Journal of Pharmacy And Bioallied Sciences

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 9  |  Issue : 5  |  Page : 88--91

Comparative evaluation of dental and skeletal fluorosis in an endemic fluorosed district, Salem, Tamil Nadu


Maya Ramesh1, N Malathi2, K Ramesh3, Rita Mary Aruna4, Sarah Kuruvilla5,  
1 Department of Oral Pathology, Vinayaka Mission's Sankarachariyar Dental College, Ariyanoor, Salem, Tamil Nadu, India
2 Department of Oral Pathology, Sri Ramachandra Dental College and Hospital, Chennai, Tamil Nadu, India
3 Department of Pedodontics and Preventive Dentistry, Vinayaka Mission's Sankarachariyar Dental College, Ariyanoor, Salem, Tamil Nadu, India
4 Department of Molecular Medicine, Penang International Dental College, Vinayaka Missions University, Salem, Tamil Nadu, India
5 Department of Pathology, Madras Medical Mission, Chennai, Tamil Nadu, India

Correspondence Address:
Maya Ramesh
Department of Oral Pathology, Vinayaka Mission's Sankarachariyar Dental College, NH 47, Sankari Main Road, Ariyanoor, Salem - 636 308, Tamil Nadu
India

Abstract

Background: High levels of fluoride in the drinking water, especially ground water, results in skeletal fluorosis which involves the bone and major joints. This study was conducted to assess the prevalence of skeletal fluorosis to compare with dental fluorosis in an endemically fluorosed population in the District of Salem, Tamil Nadu. Materials and Methods: Institutional ethical clearance was obtained. A total of 206 patients who reported to the Department of Hematology for blood investigations were the participants in this study. Age, sex, place, weight, height, dental fluorosis, and skeletal complaints were noted down. Body mass index was calculated, and statistical analysis was performed. Results: Dental fluorosis was present in 63.1% and absent in 36.9% of the samples reported. Skeletal fluorosis was present in 24.8% and was absent in 75.2%. A large number of the patients had knee pain and difficulty in bending. Chi-square test was used for statistical analysis. Skeletal fluorosis and age were compared and P value was 0.00 and was significant. Dental fluorosis and skeletal fluorosis were compared and P value was found to be 0.000 and significant. Discussion and Conclusion: There is a need to take measures to prevent dental and skeletal fluorosis among the residents of Salem district. Calcium balance should be maintained, and fluoride intake should be minimized to reduce the symptoms. The government should provide water with low fluoride level for drinking and cooking. Once the symptoms develop, treatment largely remains symptomatic, using analgesics and physiotherapy.



How to cite this article:
Ramesh M, Malathi N, Ramesh K, Aruna RM, Kuruvilla S. Comparative evaluation of dental and skeletal fluorosis in an endemic fluorosed district, Salem, Tamil Nadu.J Pharm Bioall Sci 2017;9:88-91


How to cite this URL:
Ramesh M, Malathi N, Ramesh K, Aruna RM, Kuruvilla S. Comparative evaluation of dental and skeletal fluorosis in an endemic fluorosed district, Salem, Tamil Nadu. J Pharm Bioall Sci [serial online] 2017 [cited 2022 Aug 12 ];9:88-91
Available from: https://www.jpbsonline.org/text.asp?2017/9/5/88/219298


Full Text



 Introduction



Fluoride has a beneficial effect on teeth and bone when taken in optimum concentrations through drinking water. If the body is exposed to fluoride in large amounts mainly through water, many adverse effects occur. High levels of fluoride in the drinking water, especially ground water; result in skeletal fluorosis which involves the bone and major joints. The cancellous bone which has more blood supply will be affected more by fluorosis compared to compact bone.[1]

Fluoride is absorbed into the body from different sources such as drinking water, food, gaseous industrial waste, and toothpaste. A person's diet, the general state of health and the body's ability to excrete fluoride also affects the development of fluorosis.

Fluoride will be absorbed from foods cultivated in soil rich in fluoride like tea and from wines in addition to drinking water.[2] A study was carried out in Salem and dental fluorosis was present in 56.9% of the children examined. It was mostly seen in 9 years old (72%) and male (59%) children.[3]

While dental fluorosis can be easily recognised, the skeletal involvement is not clinically obvious until the advanced stage of crippling is reached. Hence, the present study was aimed to compare the prevalence of skeletal problems in an endemically fluorosed population in the district of Salem, Tamil Nadu.

 Materials and Methods



Institutional Ethical clearance was obtained from Vinayaka Missions Sankarachariyar Dental College, Salem. The cross-sectional study was conducted at Salem, a district in the state of Tamil Nadu in India. Patients who reported to the Hematology Department for blood investigations were included in this study. Individuals who could perform three diagnostic tests (physical signs) for clinical assessment of skeletal fluorosis were included in the study. All those who could not perform three diagnostic tests (small children and sick individuals) were not included in the study. The details collected include name, age, sex, place, height, weight, Dean's index, family history of dental fluorosis, joint pain, and menopausal history.

Informed consent was obtained from the subject who took part in the study or from the parents in case of children. Following data were collected from them by a single examiner. Weight and height were measured using the standard procedures, and body mass index (BMI) was calculated using Med India BMI calculator. It was categorized using Med India itself into “underweight, normal, Overweight, Obese I, Obese II and Obese III.”[4]

Dental fluorosis was assessed on the basis of modified dean's index in this study. Only one investigator did the whole study to prevent inter examiner variability. Skeletal fluorosis was assessed using the three field tests, namely (a) touching the toes without bending the knees, (b) touching the chest with the chin, and (c) stretching the arms sideways and folding the arms to touch the back of the head.[5] Subjects who were unable to perform the three simple diagnostic tests due to pain or stiffness in the neck or pain or stiffness in the shoulder joint and backbone, respectively, were considered to have skeletal fluorosis.

