Fluorosis, though a common endemic problem of our country is more wide spread and acute

in the state of Rajasthan where all the 32 districts have been declared as fluorosis prone. While
the WHO standards (1991) permit only 1.5 mg/l as a safe limit for human consumption the
new Indian standards permit only 1 mg/l. The countries that are more affected by fluorosis are
Pakistan, Bangladesh, Argentina, United state of America, Morocco, Middle east countries,
Japan, South African Countries, New Zealand, Thailand etc. The problem has reached
alarming proportions in 17 states of India; these are:
(I) States having 50-100% districts affected - Andhra Pradesh, Tamil Nadu, Uttar Pradesh,
Gujarat, Rajasthan
(II) States having 30-50% districts affected - Bihar, Haryana, Karnataka, Maharashtra,
Madhya Pradesh, Punjab, Orissa, West Bengal
(III) States having < 30 % districts affected - J & K, Delhi, Kerala
Rajasthan is the only state where all the 32 districts have been declared as fluorosis prone. The
worst affected districts are Nagaur, Jaipur, Sikar, Tonk, Jodhpur, Barmer, Ajmer, Sirohi,
Jhunjhunu and Churu.

SOURCES OF FLUORIDE

Fluorine

The disease called fluorosis is caused by an element known as fluorine, the 13th most abundant
element available on the earth crust. This is a halogen group of element whose Molecular
weight is 19, and Atomic number is 9. Fluorine is the most electronegative of all the elements
known to the world. Fluorine exists as a diatomic molecule with a remarkably low dissociation-
energy ( 38 K cal/mole) . As a result, it is highly reactive and has strong affinity to combine
with other elements to produce compounds known as Fluorides.

Sources of fluoride in environment

Usually, the surface water does not contain high fluoride, whereas ground water may be
contaminated with high fluoride because the usual source of fluoride is fluoride rich rocks.
When water percolates through rocks it leaches out the fluoride from these rocks. The rocks
rich in fluoride are:
Fluorospar- CaF2 (Sedimentary rocks like lime stones, sand stones);
Cryolite- Na3 Al F PO6 (Igneous rocks like Granite);
Fluorapatite- Ca3 (PO)2 Ca (FCl)2

Sources of fluoride for human exposure:

Major sources of fluoride for human exposure are: Water, Food, Air, Medicament,
Cosmetics. It is roughly estimated that 60% of the total intake is through drinking
water. Fluoride present in water is in a simple form and is readily absorbed from the stomach.
Other forms of fluoride are relatively less harmful. Fluoride rich food items are also a source
of fluoride for human consumption, some of these are Water, Tea, Fluoridated toothpaste,
Plants and vegetables grown in soil and water rich in fluoride, Pan, Supari, Tobacco, Green
garlic, Onion Cabbage, Soyabean, Carrot, Corn, Potato Baking powder, egg, Cows liver &
kidney. Prolonged use of certain drugs has been associated with the chronic adverse
affects of fluoride e.g. sodium fluoride for treatment of osteoporosis, Niflumic acid for
the treatment of rheumatoid arthritis, use of fluoride mouth rinses. The use of fluorides in
industries can often lead to occupational exposure e.g inorganic fluoride compounds are used
in the production of aluminium and phosphate fertilizers’ production.

Levels of fluoride exposure and their effects on health

Fluoride present in water and air results in the following adverse effects in the shown
concentrations:

Fluoride concentration Source Effects

(mg/l)
0.002 Air Destructive effect on plants
1.00 Water Prevention of Dental caries
>= 2 Water & Air Effect dental enamel
>= 8 Water & Air Effect Bones and muscles
>50 Food & Water Changes in Thyroid
>100 Food & Water Defective development
>120 Food & Water Changes in Kidney

CHEMOBIOKINETICS AND METABOLISM

The ingested fluoride is rapidly absorbed through gastrointestinal tract and lungs. Peaks are
reached after 30 min in blood. A rapid excretion takes place through renal system over a
period of 4 to 6 h. In children less than three years of age only about 50% of total absorbed
amount is excreted, but in Adults and children over 3 years - about 90% is excreted.
Approximately 90% of the fluoride retained in the body is deposited in the skeleton and teeth.
The biological half-life of bound fluoride is several years. Fluoride also passes through the
placenta and also appears in low concentrations in saliva, sweat, and milk.

CLINICAL PRESENTATIONS OF FLUOROSIS

Fluorosis may cause Skeletal Fluorosis, Clinical Fluorosis or Dental Fluorosis, or Non Skeletal
manifestations, or any combination of the above and in final stages it may cause premature
aging.

