FLUOROSIS: AN OVER VIEW

Dr. Arjun L. Khandare

Scientist E (Deputy Director)

National Institute of Nutrition (ICMR)

Hydreabad

National Programme for Prevention and Control of Fluorosis

Fluorosis is a slow, progressive and crippling malady affecting most of the organs in the body where flouride in drinking water is > 1.0ppm.

More than 90% of rural drinking water supply programmes are based on ground water available, which is being overexploited for agriculture, causing a high influx of fluoride into water.

Endemic fluorosis has been steadily increasing ever since the disease was discovered in India during the 1930s .

Introduction

Magnitude of the problem

Global scenario Fluorosis is public health problem in 25 countries around the world.(DARK AREAS)

Arunachal Pradesh

Kerala21

Tamil Nadu28

Karnataka67

Andhra Pradesh70

Maharashtra31

Madhya Pradesh36

Orissa56

West Bengal22

Gujarat95

Rajasthan

100.0

Punjab82Haryana 63

Delhi31

Uttar Pradesh22

SikkimNagaland

ManipurMizoramTripura

Himachal Pradesh

Jammu & Kashmir

7

Bihar15

Assam9

Andaman Nicobar

70-100 % Districts affected 40-70 % Districts affected10-40 % Districts affected <10% Districts affected Endemicity not known

Source:A Treatise on Fluorosis by Dr. A.K. Susheela

No of affected District 204 (21 States /UT)

people affected, 62 million ( 6 million children)

Causative factor, excess consumption of fluoride through drinking water (>1.0ppm) and diet.

Problem in India

• Initial symptoms : Headache, constipation, vague body pains, backache, joint rigidity & general weakness.

• These were followed by multiple joint pains, mostly in the feet, knees, and back.

• Difficulty in walking

• Limitation of joint movement. Inability to close the fist

• Spinal stiffness and kyphosis developed in a few patients.

• Flexion of spine

• Neurological complication

Clinical symptoms

Types of fluorosis

Fluorosis

Dental Skeletal Non skeletal

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 .

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.

Skeletal Fluorosis

Identification

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 chin with the chest. A fluorotic subject would not be able to do so, if there is pain or stiffness in the neck.

STRETCH TEST: The individual is made to stretch the arms sideways, fold the arm and try to touch the back of the head. If there is pain or stiffness in the shoulder joint and backbone, the exercise will be difficult, suggesting possibility of fluorosis

Confirmation with X-ray

Ossified Interosseous Membrane

Types of skeletal fluorosis - I

Genu valgum, Genu varum, Anterioposterior bowing of tibia (Saber

tibia), Scoliosis, Paraplegia are severe forms of skeletal

fluorosis

Recent NIN study conducted in BiharChildren of 2-3 year were affected with sever forms of crippling bone deformities

Children affected from fluorosis

Skeletal fluorosis in Assam

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 VarumLegs 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.

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

Types of skeletal fluorosis - III

Types of skeletal fluorosis - IV

Paraplegia: Spinal cord compression due to osteosclerosis with paraplegia as a result of endemic skeletal fluorosis

Tingling sensation in fingers and toes Excessive thirst Polydypsia and polyurea Nervousness & Depression

NON SKELETAL MANIFESTATIONS

NIN Research

(1995 – TO DATE)

Effect of nutrition adequacy on severity of endemic fluorisis

No of Mild Moderate Severecases %

Nutrition adequate 290 91 8 1

Nutrition 300 11 56 33Inadequate

Incidence of Metabolic Bone Disease Accompanying Endemic Skeletal Fluorosis

(Radiological Survey)

Beneficial effect of tamarind ingestion on fluoride toxicity

Control fluoride Fluoride + Tamarind

Studies in humans

Fluorosis Mitigation : Strategies

Fluoride detection in drinking water

(Field testing kit)

Demonstration of fluoride testing by kit method (Color development)

HOUSEHOLD LEVEL BONE CHAR DEFLUORIDATOR

This is very simple and inexpensive method conceived by staff of ICOH and WHOBore well water with 3.8 ppm fluoride after passing through this defluoridator reduced to 0.18 ppm

The pipe is 75 cm feet long and 90 cm diameter with 1kg Bone Char activated by heating

Community Based Bone Char Defluoridator

Inauguration of Community Bone Char Defluoridator at endemic village of Nalgonda

District

Community Based Bone Char Defluoridator at Khudabakshpalli, Nalgonda, AP.

1.Roof catchment 2.Gutters3.Downpipe and first flush pipe

5.Filter unit

4.Storage tank

The roof catchments are relatively cleaner when compared to the ground level catchments

Built and maintained by the local communities.

Available at their door steps with least cost

1

43

5

2

Rain Water Harvesting Asbestos roof

1. Rubble (Lowest)

2. Coarse Sand

3. Charcoal

4. Thick Sand

5. Pebbles (Topmost)

The Filter Unit is a Cement container filled with filter media below - upwards.

The Filter Unit removes the debris and dirt from water that enters the tank. Direct sunlight exposure is avoided to prevent formation of algae and breeding of mosquitoes.

5400 lits. of storage water is sufficient for a family of 5 members, for 6 months ( 5 lit / person/ day)

Rain Water Harvesting: Slab House

Surgical Intervention

Fluoride meter

Measurement of fluorideRequirement

• Fluoride meter with ION selective electrode

• TISAB (total ionic strength adjustment buffer) -For masking other chemicals present in solution and making fluoride

available for measurement

• Different types of TISAB – different samplesWater/urine- TISAB-I

Serum- TISAB –II• Standards –to calibrate fluoride meter. Range depends on

type of sample.

Procedure

1.Sample preparation- 5ml of TISAB + 5 ml of sample

(water/ diluted urine/ diluted serum/ other samples)

2. Calibration

3.Expression- Concentration of fluoride is expressed in ppm (parts per million/ mg per ml/ µg per L)