Systemic fluoride

fluoride

1. SYSTEMIC FLUORIDE
By Dr. Lilavanti Vaghela
MDS in Pediatric and Preventive Dentistry

2. Content
•Introduction
•History
Types of systemic fluoride
Fluoride compounds and their concentration.
Water fluoridation
•Advantages and disadvantages.
•Feasibility in India (water fluoridation)
School water fluoridation. (Advantages and disadvantages).
Salt fluoridation
• Introduction
• Production and preparation
• Advantages and disadvantages
• Feasibility in India
• Limitations

3. Milkfluoridation
•Introduction
•Rationaleofmilkfluoridation.
•Planningamilkfluoridationprogramme.
Fluoridesupplementsandtablets
Antifluoridelobby
•Is fluoridation important?
•Reason to oppose fluoridation
•Fluoridation and law
•Controversy of fluoride
•Fluoride toxicity
•Conclusion
•References

4. Introduction
•Systemicfluoridesprovidesalowconcentrationoffluoridetotheteethoveralong
periodoftime.
•Itcirculatesthroughthebloodstreamandisincorporatedintodevelopingteeth.
•Afterteetherupt,fluoridecontactsteethdirectlythroughsalivarysecretions.
•Mostsystemicfluorideshaveatopicaleffectbuttheirprimaryeffectissystemic.
Essentials of public health dentistry, sobenpeter 5
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5. History of systemic fluoride
1800’s Fluoride
•Occurrence of fluoride in calcified tissues was already known
at the beginning of the 19
th
century.
•Magitotdemonstrated the earliest reference relating fluoride
to dental caries in 1878.
5
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

6. •1900’s Fluoride alerted researchers
•A series of events focused attention on the possible toxic effects
of fluoride on the dentition.
•The occurrence of disfigured teeth was reported in Naples, Italy
and this was believed to be due to a substance in water that
altered the calcification process.
•In the United Stated, it was also common to see the same in the
residents living in Colorado, Arizona, New Mexico and Texas.
6
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

7. •1930’s Fluoride, something weird in water;
•Churchill, 1931 developed a method for determining the
concentration of fluoride in drinking water. He showed that
below 0.9 ppmfluoride in water no toxicity and no mottled
enamel is seen.
•Dean and McKay 1939 clearly illustrated that the epidemiology
of dental fluorosis, but clearly documented the reduction in
dental caries.
7
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

8. •1939; to confirm the above hypothesis, epidemiological studies
were carries out in 4 Illinois cities. The cities were Galesberg
and Monmonthand nearby cities of Macomb and Quincy.
City F ppm in
water
No. of
children
% with no
dental caries
experience
DMF
permanent
teeth per
100 children
Galesburg 1.8 243 36.2 194
Monmouth 1.7 99 36.4 208
Macomb 0.2 63 14.3 368
Quincy 0.1 291 4.1 628
8
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

9. 1940’s beginning of water fluoridation
•US Public Health Service teams conducted studies involving 21
cities selected on the basis of varying concentrations of fluoride
in the public water supplies.
No. cities
studied
No. of children
examined
Permanent
DMF teeth per
100 children
Fluoride
concentration
of public water
supply in ppm
11 3867 > 7 < 0.5
3 1140 4 0.5 to 0.9
4 1403 3 1.0 to 1.4
3 847 2.5 > 1.4
9
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

10. Grands Rapid-Muskegon
25
th
Jan 1945
•After 6 ½ years in July,1951 the caries experience of 6 and 15 years
old children residents of Grands Rapids was half that of Muskegon
Arnold et al, 1953
•Result after 15 years of fluoridation showed a dramatic caries
reduction of 50% i.e. in 15 years old children of Grands Rapids the
DMFT of 12.48 decreased to 6.22 in 1959
Arnold et al, 1962
10
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11. Newburgh-Kingston study [1945-1955]
•Newburgh[NaF2]—river Hudson –Kingston
•David B Ast—chief of dental bureau-directed.
•Newburgh children –caries decline from 23.5 to 13.9 % after Fl.
•Confirmed the caries inhibitory property of Fluorides.
11
Essentials of public health dentistry, sobenpeter 5
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12. Age City Ppmof F
added
DMF teeth per 100
children with
permanent teeth
% reduction
6-9 yearsNewbrugh
Kingston
1 to 1.2
0
98.4
233.7
57.9
-
10-12
years
Newbrugh
Kingston
1 to 1.2
0
328.1
698.6
53
-
12Essentials of public health dentistry, sobenpeter 5
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13. 1950’s
Aneraofartificialwaterfluoridationstartedtheworldoverandmany
countriescommittedthemselvestothisprogrammeinorderto
reducetheincreasingtrendsofdentalcariesintheircommunities.
14
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

14. Evanston –Oak park study [1946-1960]
•Drs. Blayney JR, Hill IN, Zimmerman –university of Chicago memorial dental clinic.
•Evanston children —43% reduction
[5.95 to 1.66 DMF]
•Oak park children —no change observed
15

15. Dutch study [Tiel-Culemborg]
1953-1969
•Backers Dirks 1961—11-15 yrs old children.
•Tiel –Fluoridated—1.1 ppm
•Culemborg---0.10ppm control
•Fluoridation revealed not only a decrease in caries prevalence but also a 90% reduction
in mean number of extractions per child after a period of 16 years
16
Essentials of public health dentistry, sobenpeter 5
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16. New Zealand study
1954-1965
•Ludwig–Hastings conducted a retrospective study
•DMF of 10yr old
Reduction of 55%
1954 1964
5.48 2.46
17
Essentials of public health dentistry, sobenpeter 5
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17. 1960’s WHO endorses the practice of water fluoridation
The WHO and the Pan American Health Organization endorsed the practice of
water fluoridation in 1964
18
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

18. 1970’s
In the UK only about 3 million drink fluoridated water (6% of the population),
but over 100 million people (60% of the population) in the USA.
19
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

19. 1980’s Around the world
•During the 80’s Germany, Spain, Yugoslavia, USSR, China and
Japan were far away from water fluoridation.
1990’s
•Water fluoridation was accepted in U.S, Australia, Brazil,
Canada, Hong Kong, Malaysia, UK, Singapore, Chile, New
Zealand, Israel, Columbia, Costa Rica, South Africa and Ireland in
the 1990’s.
20
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

20. 2000’s
•The benefits from water fluoridation are considerably less today
than when the method was introduced, mainly because of the
increased exposure of fluoride from other sources.
•The differences in caries prevalence between fluoridated and non-
fluoridated areas have decreased.
•It should be concluded that water fluoridation needs be targeted
on high caries areas, which are normally also areas of social and
material deprivation.
21
BetulKargul. History of water fluoridation. JCPD Vol 27, Number 3/ 2003.

