Chapter 1: Introduction
Fluorine is the lightest member of the halogen family and the most electronegative among all chemical elements (Hodge and Smith, 1965). Fluorine was discovered by French chemist Henry Moissan in 1886, by passing electrolysis of potassium bifluoride dissolved in hydrofluoric acid. There are several key properties of Fluorine element which makes it an excellent reducing agent. Due to this high electronegativity, the most stable state fluorine is found in is its ionic state (the F- ion), also known as Fluoride ion. The chemical activity of the fluoride ion (Eo = -2.8 Volts), makes it physiologically more active than other elemental ion.
Fluoride containing compounds are used to increase the fluidity of metals and slugs in the glass, ceramic, and fertilizer industry. The fluoride tablets have known effect as anti-carcinogenic agent. Anhydrous hydrogen fluoride (also known as Hydrofluoric acid) is used in the production of most fluorine-containing chemicals and in the production of refrigerants, herbicides, pharmaceuticals, high octane gasoline, aluminum, plastics, electrical components, and fluorescent light bulbs. Aqueous hydrofluoric acid is used in stainless steel pickling, glass etching, and metal coatings.
High F- intake has been suspected of being involved in a range of adverse health problems in addition to fluorosis, including cancer, impaired kidney function, digestive and nervous disorders, reduced immunity, Alzheimer’s disease, nausea, adverse pregnancy outcomes, respiratory problems, lesions of the endocrine glands, thyroid, liver and other organs (Source: WHO, 1994). As per BIS, the upper limit for fluoride in drinking water is 1.0 mg/l (IS 10500, 2012).
Fluoride concentration in natural water depends on various factors such as temperature, pH, solubility of fluoride bearing minerals, anion exchange capacity of aquifer materials (OH- for F-) and nature of geological formation and contact time of water with particular formation.
The presence of fluorine in ground water is mainly a natural phenomenon, and mainly influenced by local and regional geological conditions, as the fluoride minerals are nearly insoluble in water. Hence fluorine is present in ground water only when the conditions favor their solution.
Anthropogenic sources of fluoride include many industrial applications, most notably aluminium smelting and brick making (Debackere and Delbeke 1978), glass, china and steel works, sewage, and the production and application of phosphate fertiliser and pesticides (Kabata – Pendias 2001). The existence of some of the basis dykes such as doleritic intrusions normally acts as natural barriers against the flow of underground water making the ground-water stagnated in fractures and pores. If the groundwater is more alkaline and stagnant for longer time, all the fluoride minerals in basic dyke rocks, and the overlying soil that are rich in mafic minerals undergoes greater ionization facilitating the ground water to get enriched with fluoride. The degree of ionization increases with depth resulting in an increase in total dissolved salts and alkalinity. The rocks are the natural aggregation of minerals and contain fluoride in abundant quantity. Soil is also rich in fluoride bearing minerals (Keller, 1976).
In early 1930’s fluorosis was reported only in four states of India, in 1986 it was 13, in 1992 it was 15, in 2002 it was 17 and now it is 18, indicating that endemic fluorosis has been emerging as one of the most alarming public health problem of the country. Among the affected states, Rajasthan, Andhra Pradesh and Gujarat are the three most endemic states (Susheela, 2003). The fluoride concentration in the groundwater is found to be more than 10 mg/L in the five states of India including Andhra Pradesh, Haryana, Rajasthan, Maharashtra and Madhya Pradesh.
Chapter 2: Literature Review
1. Geology of Fluoride ions:
Robinson and Edington, (1946): reported that the main source of fluorine in ordinary soil consists of clay minerals. The weathering and leaching process, mainly by moving and percolating water, play an important role in the incidence of fluoride in groundwater. As per the inferences made from the research done by Robinson and Edington, the features related to the release of fluoride into water by fluoride bearing minerals may be due to
i) The chemical composition of water
ii) The presence and accessibility of fluoride minerals to water or
iii) The contact time between the source minerals.
Fluoride rich minerals, which are present in rocks and soil, when come in contact with water of high alkalinity they release fluoride into groundwater through hydrolysis replacing hydroxyl (OH-) ion.
