Prevalence of Fluorosis in Nalgonda District

7/24/2019 Prevalence of Fluorosis in Nalgonda District

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PREVALENCE OF FLUOROSIS IN NALGONDA

DISTRICT, TELANGANA, INDIA


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I. INTRODUCTION

Fluor ide

Fluoride is an inorganic, mono-atomicanionof fluorinewith the chemical formulaF.

Fluoride is widely dispersed in nature and is estimated to be the 13 th most abundant

element on the Earth. In terms of charge and size, the fluoride ionresembles

the hydroxideion (OH-). Fluoride ions occur on earth in several minerals,

particularly fluorite (CaF2) and the presence of high fluoride in ground water is mainly

due to the leaching of fluoride ions from rocks of fluoride containing minerals.

Permissible level of f luor ide in d r inking w ater

The World Health Organization (WHO) described the drinking water quality guideline

value 1.5 mg L-1

for fluoride and the Bureau of Indian Standards (BIS) fixed 1.0 mg L-1

is

the desirable limit for fluoride in drinking water. The systemic fluoride absorption through

the gastrointestinal tract into the blood stream is nearly 100% by the process of simple

diffusion when it is ingested through water.

Prevalence of f luo rosis

Chronic intake of large quantities of fluoride through drinking water causes the risk of

dental, skeletal and non-skeletal fluorosis among human beings and animals. More than

200 million people from 25 nations are under the risk of fluorosis due to the

consumption of fluoride-rich groundwater. Furthermore, In India, high fluoride in

groundwater has been reported from 230 districts of 20 states where more than 90%

rural villages are depending on groundwater for drinking and 66.62 million people,

including 6 million children are affected by fluorosis.


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Scenar io o f prevalence of f luo rosis in Telangana and Nalgon da distr ic t

Telangana is one of the severe fluorosis endemic states in India, where the

groundwater fluoride levels were ranged from 0.4 mg L-1 to 20 mg L-1. Particularly in

Nalgonda district of Telangana, most of the children and adults are suffering from

severe dental and skeletal deformities as well as, mental retardation. About 1108

habitations are affected by fluoride in Nalgonda. Around 30% of water sources in

Nalgonda are contaminated with fluoride more than 1.5 mg/l and impacting an

estimated 10 lakh people.

Reason fo r high f luor ide in grou ndw ater and high p revalence of f luorosis in

Nalgon da distr ic t

In Nalgonda district, 90% areas are occupied with Archaean crystalline type of rocks

such as granites and gneisses containing a high level of easily exchangeable fluorides.

Especially, the granitic rocks of Nalgonda 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. Moreover, the groundwater in many areas of

Nalgonda district contaminated with large quantities of trace elements such as uranium

and strontium of more than the safe limit. Consumption of abnormal level of uranium

and strontium through drinking groundwater may aggravate fluoride toxicity and

neurological syndromes. In addition, water logging due to continuous storage of large

quantity of surface water in Nagarjuna Sagar reservoir in Nalgonda district can increase

the level of sub-soil water and facilitates the dissolution of fluoride and other trace

elements from rocks to groundwater.


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Groundwater in depth contains high fluoride, as more contact time and

high temperature facilitating the dissolution of fluoride from rocks in the deeper

aquifers. Nowadays, reverse osmosis (RO) plants were running in most of the villages

of Nalgonda district. RO plant in each villages was filtering the groundwater with 1000-

liter per hour capacity and running at least three to four hours per day discharges

minimum 2000-liter groundwater as waste. This may enhance the groundwater

depletion to high extent leads to decrease the groundwater table level and

increase the leakage of fluoride-rich pore water from intervening aquitard layers.

