Prevalence Of Dental Fluorosis
Recent estimates suggest that over 200 million people across the world are under the dreadful fate of fluorosis yet it is one of the neglected disease in the world. China and India are the two most populous countries and are worst affected by it. In India itself, 66 million people are affected with fluorosis endemic to 230 districts. This includes 6 million children under the age of 14years [1, 2, 3].
According to estimates china has over 1 million people suffering from skeletal fluorosis and 26 million from dental fluorosis as a result of elevated fluoride levels in their drinking water .Over the past few decades, the prevalence and severity of fluorosis has increased drastically in India, reaching almost epidemic proportions. At present, it is endemic to 20 out of 35 states and Union Territories [4,5,6]. It is a challenging national health problem, particularly in the states of Andhra Pradesh, Punjab, Haryana, Uttar Pradesh, Rajasthan, Gujarat, Maharashtra and Tamil Nadu .
Over 1,50,000 villages are under its threat [ 13]. In the district Nalgonda ( in Andhra Pradesh) itself, 600 villages and 3lakh people are affected by the excess fluoride content in ground water and over 10,000 people are actually crippled due to skeletal fluorosis . In a recent study done in rural areas around Lucknow (in Uttar Pradesh), prevalence of dental and skeletal fluorosis was found to be 43% and 28.64% respectively [11 ]. In a study among primary school children in rural areas of Cuddalore district (in Tamil Nadu), the prevalence of dental fluorosis was found to be 31.4% . In year 2000, a very high prevalence rate of 92.73% has been recorded among school children of rural areas of district Bhiwani, Haryana . In a study done amongst primary school children in rural area of Raichur district (Karnataka), the overall prevalence of dental fluorosis was found to be 32.6% .
In a door to door epidemiologic survey conducted in four villages of Faridabad, 58% of the population was found to have dental fluorosis, 27% have complaints suggestive of skeletal fluorosis, 41% have non-skeletal manifestations and 26% have gastrointestinal manifestations . All the drinking water samples of the fluorosis patients in this study had fluoride levels beyond the maximal permissible limit of 1ppm .Fluorosis is a disease which occurs due to the ingestion of high levels of fluoride. Fluoride enters human body through a variety of sources viz. water, food, air, medicaments and cosmetics etc. Of these, the main source responsible for high intakes of fluoride remains the ground water. Rural population who mainly depends on ground water for drinking are worst affected.Fluoride is an important micronutrient and hence is essential for the normal growth, development and maintenance.
According to 1984 guidelines published by the World Health Organization (WHO), fluoride is an effective agent for preventing dental caries if taken in 'optimal' amounts . However, the excessive intake of fluoride can lead to dental and skeletal fluorosis. Chronic fluoride toxicity can affect almost all the major systems of the body including gastrointestinal system, nervous system, cardiovascular system and reproductive system. It also affects muscles and other soft tissues of the body.Dental fluorosis occurs when excessive intake of fluoride occurs during the developmental phase of teeth i.e. during amelogenesis. While mild fluorosis is manifested as white flecks and chalky opaque areas on teeth, severe one leads to brown pitted corroded enamel surface called as mottling which may also lead to complete loss of enamel.
This makes it a potential aesthetic problem that may have huge psychological impact on youngsters. In a recent study conducted in Uttar Pradesh, it was found that majority of population above the age of 40 years was completely or partially edentulous. The author of the study founds fluorosis to be the primary cause for the same. Edentulous people suffer from nutritional deficiencies as they are unable to chew food and hence overall health of the person is compromised .Skeletal fluorosis is a more severe condition as compared to dental. It leads to paresthesia in the limbs and trunk, followed by pain and stiffness in the back especially in lumbar region and dorsal and cervical spines.
Earliest clinical sign is the restriction of spine movements leading to stooped backs. The patient becomes crippled due to crooked hands and legs."In many fluoride endemic areas of India, children with limbs twisted out of shape hobble forward with the help of walking sticks, and are forced to leave schooling. They grin with agony, pain and embarrassment because they cannot run like other children of their age; fluoride poisoning has crippled their limbs and hopes.
