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ORIGINAL ARTICLE
Year : 2012  |  Volume : 30  |  Issue : 4  |  Page : 317-322
 

Prevalence of dental fluorosis in relation with different fluoride levels in drinking water among school going children in Sarada tehsil of Udaipur district, Rajasthan


1 Department of Pedodontics and Preventive Dentistry, Faculty of Dental Science, Dharmsinh Desai University, Nadiad, India
2 Department of Pedodontics and Preventive Dentistry, Darshan Dental College and Hospital, Udaipur, Rajasthan, India
3 Department of Oral Medicine and Radiology, Karnavati School of Dentistry, Uvarsad, Gandhinagar, Gujarat, India

Date of Web Publication19-Mar-2013

Correspondence Address:
B U Sarvaiya
Department of Pedodontics and Preventive Dentistry, Faculty of Dental Science, Dharmsinh Desai University, Nadiad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.108929

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   Abstract 

Aim: To estimate the prevalence of dental fluorosis in relation with different fluoride levels in drinking water among school going children of 6-12 years age group. Materials and Methods: Dental fluorosis was recorded using Dean's index in school children of selected villages. The drinking water samples of all the selected villages were collected in polyethylene bottles and the fluoride content of these samples was determined by fluoride ion selective method using Orion microprocessor analyser. Results: The overall prevalence of dental fluorosis was found to be 69.84%. An increase in the community fluorosis index (CFI) with corresponding increase in water fluoride content was found. Conclusion: There was an increase in prevalence of dental fluorosis with a corresponding increase in water fluoride content from 0.8 ppm to 4.1 ppm. A significantly strong positive correlation was found between CFI and fluoride concentration in drinking water.


Keywords: Dental fluorosis, drinking water, fluoride


How to cite this article:
Sarvaiya B U, Bhayya D, Arora R, Mehta D N. Prevalence of dental fluorosis in relation with different fluoride levels in drinking water among school going children in Sarada tehsil of Udaipur district, Rajasthan. J Indian Soc Pedod Prev Dent 2012;30:317-22

How to cite this URL:
Sarvaiya B U, Bhayya D, Arora R, Mehta D N. Prevalence of dental fluorosis in relation with different fluoride levels in drinking water among school going children in Sarada tehsil of Udaipur district, Rajasthan. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2019 Dec 15];30:317-22. Available from: http://www.jisppd.com/text.asp?2012/30/4/317/108929



   Introduction Top


The image of a perfect smile represented by regularly arranged white teeth has gained popularity in recent decades and it has become important to have teeth with no sign of abnormality. However, teeth are exposed to a variety of elements in day-to-day life. All these exposures are bound to take its toll on tooth color. Among the several factors that are known to bring about a change in the normal appearance of tooth color, fluoride is one of the common causal factors. Though the use of fluoride has been demonstrated to be one of the most successful measures in public-health history, excessive intake of fluoride leads to multiple effects on human-health. The Bureau of Indian Standards (BIS) has set the maximum permissible level of fluoride in drinking water at 1 ppm. [1] Fluoride is a double-edged sword. Fluoride at optimal level, decreases the incidence of dental caries and is also necessary for maintaining the integrity of oral tissues but at the same time when taken in excess during developmental stages, can cause adverse effects like dental fluorosis and skeletal fluorosis. [2] Fluoride exposure with drinking water is an endemic problem in China, India, Africa and parts of Mexico. [3] In recent years, the prevalence of dental and skeletal fluorosis in India is increasing due to population overgrowth necessitating for more and more water, indiscriminate digging of tube wells leading to more usage of fluoridated water and total unawareness of the importance of water quality assessment and drinking water from any and every source. [1] Since endemic fluoride areas constitute problem of dental and skeletal fluorosis, the early detection of fluoride toxicity and methods of prevention and control of these diseases is the need of the hour. On account of scanty and erractic rainfall leading to drought like conditions and high population growth rate with its sparse distribution, Rajasthan is severely affected with drinking water supply problems. Highly rich fluoride groundwater has been reported to exist in the districts Ajmer, Barmer, Bharatpur, Bhilwara, Bikaner, Churu, Dungarpur, Jaipur, Jodhpur, Jhunjhunu, Kota, Pali, Nagur, Sikar, Sirohi, Tonk and also in some parts of Udaipur. In Udaipur district, the tehsils in which majority of villages have fluoride content more than 1.5 ppm are Mavli, Salumber, Sarada.[4] But recently water work projects have been started to provide safe water in almost all villages in every tehsil. However, Sarada tehsil is still untouched and people of this tehsil drink water from their local water sources since years. Moreover, people living here are tribal population; hence have same diet and same socio-economic status. So the severity of fluorosis in this area can be mainly related with the varying fluoride concentration in drinking water. Until today, no data is available on the prevalence and severity of dental fluorosis in school children of Sarada tehsil of Udaipur district. The reason for conducting the survey was to identify the fluoride endemic areas that require immediate adoption of remedial measures to prevent the problem of fluoride toxicity. Thus, the aim of the study was to determine the fluoride concentration in drinking water of villages in Sarada tehsil of Udaipur district, Rajasthan and estimate the prevalence of dental fluorosis in relation with different fluoride levels in drinking water among school going children of 6-12 years age group.