Areas of Nalgonda district experiences between arid to semi-arid climate

with low annual rainfall leads to high evapotranspiration and the subsequent

inadequate recharge enhances the fluoride concentration in shallow

groundwater. Hence, the fluoride level was subsequently higher in groundwater from

both shallow and deeper aquifer in Nalgonda district. Moreover, most of the people in

villages of Nalgonda district were living under low socio-economic status. Also, studies

conducted in Nalgonda district indicated that the people are under poor nutrition status

and their diet contains low nutrients than the normal diet. Many studies proved that

intake of poor nutrition diet enhance the severity of fluorosis.

Ongoin g remedial measures for f luoros is in Nalgond a distr ic t

In orderto control the fluorosis problem in Nalgonda, several remedial measures have

been adopted such as household and community-based water de-fluoridation including

Nalgonda technique. Furthermore, many previous studies suggested that, supplying of

safe drinking water available in Nagarjuna Sagar reservoir (biggest reservoir in India

situated in Nalgonda district) to the affected regions in Nalgonda is an ideal solution for


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the mitigation of fluorosis. Also, it has been reported that almost all the villages were

supplied with water from Krishna river except Parada village under Kattangur Mandal.

However, recent studies indicated that the extent of fluorosis among children and adults

are still at severe level in villages of Nalgonda district. In particular, the following 17

mandals are identified as highly affected out of 59 mandals in Nalgonda district.

Demographic p rof i le of Nalgonda distr ic t

According to the 2011 censusNalgonda district has a populationof 3,483,648. This

gives it a ranking of 88th in India (out of a total of 640). The district has a population

density of 245 inhabitants per square kilometre (630/sq mi). Its population growth

rateover the decade 2001 - 2011 was 7.26%. Nalgonda has a sex ratioof

982 femalesfor every 1000 males and a literacy rateof 65.05%.

S.No. Name of theaffected Mandal

1 Nalgonda

2 Munugode

3 Gurrampode

4 Thipparthy

5 Narkatpally

6 Marriguda

7 Nampally

8 Chandur

9 Deverakonda

10 Chitapally

11 Choutuppal

12 Narayanpur

13 Aleir

14 Yadagirigutta

15 Bibinagar16 Thurkapally

17 Veligonda


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Climate and geological prof i le of Nalgonda distr ic t

Nalgonda district experiences hot climate during the summer with the temperature

ranges from 30C to 46.5C and in winter, it varies between 16C and 29C. The

average annual rainfall of the district was 751 mm, which ranges from 2.0 mm in

February to 171 mm in July. The shallow aquifer system constitutes to a maximum

depth of 40 m and 80% of deeper aquifer systems were within 40 m to 60 m depth.

II. Toxicityof fluoride on Human health

Prolong intake of large quantities of fluoride through drinking water and diet than

the optimal safe level causes the prevalence of dental, skeletal and non-skeletal

fluorosis.

Dental f luoros is

Dental fluorosis is characterized by a mottling of the tooth surface, or enamel. As

enamel develops, there is increased mineralization within the developing tooth

accompanied by a loss of matrix proteins. Exposure to excess fluoride during this

process causes a dose-related disruption of enamel mineralization resulting in

anomalously large gaps in its crystalline structure, excessive retention of enamel

proteins, and increased porosity. Mild forms of dental fluorosis are evidenced by the

appearance of white horizontal striations on the tooth surface or opaque patches of

chalky white discolorations. In moderate to severe forms of fluorosis, the opaque

patches can become stained yellow to brown or even black, and eventually the

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


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It has been reported that dental fluorosis affects at least 60% of the population

when drinking water contains more than 2 mg/l fluoride and 100% of the population

once the fluoride content reaches 6 mg/l. The following pictures show the prevalence of

dental fluorosis among people in fluorosis endemic villages of Nalgonda district.


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Diagno se of dental f luorosis

Dentists generally use the Dean Index to diagnose the severity of fluorosisdeveloped

H. Trendley Dean. The Dean Index classifies fluorosis into five types: questionable,

very mild, mild, moderate, and severe. Deans use of the descriptors very mild

and mild to characterize the first definitive stages of fluorosis is problematic. A tooth

with mild fluorosis is defined as one which has cloudy white staining (e.g., specks,

streaks, splotches) on up to 50% of the tooths surface.