21. 1.WaterFluoridation
•CommunityWaterFluoridation
•SchoolWaterFluoridation
2.SaltFluoridation
3.MilkFluoridation
4.FluoridesTablets
Fluorides in Caries Prevention:Murray,
RuggGunn
TYPES OF SYSTEMIC FLUORIDE

22. FLUORIDES COMPOUNDS AND CONCENTRATIONS THAT ARE USUALLY
USED IN DIFFERENT SYSTEMIC FLUORIDES METHODS
FLUORIDES
METHODS
FLUORIDES
COMPOUNDS
CONCENTRATIONS
Water Fluoridation hydro fluorosilicate (FSA),
sodium
fluorosilicate, sodium
fluoride
0.7 -1.2 mg/L
Salt Fluoridation potassium fluoride , sodium
fluoride
250-300 mg/kg
Milk Fluoridation Sodium fluoride or
disodium
monofluorophosphate
5 mg/L
DietryFluorides
Supplementation
sodium fluoride, acidulated
phosphate fluoride,
potassium
fluoride, calcium fluoride
0.25 –1.0 mg/day
Fluorides in Caries Prevention:Murray,
RuggGunn

23. CARIOSTATIC MECHANISM OF SYSTEMIC FLUORIDES
1.Rendering enamel more resistant to acid dissolution
2.Inhibition of bacterial enzyme systems
3.By reducing tendency of the enamel surface to absorb proteins
4.Modification in the size and shape of the tooth
Understanding dental caries by Gordon nikiforuk

24. Reducing enamel solubility
•Stabilization of the apatite lattice
•Fluoride fills inherent voids due to missing hydroxyl groups
Understanding dental caries by Gordon nikiforuk

25. Enzymatic Action
Fluoride ion has the ability to inhibit enzyme action
exerts a direct effect in plaque bacteria
•Higher levels of ionic fluoride (>32 ppm) are required to reduce acid production by plaque
(Jenkins, 1959)
•Revived by the important finding that fluoride is concentrated within plaque (Dawes et al, 1965)
which originates from the oral fluids rather than enamel.
Understanding dental caries by Gordon nikiforuk

26. ➢The concentration of fluoride above 2 ppm in solution progressively decreases transport or
uptake of glucose into cells of oral streptococci
(Weiss et al., 1965, Schachtelaet al., 1973)
➢Plaque has been depleted of its exogenous sugar supply, fluoride inhibits metabolism of
polysaccharides present in plaque thus indirectly interfering with acid production (Weiss et al.,
1965)
Understanding dental caries by Gordon nikiforuk

27. Surface Adsorption
•Fluoride incorporated in enamel substitution of hydroxyl ions altered the surface charge or free
energy and thus indirectly alters the deposition of pellicle and subsequent plaque formation.
(Erricssonet al, 1967)
Understanding dental caries by Gordon nikiforuk

28. Tooth Morphology
•Fluoride is believed to alter the tooth morphology i.e. reduction in the cusp height, fissure depth
and increase in the fissure width thus making teeth less susceptible to caries.
(Leviuset al, 1969 and Assendenet al, 1974)
Understanding dental caries by Gordon nikiforuk

29. Systemic acquisition of fluoride
•Fluoride are incorporated pre-eruptively into enamel from tissue fluid during process of
mineralization

30. (weatherellet al,1977)
•The level of fluoride acquired is determined by concentration of fluoride in the plasma which, in
turn, is a function of the fluoride ingested in water, food or supplements.
•During the early stage of enamel formation, the f-concentration is relatively high but, surprisingly
the concentration falls as the tooth matures and acquires more mineral.
•Most of the fluoride is incorporated into the sound surface of enamel during the pre-eruptive
maturation stage when enamel undergoes rapid and more complete mineralization.
Understanding dental caries by Gordon nikiforuk

31. •Primary teeth have a shorter period of enamel maturation and therefor acquire less f-than
permanent teeth.
•The small difference in the concentration of f-between permanent teeth have also been
explained by the difference in maturation time between teeth.
•A gradient concentration, with decreasing concentration towards the DEJ, exists in unerupted as
well as erupted teeth in fluoridated and non fluoridated area.
Understanding dental caries by Gordon nikiforuk

32. Acquisition of f-in enamel
Understanding dental caries by Gordon nikiforuk

33. (Sakae and hirai,1982 )
•While most f-is aquiredduring the pre-eruptive development of teeth it is important to recognize
that a significant amount of the mineral component of enamel is acquired as a result of post
eruptive maturation.
Understanding dental caries by Gordon nikiforuk

34. Fluoride and hidden caries (occult caries)
•A popular belief has been that occult caries have resulted from the widespread
use of fluoride.
•“fluoride bombs” or “fluoride syndrome.
•This theory hypothesizes that fluoride helps in remineralization and decreases
the progress of the caries in the pit and fissure areas of enamel, but the
cavitation continues in the dentin part with the intact enamel surface at the top
of the carious lesion
Management of occult caries induced large periapical lesion N. B. Nagaveni, Shruti Virupaxi, P. Poornima, V. V. SubbaReddy 2015

35. •One study stated that occult caries is found to be with very low caries scores
because of increased fluoride exposure.
•However, there is a contradictory statement about fluoride and occult caries in a
study done in Nederland, which compared the prevalence of occult caries.
•The study observed 31% decreases in the prevalence of occult caries in the
fluoridated city. This was found in contrast to the hypothesis of “fluoride bomb,”
suggesting that fluoride has a minimal role in the pathogenesis of occult caries.
Management of occult caries induced large periapical lesion N. B. Nagaveni, Shruti Virupaxi, P. Poornima, V. V. SubbaReddy 2015

36. Water fluoridation
•Water fluoridation remains the cornerstone of any sound caries prevention program.
•It does not only the most effective means of reducing caries, but remains the most cost effective,
cost saving, convenient, and reliable method of providing the benefits of fluoride to the general
population because it does not depend on individual compliance.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

37. definition
•Controlledadjustmentoftheconcentrationoffluorideina
communalwatersupplysoastoachievemaximumcaries
reduction&aclinicallyinsignificantleveloffluorosis.
•Upwardadjustmentoftheconcentrationoffluorideionina
publicwatersupplyinsuchawaythattheconcentrationof
fluorideioninthewatercanbeconstantlymaintainedat1
ppmbyweighttopreventdentalcarieswithminpossibilityof
causingdentalfluorosis.
Fluorides in Caries Prevention:Murray,
RuggGunn

38. Water Fluoridation
•Epidemiological surveys of 1930s conducted by T.H. Dean studied the
dental caries experience of children, residents of 21 cities of USA ; fluoride
in their drinking water ranging from 0.6 to 6ppm
•Results reaffirmed the hypothesis of McKay
There was an inverse relationship between incidence of very mild mottling
and dental caries.
•Continued systematic endeavours of Dean finally established the optimal
threshold of fluoride-1ppm in drinking water, the level at which it led to
maximum reduction in caries with only sporadic instances of mild fluorosis
of no aesthetic significance
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

