Epidemiology of Fluorosis

Epidemiology of Endemic Fluorosis : 

Epidemiology of Endemic Fluorosis Dr. Muhammedirfan Momin Assistant Professor Preventive and Social Medicine Government Medical College, Surat.

Objectives of this lecture : 

Objectives of this lecture By the end of this lecture reader should understand that Fluorosis is a public health problem in many parts of the world. Onset of fluorosis is not determined simply by fluoride but a large number of agent,host and environmental factors determine its occurrence. It is one area in Community Health where scope of application of epidemiology is enormous. Although fluorosis once established is irreversible but it can be prevented through simple interventions. Commonly used de-fluoridation methods will also be known to the readers.

What is Fluorosis : 

What is Fluorosis Fluorosis is a disease caused by deposition of fluorides in the hard and soft tissues of the body. It is not merely caused by excess intake of fluoride but there are many other attributes and variables which determine the onset of fluorosis in human population. It is usually characterised by discoloration of teeth andcrippling disorders.

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Worldwide in distribution Endemic in 22 countries Asia and in Asia,India and China are worst affected Mexico in North and Argentina in Latin America East and North Africa are also endemic Magnitude of Fluorosis

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Skeletal fluorosis could however be eradicated in USA long ago by changing to a water source with low-fluoride As mottled teeth is unusually resistant to caries, fluoridation of water supplies to have a fluoride content of 1 mg/l became a standard public-health practice in most developed countries to check caries

UNICEF Map of Fluorosis : 

UNICEF Map of Fluorosis

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70-100% districts are affected in Andhra Pradesh, Gujarat and Rajasthan. 40-70% districts are affected in Bihar, National Capital Territory of Delhi, Haryana, Jharkhand, Karnataka, Maharashtra, Madhya Pradesh, Orrisa, Tamil Nadu and Uttar Pradesh 10-40% districts are affected in Assam, Jammu & Kashmir, Kerela, Chattisgarh and West Bengal. While the endemicity for the rest of the states is not known. Fluorosis in India

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Throughout India fluorosis is essentially Hydrofluorosis except in parts of Gujarat and U.P. where industrial fluorosis is also seen. In worst affected states, maps have been prepared of geographic pathology on the basis of fluoride distribution in the drinking water. Fluorosis in India

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Shortt et al. from the King’s Institute of Preventive Medicine at Chennai reported in 1937 endemic fluorosis for the first time in India in a cluster of villages around Podili and Darsi in Prakasam District, Andhra Pradesh. Pandit et al. from the same Institute established in 1940 that the toxic limit for skeletal fluorosis is 2.5 mg/l under Indian conditions owing to poor nutritional status of people. Fluorosis in India

Fluoride Levels in Indian States : 

Fluoride Levels in Indian States Gujarat:1.5 - 18.0 mg/L ,Andhra Pradesh: 0.4 - 29.0 mg/LAssam : 1.6 - 23.4 mg/L Bihar: 0.2 - 8.32 mg/L Chattisgarh: information awaited Delhi:0.2 - 32.0 mg/L Haryana: 0.2 - 8.32 mg/L Jammu & Kashmir: 0.5 -4.21 mg/L Jharkhand: 0.5 - 14.32 mg/L Karnataka: 0.2 - 7.79 mg/L

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Maximum Fluoride detected in drinking water: (An overview) Haryana (Rewari) 48.0 mg/L New Delhi (Palam) 32.0 mg/L Andhra Pradesh 29.0 mg/L Assam (Karbi Anglong) 23.0 mg/L West Bengal (Birbaum) 14.14 mg/L Gujarat (Amreli) 10.00 mg/L Gujarat (Mehsana) 18.00 mg/L Indian Guideline: 1.0 mg/L upper limit; less the better as Fluoride is injurious to health.

Districts Endemic for Fluorosis : : 

Districts Endemic for Fluorosis : Navsari , Surat ,Valsad Nadiad    • Banaskatha     • Bharuch     • Bhavnagar    • Dahod    • Gandhinagar    • Jamnagar   • Kutchh    • Junagarh    • Mehsana    •    • Godhara    • Patan    • Porbandar    • Rajkot    • Narmada    • Sabarkantha   • Surendranagar     • Vadodara

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GUJARAT Districts Graded for Water Contamination with fluoride and resulting endemicity

Dental Fluorosis and Goitre : 

Dental Fluorosis and Goitre 22,276 individuals were examined in Gujarat Presence of goitre and dental fluorosis Fluoride and iodine content of the water tested Goitre prevalence 14.1%, Fluorosis 12.2% Only 0.3 % were Goitre of Grade II or more Desai VK, et al. (1993). Epidemiological study of goitre in endemic fluorosis district of Gujarat. Fluoride. 26:187-90.