Dean's Index

classification Criteria

description of enamel

NormalSmooth, glossy, pale creamy-whitetranslucent surface

Questionable A few white flecks or white spots

Very MildSmall opaque, paper white areascovering less than 25% of the toothsurface

MildOpaque white areas covering less than50% of the tooth surface

ModerateAll tooth surfaces affected; markedwear on biting surfaces; brown stainmay be present

SevereAll tooth surfaces affected; discrete orconfluent pitting; brown stain present


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Treatment methods for dental fluorosis

Mainly there are four treatment methods for dental fluorosis described as follows

Method 1

The first phase of treatment involved oral prophylaxis. This was followed by the second

phase of treatment for in- office vital bleaching using McInnes solution aided by etching

of the teeth by 37% phosphoric acid. McInnes solution has been used for treating mild

grade fluorosis for a long time and successfully. Mainly, the in-office bleaching approach

was advocated to the case of mild grade of fluorosis. McInnes solution consists of one

part anesthetic ether, five parts hydrochloric acid (36%), and five parts hydrogen

peroxide (30%). The solution was freshly mixed and applied onto tooth using a cotton

applicator. Each bleaching session consisted of application of bleaching solution for five

minutes with one minute interval under rubber dam application followed by polishing of

teeth with prophylaxis paste viz., Proxit (Ivoclar Vivadent). The patient was satisfied with

the outcome after three sittings, which were done a week apart from each session.

Appearance of teeth before and after treatment was shown in the following figures.


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Method 2

This treatment plan involved micro and macro abrasion followed by polishing. Micro and

macro abrasion were employed in this method. This technique has been employed

successfully for mild to moderate grade fluorosis. The tooth were abraded using water

cooled fine diamond finishing flame shaped points, with diamond abrasive particle size

of 20 - 30m with a high speed hand piece to remove surface enamel layer of 0.5mm

thickness. Removal of surface enamel was done with intermittent pressure under water

coolant. Final polishing of teeth was done with polishing discs (Super Snap, Shofu

Inc.,). The appearance of tooth before and after the operative treatment was shown in

the following figures.

Method 3

Composite resin was used for the treatment of dental fluorosis. This treatment involved

veneer preparation with window design, composite resin used was nano-composite

Ceram-X Duo (Dentsply, India) enamel shade E1 and dentin shade D2 bonding agent

employed was Prime and Bond NT (Dentsply, India). Polishing of composite restoration

was accomplished with Super Snap (Shofu Inc, Japan).


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Method 4

Pre operative impressions, occlusal records, face bow transfer were taken followed by

occlusal wax up in pre operative mounted models. Anterior crown preparations were to

be done followed by temporary crown insertion with increased vertical dimension and a

new centric was recorded. Anterior temporary crowns acted as a deprogramming

device. Temporary crowns were fabricated with heat cure acrylic resin. Posterior crown

preparations were done followed by temporary crown insertion in newly raised occlusal

vertical dimension. Posterior metal ceramic crowns were luted followed in next

appointment by luting of the anterior metal ceramic crowns. Articulators used in this

case were Stratos 300 (Ivoclar - Vivadent) an Arcon type semi adjustable articulator and

Universal face bow (Ivoclar - Vivadent).

Skeletal fluorosis

Skeletal fluorosis is a pathological condition that may arise by long-term

exposure to elevated levels of fluoride. The incorporation of fluoride into bone may

increase the stability of the crystal lattice and render the bone less soluble. Bone

mineralization is also delayed or inhibited due to prolong intake of excess fluoride, and

consequently the bones may become brittle and their tensile strength may be reduced.