The main source of fluoride in groundwater originates from the mafic minerals. There are a lot of mineral sources, including mafic as well as felsic rocks. The average Fluoride content of rocks is: 1000 mg/kg in alkalic rocks, 400 mg/kg in intermediate rocks, dropping to 100 mg/kg in ultramafic rocks deficient in SiO2 (Wedepohl, 1978). Another source of Fluoride is Phosphate Fertilizers, and the research compilation of contribution is given in Table 2.
Table 1: Fluoride Content in Phosphate Fertilizers
Type Concentration (mg/kg) Reference (Contributors)
Single superphosphate 1.08-1.84 McLaughlin et al. (1997); Evans et al. (1971)
Triple superphosphate 1.3-2.4 Mordvedt & Sikora (1992); Evans et al. (1971)
Monoammonium phosphate 1.6-2.2 Mordvedt & Sikora (1992); Evans et al. (1971)
Diammonium phosphate 1.2-3.0 Mordvedt & Sikora (1992); Manoharan et al. (1996)
Fluorine is released as fluoride (F- ) during weathering. The chemical behaviour of F- in natural water differs from that of the other halogen elements. In solution, Fluoride ions form strong complexes with other ions, particularly Ca2+, Al3+, Fe3+, PO43- and B(OH)4-. The concentration of Fions in solution is often controlled by the solubility of fluorite; hence, the concentration of F- is often inversely proportional to that of Ca2+. Fluoride also sorbs to mineral surfaces such as gibbsite, kaolinite, halloysite, and freshly precipitated amorphous Al(OH)3. Sorption to these solid phases may be favoured at lower pH. Fluoride concentrations in natural water are generally less than 1 mg/l, with rivers typically containing a few tenths of a mg/l.
The composition of various mineral rocks containing Fluodide ion are given in Table 3 below.
Table 2: Mineral rocks with Fluoride composition
Mineral Composition Rocks of these minerals Average F- Content References
1. Fluorite (Fluorspar) CaF2 Pegmatite Pneumatolitic deposits as vein deposit 50 – 75 mg/l U.S. Patent (US 4078047 A)
2. Fluorapatite/ Apatite Ca5(F,Cl)PO4 Pegmatite & metamorphosed limestone. 220 mg/l (Aoba, 1997)
3. Micas
a. Biotite
K(MgFe+2)3(AISi3)O10(OHF)2 Basalts, 100 – 3400 ppm (Deer et al., 1992)
b. Muscovite KAl2(AISi3010)(OHF)2 Pegmatites, Amphibolites 100 ppm (Rimsaite, 1970)
4. Amphiboles
a. Hornblende
NaCa2(MgFe+2)4(AIFe+3).
(SiAl)8O22(OHF)2 Gneisses, schists, shales 30 to 21 400 ppm (Wedepohl, 1978)
b. Tremolite Actinolite Ca2MoFe+2)5(Si18O22)(OHF) Clay, Alkaline rocks, etc. 30 to 21 400 ppm (Wedepohl, 1978)
5. Topaz Al2SiO4(OHF)2 Acid igneous rocks, Schists, gneisses, etc. 10 – 50 ppm U.S. Patent (US 4940477 A)
Jack et al., (1980): The degree of wreathing and leachable fluoride in a terrain is more important in deciding the fluoride bearing minerals in the bulk rocks or soil. Due to weathering of rocks the Ca – Mg / Carbonate concentration which form in arid and semi-arid areas, appears to be good sink for the fluoride ion. As their studies suggested, the factors controlling the leachability of minerals into fluoride from carbonate concentration or from the topsoil horizon may be
(1) pH of the draining solution,
(2)Alkalinity, and
(3) The dissolved CO2 in water and in features in the soil.
Rameshan and Rajagopalan, (1985): Besides mineralization and leachability being the only factors, the topographic features also play an important role in the control of fluoride content.