Effect on teeth
Excess fluorides result in Discoloration, Delayed eruption, Chipping of edges, Pitting etc

The dental fluorosis is commonly classified on the basis of Dean’s scale into five categories

Fluorides result in symptoms like Heel pain, Painful and restricted joint movements,
Deformities in Limbs and in very severe cases the patient may develop a Hunch back.
Other Clinical Presentations
In extreme cases, Paralysis, Muscular wasting, premature aging may be observed among
affected individuals.

The other affected systems are: Fluorides affect Central nervous system, Muscles,
Gastrointestinal system, Urinary system, Skin.
DIAGNOSIS OF FLUOROSIS

Fluorosis can be diagnosed by the following observations:

1. High fluoride content of the drinking water
2. Endemicity of fluorosis (specially dental) in the area
3. Clinical manifestations of fluorosis in the population Dental, Clinical, Skeletal
4. Clinical examination
5. Biochemical evaluation
6. Radiological evaluation

Dental fluorosis is diagnosed by clinical examination and classified according to Dean’s scale
described earlier. Simple clinical examination includes asking people to carryout exercises.

COMBATTING THE MENACE OF FLUOROSIS

Management measures

This requires simple interventions like -regular monitoring of the water quality of different
villages and marking the wells with least fluoride (preferably under 2 mg/l of fluoride) as
green to be exclusively used for drinking and cooking; marking the wells with very high
levels of fluoride and aluminium as red prohibiting its use for drinking and cooking;
educating people about various dimensions of fluorosis, its genesis and methods for
prevention and cure through

Medical Treatment of the disease

Vitamins C and D, and, salts of Calcium, Magnesium or Aluminum were prescribed by some
researchers in an attempt to reverse these effects. Published results were, however,
inconclusive and largely negative. Recent studies conducted in Rajasthan by Dr. Sunil Kr.
Gupta and his team (references 1-3) (under Rajasthan DST sponsored studies) indicated that
fluorosis could be reversed, at least in children, by a therapeutic regimen (Calcium, Vitamin
C and Vitamin D) that is cheap and easily available. Treatment takes a lot of time and proves
costly also. It, thus have a limited application for a wide-scale useWhile the stains seem to
fade away with prolonged treatment, dentition was also observed in children who were
unable to get permanent teeth after losing their milk teeth for over a year.

Prevention

Preventive measures are relatively easier and hence highly recommended for large scale
applications. Some of these include:

AVOID: a) Water containing > 1.5 mg/l of fluoride, b) Food rich in fluoride

USE: Diet rich in Calcium and Ascorbic acid (Vitamin C). Milk and milk products can supply
the desired calcium and Amla (Indian gooseberry) can supply the requisite vitamin C. This
would require very minor re-adjustments in the existing dietary pattern. More details for
recommended dietary items are given in references 4 and 5.
 To avoid: Water containing > 1.5 mg/l of fluoride Use Domestic deflouridation. The
process to be selected after consulting PHED staff or other experts. Till then the
available water source (Well) indicating relatively the least fluoride in the concerned
village may be restricted for use for drinking and cooking purposes only. Rain water
harvesting especially for drinking purposes, adopting traditional wisdom, should also
be promoted.

Nalgonda and Activated alumina are the two technologies used at a large scale in India
for field applications the details of which are available in reference 6.

Finally, it is only imparting education about the cause, prevention and cure to the masses that
can bring about the desired change in the attitude of the people and yield efficacious results in
dealing with the disease. Such a programme can be run through IEC activities under DPIP.