The severity of the effects associated with skeletal fluorosis is related to the amount of

fluoride incorporated into bone. In a preclinical phase, the fluorotic patient may be

relatively asymptomatic, with only a slight increase in bone mass, detected through

radiographically. Sporadic pain and stiffness of the joints, chronic joint pain,

osteosclerosis of cancellous bone and calcification of ligaments are associated with the

first and second clinical stages of skeletal fluorosis. Crippling skeletal fluorosis (clinical

phase III) may be associated with limited movement of the joints, skeletal deformities,


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intense calcification of ligaments, muscle wasting and neurological deficits. A consistent

finding in cases of chronically elevated fluoride uptake is increase the mineralization lag

time of bone, which can be demonstrated by dynamic histomorphometry.

Various forms of skeletal fluorosis

Genu varum:Outward bending of long bones of lower limbs

Genu valgum: Inward bending of long bones of lower limbs (knock-knees)

Antero-posterior bowing of tibia: Forward or backward bending of tibia

Neck rigidity:Inability to touch the chest with the chin

Diagno se of sk eletal f luoro sis

The following various forms of skeletal fluorosis can be assessed based on various

tests such as Coin, Stretch and bending tests as follows.


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Treatment methods for skeletal fluorosis

Total knee arthroplasty was one of the methods for the treatment of skeletal

fluorosis. Variation from the use of intra-medullary guides should be considered in

patients with questionable bone quality undergoing total knee arthroplasty.

Non-skeletal f luoro sis

The conventional belief that fluoride affects only bone and teeth has been

negated in recent years as the evidences on the involvement of the soft tissues, organs,


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systems of the body are convincing. Investigations on soft tissue involvement in

fluorosis have attracted attention in the recent past, and convincing evidence from

fluorosis patients is now available to demonstrate the damage or involvement of skeletal

muscle, erythrocytes, gastro-intestinal mucosa, ligaments in patients of fluorosis. There

are evidences on involvement of other organs and system of animal models vizkidney,

liver, adrenal gland, brain cells and reproductive organs. It is now known that when

fluoride is ingested, it will also accumulate on the erythrocyte membrane, besides other

cells, tissues and organs.

III. Collection of water, urine and blood samples and estimation of fluoride

Importance of f luor ide analysis in dr inking water , ur ine and blood

Fluoride level within 1.0 mg/l in drinking water is safe for consumption. Water sources

containing fluoride 1.0 mg/l to 2.0 mg/l then the area can be considered as medium

fluoride area. An area can be considered as high fluoride area, when the fluoride level in

water sources more than 2 mg/l and which need more concern to supply safe drinking

water and the people in that area are highly vulnerable to fluorosis. Fluoride levels in

urine and blood samples more than 1.5 mg/l and 0.08 mg/l, respectively, indicating that

the person exposed to excess fluoride and are highly vulnerable to risk of fluorosis.

Water samp le col lect ion and analysis

About 30 ml water sample to be collected from the source using clean, high-density

polyethylene bottles with proper lable indicate the date of sample collection and exact

location of the sample source. Then the sample can be kept at room temperature, if not

being analyzed immediately. Fluoride levels in drinking water samples were measured


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by fluoride ion selective electrode with expandable ion analyzer by diluting the samples

with Total Ionic Strength Adjustment Buffer (TISAB II) in 1:1 ratio.

Urine sample col lect ion and analysis

About 30 ml spot urine samples to be collected in clean, high-density polyethylene

bottles containing 2 to 4 drops of toluene as a preservative. Each sample should be

properly labeled with number and relevant details. Then the samples can be stored at

4C till analysis.

Bloo d sample col lect ion and analysis

About 10 ml twelve hour fasting blood sample to be collected from an individual by a

trained technician and to be stored in a serum vacutainer. Serum can be separated by

centrifugation at 3000 rpm for 20 minute and to be stored in an ice lined refrigerator

(ILR) at cold condition (-80C) till analysis.