WHO Health Report (1994): Volcanoes are the major natural source of hydrogen fluoride. Sodium fluoride has been used as an insecticide, rodenticide, and fungicide. Fluorine always occurs in combined form of minerals as fluoride. It is high reactivity and represents about 0.06 to 0.09% of the earth crust. Minerals which have the greatest effect on the hydro geochemistry of fluoride are fluorite, apatite, mica, amphiboles, certain clays and villamite.
2. Health Impacts of Fluoride ions:
WHO Health Report (1996): As per the report, Fluoride is considered beneficial to human health if taken in limited quantity (0.5 to 1.5 mg/l). It prevents tooth decay by enhancing the remineralisation of enamel that is under attack, as well as inhibiting the production of acid by decay causing bacteria in dental plaque. It is also a normal constituent of the enamel itself, incorporated into the crystalline structure of the developing tooth and enhancing its resistance to acid dissolution. But it is also known to cause dental, skeletal fluorosis, osteosclerosis, thyroid, kidney changes and cardiovascular, gastrointestinal, endocrine, neurological, reproductive, developmental, molecular level, immunity effects, etc. if concentration is higher than 1.5 mg/l in drinking water.
The most interesting part of this report is that hypomineralisation of F- ion (fluoride levels below 0.5 mg/l) affects only the children bearing primary set of teeth, and the hypermineralisation (fluoride levels above 1.5 mg/l) affects all age groups, with dental fluorosis being most invasive to the same class (children bearing primary set of teeth).
Dental Fluorosis: Dental fluorosis is caused in human being consuming water containing 1.5 mg/l or more of fluorides, particularly from birth to the age of eight. Mild dental fluorosis is usually typified by the appearance of small white areas in the enamel. Individuals with severe dental fluorosis have teeth that are stained and pitted (“mottled”) in appearance. In human fluorotic teeth, the most prominent feature is a hypomineralization of the enamel. In contrast to many animal species, fluoride induced enamel hypoplasia (indicating a severe fluoride disturbance of enamel matrix production) seems to be rare in affected human enamel. The staining and pitting of fluorosed dental enamel are both post eruptive phenomena (i.e., acquired after tooth eruption and occur as a consequence of the enamel hypomineralization). Mottled enamel usually takes the shape of modification to produce yellow, brown stains or an unnatural opaque chalky white appearance with occasional striations patting. The incidence and severity of mottling was found to increase with increasing concentration of fluoride in drinking water. Mahajan (1934) reported a similar disease in cattle in certain parts of old Hyderabad state. However, Shortt et al. (1937) was the first to identify the disease as ‘fluorosis’. The incorporation of excessive amounts of fluoride into enamel is believed to interfere with its normal maturation, as a result of alterations in the rheologic structure of the enamel matrix and/or effects on cellular metabolic processes associated with normal enamel development (WHO, 1984; Aoba, 1997; Whitford, 1997). In India, Viswanathan (1951) first reported a disease similar to mottled enamel, which is prevalent in human beings in Madras presidency. Experimental animal studies suggest that this hypomineralization results from fluoride disturbance of the process of enamel maturation (Richards et al., 1986).
In extensive studies, Dean and coworkers (Dean and Elvove, 1937; Dean, 1942) have correlated the appearance and severity of dental fluorosis to different fluoride levels in the drinking water with the aid of a special classification and weighing of severity of the lesion. We’ll be talking more about it in subsequent chapters, but for the basic introduction, this classification method was known as “Dean Index of Dental Fluorosis”.
Osteoporosis: Fluoride above 4 mg/l in drinking water may cause a condition of dense and brittle bones known as osteoporosis. It affects tens of millions of people worldwide and is responsible for as many as 75% of all fractures in people over the age of 45 years. Costly and disabling fractures of spine, hip, wrist and other bones can be preceded by years of undetected bone loss. It is found that as many as 20% of those who suffer from osteoporosis related hip fractures die within 6 months. Though this study is confined to a part of a continent, but has left a serious question lying in front of us. As per his reports, women are at four time greater risk of developing osteoporosis than males (Bezerra et al., 2003).
