Fluorosis

fluorosis

1. FLUOROSIS DR PRATIK DHABALIA RESIDENT IN ORTHOPEDICS Dr DY Patil Hospital, Navi Mumbai

2. INTRODUCTION Most abundant element in nature 96% of fluoride in human body is present in bones and teeth. Helps in normal mineralization of bones and formation of dental enamel. Fluorosis is a cosmetic condition affecting teeth, bones and soft tissues.

3. EPIDEMIOLOGY Public health problem in 24 countries, including india . 5 geographical belts India and china are most affected countries

4. In india , most affected states are Andhra Pradesh, Gujarat, Rajasthan.

5. ETIOLOGY 1. Most common cause is ingestion of drinking water containing high fluoride levels. (bore wells) 2. Use of fluoridated dental products like toothpaste or mouth rinse. Children tend to swallow it. 3. Ingestion of food contaminated by coal dust, which are cooked in chulhas . 4. Inhalation by industrial workers. 5. Ingestion of fruit juices, soft drinks and sea food. 5. Drugs – 5FU, NaF , Fluoxetin , FQ

6. RDA WHO – 0.5 to 1.0 mg/L Sources: Rock salt Salted snacks (peanuts, Channa ) Pickles Preserved fruit juices Soft drinks Sea Food

7. CLINICAL MANIFESTATIONS Mainly affects 12-15 years of age Clinically can be divided into three types Skeletal fluorosis Dental fluorosis Soft tissue and other manifestations

8. Skeletal Fluorosis The fluoride incorporation into the bone hydroxyapatite, altering the size and structure of its crystals. The fluoroapatite formed decreases the mechanical competence of the bone, resulting in abnormal structure and poor quality of bone, with increased risks for fractures. Rickets, osteomalacia , secondary hyperparathyrodism and regional osteoporosis are often associated with skeletal fluorosis. The bone diseases and deformities are more severe and complex in patients with dietary calcium and vitamin-D deficiencies.

9. Causes brittle bones which increases chances of pathological fractures. Causes ossification of ligaments and cartilage which leads to stiffness Impairment of joint mobility Deformity of bones

10. Spinal manifestations Spinal deformities – fusion of vertebrae, radiculopathy, LCS, OPLL, “Poker back” spine (kyphosis) is a late manifestation of skeletal fluorosis wherein the entire spine becomes one continuous column of bone Mechanical compression of the spinal cord and nerve roots resulting from the osteophytes - reduction of the antero-posterior diameter of the spinal canal and intervertebral foramina, sclerosed vertebral column and ossified ligaments. The cervical cord is affected earlier than the dorsal cord. The progressive cervical radiculomyelopathy of fluorosis is characterized by marked wasting and atrophy of the small muscles of the hands, spastic paraparesis or quadriparesis often in flexion.

11. Dental fluorosis Asymptomatic: Few white flecks of enamel to occasional white spots Very mild: Small opaque white area which is scattered over less surface area. Mild: White opaque areas on surface up to 50% of area. Moderate: More than 50% of surface area of white opaque Severe: Almost all enamel surface is affected. Dental fluorosis is also called as mottling of the tooth enamel, due to excess fluoride during the tooth development.

12. Other manifestations Thyroid – Hypothyroidism Renal – Nephrolithiasis Cardiac – Arrhythmias and IHD Muscular – Weakness and wasting

13. INVESTIGATIONS Skeletal Fluorosis should be strongly suspected in any person with features of stiffness, rigidity, restricted movements at the spine and joints, bone and joint pains and who has been residing continuously for >6 months in endemic area.

14. Serological CBC – Anemia , ESR and CRP raised Alkaline phosphatase and fluoride levels are elevated. Serum parathyroid hormone levels are always raised as a compensatory mechanism to maintain extracellular ionised calcium equilibrium consequent to decreased solubility and reactivity of fluoroapatite crystals, fluoride induced osteomalacia and dietary calcium deficiency Plasma calcium, magnesium and phosphorus remain normal

15. Urine fluorides : They are the best indicator of fluoride intake. There is a linear relation between urinary fluoride levels and fluoride intake. 24 h samples of urine are more reliable than random or morning samples. In cases of skeletal fluorosis, values will be >0.4 ppm. Serum fluoride levels : Normal values in non-endemic regions range from 0.002 to 0.008 mg/dl. Patients with skeletal fluorosis show high levels up to 0.02–0.19 mg/dl. Bone fluoride estimation, bone biopsy and scintigraphic studies may help to support the diagnosis of skeletal fluorosis.

16. Radiological The earliest radiological findings appear within six months of continuous exposure to high intakes of fluoride and include periosteal and endosteal reactions c oarse axial trabeculations osteopenia in the metaphyseal regions Sclerosis and modelling abnormalities of the epiphyses

17. The most pronounced changes are seen in the vertebral column with marked osteosclerosis and irregular osteophyte formation resulting in beak-like lipping and a chalky-white ground-glass appearance.[ 6 ] Calcification of the interosseous membrane of the forearm is a radiographic sign of fluorosis.[ 3 ]

18. Pulmonary function tests: Due to involvement of the rib cage, fluorosis causes restrictive lung disease Computed tomography: This can help to visualise alterations in spinal canal, indentations of epidural space and calcified ligaments.. Magnetic resonance imaging: Spinal cord changes due to prolonged compression and secondary vascular compromise.

19. MANAGEMENT Medical: In many cases, fluorosis is so mild that no treatment is needed. Only withholding the intake of fluorine reverses the disease.

20. Prevention: The use of more than 100 m deep bore water supply is able to provide water with fluoride less than 1mg/L, low alkalinity and normal or high normal calcium contents and this could play a master role in the control of endemic fluorosis. Drinking defluoridated water. It is recently suggested that drinking of defluoridated water from the ″calcium amended-hydroxyapatite″ defluoridation method may help in the fluorosis reversal.

21. Calcium is the strongest antagonist of fluoride toxicity . Adequate intakes of calcium to maintain the positive calcium balance to counteract the toxic effects of fluoride is therefore essential for the population residing in endemic fluorosis villages. Avoiding intake of fluoridated water, seafood, pickles, high salt diet, preserved juices. Cautious use of dental products like toothpaste and mouth rinse.

22. Supplements – Vit C Vit D Calcium

23. Surgical In few cases with deformities, especially children, corrective plasters and orthotics can be used. In cases with pathological fractures, severe spinal deformity, cervical myelopathy surgical intervention maybe required.

24. The appearance of teeth affected by moderate-to-severe fluorosis can be significantly improved by a variety of techniques. Most of them are aimed at masking the stains. Such techniques may include: Tooth whitening and other procedures to remove surface stains Bonding which coats the tooth with a hard resin that bonds to the enamel Crowns Veeners (which are custom-made shells)