39. Relative safety of water fluoridation
•Leone et al ,1954 conducted a comprehensive medical examination of the
residents of BartletTexas, who for 15 years drank water with 8 ppmof
fluoride and compared the results with residents of Cameron, Texas, who
drank water having 0.4 ppmrevealing no unusual cases of arthritis, bone
fracture, exostosis, or hypertropicbone changes.
•Weidman et al 1963 reported no radiographic evidence of skeletal
abnormality in persons consuming water supply containing upto4 ppmof F
throughout their lives.
40
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

40. •In 1978 WHO reaffirmed its support for fluoridation.
•Thus it is evident that optimal levels of fluoride-1 ppm in drinking water is
physiologically and medically absolutely safe in addition to being useful for dental
caries prevention.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

41. OPTIMUM LEVELS OF FLUORIDE
PpmF = 0.34/ E
E= -0.038+0.0062×t in F
E= estimated daily water intake in
children in oz/lb body weight
t= mean maximum daily air
Temperature in
Degree Fahrenheit.
Annual average
max daily air temp
(F)
Optimal
fluoride
40.0-53.7
53.8-58.3
58.4-63.8
63.9-70.6
70.7-79.2
79.3-90.5
1.2
1.1
1.0
0.9
0.8
0.7
•Optimum recommended fluoride
levels varies with climate because
water consumption increases in
warmer climates.
•Cold climate-1.2ppm
•Hot climate –0.7ppm
•Moderate climate –1ppm
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

42. •The first community fluoridation program in the U.S. beganin 1945 in
Grand Rapids, Michigan, and resulted in 50-60% lower tooth decay rates
in children consuming optimally adjusted fluoridated water compared to
children consuming fluoride-deficientwater.
•Sincethattime,manystudiesonsafetyandefficacyhavebeenpublished,
makingfluoridationofpublicdrinkingwateroneofthemostwidely
studiedpublichealthmeasuresinhistory.
Fluorides in Caries Prevention:Murray,
RuggGunn

43. MATERIALS USED IN WATER FLUORIDATION
•Three types of fluoride equipments
1.Dry feeder
2.Solution feeder
3.Saturation methods
Constant monitoring is required once the water is fluoridated to maintain the constant
level of fluoride i.e., 0.8 to 1.2 ppm.

44. Compounds used in water fluoridation
Fluorospar
-CaF2is the main ingredient, 85-98%
-normal consumption >500,000 tons/year
Sodium fluoride
-White, odorless, free flowing-powder or mixture of various sized particles.
-Manufactured from HF, a byproduct of fluorospar
-Expensive
Silicofluorides
-Byproduct of purification of phosphate rocks.
Fluorides in Caries Prevention:Murray,
RuggGunn

45. -Sodium silicofluoride
-Hydrofluosilicicacid is the raw material.
-Solutions are corrosive.
Hydrofluosilicicacid
-More expensive than silicofluorideson account of transportation.
Ammonium silicofluoride
-Neutralizing fluosilicicacid with aqueous ammonia or ammonia in gaseous form.
-Desirable where ammonia is used to form chloramines with chloride.

46. Dry feeder
•Principle : NaFor silicofluoridein form of powder is introduced with aid of automatic mechanism
Factors limiting utilization:
•Need for care in handling F.
•Obstruction of pipes.
•Compaction of F while stocked at humid temp.
Recommodation:
•Medium sized town
•3.8million l/day
Essentials of public health dentistry, sobenpeter 5
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47. •Solution feeder
Principle: Volumetric pump permitting addition of hydrofluosilicicacid in proportion with water
treated.
Factors limiting utilization
•Resistant to attack by hydrofluosilicicacid.
•Necessitates construction in polyvinyl chloride.
•Imprecision in determining volume for small quantities.
•Recommendation:
•Medium sized & large sized >7.6million l/day
Essentials of public health dentistry, sobenpeter 5
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48. Saturator system
•Principle: 4% saturated sol of NaFis produced and injected at the desired concentration at the
water distribution source with the aid of pump.
Factors limiting utilization
•High hard water level
•Need to clean gravel bed
Recommendations
•Suitable for Small towns
•<3.8million l/day
Essentials of public health dentistry, sobenpeter 5
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49. Venturi flouridatorsystem
•It is non electrical system which was developed by J.N. Leo
•It is activated by the flow of water in the main water line.
•The tank containing the f-is made of a clear acrylic thermoplastic and this enables the operator to
make a visual inspection of the level of chemical, in order to replenish it.
•Adavantage
•Simple to install
•Cost effectiveness
•No possibility of accidental overdose
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50. Saturation suspension cone
•Developed in Brazil by Water & Sewage Authorities of state of Rio Grande do Sul.
•Consists of an upside down cone charged with a bag of sodium silicofluoride
through which a constant flow of water percolates.
Essentials of public health dentistry, sobenpeter 5
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51. Types of equipment for water fluoridation
Saturator
system
Dry feeder Solution feeder
Principle
4% saturated sol
of NaFis
produced and
injected
NaFor
silicofluoridein
form of powder is
introduced with aid
of automatic
mechanism
Volumetric pump
permitting addition of
hydrofluosilicicacid in
proportion with water
treated.
Factors
limiting
utilization
High hard water
level
Need to clean
gravel bed
Need for care in
handling F.
Obstruction of
pipes.
Compaction of F
while stocked at
humid temp.
Resistant to attack by
hydrofluosilicicacid.
Necessitates
construction in polyvinyl
chloride.
Imprecision in
determining volume for
small quantities.
Recommendations
Small towns
<3.8million l/day
Medium sized town
3.8million l/day
Medium sized & large
sized >7.6million l/day

52. Feasibility in india
•Increasing prevalence of dental caries and dentist population ratio is only
1:80,000 and lack of preventive awareness of oral disease, community water
fluoridation appears to be most effective.
•But the only short coming in that it can be implemented only in areas which
have central pipeline supply which constitutes only 30% of population.
Fluorides And Dental caries –A Compendium. By Dr. AmritTewari.