   Materials and Methods Top


The present analytical study was conducted among 6-12 year old school children of Sarada Tehsil, Udaipur district, Rajasthan, India in collaboration with Jalseva Talim Sanstha, Water Supply and Water Storage, Gandhinagar, Gujarat during the period of June-October, 2010. Informed consent was obtained from the school head master before the onset of study. The size of the sample was estimated to be 1,000. A total of 1,008 children participated in the study. The pilot study subjects were not included in the main study. School going children aged 6-12 years who were lifelong residents of that particular region and who were using the same source of drinking water from birth were included in the study. Children who were not the permanent residents of that particular area and with change of source of drinking water, those with orthodontic brackets, dentofacial deformities or any syndromes or uncooperative, medically and physically compromised patients were excluded from the study. Stratified sampling procedure was used for the main study. For study purpose, the entire geographical area of Sarada tehsil was divided into four zones: North, West, South and East. From each zone, the following villages were selected by simple random sampling from those villages which fulfilled the inclusion criteria. Self-administered questionnaire were distributed among the school children present in the school on the day of examination. They were asked to fill the questionnaire which consisted of information on demographic data, permanent residential address and type of drinking water source. Assessment of dental fluorosis was done by using Dean's index. The recording was made on the basis of the two teeth that are most affected. If the two teeth were not equally affected, the score for the less affected of the two was recorded. Community fluorosis index (CFI) was also recorded. The clinical examination was carried out under the adequate natural light in school premises or corridors. Collection of water sample [Figure 1] was done based on national oral health survey and fluoride mapping 2002-2003. Drinking water was collected in pre-cleaned polyethylene bottles; [Figure 2] it was then given a serial number, which represented a particular village. The common water sample drunk by school children of a particular village was taken. The fluoride content of these samples was determined by fluoride ion selective method using Orion microprocessor analyser at Jalseva Talim Sanstha, [Figure 3] Water supply and water storage, Gandhinagar, Gujarat. All the examination was carried out by a single examiner, (i.e., an investigator herself) and recording was done by another person, who was familiar with the local language and assisted the examiner in recording the details. Statistical analysis was done using a statistical package of social science (SPSS version 15; Chicago Inc., USA).
Figure 1: Various sources of drinking water

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Figure 2: Polyethylene bottles for collection of drinking water samples from sources like hand pumps, open wells and rivers

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Figure 3: Orion microprocessor analyser with fluoride ion sensitive electrode

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Criteria for Dean's fluorosis index



Community fluorosis index

The CFI is calculated based on the following point scale for the different categories of dental fluorosis (using the Dean Index):

  • Questionable Fluorosis = 0.5 points
  • Very Mild Fluorosis = 1 point
  • Mild Fluorosis = 2 points
  • Moderate Fluorosis = 3 points
  • Severe Fluorosis = 4 points



