Presentation on Mitigation of Fluorosis

Presentation on a review article entitled “ Mitigation of

fluorosis –A review”

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Published in Journal of clinical and diagnostic research on

June 2015

Mahesh R. Khairnar, Post-Gradute Student, Department of

Public Health Dentistry, ACPM Dental College, Dhule,

Maharashtra, India.

Arun S. Dodamani, Professor and Head, Department of


Maharashtra, India.

Harish C. Jadhav, Senior Lecturer, Department of Public

Health Dentistry, ACPM Dental College, Dhule, Maharashtra,

India.

Rahul G. Naik, Post-Gradute Student, Department of Public

Health Dentistry, ACPM Dental College, Dhule, Maharashtra,

India.

Manjiri A. Deshmukh, Post-Gradute Student, Department of


Maharashtra, India.

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Published by (List of authors)

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This article consists and discusses the available information in literature about various treatment methods for fluorosis and available technologies for fluoride removal from drinking water as well as ongoing fluorosis mitigation programs.

Authors mentioned that they have collected and presented the information available from databases such as Medline, PubMed, Web of Science, Google Scholar, WHO, Ebscohost, Science Direct, Google Search Engine, etc., using the keywords such as defluoridation, fluorosis mitigation, activated Alumina, defluoridator, nalgonda technique, etc.

CONTENT OF THE ARTICLE•INTRODUCTION

•FLUORIDE BELT

3 •FLUORIDE AS A DOUBLE EDGED SWORD

• AVAILABLE TREATMENT MODALITIES FOR FLUOROSIS

• PREVENTION AND MITIGATION OF FLUOROSIS

6• FLUOROSIS MITIGATION

PROGRAMS

7 •FUTURE PERSPECTIVE

8 •CONCLUSION AND REFERENCES4

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This article is well structured and

discussed the maximum available

information regarding the mitigation of

fluorosis. Hence, I selected this article for

presentation.

As well as I would like to provide some

more additional information during the

presentation for better understanding and

about the ongoing fluorosis mitigation

activities in NIN and our future perspective

on fluorosis mitigation and

recommendations for your interest.

INTRODUCTION Fluorine which has been included in

the list of 14 physiologically essential elements required for normal growth and development does not exist in the elemental state in nature. Its ionic form, fluoride, is found abundantly in a wide variety of minerals, including fluorspar, rock phosphate, etc. Due to the universal presence of fluorides in the earth’s crust, all water sources contain fluorides in varying concentrations.

6Fluorine is the 13th most abundant element , 0.065% by weight of the crust

Rocks

Soils

Atmosphere

Ground water

Surface water

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Rain water Various food-

stuffs Tooth pastes Industrial processes

SOURCES OF FLUORIDE

Especially, the granitic rocks of Nalgonda, Telangana, India possess the highest fluoride content than in any other parts of the world (about 1440 mg/kg) and responsible for the high fluoride level in groundwater through leaching.

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The hydrogeochemical cycle of fluorine

Fluorine is the most electronegative and highly reactive of all elements and hardly occurs in nature in its elemental form.

Apart from other sources, ground water is a major and common source of daily fluoride intake. High fluoride contamination in ground water is due to leaching of fluoride from the rocks containing fluoride-bearing minerals present near to shallow and deeper aquifers.

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Fluorspar (or)Fluorite (CaF2)

Topaz (Al2F2[SiO4])Amblygonite

(Li, Na)AlPO4(F,OH) Baratovite

(KCa7Ti1.5Zr0.5Li3Si12O36F2)

(Ca,U)2(Ti,Nb,Ta)2O6(OH)Betafite Cryolite

(Na3AlF6)Tainiolite

KLiMg2Si4O10F2

VilliaumiteNaF

Colorful minerals – As well as dangerous

Total No. of minerals = 7407, No. of F- containing minerals = 44 (0.6%)

FLUORIDE BELT One of the environmental health issues connected

with geogenic processes is excess fluoride in

groundwater. Its ingestion through drinking water

and food products leads to dental and skeletal

fluorosis. Geographical belt of high fluoride

content in groundwater extends from Syria

through Jordan to Kenya and another belt

stretches from Turkey to China. Endemic fluorosis

has been reported in most of the regions of Africa

and Asia with high levels of fluoride in water.