53. India does not need water fluoridation; An Illusion
•Indiaalreadyhasahighconcentrationoffluorideindrinkingwaterandassuchdoesnot
needanycommunalwaterfluoridation.
•RamaSubramanianetal1979;revealedthatonlyabout5%ofthepopulationliveinhigh
fluorideareasorknownendemicfluoridebeltseg.BhatindabeltinPunjab,Etawaharea
inUP,AnantpurandGuntakalareasinAndraPradesh,etc.
•Onlyabout3%ofthepopulationlivesinoptimalfluorideareasandtherestabout90%
ofthepopulationconsumeswater,deficientoffluoride.
•About66%areusingwaterwithfluoridecontentslessthan0.5ppmwhicharewell
belowtheoptimumfluoridelevelsrequiredforprotectionagainstdentalcaries.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

54. Fluoride status -India
•15 out of 29 states and 7 union territories are endemic.
•Andhra Pradesh, Gujarat, Rajasthan -70-100% districts affected
•Bihar, Punjab, Haryana, Karnataka, Maharashtra, Madhya Pradesh, Tamil Nadu, Uttar
Pradesh, some parts of Delhi -40-70% districts affected
•Uttaranchal, Jharkhand, Chhattisgarh, Assam, Kerala, Orissa, West Bengal, Jammu &
Kashmir -10-40% districts affected.
Place State Fluoride level
Rajauli Bihar 8 ppm
Nalgonda Andhra Pradesh 10-12 ppm
Kolar Karnataka 2.8-4.3
Unnao Uttar Pradesh 2.9 to 7.0

55. Fluoride status -India
Fluoride level States
>4.0 ppm Punjab, Haryana, Rajasthan, Gujarat,
Madhya Pradesh, Andhra Pradesh,
Tamil Nadu
4-8 ppm Gujarat (Kutch, West Jamnagar)
Madhya Pradesh (Chandi, Betul)
>5.0 ppm Andhra Pradesh (Ananthpur,
Karimnagar, Krishna districts)

56. INDIA
•Economic aspect of water fluoridation is quite obvious and the per capita cost shall be about
Rs0.25 per individual per year & the caries reduction of 50%.
•Cost to benefit ratio works out to be 1:160 i.e., for every Rs0.25 spent on water fluoridation , each
person shall save Rs40.
Fluorides And Dental caries –A Compendium. By Dr. AmritTewari.

57. ADVANTAGES OF WATER FLUORIDATION
•Largenumberofpeoplearebenefited.
•Consumptionisregular
•Fluoridateddrinkingwaternotonlyactssystemically
•Duringtoothformationtomakedentalenamelmore
resistanttodentaldecay,butalsohastopicaleffect
throughthereleaseinsalivaafteringestion.
•Fluoridationofcommunitywateristheleastexpensivewaytoprovide
fluoridetoalargegroupofpeople.
Fluorides And Dental caries –A Compendium. By Dr. AmritTewari.

58. DISADVANTAGESOFWATERFLUORIDATION
•Interfere with human rights
•Other modes are not considered
•Common source of water supply may not be present.
Fluorides And Dental caries –A Compendium. By Dr. AmritTewari.

59. Water fluoridation and child dental health
•In deciduous dentition
•Tank and storvickin 1964, USA examined 134 children aged 1-6yr, born and brought up in
corvallis(1 ppm F-in drinking water) and 114 children of similar age from Albany (f-free).
•Resultshowed that , for each age group, caries experience was lower in Corvallis than in Albany
•The mean caries rate was 56% lower in the f-area than in non f-area
Understanding dental caries by Gordon nikiforuk

60. •The effect of water fluoridation in reducing dental caries in the deciduous dentition should not be
underestimated.
•A reduction in the caries experience of the deciduous teeth is most important factor when the
need for dental treatment in a community is considered.
•In addition, it has important psychological and social benefits in that far fewer children in a
fluoride area are exposed to the unfortunate sequelae of untreated dental caries –pain, sepsis,
extraction of teeth etc.
Understanding dental caries by Gordon nikiforuk

61. Indian J Dent Res.1993 RELATIONSHIP BETWEEN CARIES, WATER FLUORIDE LEVEL
AND SOCIOECONOMIC CLASSIN 15-YEAR-OLD INDIAN SCHOOLCHILDREN.
Rahmatulla M
1
, WyneAH.
Thepurposeofthisstudywastodeterminetherelationbetweencaries experience,
water fluoride level and socioeconomic class amongthe
15-year-old school children of Tamilnadu. The study children were stratified on the basis of
water fluoridelevel and socioeconomic (SE) class.
There was a highly significant difference in the carious experienceof
15-year-old children from low fluoride (LF) areas in relation tothe SEclass, the low SE class
having the highest caries experience. The difference between caries experience of 15-year-
old children from LF and HF areas was not statistically significant. The present study has
indicated towards theneedofprovisionofmorevigorouspreventiveeffortsinlowerSEc la
sschildreninboththeurbanandruralpopulation.

62. Harding MA,O'Mullane
DM,2003
Cho HJ
et
al,2014
Water fluoridation is an effective safe means of
preventing dental caries, reaching all populations,
irrespective of the presence of other dentalservices
Thesystemiceffectoffluorideintakethroughwater
fluoridationcouldbeimportantforthepreventionof
dentalcaries.

63. Acta Med Acad.2013Nov;42(2):131-9.
WATERFLUORIDATIONAND ORALHEALTH.
Harding MA, O'MullaneDM.
Water fluoridation is an effective safe means of preventing dental caries,
reaching all populations, irrespective of the presence of other dental
services. Regular monitoring of dental caries and fluorosis is essential
particularly with the lifelongchallenge which dental cariespresents.

64. Community Dent Oral Epidemiol.2014 SYSTEMICEFFECTOFWATER
FLUORIDATION ON DENTAL CARIES PREVALENCE.
Cho HJ
1
, Jin BH, Park DY, Jung SH, Lee HS, Paik DI, Bae KH.
The aim of this study was to evaluate the systemic effect of water fluoridation
on dental caries prevalence and experience inCheongju, South Korea, where
water fluoridation ceased 7 yearspreviously.
CONCLUSIONS:
While 6-year-old children who had notingestedfluoridatedwatershowedhigher
dftintheWF-ceasedarea thaninthe non-WF area, 11-year-old children in the WF-
ceased area who had ingested fluoridated water for approximately 4 years after
birth showed significantly lower DMFT than those in the non-WF area. This suggests
thatthesystemiceffectoffluorideintakethroughwaterfluoridationcouldbe
importantforthepreventionofdentalcaries.

65. SCHOOL WATER FLUORIDATION
•Schoolwaterfluoridationisoneofthepossibleareastobeexplored.Thisprogrammehelpsin
limitingcariesinschoolchildrenwhoaretheprimeconcern.
•Itisthesuitablealternativewherewaterfluoridationisnotfeasible.
•TheamountoffluorideaddedInschooldrinkingwatershouldbegreaterthannormalbecause
childrenhavetostayintheschoolforashortperiodoftimeandtocompensateforholidaysand
vacations.
HISTORY
•Thisprocedurewasfirststartedin1954inSt.ThomasV.SVirginislandsbyUSpublichealth
servicedivision.
Fluorides in Caries Prevention:Murray,
RuggGunn

66. •Thecurrentrecommendedregimenforschoolwaterfluoridationisadding4.5times
morefluoride.
•Therehasbeenaround25to40%decreaseindentalcarieswiththisprogram.
•Simplefluoridatorsparticularlythatemploytheventurisystemaremostsuitable
,becausetheyrequirealmostnomaintenanceandcanbeutilizedeffectivelyinsmall
instalmentsofsmallormediumsizedschools.
ADVANTAGES
•goodresultsinreducingcaries.
•Minimalequipment.
•Notexpensive.