Why fluorosis concern in Gujarat? : 

Why fluorosis concern in Gujarat? Fluorosis high endemic state list includes Gujarat, Fluorosis problem is not adequately mapped Fluorosis is hardly taught, diagnosed, researched by medical colleges Fluorosis results in to serious crippling irreversible untreatable health problem Fluorosis seriously affects reproductive and child health Fluorosis seriously affect developmental mile stones Fluorosis map is widening day by day also reported from urban area Fluorosis prevention and control program have yet to prove sustainable outcome in Gujarat Fluorosis precipitates Iodine deficiency in population as it hinders absorption of iodine Fluorosis also increases prevelance of anaemia in population

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Primarily it is Fluoride which is present in drinking water when F in water is more than 1.5 mg per liter, it is toxic to health pH in terms of alkalinity of water promotes the absorption of F calcium in the diet reduces the absorption of F Hard water rich in Calcium reduces the F toxicity Fresh Fruits and Vit.C reduces the effect of F Trace elements like Molybdenum enhances the effect of F epidemiological triad AGENT FACTORS

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In School going children seen as dental fluorosis. In third and fourth decade of life seen as Skeletal Fluorosis. Males suffer more than females. Miratio influences the occurrence depending on which way people migrate. Illitrates suffer more frequently in the fluorotic belts. Where aluminium ores are mined,it is seen as occupational health hazard. epidemiological triad Host Factors

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High Annual Mean Temperature Low Rainfall Low humidity F rich Natural subsoil rocks Vegetables from high F belts Fluoridated tooth paste particularly when used by children Tropical climate Developing Countries epidemiological triad Environmental Factors

Clinical Picture of Endemic Fluorosis : 

Clinical Picture of Endemic Fluorosis Dental Fluorosis in Children Skeletal Fluorosis in Adults Non Skeletal Fluorosis

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21 Fluoride & Health Problems: Non Skeletal Fluorosis Gastro-intestinal mucosa Normal Fluorosed Fluorosed SEM F = 1.2 mg/L F = 3.0 mg/L Loss of microvilli leads to non-absorption of nutrients – resulting in anaemia

Dental Fluorosis : 

Dental Fluorosis Children living in high fluoride zone are bound to get dental discoloration which may be seen even in deciduous teeth. Initially glistening white teeth become dull and yellow-white spots appear on the surface of teeth. Gradually these spots turn brown and presents itself in brown streaks which are closer to the tip of the teeth. In late stages the whole teeth become black. Teeth may be pitted or perforated and may even get chipped off. In endemic zones people lose their teeth at an early age and may become edentate.

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Dental Fluorosis Versus Dental Caries Dental Caries Dental Fluorosis In Dental Caries unlike Dental Fluorosis, the discoloration has no pattern Cavities are formed as a result of acid production by bacteria breeding in unhygienic oral environment Cavities are formed between two teeth or hidden crevices where food debris collects

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• OCCURS ONLY IN CHILDREN IN THE PERMANENT TEETH • DISCOLORATION OF THE TEETH WITH A PATTERN • DISCOLORATION HORIZONTALLY ALIGNED / NEVER VERTICAL • DISCOLORATION AWAY FROM THE GUMS • DISCOLORATION BILATERALLY SYMMETRICAL DENTAL FLUOROSIS : Diagnosis

Dental Fluorosis : 

Dental Fluorosis

Dental Fluorosis : 

Dental Fluorosis

Skeletal Fluorosis : 

Skeletal Fluorosis It affects young as well as old. The symptoms includesevere pain and stiffness in the backbone,joints and/or rigidity in hip bones. X-ray examinations of the bones reveals thickening and high density of bones. In some patients with calcium defeciency osteomalacia type changes are seen. Constriction of vertebral canal and intervertebral foramen - pressure on nerves leads to paralysis.

Tests for Skeletal Fluorosis : 

Tests for Skeletal Fluorosis Affection of the joints can be ascertained through simple tests which can be carried out at the bed-head side and in the field: COIN TEST: The subject is asked to lift a coin from the floor without bending the knee. A fluorotic subject would not be able to lift the coin without flexing the large joints of lower extremity. 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,it indicates the presence of fluorosis. 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 reach to the occiput indicating presence of Fluorosis.

UNICEF’s Clinical Test : 

UNICEF’s Clinical Test Three simple clinical tests Forward flexion of spine Chin to Chest test Hands on the occiput test Normal person can do Person with skeletal fluorosis can not. Left figures Normal, Right Abnormal

Skeletal Fluorosis : 

Skeletal Fluorosis

Skeletal Fluorosis : 

Skeletal Fluorosis

Skeletal Fluorosis : 

Skeletal Fluorosis

Skeletal Fluorosis : 

Skeletal Fluorosis

Skeletal Fluorosis : 

Skeletal Fluorosis

Detection of Endemicity : 

Detection of Endemicity When more than one-fifth ( 20 % ) of the persons surveyed in a known high fluoride area ahows positivity of the clinical tests just enumerated, it indicates the endemicity.