Skeletal fluorosis: The chronic toxic effects of fluoride on the skeletal system have been described from certain geographical regions of the world where drinking water contains excessive quantities of natural fluoride. This form of chronic intoxication was first described in India from the state of Madras as early as 1937, with the same author who is regarded with the first findings of Dental Fluorosis in India (Shortt et al., 1937). Subsequently, cases of endemic fluorosis have been reported from other parts of India, particularly from Punjab (Singh et al., 1962a, b) and then from the other parts of the world. Skeletal Fluorosis may occur when fluoride concentrations in drinking water exceed 4 – 8 mg/l. The high fluoride concentration manifests as an increase in bone density leading to thickness of long bones and calcification of ligaments. The symptoms include mild rheumatic/arthritic pain in the joints and muscles to severe pain in the cervical spine region along with stiffness and rigidity of the joints. The disease may be present in an individual at sub-clinical, chronic or acute levels. Crippling skeletal fluorosis can occur when the water supply contains more than 10 mg/l of fluoride. In this form of Skeletal Fluorosis, the bones start fusing due to hypercalcification, and results in a crippled appearance, owing to calcified spine. The bones also become brittle and weak due to the same. The severity of fluorosis depends on the concentration of fluoride in the drinking water, daily intake, continuity and duration of exposure, and climatic conditions). Many other studies also suggest the role of dietary habits for the endemism caused. Chronic toxic effects of fluoride on the skeletal system have also been observed in relation to industrial exposure to fluorides (such as cryolite), and studies by Roholm (1937) suggests that not only home is the only source but workplace too might have been involved in cases of fluoride endemicities such as endemic fluorosis. At higher levels of ingestion from 2 – 8 mg daily when signs of fluorosis appear in teeth mineralized during the ingestion period, certain other factors (climatic conditions, malnutrition, age, storage, other constituents of water and possibly individual variations in absorption) may be involved. Under such conditions and over a number of years, skeletal fluorosis may arise characterized by an increased density of bone and demonstrated in adults radiographically (Yildiz et al., 2003). Dental fluorosis is easily recognized but the skeletal involvement is not clinically obvious, until the advanced stage of crippling fluorosis. However, radiological changes are discernible in the skeleton at a much earlier stage and provide the only means of diagnosing the early and relatively asymptomatic stages of fluorosis (Connett, 2002; Levy, 2003).
Choubisa et al. (1997): A correlation between average water fluoride concentration and prevalence of skeletal fluorosis (assessed by X-ray) was found among adults in 15 villages in Dungapur district in Rajasthan, India. The methodology was quite in line with Teotia and Teotia (1971). The prevalence ranged from 4.4% at a water fluoride level of 1.4 mg/l to 63.0% at the level of 6.0 mg/l. Crippling fluorosis was invariably spread in villages with fluoride concentrations of >3 mg/l.
Hussain et al. (2004): In a survey carried out by Hussain et al. (2004) in Bhilwara district of Rajasthan, 825 individual were examined for fluorosis due to intake of fluoride above 5.0 mg/l in drinking water. In this study, not only they carried out a survey as preliminary measure of the spread of the disease, but they also collected water samples from the study area and tested them for the fluoride levels. In this way, a correlation between fluoride concentration and levels of severity among people was established. Though the study found no direct relation between the steady incline of fluoride levels with severity, and it may be attributed to the fact that the disease spreads in context with the individual’s immuno-response and several other individual level physiological attributes. In the skeletal fluorosis positive individuals maximum individual (194, 23.52%) have Grade I skeletal fluorosis, which is characterized by bone and joint pain. Only 4 individual (0.48%) have Grade III skeletal fluorosis in which bone and joint pain, stiffness and rigidity of dorso-lumbar spine and restricted movements at spine and joints are general symptom inclusive deformities of spine and limbs, knock knees, crippled or bed ridden state, kyphosis, invalidism, etc. Prevalence and severity of skeletal fluorosis were found also increasing with increasing fluoride concentration.
