Fluorosis Diagnosis, Patient Management, Monitoring and Recovery

Dr Ingole, MD

Fluorosis Diagnostic Procedure

• Good history retrieval namely : 1. Place of birth, 2. Place of stay, 3. Duration of stay, 4. Source of drinking water, 5. Health complaints, 6. Clinical examination 7. Assess

Fluorosis Diagnosis : Essential Tests

• Samples to be tested for fluoride in : Serum, Urine, Drinking water

• Do not use KITS

• Instead Use :: Ion Selective Electrode technology (reported in mg/L)

Sample collection (Precautions)

• Spot Urine Sample* • Collect in Plastic bottle only • Why glass bottles is Not used : Silica in

glass will bind with fluoride (False low level of Fluoride in test)

* Applicable for Blood, urine and water samples also

X Ray forearm is a must even though there is No Pain

Interpretation of Test Results • What is the significant • Patient should know what is his/her report and what is

significance intervention – • Early stages complete recovery • Non compliance to treatment disease will advance and

no recovery • Low Hb : Multiple Nutritional deficiency due to gastric

villi atrophy• If they understand the gravity of situation, their

treatment compliance will be better.

Interpretation of Test Results

• Logical and Interconnected interpretation(s)

• For example : Low hemoglobin can be due to Fluoride excess and; same patient can also suffer from Multiple nutrient deficiency due to gastric villi atrophy

Test Normal Level

Serum Fluoride 0.02-0.1mg/L

Urine Fluoride 0.1-1.0mg/L

Drinking Water Fluoride

Up to 1mg/L *

A Treatise on Fluorosis; AK Susheela ; 3rd edn. 2007: Page 64

* Body may tolerate ; Less the better

Evaluation of test reports

Possibility 1 : Confirmed case of Fluorosis • All samples (Urine, Serum, Water) =

Fluoride beyond normal range • X Ray forearm = Calcification of

interosseous membrane

Evaluation of test reports

Possibility 2 • Water Fluoride - Normal • Urine and serum Fluoride - Beyond

Normal Range • Suspect fluoride consumption

through other sources• Find source of fluoride; interview

patient again ; Look out for Interosseous Membrane calcification

Evaluation of test reports

Possibility 3 : Fluorosis with renal failure • Amongst the 3 samples tested, Fluoride in

drinking water and serum is high. Urine level normal; X Ray Calcification of ligament is evident

• Since Urine fluoride level is normal, get kidney function tests done.

• Disease Confirmed.

Steps to follow after disease is diagnosed .. 1

• Doctor to explain patient the nature of disease and inform that fluoride is poison entering in body unknowingly

• Also tell that X Ray film is showing strong evidence of Fluorosis

Steps to follow after disease is diagnosed ..2

• Patient should be made aware that the lesser Fluoride level the better

• Use RO Water filter • Get ground water samples tested from

neighborhood

Steps to follow after disease is diagnosed ..3

• Doctor should advise patient regarding Diet editing, Diet counseling

• Patient should be referred to diet counselor who is trained for counseling for fluorosis.

Diet Counselor

• Should go through health complaints • Would advise regarding Diet editing and

counseling to FEMALE members of patient’s home, who cook the food.

• Diet Counselor should not provide ready made printed advise to patient.

• Diet advise should be patient specific.

Diet Counselor • Dietician should provide blank sheet initially and ask to

list out the items consumed for breakfast lunch and dinner.

• Dietician to point out fluoride containing items

• To promote nutrients through fruits, vegetable and dairy products

• Fruits for breakfast, Mixed vegetables & Salad for lunch ; and multiple vegetables soup for dinner

• First follow up after 15 days of starting intervention when non skeletal fluorosis complaints will start to disappear

• Second and 3rd follow up : 3 & 6 months later

• What tests ? : Urine fluoride and Hb :: Reduction in Urine fluoride will lead to rise in Hemoglobin

Follow Up & Monitoring

Follow Up & Clinical assessment

• Non Ulcer dyspeptic symptoms +++• Polyuria/Polydipsia ++• Muscle weakness +• Fatigue +

Items are Listed in the approximate order in which patient will experience likely benefit

Diet or drug

• Patient would ask for tablets and drugs.

• Explain merits of diets to patient rather than drug

• Recovery is faster with diet than drug

Graphs : Showing Mean Concentration of Fluoride in Drinking Water, Urine & Blood among the study persons, before and during the 1st, 2nd and 3rd impact assessment

Interventions to Practice

• Use RO water filter • Avoid foods or food items rich in fluoride• Follow up patient • Urine FLUORIDE BELOW 1MG/• Measure Hb : It will increase beyond

Anemic level

Follow Up : Fluoride Levels

• Hb, Serum & Urine Fluoride levels after : 15 days of starting of intervention, 3 months, 6 months & further as may be required

Take Home Messages • Infrastructure for diagnosis requires to be developed • Update for doctors is required in all institutions • Precoded forms are required for use across all

departments for retrieving history. • Dietician require training & update• Patient should not change doctors. • Some patient need to reminded to come for monitoring• Recurrence may occur due to contamination or

consumption unknowingly.

Thanks

Dr Jitendra IngoleMD Medicine