Essentials of Fluorosis Mitigation

G. Roy DPH MAE

Dy.CMOH-II, D/Dinajpur September-2011

Normal Requirement of Fluorine

Fluorine is abundant in nature, found in compound form like fluoride

Fluorine is essential for mineralization of bones & formation of dental enamels

Fluorine deficiency: Dental caries 96% of fluoride of body found in bones

& teeth Normally small amount of fluoride is

required (0.5 to 0.8 mg/lit) in drinking water

What is Fluorosis ?

Fluorosis is a major public healthproblem caused by intake of excess amount of fluorides over a long period resulting permanent and irreversible damages like dental, skeletal and non-skeletal fluorosis

Dental Fluorosis

Skeletal Fluorosis

Skeletal Fluorosis

Source: An intervention study conducted in Mandla district, MP, by ICMR

Sources of Fluoride

Contaminated drinking & cooking water, agricultural & food products, drugs and industrial emissions & pollutants

Contaminated ground water is the main source

Permissible Limit of Fluoride

Permissible limit of fluoride in drinking water: One mg. / liter or one p.p.m. in drinking water as per Bureau of Indian Standard (BIS)

Suspected Cases of Dental Fluorosis

Chalky white teeth Transverse yellow brown or dark

brown bands

Images of Dental Fluorosis

Suspected Cases of Skeletal Fluorosis

Severe pain & stiffness in the neck & back bone

Severe pain & stiffness in joints Severe pain & rigidity in pelvic girdle Increased girth, thickening & density of

bone seen in X- Ray Genu valgum & osteoporosis Knock knee / Bow leg Inability to squat Defective gait & posture

Images of Skeletal Fluorosis

Skeletal Fluorosis – Radiological diagnosis

Suspected cases of Non – skeletal Fluorosis

Gastro –intestinal problems: Consistent abdominal pain, intermittent diarrhoea/constipation, blood in stool

Neurological manifestations: Nervousness & depression, tingling sensation in fingers & teeth, polydypsia, polyurea

Muscular manifestations: Muscle weakness & stiffness, pain in the muscle, loss of muscle power

Confirmation of Fluorosis

Any suspect case with high level of fluoride in urine (>1mg/L)

Any suspect case with inter-osseous membrane calcification in the forearm confirmed by X-ray

Prevention of Fluorosis I Abandoning contaminated source Discarding use of ground water Using treated water from rivers,

canals, ponds etc. surface water Using de-fluoridated ground water

where surface water not available Conservation and harvesting of rain

water for agriculture and household use

Prevention of Fluorosis II Restrict fluoride rich food: black tea,

black salt, rock salt, tobacco, brittle nut

Avoid fluoride rich cosmetics & drugs Intake calcium, iron and vitamin rich

food: milk, milk products, green vegetables, citrus & other fruits

Banning fluorinated toothpaste for children in endemic areas

Treatment of Fluorosis

Medical treatment: No specific treatment; treatment supplementation with vitamin C & D, antioxidants, calcium & correction of malnutrition

Treatment of deformities: Orthoses, surgical shoes, physiotherapy, reconstructive surgery

Mitigation of Fluorosis - I Closing contaminated water source Arranging alternative safe water source Flocculation, sedimentation, coagulation

(with lime & alum), filtration of drinking water before use

Health education, dietary counseling & nutrition

Dietary supplementation of calcium, vitamin C, D3 & iron

Mitigation of Fluorosis - II Enhanced surveillance, early

detection, proper treatment & rehabilitation

Rain & surface water harvesting for agriculture & household

Supply of pipeline river water from water treatment plant

Water treatment gadgets in tube wells where surface water is not available

Global Prevalence

Indian Scenerio 1930 : First reported from Andhra Pradesh 1937 : First published report 19 states & UTs and 196 districts endemic Birbhum, Purulia and Dakshin Dinajpur

endemic in West Bengal >66 million (>6.6 crores) population

affected 2008 : National Programme for Prevention

& Control of Fluorosis (NPPCF)

Goal of NPPCF

Goal of National Programme for Prevention and Control of Fluorosis (NPPCF): To prevent and control of fluorosis cases in the country

Objectives of NPPCF

To collect & use of baseline survey data of fluorosis

Comprehensive management of fluorosis in endemic areas

Capacity building for prevention, diagnosis & management of fluorosis cases

Programme Framework & Phasing

Phase I (2008-09) : 5 districts

Phase II (2009-10) : 15 districts

Phase III (2010-11) : 40 districts

Phase IV (2011-12) : 40 districts

Strategies of NPPCF Training of field level health

personnel Capacity building of District Hospitals

& Medical Colleges Laboratory support development in

District Hospitals & Medical Colleges Information, Education &

Communication (IEC) for the community

Activities under NPPCF-I

Community diagnosis of fluorosis - village/block/cluster wise

Facility mapping from prevention, health promotion, diagnostic facilities, reconstructive surgery and medical rehabilitation point of view – village/block/district wise

Activities under NPPCF-II

Gap analysis in facilitation & organization of physical & financial support for bridging the gaps

Diagnosis of individual cases & providing its management

Public health intervention on the basis of community diagnosis

Behavioral change by IEC

Thank You

Acknowledgement Communiqués of Nutrition & IDD Cell, DGHS, GOI Preventive & Social Medicine – K. Park, 20th Edition Dr. Bhusan Chakraborty, ADHS(MPHWS), Govt. of W.B. Dr. Tapas Chakma, Dy.Director, RMRC, Jabalpur Dr. Asit Mandal, CMOH, Dakshin Dinajpur Mr. D.Banerjee, Exe. Engineer(PHE), Dakshin Dinajpur Mr. Biplob Goswami, Ex-HS, Dy.CMOH-II Office Mr. Nilay Sarkar, DEO, IDSP, Dy.CMOH-II Office Google Search