67. DISADVANTAGES
•Childrendonotreceivethebenefituntiltheygotoschool.
•Notallchildrengototheschoolinpoorcountriesandtownsandvillages.
•Amountofamountwaterdrunkcan’tberegulated.
Fluorides And Dental caries –A Compendium. By Dr. AmritTewari.

69. •Young and Elliot, 1966
➢Apatite is a hexagonal crystal with two equal axis,
120°apart and a third axis perpendicular to these
two.
➢In order to maintain symmetry, hydroxyl ions must
be located on side of the calcium plane as often as
on the other.
➢To avoid this steric interference one of the
hydroxyl ions gets exterminated creating a void or
reversal points.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

70. •This isomorphic replacement possible due to similarity of ions.
•The number of reversal points cannot be large or there would be no tendency of
hydroxyapatite to be stable.
•If all the hydroxyapatite were to get converted to fluorapatite the amount of
fluoride present in the enamel would have been 38000 ppm in comparison 1000
to 2000 ppm in its outermost surface.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

71. •According to Jain Min Sim at al in 2011
•He did feasibility study on f-in drinking water in mehsana,Gujarat
•Average concentration of f-is >1.5ppm

72. •According to R.K.Verma,2014
•He publishes one report for ground water in Gandhinagar district, Gujarat
•He mentioned minimum f-conc in water 1.25ppm
maximum f-conc in water 2.65ppm
GROUND WATER BROCHURE GANDHINAGAR DISTRICT GUJARAT ,2014

73. •According to Fawaz at al in 2015
•Title –status of water fluoride-An update from the Asian contries
•He stated that in indiaOut of a total of 609 districts, 220 districts are known to
have high fluoride levels in ground water.
•It is also argued that India already has a high concentration of fluoride in drinking
water and does not need any community water fluoridation.
Dr. Fawaz Pullishery, et al. STATUS OF WATER FLUORIDATION STATUS OF WATER FLUORIDATION STATUS OF WATER
FLUORIDATION STATUS OF WATER FLUORIDATION--AN UPDATE FROM AN UPDATE FROM AN UPDATE FROM AN UPDATE
FROM THE ASIAN COUNTRIES ,2015

74. •However, only 6% of the population lives in high fluoride areas or known endemic
fluoride belts. About 3% of the population lives in optimal fluoride areas and rest
about 90% of population consumes water deficient in fluoride.
Dr. Fawaz Pullishery, et al. STATUS OF WATER FLUORIDATION STATUS OF WATER FLUORIDATION STATUS OF
WATER FLUORIDATION STATUS OF WATER FLUORIDATION--AN UPDATE FROM AN UPDATE FROM AN UPDATE
FROM AN UPDATE FROM THE ASIAN COUNTRIES ,2015

75. •Accoto MeththikaVithanage ,2015
•Of the 85 million tons of fluoride deposits on the earth’s crust, 12 million tons are found
in India.
•About 50 % of the ground-water in Delhi exceeds the maximum permissible limit for
fluoride in drinking water
•Fluoride content was higher in deeper aquifers of Maharashtra (Madhnureet al.
2007)which was due to long residence time than shallow groundwater.
Fluoride in the environment: sources, distribution and defluoridation,MeththikaVithanage,2015

77. •According to shakirAli Khan,
May 2019
S. Ali, et al. Groundwater for Sustainable Development 9 (2019) 100224

78. •According to one
project –Shodhganga
OCCURRENCE OF FLUORIDE IN GUJARAT,shodhganga,2014
Chapter-8

79. OCCURRENCE OF FLUORIDE IN GUJARAT,shodhganga,2014
Chapter-8

80. SALT FLUORIDATION
•Saltfluoridationisacontrolledadditionoffluoride,usuallysodiumor
potassiumfluoride,duringthemanufactureofsaltforhumanconsumption.
HISTORY
•FirstfluoridatedsaltwasintroducedbyWESPIinSwitzerland1948.ithas
beenonsaleinSwitzerlandsince1955.
•Experimentshavebeenconductedwithconcentrationoffluorideinsalt
rangingfrom90mgoffluorideperkg.saltto200-350mg/kg.

81. •Initial clinical trial of 90 mg/kg fluoride salt showed 20-25 % of reduction of
dental caries.
•In 1967 Muhlemanshowed the safe dose of fluoridated salt, that 300 mg/kg
yields 1.5 mg fluoride/5 gm of salt.
•Tooth from Hungary, after 8 years of salt fluoridates at the level of 250 mg
fluoride /kg reported 35-58% of caries reduction
Fluorides in Caries Prevention:Murray,
RuggGunn

82. PRODUCTION AND PREPARATION OF FLUORIDATED SALT
•For effective caries prevention, fluoride must be present in ionic form when salt
(sodium chloride) is dissolved in water .
•Fluoride is added to salt by spraying concentrated solutions of sodium fluoride or
potassium fluoride.
•Premixed granules of NaF and CaF2 with PO4 are added to common salt.
Fluorides in Caries Prevention:Murray,
RuggGunn

83. ADVANTAGES
•Fluoridated salt is safe.
•Theoretically fluoridated salt prevents dental caries by both systemic as well topical
action.
•It does not require community water supply as in case of water fluoridation.
•It permits individual to accept it or reject it.
•Low cost
•Fluoridated salt and iodized salt can be made available to the population.

84. DISADVANTAGES
•No precise control over indicated consumption, since salt
intake varies greatly among people.
•Less sodium (Na) intake to help control hypertension.
Fluorides in Caries Prevention:Murray,
RuggGunn

85. FEASIBILITY IN INDIA
•Saltfluoridationappearstobeaviableandfeasiblemethodof
fluorideingestionsystemicallybecauseitsdistributioncanbe
easilymonitoredasthesupplycanbeeffectivelycontrolled
especiallyforthoseareaswhichdonotneedsupplemental
fluorides.
•Moreover,individualmonitoringisnotrequiredasthelevels
aresoadjustedsoastoprovideoptimumlevelsoffluoride
keepinginviewthefactthatonanaverageanindividual
consumes5-8gmsofsaltperday.
Fluorides in Caries Prevention:Murray,
RuggGunn

86. •Alsosaltisfreelyavailableandisusedonalargescalealloverthe
countrybymajorityofthepopulationofvariousethnicandregional
groups.
•Regardingtheacceptabilityofthepopulationitshallbereadily
acceptedastheadditionoffluoridetosaltdoesnotalteritscolour
asincaseofsaltiodization.
Fluorides in Caries Prevention:Murray,
RuggGunn