Karthikeyan et al. (1996): In a clinical survey, intended for fluorosis isolation in a random sample of residents in five areas in Tamil Nadu, South India, the drinking-water fluoride concentration was directly related to the prevalence of dental fluorosis in children (8–15 years of age) and adults. Among children, no skeletal fluorosis (no information on diagnostic criteria provided) was observed. In case of adults, the prevalence of fluorosis was 34% (157 individuals surveyed) in the area with the highest drinking-water fluoride concentration (summer month average – 6.8 mg/l, non-summer month average – 5.6 mg/l). The whole survey was done on an estimated total daily fluoride intake of 20 mg. No skeletal fluorosis was observed in the other areas, where the mean fluoride concentrations were lower than 4 mg/l (2.2 mg/l – summer months; 1.8 mg/l – non-summer months).
Chapter 3: Study Area
Figure 1: Endemic Districts of India with High Fluoride Concentrations (mg/l) in Groundwater
S. No. State Study Location Fluoride level (mg/l) Reference
1 Assam Kamrup 1.45 – 7.8 Susheela, 1999
Guwahati 0.18 – 6.88 Das et al., 2003
2 Andhra Pradesh Hyderabad 1.8 – 8.4 Susheela, 1999
Nalgonda 0.4 – 20 Rao et al., 1993
Kurmapalli <21 Mondal et al., 2009
Vamsadhara <3.4 Rao, 1997 Visakhapatnam 0.6 – 2.1 Rao, 2009 Wailapall 0.5 – 7.6 Reddy et al., 2010 3 Bihar Buxar 1.7 – 2.85 Susheela, 1999 4 Chattisgarh Bastar 1.5 – 2.7 Susheela, 1999 5 Delhi New Delhi 1.57 – 6.10 Susheela, 1999 6 Gujarat Ahmedabad 1.60 – 6.80 Susheela, 1999 Mehsana 0.94 – 2.81 Salve et al., 2008 Narmada 1.6 – 6.8 Susheela, 1999 7 Haryana Bhiwani 0.14 – 86 Garg et al., 2009 Rest of Haryana 1.5 – 17 Das et al., 2003 8 Jammu & Kashmir Udhampur 2.0 – 4.21 Susheela, 1999 9 Karnataka Bangalore 1.5 – 4.4 Susheela, 2000 Bellary 0.33 – 7.8 Wodeyar & Sreenivasan, 1996 10 Kerala Palakkad 2.5 – 5.7 Susheela, 1999 Palghat 0.2 – 5.75 Shaji et al., 2007 11 Maharashtra Nagpur 1.45 – 4.1 Susheela, 1999 Yavatmal 0.30 – 13.41 Madhnure et al., 2007 12 Madhya Pradesh Gwalior 1.5 – 10.7 Susheela, 1999 13 Odisha Cuttack 1.52 – 5.2 Susheela, 1999 14 Punjab Amritsar 0.44 – 6.0 Susheela, 1999 15 Rajasthan Ajmer 1.54 – 11.3 Susheela, 1999 Hanumangarh 1.01 – 4.42 Suthar et al., 2008 Jaipur 1.54 – 11.3 Susheela, 1999 16 Tamil Nadu Coimbatore 1.5 – 3.8 Susheela, 2000 Erode 0.5 – 8.2 Karthikeyan et al., 2010 Vellore 1.5 – 3.8 Susheela, 1999 17 Uttar Pradesh Agra 1.5 – 3.11 Susheela, 1999 Kanpur 0.14 – 5.34 Sankararamakrishnan et al., 2008 18 West Bengal Bardhaman 1.5 – 9.1 Susheela, 1999 Hooghly 0.01 – 1.18 Kundu & Mandal, 2009 The study area was so chosen in order to assess the basic problems present in the landscape of Rajasthan. As we can see from figure 1, there’s a huge part of India that is under the grip of Fluorosis. Be it Dental, Skeletal, or Non skeletal, all forms together combine to cover a large area of the rural and urban parts. Rajasthan is India’s largest state, which covers 10% of the country area but receives only 1/100 of the total rains. It shares only 1/10 of the average share of water than rest of the country. The geographical and geological setup leads to deterioration of water quality. Therefore, state faces acute water crisis. The great Indian Thar Desert covers most of the area affected by fluoride. Thus extremely arid and dry climate conditions prevail, receiving 5 mm to 20 mm annual rainfall. Groundwater is deeper and contains high mineral concentrated chemicals which makes the water unfit to drink. The eastern part of the state is semi desert and hilly, therefore the water availability in this region is also limited. As it is cited in previous publications, Rajasthan is the only state in India where almost all the districts are affected by high fluoride (beyond the permissible limit). In 23 districts, the fluorosis problem can be visualized at various intensity level i.e. Dental fluorosis, skeletal fluorosis, non-skeletal manifestation etc. The studies made by Rajasthan Voluntary Health Association in 1994, has showed that the total number of villages having fluoride problem in Rajasthan is 2433 covering nearly 2.6 million population. Moreover, nearly 30,000 people are drinking water with concentration of 10.0 mg/l of fluoride. Data on number of population in affected villages and fluoride concentration is shown in Table 1. Table 3: Fluoride concentration and affected population of villages in Rajasthan S. No. Fˉ concentration (mg/l) No. of villages affected Population under threat 1 1.20 – 2.99 1467 1643542 2 3.00 – 4.99 668 719309 3 5.00 – 9.99 255 238447 4 ˃10 43 35477 Total: 2433 Source: Rajasthan Voluntary Health Association (1994). Figure 2: Study area showing survey sites, in respect of their geographical coordinates
