fluoride and fluorosis old and new
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Fluoride and Fluorosis
Old and New
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PREVELANCE OF FLOUROSIS
Prevalent all over the worldInternational Status
National Status
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FLUORIDEEXPOSURE
INTERNATIONAL STATUS
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FLUORIDEEXPOSURE
NATIONAL STATUS
People forced to consume water having even
up to 44mg/l FRural population is the major sufferer
17 states are endemic
4 States: 30% districts affected
8 States: 30-50% districts affected
5 states: 50-100% districts affected
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FLUORIDEEXPOSURE
RAJASTHAN STATE STATUS
All 32 districts are endemicWorst affected districts are
Nagaur, Tonk, Jaipur, Sikar, Barmer,
Jodhpur, Ajmer, Sirohi, Jhunjhunu,
Churu, Bikaner, Ganganagar
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Sources of fluoride insurface or ground waters
The sea
The atmosphere The earth's crust
Rock forming Minerals
Rocks
Commercial ores
Soils
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ROCK FORMING MINERAL
The rocks rich in fluoride are:
Flurospar CaF2 ( Sedimentary rocks, lime
stones, sand stones)
Cryolite Na3AlFPO6 ( Igneous, Granite)
Fluoroapatite Ca3(PO)2 Ca(FCl)2
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SOURCES OF FLUORIDE IN HUMANS
Water
Food
Drugs: Sodium fluoride, Niflumic acid,fluoride mouth rinse
Air : aluminum, phosphate fertilizers
Cosmetics:Toothpastes & Mouth Rinses Other : Bottled mineral water
Source - Villena-RS et al. 1998
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CHEMOBIOKINETICS & METABOLISM
Rapidly absorbed (GIT) & lungs (peaks after 30min)
Distributes in bloodExcreted via renal sys.( 50 - 90% over 4-6 h )
low conc. in saliva, sweat, and milk.
passes through the placenta also
90 % of remaining gets accumulated in calcifiedtissues (esp. skeleton and teeth).
Biological half-life of bound F is several years.Source:Ericsson, 1958; Weddle and Muhler, 1954;Hudge, 1965
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Excess fluoride damages
Teeth
Bones
Joints Muscles
IN FINAL STAGE Paralysis
Premature aging
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Effects on Teeth
Discoloration Delayed eruption
Chipping of Edges
Pitting
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Dental Fluorosis
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Dental Fluorosis
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Dental Fluorosis
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DENTAL FLUOROSIS
Effect on Developing Fully developed
Teeth Teeth Teeth
Systemic ++++ +
effect
Direct +++ +++
effect
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Bones and Joints
Heel Pain
Painful and restricted joint movement
Deformities in legs
Hunch back
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Painful and restricted joint movement
(Bones and Joints)
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Deformities in legs
(Bones and Joints)
Conditions like osteo arthritis due to damage of
Articular Cartilage (Basically structured by GAG
and Sialic acid)
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Hunch back
(Bones and Joints)
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Hunch back
(Bones and Joints)
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Skeletal fluorosis
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Skeletal fluorosis
Severe OsteopeniaNormal serum Calcium, PTH Hyper secretion, Elevated Osteocalcin, and,
normal 25 OHD and 1,25 (OH)2 D (Ref.: Srivastava RN et al, 1989)
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Calcification of interosseous membrane(Skeletal fluorosis)
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Clinical Fluorosis
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Extreme Cases
Paralysis
Muscular Wasting
Premature Aging
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Paralysis
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Bone and Muscle
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Premature Aging
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Neurological manifestation(NSM)
Nervousness & Depression
Tingling sensation in fingers and toes
Excessive thirst and tendency tourinate frequently (Polydypsia and
plyurea): The control by brain appears to
be adversely affected)
Headache Mental efficiency :reduced mental work
capacity (MWC); hair zinc content ;
decreased 5-hydroxy indole acetic acid
and increased norepinephrine in rat brain
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Muscular manifestations(NSM)
Muscle Weakness &
stiffness
Pain in the muscle and
loss of muscle power
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Skin manifestation(NSM)
Very painful skin rashes,
which are peri vascular
inflammation. Prevalent
in women and children
Pinkish red or bluish redspots, round or oval shape
on the skin that fade and
clear up with in 7-10 days.