 Results



A total of 206 people who are living in the endemically fluorosed area of Salem were evaluated. People who participated in the study were in the age group of 10 to 80. Among this, 25.2% of the people were between 10 and 20 years, 12.6% of the people were between 21 and 30 years, 7.8% of the people were between 31 and 40 years, 16.5% of the people were between 41 and 50 years, 21.8% of the people were between 51 and 60 years, 12.6% of the people were between 61 and 70 years, and 3.4% of the people were between 71 and 80 years [Table 1]. Out of these, 48.5% were males and 51.5% were females [Table 2]. People were divided on the basis of BMI, 5.8% were underweight, 54.4% were normal in weight, 30.1% were overweight, 9.2% were Obese I, 0.5% were Obese II, and 0% Obese II [Table 3]. Dental fluorosis, Dean's index 0 was present in 36.9%, 0.5 was present in 16.5%, 1 was present 10.2%, 2 was present 13.6%, 3 was present in 1.9%, and 4 was present in 20.9% of the people [Table 4]. Nearly 24.8% had skeletal fluorosis, and 75.2% were free of skeletal fluorosis [Table 5]. More number of subjects in our study showed back pain, knee pain and difficulty to bend. There were 2.41% of patients showing all three features of skeletal fluorosis in this study. Chi-square test was used for statistical analysis. Skeletal fluorosis and age were compared, and P value was 0.00 and was statistically significant [Table 6]. Skeletal fluorosis and sex were compared and P value was found to be 0.421 and was not significant. Although the value was not significant skeletal problems were more in females [Table 7]. Skeletal fluorosis and BMI were compared and was found to be 0.184 and not statistically significant [Table 8]. Dental fluorosis and skeletal fluorosis was compared and P value was found to be 0.000 and statistically significant [Table 9]. Two children showed exostosis in the ankle of the feet which is reported as a feature of skeletal fluorosis.{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}

 Discussion



Reddy reported that endemic skeletal fluorosis developed due to: (a) High fluoride intake through water and food; (b) continued exposure to fluoride; (c) strenuous manual physical activity; (d) poor nutrition; (e) impaired renal function and (f) abnormal concentrations of certain trace elements.[6] Ramesh et al. reported that fluoride concentration in the drinking water supplied by the government in the District of Salem varied from 0 to 3 ppm.[3] Periakali et al. reported that fluoride concentration of ground water samples in Salem varied from 0.8 to 14.7 ppm with an average concentration of 3.7 ppm.[7]

The skeletal fluorosis show changes such as gross changes in the skeleton, radiological changes, the chemical composition of bones, the histopathological changes, and deformities.[8] Radiographs help in the early detection of asymptomatic skeletal fluorosis. It may lead to generalized bone pains, especially in the spine and joints, and also result in exostosis and deformities such as kyphosis, flexion deformity of the knees, etc.[9]

Symptoms such as vague pains in hands, feet and knee, numbing of extremities, tingling sensation, restricted movement of the trunk, hips and neck, stiff and useless body have been reported.[10]

Neck pain, hip pain, tingling sensation, kyphosis,[11] inability to close fists, stiffness, the rigidity of spine, difficulty in walking, crippling[12] with varied severity, and percentage were other reported symptoms.

The present study showed 24.8% of people with skeletal pain though only 2.41% with all three symptoms of skeletal fluorosis. Skeletal fluorosis was more in higher age group subjects. Those who had higher grades of dean's index had more skeletal fluorosis compared to those with low dean's index. Among the skeletal symptoms back pain, knee pain, and difficulty in bending and sitting on the floor were more. Shoulder pain, neck pain, and tingling of the extremities were observed to a lesser extent.

Skeletal fluorosis and age

In our study, people who were above 40 years had more skeletal complaints with a maximum between 41 and 50 years. However, there was slight decrease in skeletal fluorosis in persons above 50 years. This may be due to the usage of drinking water with less fl uoride content in the areas where people above 50 in our study lived. Abhay Nirgude reported that prevalence of skeletal fluorosis increased with increasing age.[13] Shruthi et al. reported that as age increases, the prevalence rate of skeletal fluorosis also increases.[14] Xiang et al. also reported similarly with skeletal fluorosis increasing with age.[15]

Skeletal fluorosis and sex

Our study showed that females were more affected by skeletal pain compared to males. Abhay Nirgude reported that skeletal fluorosis was more in males.[13] John et al. reported that men were more affected by mild, moderate, and severe skeletal fluorosis than women.[15] Many of the studies showed more skeletal fluorosis in men. The difference seen in our study may be due to the fact that we had more women and more menopausal females in our study. 55% of the menopausal women in our study had skeletal fluorosis. Xiang et al. also reported that skeletal fluorosis was more in females than in males which was similar to our study.[16]

Skeletal fluorosis and dental fluorosis

Skeletal fluorosis was more seen in subjects with higher grades of dental fluorosis in our study. This is similar to Abhay Nirgude's study in which skeletal fluorosis was present in 24.9%, whereas dental fluorosis was present in 30.6%.[13]

 Conclusion



Prevalence of dental fluorosis and skeletal fluorosis in our study were 63.1% and 24.8% respectively. Prevention of is the most important key to treatment. Hence, there is a need to take measures to prevent dental and skeletal fluorosis through safe drinking water supply and by teaching better dietary habits using various effective medias. If the exposure to high fluoride level is reduced, Vitamin D and calcium nutrition are balanced, clinical improvement occurs. Once the symptoms develop, treatment largely remains symptomatic, using analgesics, and physiotherapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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