87. LIMITATIONS
1.Largevariationsinsaltintakeindifferentgroupsofpeople.fluoridatedsalt
consumptionislowestwhentheneedforfluoridesisgreatest–inearlyyears
oflife.
2.Theamountoffluoridatedsaltingestedmaydecreasewithincreasing
consumptionofprocessedfoods.
3.Difficultiesarisewhentherearemultipledrinkingwatersourceswhichhavea
naturallyoptimalorexcessivefluorideconcentration.
4.Itrequiresrefinedsaltproducedwithmoderntechnologyandahighlevelof
technicalexpertise.
5.Thecurrentviewdatahighsaltintakemaycontributetohypertension.
Fluorides in Caries Prevention:Murray,
RuggGunn

88. •Milkfluoridationistheadditionofameasuredquantityoffluoridetobottledor
packagedmilktobedrunkbychildren.
HISTORY
•ItwasintroducedbyZeigler,apaediatrician,whostartedthefirstprojectwith
fluoridatedmilkinSwisscityofWinterthurin1953.
•In1971,Dr.EdgarborrowestablishedtheBorrowfoundation(formallythe
Borrowdentalmilkfoundation)inEngland,withtheaimofpromotingtheuse
ofmilkasavehicleforfluorideforthebenefitofchildren’soralhealth.
•Thefirstcommunitybasedmilkfluoridationschemewasintroducedin1988,in
Bulgaria,undertheinternationalmilkfluoridationprogram.
MILK FLUORIDATION

89. RATIONALE OF MILK FLUORIDATION
•The nutritional value of milk has been well documented .
•Milk is often available to children through school and nutritional programs and
the use of such distribution systems can provide a convenient and cost efficient
vehicle.
•Virtually all forms of milk products are suitable for fluoridation and the process is
relatively simple.
•Milk fluoridation can be targeted at those communities in greatest need.
Fluorides in Caries Prevention:Murray,
RuggGunn

90. •Researchhasbeendemonstratedtheeffectivenessoffluoridatedmilkin
preventingdentaldisease.
•Thebioavailabilityoffluorideisnotreducedbymilk.
•Fluoridatedmilkkeepsapermanentlylowlevelofionizedfluoridewithin
theoralcavity,promotingremineralisation.Thistopicalmechanism
contributestothecariespreventiveeffectoffluoridatedmilk.
Fluorides in Caries Prevention:Murray,
RuggGunn

91. COMPOUNDS USED FOR MILK FLUORIDATION
•Calcium fluoride
•Sodium fluoride
•Disodium monofluorophosphate
•Disodium silicofluoride
Fluorides in Caries Prevention:Murray,
RuggGunn

92. FEASIBILITY IN INDIA
➢Thoughtheoreticallymilkfluoridationisadvantageous,inaddition
beingthestaplefoodforchildrenanditsconsumptioncanbe
confinedtogroupswhoneeditmost,thatpracticallyspeakingthat
thisscheme/methoddoesnotseemtobeviableandfeasible
becauseof:
Fluorides in Caries Prevention:Murray,
RuggGunn

93. •InINDIA,majorityofchildrenpopulationlivinginruralandurbanareascannot
affordmilkdaily.
•CentralmilksupplysystemdoesnotexistinIndia.
•Variationofintakeandquantityofmilkisanotherwhichcannotbecontrolled
sinceitdependsuponthesocio-economicreligiousandethnicfactors.
Fluorides in Caries Prevention:Murray,
RuggGunn

94. DENTAL CARIES AND FLUORIDE LEVELS IN WATER AND MILK IN 13-15YEAR OLD
ADOLESCENT POPULATION IN DAKSHINA KANNADA DISTRICT, INDIA
Mithra N. Hegde,2013
•The range of fluoride levels in waters samples was 0.01 to 0.17 ppm and that of
milk samples was 0.176 to 1.38 ppm.
•There was no much difference in fluoride levels of different milk sources.
•Hence association between DMFT and milk fluoride levels was not statistically
significant

95. FLUORIDE SUPPLEMENTS
•Fluoride supplements are available in different forms such as fluoride tablets
,drops , lozenges.
•Fluoride tablets, drops and lozenges are not available over the counter but
prescribed by the dentist or paediatrician to individual patients or as a part of
school or home based preventive dentistry program.
Fluorides in Caries Prevention:Murray,
RuggGunn

96. Fluoride tablets-a dual approach in prevention of dental caries
•Drinking water fluoridation is the most effective mass preventive method against dental
caries.
•However, large population groups are unable to benefit from this measures.
•In some countries there are lack of financial and technical resources for water
fluoridation.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

97. •Fluoridated salt, milk and f-tablets have long attracted interest as potential vehicle for
fluoride which might serve for systemic and topical use as an alternative to f-drinking
water.
•F-tablets provide systemic effect before mineralization of primary and permanent
dentition is completed and topical effect thereafter.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

99. Effect of f-tablets in deciduous teeth
•Majority of the studies investigating the cariostaticeffectiveness of f-in deciduous teeth
and reduction ranging from 50-80% when f-administration in the form of tablets was
started before 2 yrsof age and continued for a minimum 3-4 yrs.
•Hoskova( 1968) found deft reduction of 93% when f-tablets were started prenatally and
54% reduction when tablets were given since birth.
•Hennon(1971) reported 78% defsreduction, 3 yrsafter ingestion of f-tablets since birth.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

100. •The American Center for Disease Control (CDC) also has published in 2001
recommendations for using fluoride to prevent and control dental caries. They concluded
that the quality of evidence to support use of fluoride supplements by children aged less
than 6 years was low.
•Hasson et al., in 2008, examined evidence regarding the effectiveness of fluoride
supplements in preventing caries and their association with dental fluorosis. They
concluded that “there is weak and inconsistent evidence that the use of fluoride
supplements prevents dental caries in primary teeth.”

101. •Stephanie Tubert-Jeannin(2011) reported that the effectiveness of fluoride supplements
in preventing tooth decay in young children (less than 6 years of age) with deciduous
teeth.

102. Effect of f-tablets on permanent teeth
•Studies starting supplements after the age of 3yrs do not measure optimum effects since
many teeth had already been calcified and erupted prior to f-ingestion.
•Naf2.2mg –1 mg f-
1.1mg –0.5mg f-
0.55mg –0.25 mg f-
•Naftablets with vitamin combination are also available.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

103. F-tablets: as dental public health measures in rural india.
•Because of non availability of distilled water, f-mouth rinses can not be prepared and
stored in large quantities.
•F-tablets have been found to be easiest vehicle for the preparation of daily fluoride
mouth rinses for home use for with 10mg Naftab got manufactured
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

104. •A dual rule of f-tablets in the prevention of dental caries both in topical form ( for mouth
rinse and chewing) as well as in systemic form make them an imp means for dental caries
prevention at mass level especially in the rural communities.
Fluorides And Dental caries –A Compendium. By Dr. Amrit Tewari.