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Gastro - intestinal problems(NSM)
Acute abdominal pain
Diarrhea
Constipation
Blood in stool
Bloated felling (Gas)
Tenderness in stomach Feeling of nausea
Mouth sores
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Gastro - intestinal problems(NSM)
Gastric manifestations are mediated by:
1. Local actionMediatedthrough formation of HF,which dissipates theBicarbonate gradient in visiblemucous (mucin)
2. Systemic ActionMediatedthrough PTH causing breakdown of Mucin layer ofStomach
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Urinary tract manifestations(NSM)
Urine may be much lessin volume
Yellow red in color
Itching in the region.
Kidney's
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PregnancyIn vivo effects
SGA new born babies
are more common Effects primary tooth
budding in infant
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T- CELL FUNCTION
Fluoride effects the cell mediatedimmunity by modifying T-cell functions
Clinically Important in
Immunization
may modify the immune responseto vaccination
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R.B.C;Ligament & Blood vessels:Thyroid(NSM)
RBC: Formation of eccynocytes. Eccynocytes
have less life span causing anemia
Ligaments and Blood Vessel Calcification
Fluoride and thyroid: Fluoride has inhibitoryeffect on iodine uptake causing manifestations of
hypothyroidism
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Cancer;Diabetes;Lactation(NSM)
Fluoride and Cancer: Sodium fluoride promotedthe growth of precancerous lesions of the liverinduced by DEN in rats.
Fluoride and diabetes: significant abnormalities inglucose tolerance which are reversible uponremoval of the excess fluoride. (Trivedi-N et al. ,1993)
Fluorosis and lactation: Inhibition of lactation in
lactating rats; During chronic fluorosis serum PRLlevel was decreased from pituitary lactotrophs andan enhanced function of dopaminergic system inhypothalamus (Yuan-SD et al., 1991)
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OTHER EFFECTS OFHIGH F INGESTION
Fluoride and SAP (F significantly increasedthe enzyme's activity in DP-1 and TE-85 by177 +/- 12% and 144 +/- 12.3%)
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Fluoride and Geno toxicity
Dose and time dependant effects
Increased chromosomal aberration
Sister chromatid exchangeThis iscontrolled by micro tubules, which shortenduring anaphase. This process is calcium
dependant. Unscheduled DNA synthesisMay cause
neoplastic transformation of embryo cells
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Fluoride and Fertility
Fluoride reduces the fertility (#) by causing (Zahvoronkov AA et al, Fluoride 1981)
Hypogonadism;
Decreased leydig cell function
Decreased testosterone levelsDecreased spermatogenesis
Disturbed Sertoli Cell function
Break down of blood testicular barrier
Decreased tRNA synthesisDecreased tRNA to spermatid
Decreased protein synthesis
Decreased intra testicular conc. of testosterone
Decreased spermatogenesis
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Fluoride and Fertility
Fluoride reduces the fertility (#) by causing(Zakrzewska H et al, Fluoride 2002)
Decreased spermatozoal motility Decreased activity of androgen dependant
enzymes ; Acid phosphatase, Lactate
dehydrogenase and gamma glutamyltransferase
Increased activity of Asperate transaminase
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Quantification of fluoride toxicity on
human health (Smith and Hodge)
Fluoride (mg/l)
Concentration
Source Effects
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
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Diagnosis
Endemicity of the disease in the area
Fluoride content in drinking water
Clinical manifestationsDental and Clinical
Clinical examination
Biochemical evaluations
Radiological evaluations
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Diagnosis
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PROPOSED PATHOPHYSIOLOGY OF FLUOROSIS
Fluoride ingestion INCREASED BLOODFLUORIDE
sequestration of calcium
Lowering of serum calcium(HYPOCALCEMIA)INCREASED PTH
increase in immatureosteoblast
increasedosteocalcin
Decreased Collagen synthesisand decreased in serum PICP
increased matrix formation increased osteoclastformation
increased collagenremoval
failure of mineralization Bone resorption
Decreased bone collagenHyperosteoidosis Restoration of serumcalcium
Increased Serum andBone GAG
Decreased bonecalcification
PROPOSEDPATHOPHYSIOLOGY OF
FLUOROSIS Pathophysiology
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Pathophysiology of fluorosis
(Brief Summary)
F ingestion Disturbs calcium homeostasis
Increased PTH
Changes in extra cellular Matrix, so
that calcium may be released from tissues
Maintains Calcium balance
Supplementcalcium andVit. D to avoid it
For restructuring ofgood quality of extracellular matrixSupplement Vit. C
with good proteinand Iron
Manifestationof fluorosis
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TREATMENT AND PREVENTION
Treatment : Possible in Children
Prevention : Avoid use of F rich
Diet and Water
Use diet rich in
Protein, Vitamin C and Calcium Changing dietary habits (e.g. cooking practices that
destroy Vitamin C during cooking) within their
available resources.