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Nutritional Interventions

It is known that deficiencies in protein, vitamin C, calcium in diet and poor nutrition in general

aggravate fluoride toxicity. Data obtained from dietary surveys, suggested that inadequate

ascorbic acid and calcium are related to severity of fluorosis. Earlier studies reported that toxic

effects of fluoride are reversible and could be effectively reversed by withdrawal of the fluoride

source and subsequent supplementation of calcium, vitamin C, E and D. The extent of reversal

observed was more pronounced and highly beneficial by combined supplementation of calcium

and vitamin C on the recovery of the fluoride induced alterations on structure and metabolism of

soft tissues. The rate of prevalence of fluorosis and other symptoms of fluoride toxicity was

lower among the milk-consuming children than that of non-milk-consuming children. The

treatment with calcium, vitamin C and D showed a significant improvement in the skeletal

fluorosis and biochemical parameters in children consuming water containing 4.5 mg/L of

fluoride. A protective role of carotene and superoxide dismutase was observed on impaired

growth and poor antioxidant state of the rat due to fluoride toxicity. Fluorosis, being an

untreatable disease, can only be mitigated through prevention and control. If the disease is

diagnosed early, it is easily preventable. Apart from supplying safe drinking water to the

fluorosis endemic villages, nutritional supplementation is also needed for combating with the

health complaints arising due to fluorosis.

Nutritional supplementation

Nutritional supplementation requires counseling of the patients and to educate the female

members of the household who are responsible for cooking and serving the food for the

families. It is necessary to inform about the locally grown / available food items which are rich in

calcium, vitamin C, E and antioxidants that they need to be consumed on a daily basis, through

breakfast, lunch and dinner. Before counseling the patient, the status of the diet that the family

consumes, food habits and way of cooking the food are to be assessed. Then they are advised

to consume food rich in calcium, vitamin C, E and anti-oxidants and the different recipes for


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consuming the nutrient rich items are also explained. The food items suggested to the family

should be affordable and easily available.

Using infant formulae and declining of breast feeding

Substantial declines in breast feeding practices have occurred over the past 30 years and

using high fluoride containing infant formulae and processing with high fluoride water leads

to enhance the fluoride intake and fluorosis risk to the infants at early stage.

Declining of milk consumption and increase of tea drinking habit

There are 36 thousand slaughter houses (number represent official only) are running in our

country, where we installed modern killer machine (Halal cattle slaughter line) for killing

cows with capacity to kill 10,000 cows per hour, and killing around 2 lakhs of cows per day

around the country. Decrease the number of cows may be the reason for the deficiency and

high cost of milk and milk products. Nowadays, more than 85% Indian children were

possess the habit of consumption of tea. However, the tea contains 20 to 30 times more

fluoride (5 mg/l to 600 mg/l) than other dietary items.

Usage of fluoride containing tooth pastes, tobacco products

Most of the children were not properly washing their mouth after tooth brushing leads to

swallowing of fluoride through tooth paste residues leads to fluorosis risk.

General steps to mitigate fluorosis

Need to identify fluorosis endemic areas and fluoride rich water sources around the

country.

Need to supply water with safe fluoride level contain essential minerals in permissible

levels to the regions with prevalence of fluorosis.

Avoid the usage of high fluoride water for drinking and cooking

Avoid the practice of feeding infant formulae and encourage the breast feeding

practices.


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Avoid the usage of fluoride containing tooth pastes, tea and tobacco products and

needed to encourage the habit of consuming milk and milk products.

Water used for cooking also need more concern, because usage of water for

processing food, tea and infant formulas enhance the fluoride level of the final

products.

Encourage the defluoridation instead of RO filtration for fluoride removal, in order to

avoid the loss of essential minerals (100% bioavailable form).

Enhance the consumption of calcium and vitamin C and D and protein rich foods.

Documents

Prevalence of Fluorosis in Nalgonda District