Fluorosis in India : 6 Million
 (Dr. Raja Reddy , NIN , Hyderabad)
 Persons suffers from Fluorosis in West Bengal: 2.20 Lakh
 Persons Suffers from Fluorosis in Bankura: 90,742
 Current Status of Fluorosis In Bankura District
Affected Pop.
Affected Pop.
Affected Vill.
Tot. Blocks
Tot. Village
in Bankura
Habitation
Habitation
(Approx)
(Approx)
Affected.
Tot. Pop.
Tot. Pop.
Affected
Affected
Block
Pop.
Pop.
Tot.
22 31,92,695 15 20,21,341 90,742 3832 31,92,695 271 90,742 7778 1005
90,742

41. 4.2 GIS Mapping of fluorosis endemic Block

43. Bnakura)
The Adviser (Nutrition) The District Consultant
MH&FW.New Delhi.India (NPPCF.Bankura)
I
The National
Consultant(NPPCF)
The District Lab
Tech
(NPPCF)
The DHS
SH&FW. W.B.
Field Workers
The Add. (NPPCF)
DHS(PH&CD)
SH&FW.
Swasthya
Bhaban. Kol-91.
W.B.
The
ADHS(MPHWS)
& SPO
(NPPCF)Swasthy
a Bhaban. Kol-91.
W.B.
The CMOH
and District
Programme
Officer. (NPPCF)
The Dy. CMOH-
II
and District
Nodal
Officer(NPPCF)

44. 7.Performance and duties done by District Fluorosis Control
Unit.Bankura.
• Successful implementation of this National
Programme
• Monitoring the programme by consulting all its
The District Consultant Stake-Holders/Concern Persons under direct
control of District Programme officers/District
Nodal Officers.
• Management and safe operating of Lab.
Instrument.
The District Lab Tech • Make ready report , Testing of Collected sample and as
necessary he should also visit the endemic village for blood
collection under supervision of his consultant and direct
control od district officers.
• Field Survey , sample collection and make ready
report.
• Make data-entry of patient line listing (As per state
Field Investigators needed)
• This National Programme will be successful if all district
programme holders wants.

45. Table of Content: PART - B
1. Fluorosis and fluoride
1.1 Fluoride
1.2 Pathophysiology of Fluorosis
2. Dental fluorosis
3. Skeletal Fluorosis
4. Non-Skeletal Manifestation
5. Laboratory Support
6. Prevention and Control Measure
7. Roll of PHED & DH&FWS. Bankura
5. Current Research on fluorosis

46. Fluorosis and fluoride
1.1 Fluoride

47. 1.2 Pathophysiology of Fluorosis

48.  Ingestion of fluoride causes decrease in ionised calcium.
 This hypocalcemia leads to changes in internal milieu of the body to maintain the
calcium levels and leads to secondary hyperparathyroidism.
 The increased parathyroid hormone causes increased activity of Osteoclasts in bone
by activating membrane bound 3'5' Cyclic AMP.
 This increased osteoclastic activity causes, increases in citric acid and lactic acid
release from ruffled border of osteoclasts. This causes increase in hydrogen ion
concentration, and hence lysis of lysosomes.
 Release of lysosomal enzymes viz. acid protease, collagenase, hyaluronic acid in
bone and other tissues of the body which catalyzes the reactions favoring the
depolymerization of the glycoprotein of bone and of cartilage. This causes breakdown of
hydroxyproline, which is responsible for stabilization of collagen triple helix.
 As the protein polymer desegregates and dissolves, the mineral-binding capacity is
also reduced and calcium is liberated, which helps in maintaining the serum calcium level.
As a result the solubility of hydroxyappetite crystals also increases, causing its breakdown
along with reduced laying down of collagen by reducing Hydroxylation of proline and
lysine.
 This event simultaneously led to the elevation of the serum mucoprotein or
polysaccharide levels. The net result of degradation of ground substance in, bones and
other calcified tissues like teeth leads to symptoms of Fluorosis like, delayed eruption of
teeth, dental Fluorosis, clinical Fluorosis, premature aging etc

49. Dental fluorosis
Normal:
The enamel surface is smooth, glossy
and usually a pale creamy white in
color.
Mild: The white opacity of the
enamel of the teeth is more
extensive, but covers less than
50% of the tooth surface .

50. Moderate:The enamel surface of the teeth
shows marked wear and tear with brown stain
and is frequently a disfiguring feature .
Severe: The enamel surface is badly
affected and hypoplasia is so marked that
the general form of the tooth may be
affected. There are pitted/worn out areas
and widespread brownish discoloration
with the teeth often having a corroded
appearance.

51. Types of skeletal fluorosis - I
Genu valgum (KNOCK KNEES)
Legs are bowed inwards in the standing
position. The bowing usually occurs at
or around the knee, and when standing
with knees together, the feet are far
apart.
Genu Varum
Legs are bowed outwards in the
standing position. The bowing
usually occurs at or around the
knee. When standing with the feet
together, the knees remains far
apart.

52. Types of skeletal fluorosis - II
Kyphosis: – Forward bending of spine.
Fixed and rigid thoracic cage as well as
spinal cord compression occur
Anterioposterior
bowing of tibia

53. Types of skeletal fluorosis - III
Paraplegia: Spinal cord
compression due to
osteosclerosis with
paraplegia as a result
of endemic skeletal
fluorosis

54. NON SKELETAL MANIFESTATIONS
 Tingling sensation in fingers and toes
 Excessive thirst
 Polydypsia and polyurea
 Nervousness & Depression

55. Laboratory Support

56. Table of Content: PART - C
1. Diagramatic view of Programme holder. NPPCF
2.Work Structure of National Programme for Prevention and
Control of Fluorosis
2.1 District level planning of programme outlet.
2.2 Duties of Block Medical Officer of Health at District(BMOH)
2.3 Duties of Block Public Health Nurse(BPHN)
2.4 Duties of Supervisor at Gram Panchyaet Level.
2.5 Importance of ASHA at next phase of the
programme.