Rain Water Harvesting
TREATMENT
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TREATMENT
Fluorosis could be reversed, atleast in children by Calcium,
Vitamin C and Vitamin D
supplementationSource: Gupta et al. 1994,1996; NEERI 2002
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Delayed dentition(Reversal of fluorosis)
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Dental fluorosis(Reversal of fluorosis)
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Dental fluorosis(Reversal of fluorosis)
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Clinical fluorosis(Reversal of fluorosis)
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Skeletal fluorosis(Reversal of fluorosis)
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Role of calcium supplementation:
Improving serum calcium levels
Extra calcium in gut directly inhibits theabsorption of fluoride ions.
Inhibits the excessive release of PTH therebypreventing excessive activation of osteoblastsand osteoclasts, thus preventing
hyperosteoidosis and osteopenia (Tortora JG &Anagnostakas NP, 1990).
Also help in laying down of bones and teethmineralisation.
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Doses of Calcium
Doses of Calcium in terms of elemental Calcium
RDA 1000 mg per day
If F intake is 250 mg per day
10 mg per day
(25 mg elemental Ca/ mg of F)
One tablet of 500 mg calcium carbonate providesabout 200 mg elemental calcium
Doses of Vitamin D : 60,000 IU of Vitamin D
twice a week can be given safely
CALCIUM RICH DIETS
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CALCIUM RICH DIETS
(mg/100gm)
Ajwayan (1525) Til (1450)
Skimmed Milk Powder (1370) Mar (Agathi) (1130)
Jira (1080) Khoa (990)
Whole Milk Powder (950) Kantewali Chaulai (800)
Long Dry (740) Shalgam Ka Sag (710)
Hing (690) Dhania (630) Phool Gobhee (626)
Bathuva (520) Paneer (480) Kali Mirch (460)Coconut Dry (400) Chaulai Sag (397) Chukandar (380)
Methi Sag (395) Kaddu (392) Chumli (Arai) (364)
Chana Sag (340) Gajar Sag (340) Samp Machli (330)
Kala Til (300)
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Role of Vitamin D supplementation
Enhances calcium absorption andretention without causing hypercalcemia
Inhibits the excessive release of PTH byimproving hypocalcemia
And hence prevent excessive activation ofosteoblasts & osteoclasts thus preventinghyperosteoidosis and osteopenia.
Increases turnover of immature collegeninto more mature type that calcifies innormal manner
Inceases blood levels of both calcium andphosphorus, so more is available for
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Role of vitamin C in collagen synthesis
- Ketoglutarate [18O] Succinate
18O2Ascorbate
Pro Pro
18OH
Fe 2+
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Role of vitamin C supplementation
1. Induce massive and rapid collagen
synthesis by Inducing hydroxylation of
proline2. Making hyaluronic acid molecule
depolymerised and more diffusable.