   Results Top


Out of the total population, 51.60% were males and 48.40% were females. In age group of 6-8 years, there were 49% males and 51 % females, in 8-10 years age group, there were 56.30% males and 43.70% females and in age group of 10-12 years, there were 49.30% males and 50.70% females [Table 1]. The overall prevalence of dental fluorosis was found to be 69.84%. An increase in prevalence of dental fluorosis with corresponding increase in water fluoride content was found [Table 2]. There was significant difference found between different age groups and prevalence of dental fluorosis (P < 0.001). Children of 10-12 year age group were found to have the highest prevalence of dental fluorosis, i.e., Chi-square value: 725.29 [Table 3]. A stepwise increase in the CFI with corresponding increase in water fluoride content, 0.25 at 0.8 ppm F to 2.21 at 4.1 ppm F was found with the mean CFI value of 1.13 + 0.75. Thus, a significantly very strong positive correlation (P < 0.001) was found between CFI and fluoride concentration in drinking water. Regression analyses thus, showed significantly higher CFI by increased fluoride concentration in drinking water [Table 4].
Table 1: Distribution of study group according to age and gender

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Table 2: Prevalence of dental fluorosis at varying levels of fluoride concentration in drinking water


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Table 3: Prevalence of dental fluorosis in study population according to age groups

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Table 4: Relation between Community fluorosis index and water fluoride level

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   Discussion Top


The intent of the study was to examine the effect of different fluoride levels in drinking water on dental fluorosis in Sarada tehsil of Udaipur district in Rajasthan. School based approach was used to assess the prevalence of dental fluorosis and dental caries in the present study. Schoolchildren of age group 6-12 years were chosen. As this being the period of mixed dentition, effect of dental caries can be assessed on both the primary as well as permanent dentition. Moreover, the sample population of this particular age group was readily available from primary schools only. The present study reported high concentration of fluoride in groundwater (hand pump and open well as compared to surface water of rivers). The average fluoride concentration was recorded to be 2.42 mg/dL. Similarly, a study from the Northern Rajasthan, India, reported fluoride concentration in groundwater in the range of 4.78-1.01 mg/L with the average concentration being 2.82 mg/L. [5] Climate has a significant influence on the fluoride concentration in water, with fluoride content increasing after a drought and decreasing, as a result of dilution, after heavy rains. [6],[7] Therefore, the water samples in this study had been collected in October 2010 during the dry season. The BIS has set the maximum permissible level of fluoride in drinking water at 1 ppm. [1] The universal acceptance of 1 ppm fluoride as the optimum level does not seem to be appreciable to Indian conditions as this level depends upon climatic, environmental, dietary habits and occupational status. Allowable concentration for fluoride in drinking water for a region depending on its climatic conditions because the amount of water consumed and consequently, the amount of fluoride ingested being influenced primarily by the air temperature. The fluoride-related problems are closely associated with climate. In hot tropical part of the world, people consumed more water and consequently, the risk of fluoride accumulation increases. [5] Applied to Udaipur conditions, the relatively higher daily temperature when compared to temperate regions of the world necessitates comparatively increased consumption of water per day, which leads to an increased ingestion of fluoride. This in turn results in higher prevalance of dental fluorosis. The findings in the present study go hand in hand by the studies conducted by Khan et al., [8] in Pakistan and Menon and Indushekar [9] in Dharwad. They stated that even 0.5-1.2 ppm fluoride in drinking water resulted in higher prevalence of dental fluorosis. The overall prevalence of dental fluorosis was found to be 69.84% in the present study having fluoride concentration ranging from 0.8 ppm to 4.1 ppm. It was found that at fluoride concentration of 0.8 ppm prevalence of dental fluorosis was 29.76% and at 4.1 ppm the prevalence of dental fluorosis was 93.24%. In the present study, there was an increase in percentage of children affected with dental fluorosis with every unit increase in fluoride level in drinking water which was in close agreement with few studies. [10],[11],[12] In a study carried out by Budipramana et al. [13] , fluorosis prevalence was 96% in the fluorosis endemic area of Asembagus, Indonesia with fluoride content in drinking water, ranging from 0.41 ppm to 3.25 ppm. Ibrahim et al. [14] showed that 91% of children living in a 0.25 ppm fluoride area in Sudan had dental fluorosis. In the present study, a stepwise increase in the CFI with corresponding increase in water fluoride content, 0.25 at 0.8 ppm F to 2.21 at 4.1 ppm F, was found with the mean CFI value 1.26. Thus, a significant positive correlation was found between CFI and fluoride concentration in drinking water. These findings were supported by studies carried out by Chandrashekar and Anuradha [2] and Budipramana et al. [13] Dental fluorosis is a health condition caused by a child receiving too much fluoride during tooth development. [15] It occurs because of the excessive intake of fluoride, either through fluoride in the water supply, naturally occurring or added to it; or through other sources. Fluoride in drinking water is commonly the single largest contributor to daily fluoride intake. The damage in tooth development occurs between the ages of 3 months to 8 years, from the overexposure to fluoride. Excessive fluoride can cause white spots, and in severe cases, brown stains or pitting or mottling of enamel. Teeth with fluorosis have an increase in porosity in the subsurface enamel (hypo-mineralization). The increased porosity of enamel found in fluorosis is a result of a fluoride-induced impairment in the clearance of proteins (amelogenins) from the developing teeth. [16] In addition to affecting the enamel, dental fluorosis may also affect the underlying dentin as well, thus suggesting that "fluoride may exert effects at the cellular level well beyond tooth development."