Chapter 4: Materials and Methods
Questionnaire Development: After literature studies of lots of research articles, it was inferred that a survey and examination (Dental and Physical) are the only plausible methodologies available (for identification purposes), without any known side effects. A structured survey questionnaire was developed in line with the identification of most important physiological features defining the Fluoride affected individuals. The survey included basic information of the individual, the diet regime, the drinking water source, and the scores of CFI (Community Fluorosis Index) and TSIF (Total Surface Index of Fluorides). Site Identification: The sites for survey were chosen on a random basis, keeping in view of the Geographical expanse of the study site. The survey sites thus were selected at a stratified random basis. Since Kishangarh Tehsil contains numerous villages (69), few notable villages were selected for Survey and Dental & physical examination purpose. These villages are already mentioned in Study Area. A. Dental Fluorosis Study: The data for dental fluorosis was collected through dental examinations, and applying suitable Dental fluorosis indices, which were CFI and TSIF for the case being. Community Fluorosis Index was developed on the basis of observational index for dental fluorosis formulated by Dean (1934). Dean’s Index was more of an observational one, stressing on the quality (severity) of dental fluorosis. On the other hand, CFI was the statistical manifestation of Dean’s Index, where weights were given to the observations made, and on the basis of these weights, an estimate of the severity of Dental fluorosis on a community population can be easily estimated. Dean’s Index: It was first described in 1934 and was later modified in 1942. The index was developed to gain an understanding of the relationship between fluoride concentrations in drinking waters and mottled enamel. It was designed to reflect the clinically visible features of dental fluorosis in a population and approximate the actual biologic effects of fluoride on developing dental enamel. 1. Normal: the enamel represents the usual transluscent semi vitriform type of structure, surface is smooth, glassy, pale, creamy white transluscent. 2. Questionable: The enamel discloses slight aberrations from the translucency of normal enamel ranging from a few white flecks or occasional white spots. 3. Very mild: Small opaque paper white area scattered irregularly over the tooth covering less than 25% of tooth surface. Bicuspids / second molars not showing more than 1-2mm of white opacity at the tip of summit of cusps are also frequently involved in this classification. 4. Mild: Opaque white area in the enamel of the tooth covering less than 50% of the tooth surface. 5. Moderate: All enamel tooth surfaces are affected, and surfaces subject to attrition show marked wear. Brown stain may be present. 6. Severe: All enamel surfaces are affected and hypoplastic brown stains are widespread and teeth often present as corroded appearance. The major diagnostic sign of this classification is the discrete or confluent pitting. CFI (Community Fluorosis Index): CFI is calculated based on the following point scale for the different categories of dental fluorosis (using the Dean Index): 1. Questionable Fluorosis = 0.5 points 2. Very Mild Fluorosis = 1 point 3. Mild Fluorosis = 2 points 4. Moderate Fluorosis = 3 points 5. Severe Fluorosis = 4 points After determining how many children have these types of fluorosis, the points are added up and divided by the number of children examined. Fluoride Index was calculated by the following formula: Community Fluorosis Index (CFI) = ∑(scores × no. in each score group)/no. of cases examined The scores represent to a particular value given to the various degrees of dental fluorosis. It is 