Fluorosis: fluoride contamination,

A Social Disaster For Assam and other Areas

Recently there have been some concern about fluoride in Bangladesh also but, as only a small percentage of tubewells have been tested for this, it is difficult to make any assessment on what the presence of fluoride in the water could have on a population already struggling with arsenic. As there have been numerous incidents of fluoride poisoning, including mass poisoning cases around the world which include some well documented cases in England and the United States, we would be wise to consider fluoride as a factor. This is an issue that has already been raised by DCH and others but little importance appears to have been attached to it.

Flourosis is creating trouble for more than 23 countries including Japan, China, Thailand, Bangladesh, Pakistan, Sri Lanka, Jordan, Iraq, Iran, Palestine, Algeria, Australia, England, Italy, France, Spain, Portugal, Czechoslovakia, Libya, Morocco, Mexico, New Zealand, Germany, Syria, Turkey, UAE, USA, Argentina, Egypt and African Nations (Senegal, Kenya, Tanzania, Ethiopia, Uganda) in the globe (The Daily Observer, San Feature, 7.11. 03).

Film director Manju Bora has come to Diphu for making a docu-feature on a Karbi legend. The script for the production was prepared by Diphu based writer Basanta Das, who had already selected a beautiful Karbi girl for the lead role. Prior to the shooting schedule, the director wanted the girl at least two days earlier for briefing. And accordingly she came with her brother. While looking at Kadam, the director get shocked. Because, Kadam was not so beautiful. Her teeth are mottled, neck been fixed, face got wrinkles. And over all, she looked like so tired and pensive.

The director could not take any decision regarding the choice of Kadam by Basanta Das. Then arrived Mr Das, who himself got surprised to look at Kadam. "But Kadam was really beautiful, when I met her three years back in Bagh Pani Bazar," astonished Mr Das. Then what has gone wrong with Kadam!

Kadam is suffering from Hydrofluorosis, a water borne disease. Widely known as Fluorosis, the disease affects one to all, young to old, poor to rich and male to female. With Kadam there are at least 2,00,000 people in Assam, who are in the grip of fluorosis. Hundreds of villages in Karbi Anglong, Nagaon and Kamrup districts are identified as the fluorosis prone area. According to statistics, more than six million children (all together 62 million people in India are afflicted) are suffering from fluorosis.

The first fluorosis case in Assam was detected in May 1999 in the Tekelangjun area of Karbi Anglong, where fluoride levels were found to be as high as 5-23 mg per litre.

The man behind the discovery of fluorosis in Assam Mr Paul narrated the symptoms of the disease, "Severe anaemia, stiff joints, painful and restricted movement, mottled teeth, loose muscles, kidney failure, premature death and physical disability are some basic manifestations of fluorosis." Recently conducted a Dental Survey report by PHE department with financial assistance from UNICEF disclosed that over thousand school children in Karbi Anglong itself are affected by dental fluorosis. "We found at least 1193 school children are suffering from dental fluorosis," told Mr Paul. The survey, till April 2003 has covered 23,980 students from 229 schools in eight blocks of the district namely Rongkhang, Chinthong, Hawraghat, Nilip, Langsomepi, Amri, Lumbajong and Samelangso.

Over 20 states of India are endemic to the disaster. States like Andhra Pradesh (first ever case of fluorosis in India was detected here in early 1930), Gujarat, Rajasthan (where 70-100% districts are affected), Bihar, Punjab, Haryana, Karnataka, Maharashtra, Madhya Pradesh, Tamil Nadu, Uttar Pradesh, some parts of Delhi (40-70% districts affected), Uttranchal, Jharkhand, Chattisgarh Assam, Kerala, Orissa, West Bengal, Jammu & Kashmir (10-40% districts affected) are identified as significantly affected

There is distinctive relationship between poverty and fluorosis. Almost 70 per cent of the affected population in Assam are very poor. Health care awareness is certainly the need of the hour. But to create awareness the people have to be economically self-dependent. Besides, malnutrition adds to the aggravation of the disease. More over women and children are more prone to the ailment as they remain at home and are thus in contact with contaminated water for a longer period. At the same time malnutrition during childhood renders the women more vulnerable to fluorosis.