In the present study, dental fluorosis was not found in primary teeth. This fact can be explained by the following reasons.

The stage of enamel development most vulnerable to excessive fluoride intake is the transitional stage, which occurs between late secretory and early maturation stages. In primary teeth, the maturation phase occurs in utero while the placenta acts as a barrier to the transfer of fluoride. [13] The primary teeth develop in a shorter time than the permanent teeth and therefore, less able to acquire fluoride. [7] The effect of excessive fluoride intake upon ameloblasts, which is of major aesthetic and clinical importance, occurs during the formation of anterior permanent teeth from birth to 5 years of age [17] which may be why dental fluorosis is less severe and less frequent than fluorosis observed in permanent teeth. In the present study, a significant difference between different age groups was found with the children of 10-12 year age group having the highest caries prevalence. Fluorosis becomes more severe with age, an observation which could be explained by subsurface porosities, which are created during development of the enamel when high concentration of fluoride are in the environment and disturb the ameloblasts in creating regular enamel rods. These subsurface porosities might change into pitting and elevate the definition of the fluorosis severity. [18],[19] In a study carried out by Rwenyonyi et al., [20] among children of age group 10-14 years, there was a significant increase in the severity of fluorosis with increasing age in a high fluoride community having 2.5 ppm of fluoride level in drinking water.


   Conclusion Top


The following conclusions were drawn from the study:

  • The overall prevalence of dental fluorosis was found to be 69.84%. There was an increase in prevalence of dental fluorosis with a corresponding increase in water fluoride content from 0.8 ppm to 4.1 ppm.
  • An increase in the CFI with a corresponding increase in water fluoride content was found. Thus, there was a significantly very strong positive correlation between CFI and fluoride concentration in drinking water.


 
   References Top

1.Susheela AK. A treatise on fluorosis. Fluoride 2007;40:248-9.  Back to cited text no. 1
    
2.Chandrashekar J, Anuradha KP. Prevalence of dental fluorosis in rural areas of Davangere, India. Int Dent J 2004;54:235-9.  Back to cited text no. 2
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3.Alarcon-Herrera MT, Martin-Dominguez I, Trejo-Vazquez R, Rodriguez-Dozal S. Well water fluoride, dental fluorosis, and bone fractures in the Guadiana Valley of Mexico. Fluoride 2001;34:139-49.  Back to cited text no. 3
    
4.Jain Sk, Ray A, Shekhar S, Chandra R, Shrivasatava K, Sharma V. Ground water quality in shallow aquifers of India: Central ground water board ministry of water resources. Faridabad: Government of India; 2010. p. 1-117.  Back to cited text no. 4
    