TREATMENT AND PREVENTION

There is a crying need to overcome the problem of fluorosis. Three approaches are suggested:
1. Health education
2. Treatment of the children,
3. Preventive measures.
Health Education
Creating awareness about the disease
The main area of interest will be
a. Creating disease awareness
Creating awareness about the disease should be in form of graphic presentation of the final
consequences of the disease to the extent possible.
If required live presentation of the patients, who are suffering from the severe form of the
disease,
in areas where the gravity of problem has not reached to that extent. It may be of use, to
demonstrate the most severe extent of the disease and to motivate them to use the preventive
or therapeutic measures.
b. Creating awareness about the sources of the fluoride
The creation of awareness will help in implementing the need based preventive measures in
the
affected community.
Treatment of the disease
Vitamins C and D, and, salts of Calcium, Magnesium or Aluminum were prescribed in an
attempt
to reverse these effects16,43-48 Published results were, however, inconclusive and largely
negative.
Recent studies conducted in Rajasthan under Rajasthan DST sponsored studies indicated that
fluorosis could be reversed, at least in children28,49,50,51,52, by a therapeutic regimen
(Calcium,
Vitamin C and Vitamin D) which is cheap and easily available.
The choice of the reported therapy was logical. The presence of calcium in gut directly
affects
the absorption of fluoride ions and will also improve serum calcium levels as observed by
Teotia
et al53 Vitamin D3 in low doses enhances calcium absorption and retention without causing
hypercalcemia and thus directly affects the absorption of fluoride ions. It also inhibits the
excessive release of parathyroid hormone thereby preventing excessive activation of
osteoblasts
thus preventing hyperosteoidosis and osteopenia. Ascorbic acid controls collagen formation,
maintains the teeth structure and is also essential for bone formation. These structures are
adversely affected by higher fluoride intake.
10
Prevention
a. Providing defluoridated water for drinking purpose
Methods of deflouridation recommended so far are aimed at bringing the fluoride levels to
the
WHO standards (Details have been appended in annexure 5).
Desirable characteristics of defluoridation process
l Cost-effective
l Easy to handle/operate by rural population - the major sufferer
l Independent of input Fluoride concentration, alkalinity, pH, temperature
l Not affect taste of water
l Not add other undesirable substances (e.g. Aluminum) to treated water (Details of toxicity
relating to aluminum have been depicted in annexure 6.
It is estimated that the daily consumption of water for all purposes per capita is about 135
lpcd in
urban areas and about 40 lpcd in rural areas, whereas for drinking and food preparing
purposes
it is only 8 lpcd.
Keeping in view the cost involved in defluoridating the water it is desirable that the
defluoridation
of water should be restricted to drinking water only. Hence the only economical and
practicable
choice left is Domestic defluoridation.
It is now desirable to test the various domestic defluoridation processes, especially in terms
of
acceptance by people without the need of any supervising agency, and recommend suitable
alternatives so that effective long-term implementation can be achieved.
b. Changing the dietary habits
Deflouridation of drinking water alone shall not bring the fluoride level to a safe limit. It
would be
necessary to overcome the toxic effects of the remaining fluoride ingested through other
source.
This can be done by effecting minor changes in the diet and dietary habits of the population
compatible with their social system and available resources. The main aim should be to
l Restrict use of fluoride rich food
l avoiding use of fluoride rich cosmetics
l Use of food rich in calcium, vitamin C and proteins ((Details have been appended in
annexure 3,4).
c. Water harvesting (alternative water source)
Fluoride not only affects the people but it also affects the animals. Therefore it is desirable
that
the animals should also be provided with fluoride free water for maintaining their longevity.
Defluoridation of drinking water for animals will be too costly and not feasible, and therefore
the
only solution of this problem is water harvesting. The water harvesting technologies should
be
aimed not only to provide fluoride free water to human beings but also to animals.
Rainwater storage can be a major source of fluoride free drinking water for the animals.
This three pronged attack can prove to be a blessing for the population especially for the
younger
generation living in fluoride rich areas having no choice except to drink the water
contaminated with fluoride
and suffer the inevitable consequences including permanent deformities.
This may make this program
“By the people-For the people”

COMMONLY USED DOMESTIC DEFLUORIDATION PROCESSES

Various commonly used processes available for defluoridation with basic advantages and
disadvantages are
given below.
1) Nalgonda process:57
It looks a cumbersome technique not suitable for use by less-educated population - the
section that
needs it the most. The process can be used only for water having a fluoride content of less
than 10 ppm
and turbidity less than 1500 ppm. There is a high residual aluminum content in output
drinking water. It
is reported that the residual aluminum ranges from 2.01ppm to 6.86ppm. It is relevant to note
that
Aluminum is a neurotoxin and concentration as low as 0.08ppm of aluminum in drinking
water is reported
to have caused Alzheimer’s disease. The ISO 10500 for drinking water sets an absolute
maximum limit
of 0.2ppm for Aluminum, which is well below the minimum reported in the output water,
generated by this
technique. Also the taste of the output water is generally not acceptable.
2) Activated Alumina process:58-61
Reactivation of filter material is cumbersome and it can be done only with the help of trained
persons generally not available in most of our villages. This process also results in high
residual aluminum in
output water ranging from 0.16ppm to 0.45ppm.
3) Other processes:
Processes like Electro-dialysis, Reverse Osmosis etc. require special equipment, a lot of
power, specially
trained persons to operate, require a lot of maintenance and are very expensive.
4) KRASS Process:62-65
In this process the fluoride contaminated water is passed through a bed of specially designed
filter media
to get the defluoridated water.
This process differs from the known processes in its simplicity, cost effectiveness and only
traces of
residual aluminum in outlet water. There is no limit on fluoride concentration in input water.
Temperature,
pH, alkalinity and Total Dissolved Solids of input water do not effect this process. It is a
practical
approach especially for our rural population.
The importance of the process is a defluoridation process, which is easy to use by illiterate
villagers,
requires minimal involvement of technical personnel, is harmless and is cost effective.
In the process, once the filters are laid the only expenditure is in terms of recharging with
alum. This
process has been verified by CSIR and PHED of Rajasthan. The large scale field installation
of plants of
KRASS is under process.