Approximately, 100 million people worldwide are

suffering from fluorosis. Natural concentrations of

fluoride in water as high as 2800 ppm (Lake

Nakuru, in Rift valley in Kenya) have been

reported.

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11Groundwater with fluoride concentration above 1.5 mg/l

High temperature in deep ground level

Low rainfall High evapotranspiration Groundwater depletion

PREVALENCE OF FLUOROSIS IN VARIOUS PARTS OF WORLD

India, China, Sri Lanka, West Indies, Spain, Holland, Italy, Mexico, Syria, Jordan, Egypt, Libya, Algeria, Sudan American

countries12

FLUOROSIS ENDEMIC STATES IN INDIA

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In India, Fluorosis is considered to be a major public health problem. More than 60 million people are suffering with fluorosis. According to the available literature, more than 15 States in India are endemic for fluorosis The most seriously affected states are Rajasthan, Gujarat, Andhra Pradesh, Punjab, Haryana, Orissa, Uttar Pradesh, Tamil Nadu, Karnataka and Maharashtra.

FLUORIDE AS A DOUBLE EDGED SWORD

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Double edged sword? Then what is my future if I do

research in fluoride?

Low fluoride

• creates dental decay

and dental caries

• Affect bone and teeth

formation and health

High fluoride

• Dental fluorosis

• Skeletal fluorosis

• Non-skeletal fluorosisThen what is the safe intake level? How can I measure and take?

SAFE LIMIT OF FLUORIDE INTAKE

The safe limit of fluoride intake is 0.05mg/kg/day.

This intake level is recommended for all age

groups of people greater than 6 months.

Adequate intake level of fluoride for infants of

below 6 months is about 0.01 mg/kg/day.

The National Research Council has estimated

‘‘adequate and safe’’ daily fluoride intake is to be

1.5 mg to 4.0 mg for adults.

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DENTAL FLUOROSISExcess fluoride intake causes dental fluorosis with the symptoms of White horizontal striations

on the tooth surface becomes chalky white discolorations to Stained yellow and to brown or even black.

Increased tooth porosity leads to structural damages such as pitting or chipping.

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APPEARANCE OF DENTAL FLUOROSIS SYMPTOMS AMONG CHILDREN

Prolong intake of excess fluoride causes Skeletal fluorosis with the Symptoms of

Periodic pain

stiffness of the joints.

Chronic joint pain. Symptoms of crippling skeletal fluorosis are

Limited movement of the joints,

Skeletal deformities.

Intense calcification of ligaments 18

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PEOPLE WITH SYMPTOMS OF SKELETAL FLUOROSIS

METABOLISM OF FLUORIDE IN HUMAN BODY

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Fluoride absorption, distribution and renal excretion are pH dependent because the coefficient of permeability of lipid bilayer membranes to hydrogen fluoride (HF) is 1 million times higher than that of F–. This means that fluoride readily crosses cell membranes as HF. The majority of fluoride not absorbed from the stomach will be absorbed from the small intestine. Fluoride not absorbed will be excreted in feces. Peak plasma fluoride concentrations are reached within 20–60 min following ingestion. The levels start declining thereafter due to two main reasons: uptake in calcified tissues and excretion in urine.

AVAILABLE TREATMENT MODALITIES FOR FLUOROSISDiscoloration of teeth is the most common reason

for patients seeking treatment for fluorosed teeth. To restore the natural white creamy enamel

appearance, the tooth may be bleached or can be subjected to micro-abrasion or macro-abrasion.

Crowns are preferred in cases where more than 50% of surface enamel has been lost as a result of fluorosis.

As such, there is no standard treatment for skeletal fluorosis; but it can be said to be reversible in some instances.

After fluoride ingestion is stopped, existing fluoride level in the bone starts depleting and fluoride is excreted via urine. But this is a slow process and hence negligible results are seen. Also, treatments of the side effects are tough to deal.

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Bleaching of teeth for dental fluorosis

Micro and macro abrasion followed by polishing for dental fluorosis

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PREVENTION AND MITIGATION OF FLUOROSIS

Dental fluorosis is irreversible in nature and its treatment requires complex and expensive procedures which are time consuming and are not easily available to rural population. In case of skeletal fluorosis, there is no specific treatment. Therefore, due to lack of sustainable treatment measures for any form of fluorosis, prevention and control through interventions (provision of safe water and safe food) is said to be the best approach to mitigate fluorosis

Drinking water standards for fluoride ion has been prescribed by various authorities [Table-1], which helps to limit the occurrence of fluorosis when followed properly

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There are two interventions to practice for the management of the disease. Fluorosis can be totally prevented and the individual can lead a normal, healthy life.