105. •Correct dosage is based on the concentration of fluoride in drinking
water, age and weight of the child and other available fluoride.
•Not more than 1 milligram of fluoride should be ingested each day from
all available systemic sources.

106. INDICATIONS FOR USE
•Inareaswheretherearenocentralsupplies,wherethefluoride
concentrationofwell-waterislowandwhereparentalmotivationis
veryhigh.
•Asaninterimmeasureinthesecommunitieswithacentralwater
systemthathavenotyetimplementedcommunitywater
fluoridation.
•Inareaswherewaterfluoridationorsaltfluoridationschemescannot
beimplemented.
•Infamilieswherethereishighdegreeofmobilityinvolvingfrequent
changesintheplaceofworkandresidenceandwhereparentswish
toensuredailyfluoridesupplementationthemselves.
Fluorides in Caries Prevention:Murray,
RuggGunn

107. PRECAUTIONS
•Accidentalingestionoffluoridesupplementscancausestomachupset.
•Nomorethan2.2mgsodiumfluoridetabletshouldbedispensedatonetime.
•Thereisnoriskofdentalfluorosisiftheproperregimeisfollowed.
•However,fluoridesupplementswheningestedpriortotootheruptionarearisk
factorfordentalfluorosis.
Fluorides in Caries Prevention:Murray,
RuggGunn

108. ANTI FLUORIDE
LOBBY

109. •Is fluoridation important?
•Reason to oppose fluoridation
•ethics
•Fluoridation and law
111

110. Introduction
•Fluoridesareaddedtoanumberofconsumerproducts,suchas
toothpastes,mouth-rinsesandgels,inordertotrytoreducetooth
decayinchildren.
112
BarbierO. (2010) Molecular mechanisms of fluoride toxicity. Chemico-Biological
Interactions. 188: 319–333.

111. •Onthequestionofrisks,somedentalandmedicalauthorities
havesomehowmanagedtoconveytheincorrectimpressionthat,
apartfromstrengtheningteeth,fluorideisinertinthehuman
bodyandisthereforeharmless.
•Thebiochemistryandphysiologyoffluorideinthehumanbody
contradictsthisnotion.Notonlyisfluorideincorporatedinto
teeth,butalsointoboneandmanysofttissues.
113
BarbierO. (2010) Molecular mechanisms of fluoride toxicity. Chemico-Biological
Interactions. 188: 319–333.

112. ‘is fluoridation important ???’
•Fluoride is not an essential nutrient. No disease has ever been
linked to a fluoride deficiency. Humans can have perfectly good
teeth without fluoride.
“Fluoride is the only chemical added to water for the
purpose of medical treatment”
•All other water treatment chemicals are added to improve the
water's quality or safety, which fluoride does not do.
114
BarbierO. (2010) Molecular mechanisms of fluoride toxicity. Chemico-Biological
Interactions. 188: 319–333.

113. •Fluoride is not an essential nutrient (National Research Council
[NRC]; Institute of Medicine [IOM].
•No disease has ever been linked to a fluoride deficiency. It has
never been shown that ingested fluoride is needed to produce
decay free teeth.
•Not a single biological process has been shown to require
fluoride. On the contrary there is extensive evidence that fluoride
can interfere with many important biological processes.
115
BarbierO. (2010) Molecular mechanisms of fluoride toxicity. Chemico-Biological
Interactions. 188: 319–333.

114. •Only eight countries in the world have more than 50% of their
populations drinking artificially fluoridated water (Australia,
Colombia, Ireland, Israel, Malaysia, New Zealand, Singapore,
and the USA).
116
BarbierO. (2010) Molecular mechanisms of fluoride toxicity.
Chemico-Biological Interactions. 188: 319–333.

115. Fluoridation is unethical
•Informed consent is standard practice for all medication, and
one of the key reasons why most of Western Europe has ruled
against fluoridation.
•Compulsory mass medication
•With water fluoridation we are allowing governments to do to
whole communities (forcing people to take a medicine
irrespective of their consent) what individual doctors cannot do
to individual patients.
117
BarbierO. (2010) Molecular mechanisms of fluoride toxicity. Chemico-Biological
Interactions. 188: 319–333.

116. Fluoridation's role in the decline of tooth decay is in serious doubt
•The largest survey ever conducted in the US (over 39,000
children from 84 communities) by the National Institute of Dental
Research showed little difference in tooth decay among children
in fluoridated and non-fluoridated communities.
•According to NIDR researchers, the study result was not shown
to be statistically significant.
118
Lawrence G, BammerG, Chapman S: 'Sending the wrong signal': analysis of print media. AustN Z J Public Health 2000, 24:254-264.

117. Fluoridation's role in the decline of tooth decay is in serious doubt
•The largest survey ever conducted in the US (over 39,000
children from 84 communities) by the National Institute of Dental
Research showed little difference in tooth decay among children
in fluoridated and non-fluoridated communities.
•According to NIDR researchers, the study result was not shown
to be statistically significant.
119
Lawrence G, BammerG, Chapman S: 'Sending the wrong signal': analysis of print media. AustN Z J Public Health 2000, 24:254-264.

118. The dose cannot be controlled
•Once fluoride is put in the water it is impossible to control the
dose each individual receives because people drink different
amounts of water.
•Being able to control the dose a patient receives is critical.
•Some people (e.g., manual laborers, athletes, diabetics, and
people with kidney disease) drink substantially more water than
others.
120
Lawrence G, BammerG, Chapman S: 'Sending the wrong signal': analysis of print media. AustN Z J Public Health 2000, 24:254-264.

119. Tooth decay does not go up when fluoridation is stopped
•Where fluoridation has been discontinued in communities from
Canada, the former East Germany, Cuba and Finland, dental
decay has not increased but has generally continued to decrease
(Maupomé 2001; Kunzel 2000; Seppa 2000).
121
Slade GD, Spencer AJ, Davies MJ, Stewart JF: Caries experience among children in fluoridated
Townsville and unfluoridatedBrisbane. AustN Z J Public Health 2009, 20:623-629

120. NIH-funded study on individual fluoride ingestion and tooth decay
failed to find a significant correlation
•A multi-million dollar, U.S. National Institutes of Health (NIH) -
(Warren 2009) found no relation between tooth decay and the
amount of fluoride ingested by children.
•This is the first time that tooth decay has been investigated as a
function of individual exposure as opposed to mere residence in
a fluoridated community.
122
Slade GD, Spencer AJ, Davies MJ, Stewart JF: Caries experience among children in fluoridated
Townsville and unfluoridatedBrisbane. AustN Z J Public Health 2009, 20:623-629

121. The Centers for Disease Control
The mechanisms of fluoride’s benefits are mainly TOPICALand
not SYSTEMIC. Thus, you don't have to swallow fluoride to
protect teeth.
•As the benefits of fluoride (if any exist) are topical, and the risks
are systemic, it makes more sense, for those who want to take the
risks, to deliver the fluoride directly to the tooth in the form of
toothpaste.
123
Slade GD, Spencer AJ, Davies MJ, Stewart JF: Caries experience among children in fluoridated
Townsville and unfluoridatedBrisbane. AustN Z J Public Health 2009, 20:623-629

122. People now receive fluoride from many other sources besides water
•Fluoridated water is not the only way people are exposed to
fluoride. Other sources of fluoride include food and beverages
processed with fluoridated water (Heilman1999), fluoridated
dental products (Levy 1999), mechanically deboned meat (Fein
2001), tea (Levy 1999) and on food (Burgstahler1997).
•It is now widely acknowledged that exposure to non-water
sources of fluoride has significantly increased since the water
fluoridation program first began (NRC 2006).
124
ConnetP. 50 reason to oppose fluoridation.