Touchingly, parents are forced to take their kids suffering from severe skeletal fluorosis to nearby hospitals for getting them certified as 'physically handicapped.' Thus severe fluorosis has acquired the dimensions of a socio-economic problem rather than a public health problem in India " ."One of the most intriguing aspects of fluoride toxicity is that the entire population consuming high fluoride content may remain asymptomatic. There are several possible reasons for an individual to remain asymptomatic.
These include differences in kidney function and its efficiency in excreting fluoride, circulating levels of certain hormones (e.g. steroids, calcitonin and parathormone), and dietary factors (e.g. adequate calcium and vitamin C)" .Moreover it is often misdiagnosed as ankylosing spondylitis, arthritis or idiopathic back pain. "The victims of fluorosis are often helpless and continue to suffer without their disease being diagnosed, undergo treatment with medicines of different kinds; some even undergo surgical interventions, adding to their desolation with no sign of healing or relief to the pain or disability" .The 1984 WHO guidelines suggested that, the optimal fluoride concentration in drinking water should remain below 1 mg/litre (1ppm or part per million) in areas with a warm climate, while in cooler climates it could go up to 1.2 mg/litre. The differentiation derives from the fact that we perspire more in hot weather and consequently drink more water.
According to the guideline the maximum permissible upper limit for fluoride in drinking water was set at 1.5 mg/litre. Because of the severe impacts of excess fluoride content in groundwater, this limit in India has been reduced to 1.0 ppm in 1998 [7, 8]. However, levels above WHO guideline have been identified in numerous countries around the world .Fluoride is used to prevent dental caries and hence has been used as an addition in various toothpastes, gels and mouthwashes for self application by patients. It is also used professionally by the dental surgeons in the form of fluoride gels and varnishes as a caries preventing agent.
Also fluoride has been added to drinking water from many years through various community water fluoridation programs all over world. About 73% of American communities fluoridate their water . The United States Department of Health and Human Services proposed to lower fluoride concentrations in drinking water to 0.7 mg/L from 0.7-1.2 mg/L. The lower level "provides the best balance of protection from dental caries [tooth decay] while limiting the risk of dental fluorosis," the department stated in a release in 2011 [20, 21].It is a paradoxical situation as fluorosis being a big national problem, use of fluoride in drinking water, toothpastes, gels and salt is still being advocated. Not only drinking water fluoride but also other dietary factors are contributing to the risk of fluorosis.
Since the availability of fluoride from different sources, easily leads to doses above the recommended levels, it contributes to an overall increase in the prevalence of fluorosis. Hence the optimum fluoride levels in drinking water has to be determined based on climate, source of water supply, dietary habits and other related factors.It is observed in our literature search, that there is a wide variation in the prevalence of fluorosis in different populations. This could be attributed to different levels of fluoride in ground water in different geographic terrains and also to the different diagnostic criteria and study instruments being employed.
As fluoride content in the diet depends on the geography, climate, socio-economic status and dietary habits of a particular community, data from one study area may not be applicable to other areas. In order to implement any public health program in a particular community to prevent fluorosis, the exact burden of the disease and the fluoride content in that area should be known.There are various studies done in past in the field of fluorosis but most of them have targeted only rural population. This study is therefore aimed to compare the prevalence of dental fluorosis among rural and urban children of the same district.
We propose to find out the burden of dental fluorosis in urban population because of the changing dietary habits and more usage of fluoride containing products on daily basis.
AIMS AND OBJECTIVES:
The aim of our study is toâ€¦â€¦The primary objective of our study is to find out the prevalence of dental fluorosis in children of rural and urban areas of district Faridabad. The secondary objective is to compare the differences in the prevalence among rural and urban population and to find out the factors that leads to such differences.
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