5.Suthar S, Garg VK, Jangir S, Kaur S, Goswami N, Singh S. Fluoride contamination in drinking water in rural habitations of Northern Rajasthan, India. Environ Monit Assess 2008;145:1-6.  Back to cited text no. 5
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6.Bischoff JI, van der Merwe EH, Retief DH, Barbakow FH, Cleaton-Jones PE. Relationship between fluoride concentration in enamel, DMFT index, and degree of fluorosis in a community residing in an area with a high level of fluoride. J Dent Res 1976;55:37-42.  Back to cited text no. 6
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7.Haikel Y, Cahen PM, Turlot JC, Frank RM. Dental caries and fluorosis in children from high and low fluoride areas of Morocco. ASDC J Dent Child 1989;56:378-81.  Back to cited text no. 7
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8.Khan AA, Whelton H, O'Mullane D. Determining the optimal concentration of fluoride in drinking water in Pakistan. Community Dent Oral Epidemiol 2004;32:166-72.  Back to cited text no. 8
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9.Menon A, Indushekar KR. Prevalence of dental caries and co-relation with fluorosis in low and high fluoride areas. J Indian Soc Pedod Prev Dent 1999;17:15-20.  Back to cited text no. 9
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10.Grobleri SR, Louw AJ, van Kotze TJ. Dental fluorosis and caries experience in relation to three different drinking water fluoride levels in South Africa. Int J Paediatr Dent 2001;11:372-9.  Back to cited text no. 10
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11.Ermis RB, Koray F, Akdeniz BG. Dental caries and fluorosis in low- and high-fluoride areas in Turkey. Quintessence Int 2003;34:354-60.  Back to cited text no. 11
    
12.Wondwossen F, Astrøm AN, Bjorvatn K, Bårdsen A. The relationship between dental caries and dental fluorosis in areas with moderate- and high-fluoride drinking water in Ethiopia. Community Dent Oral Epidemiol 2004;32:337-44.  Back to cited text no. 12
    
13.Budipramana ES, Hapsoro A, Irmawati ES, Kuntari S. Dental fluorosis and caries prevalence in the fluorosis endemic area of Asembagus, Indonesia. Int J Paediatr Dent 2002;12:415-22.  Back to cited text no. 13
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14.Ibrahim YE, Affan AA, Bjorvatn K. Prevalence of dental fluorosis in Sudanese children from two villages with 0.25 and 2.56 ppm fluoride in the drinking water. Int J Paediatr Dent 1995;5:223-9.  Back to cited text no. 14
    
15.Abanto Alvarez J, Rezende KM, Marocho SM, Alves FB, Celiberti P, Ciamponi AL. Dental fluorosis: Exposure, prevention and management. Med Oral Patol Oral Cir Bucal 2009;14:E103-7.  Back to cited text no. 15
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16.Allen K, Agosta C, Estafan D. Using microabrasive material to remove fluorosis stains. J Am Dent Assoc 2004;135:319-23.  Back to cited text no. 16
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17.Nanci A. Development of the tooth and its supporting tissues. In: A. R. Ten Cate, John Dolan, Arnold R, editors. Ten Cate's Oral Histology. Development, Structure and Function. 5 th ed. St. Louis, Mo, USA: Mosby Elsevier; 1985. p. 78-108.  Back to cited text no. 17
    
18.Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes. Community Dent Oral Epidemiol 1978;6:315-28.  Back to cited text no. 18
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19.Baelum V, Manji F, Fejerskov O. Posteruptive tooth age and severity of dental fluorosis in Kenya. Scand J Dent Res 1986;94:405-10.  Back to cited text no. 19
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20.Rwenyonyi CM, Birkeland JM, Haugejorden O, Bjorvatn K. Age as a determinant of severity of dental fluorosis in children residing in areas with 0.5 and 2.5 mg fluoride per liter in drinking water. Clin Oral Investig 2000;4:157-61.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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