3. Deficiency of Vitamin C is responsible forcreating acidic environment in the groundsubstance supplementation preventsthese changes
Ascorbic acid (Vitamin C)
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Ascorbic acid (Vitamin C)
rich diet (mg/100gm)
Amla (600) Shalgam (180) Mar (Agathi) (169)
Hara Dhania (135) Band Gobee (124) Mirch Green (111)
Chaulai Sag (99) Mooli Ka Sag (81) Gajar Sag (79)
Chotee Gobee (72) Chukandar (70) Neembu (63)
Phul Gobi (56) Malta (54) Methi Sag (52)
Mirch Dry (50) Mausambi (50) Guar Ki Phalli (49)
Shalgam (43) Nimbu Bada (39) Kalni Sag (37)Bathua Sag (35) Kantewali Chaulai (33)
Sarson-ka-sag (33) Raspberry (30) Palak (28)
Tomato (27) Pudina (27) Sem (27)
HIGH FLUORIDE CONTAINING
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HIGH FLUORIDE CONTAINING
FOOD
F Rich water Tea Fluoridated tooth paste
Pan Supari Tobacco
Green Garlic Onion Cabbage
Soya bean Carrot Corn
Potato Baking powder Egg
Cows liver and Kidney
Plant and vegetables grown in high fluoride containingwater
Rain Water Harvesting
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Rain Water Harvesting
(Some old methods and designs)
Rain Water Harvesting
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Rain Water Harvesting
(Some old methods and designs)
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DEFLUORIDATION
(ROL)
Adsorption
Ion Exchange Methods
Precipitation Methods
Miscellaneous Methods.
Source: Killedar et al.. 1988
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DEFLUORIDATION
Fluoride Removal Process based on adsorption
Commonly used techniques -
Nalgonda Activated Alumina
Recently Developed
KRASS Process
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DESIRABLE CHARACTERISTICS
Cost-effective
Independent of raw water Fluoride
concentration, alkalinity, pH, temperatureEasy to handle/operate by rural population -
the major sufferer
Should not affect taste of waterShould not add other undesirable
substances (eg. Aluminum) to treated water
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NALGONDA TECHNIQUE
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NALGONDA TECHNIQUE
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NALGONDA TECHNIQUE
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NALGONDA TECHNIQUE
Cost-effective
NOT independent of raw water Fluoride
concentration, alkalinity, pH NOT Easy to handle/operate by rural
population - the major sufferer
AFFECTS taste of water ADDS aluminum & TDS to treated water
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ACTIVATED ALUMINA
NOT Cost-effective
INDEPENDENT of raw water Fluoride
concentration, alkalinity, pH NOT easy to handle/operate by rural
population - the major sufferer
DOES NOT affect taste of water ADDS moderate aluminum to treated water
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ACTIVATED ALUMINA
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KRASS TECHNIQUE
Cost-effective
Independent of raw water Fluoride
concentration, alkalinity, pH, temperatureEasy to handle/operate by rural population -
the major sufferer
Does not affect taste of waterAdds other undesirable substances (eg.
Aluminum) only in traces.
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KRASS TECHNIQUE
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RESIDUAL ALUMINUM
In treated water
KRASS : Traces
Nalgonda : 2.01 - 6.86 mg/L (AAS+GF)
A. Alumina : 0.16 - 0.45 mg/L (Aluminon)
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ALUMINUM IN WATER
Desirable Limit : 0.03 mg/L
Permissible Limit : 0.2 mg/L
TOXIC EFFECTS OF
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TOXIC EFFECTS OF
ALUMINUM
CNS: Neuro-toxin-Alzheimers Disease, Enceph.
Impair Cognitive & motor function,
Peripheral Neuropathy , Myopathy,
BONES: Osteomalacia, Rickets, Pathological #
X-ray of BONE: Non healing #, Osteopenia,
Reduction in calcified tissue
ALLERGY : Itchy dermatitis axilla
RESP. TRACT: Pulm. Fibrosis, Asthma, Ch. Bron.
Blood: Microcytic Anemia
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Aluminofluoride complexes
Aluminofluoride complexes are formed spontaneouslyin a water solution containing fluoride and traceamounts of aluminum.
Affect G proteins (guanine nucleotide binding proteins).
G proteins have key role in all body system function(Specially liver, kidney, blood cells, bones cells ets)including brain where it causes neurotransmission andintercellular signaling in the brain.
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Summary of Al & F synergistics
Studies were conducted in two areas with similar
fluoride but different aluminum
Decreased MWC was observed in areas with higheraluminum. (Satyaprakash, 1999)
More severe presentations of fluorosis in areas with
higher aluminum (Sayal, 2000 and Jajoo, 2001)
Significant differences in neurological symptoms
like tremors, loss of co ordination, deterioration an
hand writing etc. (Sayal, 2000 and Jajoo, 2001)
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Is fluoridation practiced in
the west safe?
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THANK YOU
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