The interventions to practice are Provision of safe drinking water and Nutritional intervention

Provision of safe drinking water • Locating alternative sources of safe water (Best method) • Bringing in water from a distant, safe source • Dual water source (drinking, cooking – other domestic purpose)• Rain water harvesting • Removal of fluoride from water (defluoridation), using suitable techniques • Prevention of industrial fluorosis by rigorous enforcement of procedures for minimizing industrial fluoride pollution.

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Defluoridation of water: The downward adjustment of level of fluoride in drinking water to the optimal level

(i) the treatment of water at the source (central treatment – at community

level).

Preferred method in most of the developed countries.

Carried out on a large scale under direct supervision of

skilled personals

(ii) the treatment of water at the household level (point of use

treatment- at household level).

Preferred in less developed countries.

Only water required for cooking and drinking purposes can be

treated (cost effective)

Create less amount of sludge as compared to community level

defluoridation

Defluoridation can be achieved by the following ways

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Defluoridation techniques can be broadly classified into following categories

1. Adsorption technique

2. Ion-exchange technique

3. Precipitation technique

4. Other techniques, which include electro

chemical defluoridation and Reverse

Osmosis.

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1. Adsorption: This technique functions on the adsorption of fluoride ions onto

the surface of an active agent.

In the adsorption method, raw water is passed through a bed

containing defluoridating material.

The material retains fluoride either by physical, chemical or ion

exchange mechanisms.

The adsorbent gets saturated after a period of operation and

requires regeneration.

Examples of adsorbents for fluoride1. Activated Alumina 2. Bone Char 3. Calcined Clay 4. Mud Pots 5. Natural Adsorbents - Seeds of the Drumstick, Tamarind seeds, tea ash, egg shell powder, etc.,

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Ion Exchange The different ion exchange materials studied include bone, bone char, anion and cation exchange resins such as carbon, defluoron-1, defluoron-2, etc. Precipitation In this method, chemicals added to raw water cause precipitation of the fluoride salt as insoluble fluorapatite, which is separated from the water. Commonly used materials in precipitation technique are Aluminium salts (e.g. Alum), lime, Poly Aluminium Chloride, Poly Aluminium Hydroxy sulphate and Brushite. There are three precipitation methods for fluoride1. Nalgonda Technique - Aluminium salts, lime and bleaching powder 2. Contact Precipitation – Compounds of Ca and po4 3. IISc method – Mgo, Cao and sodium bisulfate

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IISc Method:

The Indian Institute of Science (IISc), Bangalore developed this

simple defluoridation technique. The method uses magnesium

oxide, calcium hydroxide and sodium bisulfate. Magnesium

oxide removes dissolved fluoride ions from water samples by

precipitating fluoride as insoluble magnesium fluoride;

MgO + H2O → Mg (OH)2

2NaF + Mg(OH)2 → MgF2 + 2 NaOH

A simple to use domestic defluoridation unit was developed for

fluoride removal based on IISc Method at Kolar, Karnataka to

treat 15 litres of fluoride contaminated water.

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Other techniques of defluoridation of water:Reverse osmosis, electrolysis & electro dialysis and distillation are physical methods that are tested for defluoridation of water. Though they are effective in removing fluoride salts from water, but there are certain procedural disadvantages that limit their usage on a large scale.

Prevention of Industrial fluoride emission :In the industrialized western world, industrial fluorosis leads to inhalation of fluoride dust or gas or fumes. Workers in industries and mining exposed to fluorides should be monitored and it should be ensured that their fluoride content of urine is below 5 PPM. If the workers are found to be suffering from skeletal fluorosis, they should be removed from exposure to fluoride. Central Pollution Control Board, Ministry of Environment & Forest, Govt. of India (1998), has given a permissible limit of industrial emission of fluoride which is less than 25 mg/Nm3

NUTRITIONAL INTERVENTIONS

Adequate intake of foods rich in calcium, vitamins C, D & E and anti-oxidants, along with consuming safe drinking water. Along with these interventions, people residing in endemic areas should be made aware about the adverse health impacts of excessive fluoride and need to be motivated to adapt to the methods for mitigating fluorosis .