Ironically, it is the government-sponsored schemes to provide drinking water to villages that have unwittingly been the cause of the problem in some areas. Now rural poulation prefer to collect water from Dug Wells Kacha Kuwa (low depth well). The residents of Burha Teron were lucky that they relied on groundwater supply for only a few years.

Now come back to the story of Kadam. The girl without knowing why conceived the disease in her body, which has snatched away her scope to perform in the production. The director Ms Bora however consoled that Kadam would be given a chance in her next venture. Till then Kadam should take care of her health- advised Ms Bora (The Daily Observer, San Feature, 7.11. 03).

Ingestion of excess fluoride

Ingestion of excess fluoride, most commonly in drinking-water, can cause fluorosis which affects the teeth and bones. Moderate amounts lead to dental effects, but long-term ingestion of large amounts can lead to potentially severe skeletal problems.Fluorosis is caused by excessive intake of fluoride. The dental effects of fluorosis develop much earlier than the skeletal effects in people exposed to large amounts of fluoride. One expert says, although he has found only one reference to fluoride as a factor in neuro-chemistry in the medical literature, this is extremely worrying because it links to the very severe damage that can be caused by free radicals.

Chronic high-level exposure to fluoride can lead to skeletal fluorosis. In skeletal fluorosis, fluoride accumulates in the bone progressively over many years. The early symptoms of skeletal fluorosis, include stiffness and pain in the joints. In severe cases, the bone structure may change and ligaments may calcify, with resulting impairment of muscles and pain. Acute high-level exposure to fluoride causes immediate effects of abdominal pain, excessive saliva, nausea and vomiting. Seizures and muscle spasms may also occur.

Fluoride in soft drinks could lead to fluorosis

The presence of fluoride in foods and beverages, particularly soft drinks, could be an important part of total fluoride intake for young children and should be considered by physicians and dentists when thinking about prescribing fluoride supplements, according to University of Iowa College of Dentistry researchers.Soft drinks have a lot of sugar and acidity and lack important nutrients. Consuming them is not conducive to oral health, so they should be taken in moderation

Skeletal Fluorosis

  • The diagnosis of skeletal fluorosis, until recent years, was made with the help of radiographs which reveal interosseous membrane calcification, enhanced bone density, and bone mass. These are, however, late characteristics of the disease. Recognizing the disease at such late stages does not help prevention. The disease is usually irreversible by then.
  • According to the U.S. Public Health Service, fluoride makes dental enamel more porous, and makes bones more brittle. The disease known as crippling skeletal fluorosis develops in stages, with phase two described as chronic joint pain, dose-related calcification of ligaments, osteosclerosis, and possible osteoporosis. Phase three includes "crippling deformities of the spine and major joints."

    Major Related Diagnoses

    Alzheimer's disease/demyelinizing diseases, anemia, arthritis, breast cancer, carpal tunnel syndrome, decrease in testosterone/spermatogenesis, altered vas deferens/testicular growth, decreased dental arch, dental crowding, delayed tooth eruption, diabetes insipidus, diarrhea, Down syndrome, early onset of puberty, eosinophilia, eye/ear/nose disorders, fever, gastro-intestinal disturbances, gingivitis, heart disorders, hypertension, hypoplasia, hypothyroidism/thyroid cancer, kidney dysfunction, osteosarcoma, low birth weight, candidiasis, multiple sclerosis, oral squamous cell carcinoma, Parkinson's disease, seizures, slurred speech, skin irritations, ankylosing spondylitis, telangiectasia, thrombosis, ulcerative colitis, uterine cancer, vaginal bleeding, weak pulse.