Non-Skeletal Fluorosis : 

Non-Skeletal Fluorosis There are convincing evidence of involvement of skeletal muscles, erythrocytes, G-I mucosa, ligaments and spermatozoa on consuming more than optimal intake of fluorides. Detection of Fluorosis at early stage is possible by understanding the soft tissue manifestation. In the fluorosed muscles,actin and myosin filaments are destroyed and mitochondria lose their structural integrity thereby providing evidence of depletion of muscle energy. The erythrocyte membrane loses its calcium content in presence of high fluoride. Non-ulcer dyspeptic complaints are manifested by consuming high F in water and food. Infertility due to oligospermia and azoospermia is commonly seen in fluorotic belts.

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39 GASTRITIS AND IRRITABLE BOWEL SYNDROME (due to fluoride ingestion ) Complaints are: Loss of Appetite Nausea Pain in the stomach Constipation Intermittent Diarrhoea Bloated Stomach (Flatulence )

Optimal Fluoride Intake : 

Optimal Fluoride Intake W.H.O. Monograph on Fluoride and Human Health (1970) has enumerated the use of Community Fluorosis Index in determining the optimal Fluoride Intake. W.H.O. recommonds the permissible limit of 1.5 mg/litre Shiv Chandra determined the optimal intake in north-west India and found that optimal intake has to be determined on the regional basis.

The Indian Guideline for fluoride in drinking water : : 

The Indian Guideline for fluoride in drinking water : The guideline for fluoride in drinking water is 1.0 mg fluoride/liter; it is the maximum the that body may tolerate; less the better as fluoride is injurious to health. It is the observation in India, that there are safe and unsafe water sources existing in the villages. Testing for fluoride should apply to cent percent sources. This would enable to identify safe sources existing in a village and the maximum contaminant level of fluoride in a village

Prevention of Fluorosis : 

Prevention of Fluorosis Fluorosis has no treatment or medicine. The disease if diagnosed correctly at an early stage of onset can be prevented easily. The two Interventions the individual / patient has to practice are:

To stop fluoride entry to the body which may be through consumption of water, food, dental products and / or drugs. By doing so, the progression of the disease is arrested. If water is the source of fluoride, consumption of safe water with fluoride as low as possible but should never exceed 1.0 mg/l of water. : 

To stop fluoride entry to the body which may be through consumption of water, food, dental products and / or drugs. By doing so, the progression of the disease is arrested. If water is the source of fluoride, consumption of safe water with fluoride as low as possible but should never exceed 1.0 mg/l of water.

To promote nutrients through diet supplementation, adequate intake of essential nutrients, vitamins and antioxidants instead of pharmaceutical products. By doing so, the repair and maintenance of the damaged parts of the cells, tissues and organs are achieved. The protocol would be varying from individual to individual depending upon the disease status and whether they belong to the lower or higher socio-economic strata. Affordability is an important criterion to ensure sustainability of nutritional intervention. The recipes are designed through discussion with the patient : 

To promote nutrients through diet supplementation, adequate intake of essential nutrients, vitamins and antioxidants instead of pharmaceutical products. By doing so, the repair and maintenance of the damaged parts of the cells, tissues and organs are achieved. The protocol would be varying from individual to individual depending upon the disease status and whether they belong to the lower or higher socio-economic strata. Affordability is an important criterion to ensure sustainability of nutritional intervention. The recipes are designed through discussion with the patient

Dietary Modification : 

Dietary Modification Supplementation of Calcium Supplementation of Vitamin C and or other Antioxidants

Gujarat’s Initiatives :By Health Department : 

Gujarat’s Initiatives :By Health Department

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Antenatal women Supplementation of Calcium to meet out growing demand of fetus for bone development and to replenish mother Calcium stores. Calcium tablet 500 mg per day for 3 months During 7th, 8th and 9th month of pregnancy 2008-09 Expected beneficiaries: 15,92,171 Postnatal women Calcium tablet 500 mg per day for 3 months Calcium Supplementation

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Sensitization Workshop : 6 Sensitization workshop at Medical Colleges organized Development of Diagnostic Facility: Ion meter were supplied to Biochemistry depts. of all Govt.Med.College Hospitals Mapping of Fluorosis affected Villages Training Asstt.Prof. Biochem. Department from all Med.College were trained . Training of Lab.Tech.at Biochem.dept. of Medical College IEC Supplementation of Calcium & Vitamin C along with diet Counseling Activities under Fluorosis Control Programme

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References : 

References W.H.O. Monograph on Fluoride and Human Health, W.H.O., Geneva,1970. Shiv Chandra et al:Determination of Optimal Fluoride Intake,Comm Dent. & Oral Epidemiol,8:35-40,1980. Susheela A.K.: A Treatise on Fluorosis; Fluorosis Research and Rural Development Foundation,New Delhi, 2001.

THANK YOU : 

THANK YOU Mobile: 9426845307 E-mail: drmhmomin@yahoo.co.in www.fluorideandfluorosis.com