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FLUOROSIS MITIGATION PROGRAMS

Various fluorosis mitigation programs have been conducted

worldwide using defluoridation untis. Some of them include-

1) Defluoridation unit in Ngurdoto Village, Tanzania using

Bucket Defluoridator using bone char.

2) Fluorosis mitigation project in Ban Sankayom village in

Thailand using bone char defluoridator.

3) ICOH Mobile Bus Unit Project in Thailand which emphasized

on creating awareness among people regarding effects of

excessive consumption of fluoride on health, helping them

with on-site analysis of fluoride content of water samples and

consulting them to solve the problem using possible

alternatives. 32

FLUOROSIS MITIGATIONPROGRAMS IN INDIA

1) Project SARITA(Dungarpur, Rajasthan).

2) Sachetana Plus – Karnataka.

3) Fluorosis mitigation project at Sonbhadra, UP

4) Fluorosis Mitigation in Nuapada District, Orissa .

5) Fluorosis mitigation project in Dhar District, MP.

6) Mitigation of Fluorosis in Nalgonda District

Villages –by Sai Oral Health Foundation.

7) Integrated Fluorosis Mitigation, Madhya Pradesh.

8) National Rural Drinking Water Program (NRDWP).

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FUTURE PERSPECTIVE

Mass media or social media can play a vital role in preventing and limiting problem of fluorosis.

The Rajasthan and Telangana government has added a chapter on Fluorosis mitigation in the curriculum of Class VIII students.

Government should make way for public private partnership in the process of mitigation. One such project i.e. Hogenakkal Integrated Drinking Water Project for fluorosis mitigation has been undertaken by Govt. of Tamil Nadu, with funding from Japan Bank for International Cooperation (JBIC) using Tamil Nadu's share of Cauvery river water.

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Dentists, who come across fluorosis

patients in their routine clinical practices,

can educate and motivate these people to

adapt to practices regarding safe drinking

water

Need to promote the sale of domestic

defluoridator units.

Public health dentist can also help

government in policy making, implementing

various projects like NRHM, NRDWP, etc.35

PROPOSED STRATEGY:1. Educating people regarding importance of safe drinking

water and hazards of excessive fluoride in drinking water.2. Health Education activities like health talks, lectures,

health screening camps, demonstration of defluoridation techniques, etc.

3. Muti-sectoral approach: Involvement of Public health dentist along with PWD, Public Health Engineering Department, Chemists, Local Governing bodies such as municipal corporation, Water Department, etc.

4. Community participation.5. Establishment of water fluoride testing laboratories in

rural areas in chemistry laboratories of local colleges in that area.

6. Establishing of a data base on fluoride levels in drinking water for entire country.

7. Motivating people to adapt safe drinking water and food practices where needed.

8. Follow up of the services provides. 36

CONCLUSION It is rightly said “Much has been done

but much is left to do”. More and more areas are being

discovered regularly that are affected by fluorosis in different parts of the country.

It is evident from studies by several researchers worldwide that fluoride in groundwater has been a potential problem to human society.

To remediate the groundwater with high fluoride, defluoridation techniques are adopted.

But ultimate solution for this fluoride menace remains to be the principal of “Precaution is better than cure”.

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ONGOING FLUOROSIS MITIGATION ACTIVITIES IN NIN

Project entitled “Integrated fluorosis mitigation activities in Nalgonda district” funded by UNICEF is going on in our institute under the Head of

Dr. Arjun L Khandare, Scientist – F, Head, Dept. of Food Toxicology, NIN

Under this project we have surveyed 2066 school going children between the age 8-14 years and 1087 people in villages of Nalgonda district, Telangana. Also we have collected water, urine and blood samples and analyzed for better understanding and finding suitable diagnostic and treatment methods. 39

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1. Curry (Kariveppilai) leaves

Total calcium = 824 ± 42 mg/100g.

Bio-available calcium = 272 ± 14 mg/100 g

Percentage of calcium bioavailability = 33%.