    Studies have shown that ingested fluoride damages gastroduodenal mucosa. Gastrointestinal discomfort can be an early warning sign of fluorosis, so fluoride toxicity should be considered a possible reason for non-ulcer dyspepsia and gastrointestinal discomfort in the form of dyspeptic symptoms should be an important diagnostic feature when identifying fluorosis patients and should not be dismissed as non-specific. [Susheela AK, Das TK, Gupta IP, Tandon RK, Kacker SK, Ghosh P, and Deka, Fluoride ingestion and its correlation with gastrointestinal discomfort, Fluoride, 1992, 25:l, pp.5-22] The gastro-intestinal system is one of the most sensitive systems in the body to react adversely to fluoride toxicity. There are now many case histories available to establish the correlation of fluoride toxicity to gastro-intestinal problems.

    Signs, symptoms & indicators of Fluoride Toxicity

  • Excessive thirst (and resultant frequent urination) can be early warning signs of fluorosis.
  • Loss of appetite is an early sign of fluorosis.
  • Nausea (symptoms resulting from an inclination to vomit.) is an early sign of fluoride toxicity.
  • Persistent headaches are one sign of fluorosis.
  • Fluorides destroycolla gen (the primary protein within white fibers of connective tissue and the organic substance found in tendons, ligaments, cartilage, skin, teeth and bone) , which is the glue that adds strength to the bones
  • Though apparently vague and non-specific, most of the symptoms of fluoride toxicity point towards some kind of profound metabolic (The chemical processes of living cells in which energy is produced in order to replace and repair tissues and maintain a healthy body. Responsible for the production of energy, biosynthesis of important substances, and degradation of various compounds) dysfunction, and are strikingly similar to the symptoms of hypothyroidism (diminished production of thyroid hormone, leading to low metabolic rate, tendency to gain weight, and sleepiness).

    The cause

    Acute high-level exposure to fluoride is rare and usually due to accidental contamination of drinking-water or due to fires or explosions. Moderate-level chronic exposure (above 1.5 mg/litre of water - the WHO guideline value for fluoride in water) is more common. People affected by fluorosis are often exposed to multiple sources of fluoride, such as in food, water, air (due to gaseous industrial waste), and excessive use of toothpaste. However, drinking water is typically the most significant source. A person's diet, general state of health as well as the body's ability to dispose of fluoride all affect how the exposure to fluoride manifests itself.

    Distribution of the disease

    Fluoride in water is mostly of geological origin. Waters with high levels of fluoride content are mostly found at the foot of high mountains and in areas where the sea has made geological deposits. Known fluoride belts on land include: one that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya, and another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan. In these areas fluorosis has been reported.

    Fluoride & Arthritis

    Although skeletal fluorosis has been studied intensely in other countries for more than 40 years, virtually no research has been done in the U.S. to determine how many people are afflicted with the earlier stages of the disease, particularly the preclinical stages. Because some of the clinical symptoms mimic arthritis, the first two clinical phases of skeletal fluorosis could be easily misdiagnosed [as arthritis]... Even if a doctor is aware of the disease, the early stages are difficult to diagnose.


    • Removal of excessive fluoride from drinking-water is difficult and expensive. The preferred option is to find a supply of safe drinking-water with safe fluoride levels. Where access to safe water is already limited, de-fluoridation may be the only solution. Methods include: use of bone charcoal, contact precipitation, use of Nalgonda or activated alumina (Nalgonda is called after the town in South India, near Hyderabad, where the aluminium sulfate-based defluoridation was first set up at a water works level). Since all methods produce a sludge with very high concentration of fluoride that has to be disposed of, only water for drinking and cooking purposes should be treated, particularly in the developing countries.
    • Health education regarding appropriate use of fluorides
    • Mothers in affected areas should be encouraged to breastfeed since breast milk is usually low in fluoride.
    • It has been observed that the ingestion of calcium, vitamin C or vitamin D, individually, is effective in protection from fluoride toxicity to a certain extent.
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