PREVALENCE OF FLUOROSIS IN NALGONDA

DISTRICT, TELANGANA, INDIA

I. INTRODUCTION
Fluoride
Fluoride is an inorganic, mono-atomic anion of fluorine with the chemical formula F.
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 ion resembles
the hydroxide ion

(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 fluoride in drinking water
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 fluorosis
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.

Scenario of prevalence of fluorosis in Telangana and Nalgonda district

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 for high fluoride in groundwater and high prevalence of fluorosis in
Nalgonda district
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.

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 1000liter 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.
Ongoing remedial measures for fluorosis in Nalgonda district
In order to 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

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.
S.No. Name of the
affected 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
Bibinagar
16
Thurkapally
17
Veligonda

Demographic profile of Nalgonda district

According to the 2011 census Nalgonda district has a population of 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
rate over the decade 2001 - 2011 was 7.26%. Nalgonda has a sex ratio of
982 females for every 1000 males and a literacy rate of 65.05%.

Climate and geological profile of Nalgonda district

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. Toxicity of 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 fluorosis
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.

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.

Diagnose of dental fluorosis

Dentists generally use the Dean Index to diagnose the severity of fluorosis developed
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
Normal

Smooth, glossy, pale creamy-white

translucent surface

Questionable

A few white flecks or white spots

Very Mild

Small opaque, paper white areas

covering less than 25% of the tooth
surface

Mild

Opaque white areas covering less than

50% of the tooth surface

Moderate

All tooth surfaces affected; marked

wear on biting surfaces; brown stain
may be present

Severe

All tooth surfaces affected; discrete or

confluent pitting; brown stain present

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.

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).

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,

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
Diagnose of skeletal fluorosis
The following various forms of skeletal fluorosis can be assessed based on various
tests such as Coin, Stretch and bending tests as follows.

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 fluorosis
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,

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 viz kidney,
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 fluoride analysis in drinking water, urine 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 sample collection 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

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 collection 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.
Blood sample collection 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.

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

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.

 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.