0 for normal, 0.5 for trace, 1.0 for very mild, 2.0 for mild, 3.0 for moderate, and 4.0 for severe. Total Surface Index of Fluorosis (TSIF): This was proposed by Horowitz et al (1984), in an attempt to reduce some of the shortcomings of Dean‘s index. It allows for separate assessment of cosmetic fluorosis, i.e. fluorosis discoloration, staining or pitting on surfaces visible to others. According to the authors, a separate score is given to each unrestored tooth surface. Two scores are assigned to anterior teeth (from the labial and lingual aspects) and three to the posterior teeth (from the buccal, lingual and occlusal aspects). More sensitive than Dean‘s Index for mildest forms of fluorosis, the tooth surface index of fluorosis has identified seven types. 1. Enamel shows no evidence of fluorosis 2. Enamel shows definite evidence of fluorosis namely areas with parchment white color that total less than one third of visible enamel. This category includes fluorosis confined only to incisal edges of anterior teeth and cusp tips of posterior teeth (snowcapping). 3. Parchment – white fluorosis at least one third of the visible surface, but less than two thirds. 4. Parchment- white fluorosis total at least two-thirds of the visible surface. 5. Enamel shows staining in conjunction with any of the preceding levels of fluorosis, staining is defined as an area of definitive discoloration that may range from light to very dark brown 6. Discrete pitting of the enamel exists, unaccompanied by evidence of staining of intact enamel. The pitted area is usually stained or differs in color from the surrounding enamel. Both discrete pitting and staining of the intact enamel exist. 7. Confluent pitting of the enamel surface exists. Large areas of enamel may be missing and the anatomy of the tooth may be altered. Dark brown stain is usually present. In the same manner as CFI was calculated for a community, TSIF is present with more flexibility. TSIF allows for comparative studies not only at community level, but also at other demographics. One can do comparative assessment for rural versus urban areas affected from fluoride ion excessive levels, or apply it for male versus female. For the ongoing study, the TSIF will be used for comparing different villages for their endemicity, compares male and female endemic fluorosis levels, and also compares children, adults, and old age populations for their vulnerability levels. B. Skeletal Fluorosis Study: For the evidence of skeletal fluorosis, only adult individuals (>21) residing in the area since birth are to be considered. This accounts for the reason that skeletal fluorosis is rare in Children, or those below 18 years of age (Teotia et al., 1969). Vague aches and pains in the body, restricted and painful movements of cervical, dorso-lumbar spine, pelvic, and forearm and leg joints are the systems of skeletal fluorosis in human beings. Some visible deformities such as crippling, kyphosis, invalidism, genu-varum (convergent banding of legs), and genu valgum (divergent banding of leg bones) and secondary neurological complication, para, and quadriplegia are also clinical symptoms of skeletal fluorosis (WHO 1984; Susheela 1993).
The adults showing dental fluorosis were asked for the aforementioned symptoms, and the visible symptoms and deformities were also checked out. Simultaneously, bending or movements of different parts of the body also observed for their easiness in movements or bendings in suspected cases of skeletal fluorosis and such was done randomly. The grading proposed by Teotia et al. (1985) for clinical skeleton fluorosis was considered, and used for the current study.
The characteristics of different grades are:
Grade I: Generalized bone and joint pain.
Grade II: Generalized bone and joint pain, stiffness and rigidity of dorso-lumbar spine and restricted movements at spine and joints.
Grade III: Symptoms of grade II with deformities of spine and limbs knock knees, crippled or bedridden state, kyphosis, invalidism, genu-varum and genu-valgum.
These grades are then identified in number of incidences, and subsequent data is collected, and recorded for its contribution towards additional usage in identifying vulnerability levels of Endemic Fluorosis.
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