ALUMINUM IN WATER
Desirable Limit : 0.03 mg/L Permissible Limit : 0.2 mg/L
TOXIC EFFECTS OF ALUMINUM 73
CNS: Neuro-toxin, Alzheimer’s Disease, Encephalopathy, Impaired Cognitive & motor
function, Peripheral Neuropathy , Myopathy,
BONES: Osteomalacia, Rickets, Pathological fracture
X-ray of BONE: Non healing fracture, Osteopenia, Reduction in calcified tissue
ALLERGY : Itchy dermatitis in axilla
RESP. TRACT: Pulmonary Fibrosis, Asthma, Chronic Bronchitis.
BLOOD: Microcytic Anemia
Aluminum salts have been commonly used as coagulants in water treatment. A small amount
of residual
aluminum may remain in treated water. Driscoll and Letterman74 reported that
approximately 11% of the aluminum
input remained in the finished water as residual aluminum and is transported through the
distribution system
without any significant loss.
Under normal circumstances this residual aluminum forms only a small part of the total daily
intake, but
this is largely uncomplexed in nature. This uncomplexed form of residual aluminum gets
absorbed from
gastrointestinal tract in preference to the complexed forms, which are found in other dietary
sources
Aluminum compounds are used in most of the defluoridation technologies used on a field
scale. The
concentration of these compounds for defluoridation is much higher than that required for
general coagulation
purposes. The Nalgonda technique75 of defluoridation, which is largely used for field
application in India, involves
addition of alum along with lime to the fluoride rich water followed by flocculation and
sedimentation or filtration.
It has been reported that the treated water from Nalgonda technique contains residual
aluminum in the range of
2.1 to 6.8 mg/L under various operating conditions76. This concentration of uncomplexed
aluminum in treated
water for drinking purpose can result in a grave public health problem.
In a recent study63 residual aluminum was analysed in the treated water from activated
alumina and
KRASS processes. The raw water F in activated alumina process was 24.1ppm and the
treated water showed
1-1.5 ppm F & 0.18-0.45 ppm aluminum in effluent. It was observed that in composite
effluent through KRASS
process both fluoride and aluminum were in traces for raw water F of 10 & 24.1 ppm.
Fluoride ions in the presence of trace amounts of aluminum form Aluminofluoride
compounds and may
act with powerful pharmacological effects. Aluminofluoride complexes appear to be a new
class of phosphate
analogs for laboratory investigations. Experimental data clearly indicate that aluminofluoride
complexes stimulate
various G proteins (details given below). These metallofluoride complexes may thus mimic
or potentiate the
action of numerous extracellular signals and significantly affect many cellular responses.
With the appearance
of acid rain and due to the widespread use of aluminum in industry, there has been a dramatic
increase in the
amount of reactive aluminum appearing in ecosystems, food, and water sources.77-79
Together with the increase
of fluorides now in the environment and food chain , the possibility exists that the near future
dangers of fluoride
and trace amounts of aluminum would be evident in human race.
G proteins. Knowledge about the role of G proteins in signal transduction has expanded
enormously
during the last decade, as over one hundred G protein-coupled receptors have been
described.80,81 G proteins
couple membrane-bound heptahelical receptors to their cellular effector systems.
A recent study82 revealed that the performance indicators in school children of two villages
of Sanganer,
Jaipur wherein the drinking water contained the same level of fluoride (approx 6 ppm) but a
very different levels
of Aluminum (0.03 and 0.11 ppm) were significantly different. The village with higher
Aluminum showed a poor
performance and also a much higher severity of skeletal fluorosis. This gave strong support to
the hypothesis
that fluoride and aluminum have synergistic effects, a fact very essential to consider while
designing a suitable
defluoridation technology.