2. Cauliflower leaves




3. Tropical Amaranth (Sirukeerai) leaves




RESULTS - TOTAL AND BIOAVAILABLE CALCIUM LEVELS IN LEAFY VEGETABLES

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4. Bakphul (agathi) leaves



Percentage of calcium bioavailability = 10%

5. Coriander (Kottamalli) leaves




6. Black- nightshade (Manathakkali keerai) leaves




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7. Mint (Pudina) leaves




8. Dwarf copper (Ponnankanni) leaves




9. Spinach (Passalai keerai) leaves




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12. Red-spinach (Thandukeerai)




10. Tamarind (Puli keerai) leaves




11. Punarnava (Mukirattai keerai)




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15. Common-purslane (Paruppu keerai)




13. Spiny- pigweed (Kuppakeerai)




14. Betel (Vetrilai) leaves




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18. Cabbage (Muttikose) leaves




16. Drumstick (Murungai keerai)




17. Susni-sag (Araikeerai) leaves




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Percentage of bio-available

calcium levels in leafy vegetables

Bakphul (Agathi), Curry leaves (Kariveppilai), Cauliflower leaves, Punarnava leaves (Mukirattai keerai) and Dwarf-copper (Ponnankanni) show the total calcium level more than 500 mg/100 g.

Even though Amaranth (Sirukeerai), coriander (Kottamalli), spinach (Passalai keerai), red-spinach (Thandukeerai), spiny-pigweed (Kuppakeerai) and Common-purslane (Paruppu keerai) show considerable level of total calcium, the bioavailability levels of calcium are considerably low.

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TOTAL AND BIOAVAILABLE CALCIUM LEVEL IN MEDICINAL (CASSIA SPECIES) PLANTS

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1. Coffee-cassia (Cassia tora – Usei thagarai)




2. Ringworm-senna (Cassia alata – Seemai agathi)

Total calcium = 267 ± 20mg/100g.



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5. Indian-laburnum (Cassia fistula – Sarakkondrai)




3. Senna (Cassia angustifolia – Tirunelveli senna)




4. Avaram-senna (Cassia auriculata - Avarai)




TOTAL AND BIOAVAILABLE CALCIUM LEVEL IN

TUBERS AND VEGETABLES

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3. Small onion




1. Carrot




2. Big onion




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6. Cauliflower




4. Radish (Mullangi-rose red)




5. Ash gourd (Poosani kai)




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9. Potatos (Urulai kizhangu)




7. Turkey berries (Sundaikai)




8. Tomatos (Thakkali)




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12. Broad beans (Avarai kai)




10. Bottle-gourd (Suraikai)




11. Brinjal (violet) (Kathirikai)




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15. Snake gourd (Pudalai kai)




13. Ladies finger (Vendaikai)




14. Ridge gourd (Pirkkankai)




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Percentage of bio-available calcium

levels in Tubers and vegetables

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3. Rice grain (Arisi (Ponni))




1. Finger millet (Ragi)




2. Pearl-millet (Kambu)




Total and bioavailable calcium level in cereals and pulses

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6. Wheat (Gothumai)




4. Jowar (Cholam)




5. Kodo millet (Varagu)




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9. Red-gram (Tuvaram paruppu)




7. Horse gram (Kollu)




8. Soya bean




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12. Ground nut




10. Green-gram (Payatham parupu)




11. Bengal Gram (Kadalai parupu)




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Percentage of bio-available

calcium levels in

Cereals and pulses

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3. Apple




1. Coconut




2. Amla




TOTAL AND BIOAVAILABLE CALCIUM LEVEL

IN FRUITS AND NUTS

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6. Orange




4. Dates




5. Grapes




9. Mango




8. Papaya




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7. Sapota




10. Banana


Bio-available calcium = 6 ± 1mg/100 g


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Percentage of bio-available calcium

levels in Fruits and nuts

Among the tubers and vegetables; Cauliflower, potato, Carrot and Brinjal (violet) show considerable level of bio-available calcium when compared with other selected vegetables.

Also among fruits; Orange, Papaya and Mango contain rich bio-available calcium. Commonly some organic compounds such as ascorbic acid, citric acid, tartaric acid and malic acid are present in most of the fruits and tubers.

Presence of these organic compounds may be useful to enhances the solubility of calcium in gut.

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From the result, it has been concluded that among the selected plant materials; Leafy vegetables such as Black-nightshade, Dwarf-copper, Curry, Cabbage, Drumstick and Mint leaves,

Cereals such as Rice, Red gram and Finger millet,

Vegetables such as Cauliflower, Potato, Carrot and

Brinjal (violet); Fruits such as Orange, Papaya and Mango

show considerable level of total and bio-available calcium level.

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CONCLUSION

Documents

Presentation on Mitigation of Fluorosis