NPPCF_Fluorosis Consultant Bankura

1. Fluorosis: Epidemiology
Dipta K. Mukhopadhyay
Asst. Professor, Community Medicine
B. S. Medical College, Bankura

2. Fluorosis
• A crippling & painful disease caused by excess
intake of / exposure to fluorides.
• Fluorides can enter through Water, Food,
Toothpaste, Mouth rinses & Drugs.
• Fluoride dust & fumes from aluminium/ smelting
industries.
• Fluoride in groundwater in India discovered in
1930 & first reported in 1937.
• Fluorosis can manifest as dental, skeletal, non-
skeletal fluorosis.

3. Fluoride: Myth
• Fluoride inhibit enzymes breeding acid producing
oral bacteria
• Fluoride ion binds with calcium ions making teeth
enamel strong
• Harmful effect of Fluoride on other useful enzymes
outweighs the benefit
• Excessive fluoride displaces calcium from tooth
matrix
• Chronic & cumulative exposure cause skeletal
fluorosis

4. Magnitude
• Fluorosis- an important
Public Health Problem
in 24 countries
including India.
• Fluoride belt extends
from Turkey to China &
Japan through Iraq, Iran
& Afghanistan.
• Around 70 millions are
affected

5. Indian scenario
• Fluorosis is endemic in 20 states of India out of 35 states
& UTs.
• 70-100% districts affected: AP, Guj, Raj.
• 40-70% districts affected: Bih, Del, Har, Jhar, K’taka,
Mah, MP, Orissa, TN & UP.
• 10-40% districts affected: Assam, J&K, Kerala, CG & WB.
• 25 million people suffering from Dental/ Skeletal/ Non-
skeletal Fluorosis incl. 1 million incapacitating skeletal
fluorosis.
• Nearly 66 million people consuming fluoride containing
drinking water

7. West Bengal
• Fluorosis is a Public
Health Problem in 9
districts of West Bengal.
• Worst affected districts:
Purulia, Bankura.
• 17 blocks of Bankura
are affected.

8. Agent
• Primarily, Fluoride is present in drinking water
• When F in water is more than 1.5 mg/L ,it is toxic
to health
• Acidic pH promotes absorption in stomach
• Ca in the diet reduces the absorption of F
• Hard water rich in Ca reduces the F toxicity
• Fresh Fruits and Vit.C reduces the effect of F
• Trace elements like Molybdenum enhances the
effect of F

9. Host
• Dental Fluorosis seen in school going children
• Skeletal Fluorosis seen in third and fourth
decade of life.
• Males suffer more than females.
• Migration influences the occurrence depending
on which way people migrate.
• Illiterates suffer more frequently in the fluorotic
belts.
• In aluminium ores mines, it is an occupational
health hazard.

10. Environment
• 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

11. Natural history
• Dental fluorosis manifested due to exposure to
moderate amount of fluoride during 1-4 years
• F ion replaces hydroxyl ion of tooth dentin
• Hypoplasia & hypomineralization makes tooth brittle
• Skeletal fluorosis occurs due to exposure to excessive
amount of fluoride for longer duration
• Brittle bone, periosteal bone formation, narrowing of
medullary cavities, ossification of interosseus
membranes & muscle tendons
• Skeletal fluorosis is consequence of exposure to > 14
mg/ day fluorine

12. Natural History
• Dental fluorosis has
different grades:
• Questionable:
• Very mild:
• Mild:
• Moderate:
• Severe:
• Skeletal fluorosis has
four grades:
• Pre-clinical:
• Phase-I:
• Phase-II:
• Phase-III:
Community Fluorosis Index (CFI) is the way to
measure community burden of dental fluorosis

13. Sources of Fluorides
• Drinking water: Particularly in tropics
• Food contamination:
- Black tea/ Rock salt/ Black salt.
- Readymade masala /Street foods
- Preserved foods- canned fish, fruit juice
• Dental products: Toothpaste, mouth rinses
• Drugs: Anti-depressants & Lipid lowering
• Industries: Brick & Almunium
• Fuel: high fluoride containing coal

14. Safe limit of Fluoride in water
• W.H.O. recommends the permissible limit
of 1.5 mg/L.
• Bureau of Indian Standards made the safe
limit of F- 1.0 mg/L.
• Countries like China, Thailand 7 West
Africa made it 0.5mg/L.

15. Time-trend
• Quality of ground water depends on lithology
& soil.
• Fluoride concentration increases through
weathering of rocks & leaching of fluoride
bearing minerals.
• Evaporation also increases fluoride
concentration.
• Amount of fluoride increased with lowering of
ground water level.

16. Interventions
• No definite treatment available.
• Intervention 1: Stop fluoride entry
- Safe drinking water: Surface water/ defluoridation
- Avoid fluoride containing foods.
- Avoid drugs and dental products.
• Intervention 2: Promote adequate intake of essential
nutrients viz. Ca, Fe, Vit C, Vit E & other anti oxidants
- Diet rich in cereals, fruits & vegetables
- Pharmaceutical products

17. What to do ?
• Promoting better understanding of the problem
• Advocacy & raising awareness of all stake holders
• Strengthening the system of risk assessment
• Provision & consumption of safe water & food
• Reduction of exposure to fluorides from other
sources