123. There has never been a single randomized clinical trial to
demonstrate fluoridation's effectiveness
•Despite the fact that fluoride has been added to community water
supplies for over 60 years, "there have been no randomized trials
of water fluoridation" (Cheng 2007).
•The U.S. Food and Drug Administration (FDA) continues to
classify fluoride as an "unapproved new drug."
125
ConnetP. 50 reason to oppose fluoridation.

124. Report of “The York Review”
•A systematic review of public water fluoridation.
•This was the 1
st
systematic review based on search of 25
electronic database world wide with inclusion of 214 studies on
the subject of water fluoridation and rigorous search of the
published and unpublished literature of human epidemiological
studies. (McDonagh 2000)
126
ConnetP. 50 reason to oppose fluoridation.

125. •Body of evidence available on the efficacy and safety of water
fluoridation was of lower quantity and quality.
•Fluoride of drinking water supplies reduces caries prevalence,
but is associated with dental fluorosis.
•Balance of evidence did not show an association between any
fracture and water fluoride.
127
Conclusions of York rivew
ConnetP. 50 reason to oppose fluoridation.

126. Overall limitations of “yorkreview”
•Very few studies followed the same individuals longitudinally.
•Lack of analysis of confounding variables.
•Failure to undertake appropriate statistical analysis.
•Despite discontinuation of water fluoridation, no increase in
the caries tooth decay was seen, but has actually decreased
Canada, former East Germany, Cuba and Finland.
128
ConnetP. 50 reason to oppose fluoridation.

127. There is no margin of safety for several health effects
•No one can deny that high natural levels of fluoride damage health.
Millions of people in India and China have had their health
compromised by fluoride.
•The real argument is about whether there is an adequate margin of
safety between the doses that have been shown to cause harm in
published studies and the total dose people receive consuming
uncontrolledamounts of fluoridated water and non-water sources of
fluoride.
129

128. •Fluoride accumulates in the body
•Children are being over-exposed to fluoride

129. The highest doses of fluoride are going to bottle-fed babies
•Because infant exposure to fluoridated water has been repeatedly found to be a
major risk factor for developing dental fluorosislater in life, a number of dental
researchers have recommended that parents of newborns not use fluoridated
water when reconstituting formula (Brothwell2003; Marshall 2004).
•Even the American Dental Association (ADA), the most ardent institutional
proponent of fluoridation, distributed a November 6, 2006 email alert to its
members recommending that parents be advised that formula should be made
with "low or no-fluoride water.”
131
ConnetP. 50 reason to oppose fluoridation.

130. The level in mothers' milk is very low
•The level of fluoride in mother's milk is remarkably low (0.004
ppm, NRC, 2006).
•This means that a bottle-fed baby consuming fluoridated water
(0.6 –1.2 ppm) can get up to 300 times more fluoride than a
breast-fed baby.
•There are no benefits, only risks, for infants ingesting this high
level of fluoride at such an early age
132
ConnetP. 50 reason to oppose fluoridation.

131. •Fluoride may damage GI tract
•Fluoride may effect the growth
•Fluoride may damage the brain
•Fluoride may lower IQ
•Fluoride affects the pineal gland
•Fluoride affects thyroid function
•Fluoride damages bone
•Fluoride causes arthritic symptoms
•Fluoride may increase hip fractures in the
elderly
•Fluoride may cause reproductive problems
Bernhardt M, Sprague B: The poisonmongers. In The tooth robbers Edited by: Barrett S, RovinS. Philadelphia: GF
Stickley; 1980:1-8.
DoolandCA: Repeating is believing: an investigation of the illusory truth effect. In PhD Thesis State University of New
York at Albany, Psychology; 1999.

132. Fluoride may leach lead from pipes, brass fittings and soldered joints
•Maas et al (2007) have shown that fluoridating agents in combination
with chlorinating agents such as chloroamineincrease the leaching of
lead from brass fittings used in plumbing.
•While proponents may argue about the neurotoxiceffects of low levels
of fluoride there is no argument that lead at very low levels lowers IQ in
children.
134

133. No health agency in fluoridated countries is monitoring fluoride exposure
or side effects
•No regular measurements are being made of the levels of fluoride in
urine, blood, bones, hair, or nails of either the general population or
sensitive subparts of the population (e.g., individuals with kidney
disease).
135
ConnetP. 50 reason to oppose fluoridation.

134. Many scientists oppose fluoridation
•Today, as more and more scientists, doctors, dentists and other
professionals, read the primary literature for themselves, rather
than relying on self-serving statements from the ADA and the
CDC
•As of July 2011, over 3700 professionals have signed a statement
calling for an end to water fluoridation worldwide.
137
ConnetP. 50 reason to oppose fluoridation.

135. FLUORIDATION AND THE LAW
▪Fluoridation is not simply a health issue, it is a political one. The
decision to implement fluoridation must ultimately come from
public authorities, who are usually responsive to political
pressure.
Mandatory legislation:
▪Legislation making fluoridation of public water supplies
compulsory under government policy.

136. Enabling legislation:
▪It empowers health authorities or local governments to institute community water
fluoridation.
▪While such legislation does not automatically lead to fluoridation of water
supplies, it opens the way for national or local health officials to act on the matter

137. •In 1987, the Government of India launched a Technology Mission on Safe
Drinking Water (Rajiv Gandhi National Drinking Water Mission) for ensuring
provision of safe drinking water to rural population.
•Under this programme, the Ministry of Rural Areas and Employment, Which is
the nodal Ministry for providing safe water, has laid emphasis on water quality
through removal of excess fluoride, arsenic and other pollutants in water.

138. Conclusion
•Itisimportantthatpublichealthofficialsareawareofthesetactics
sothattheycanbettercountertheirnegativeeffect.

139. •Whenusedappropriately,fluorideisasafeandeffectiveagentthatcanbe
usedtopreventdentalcaries.
•Systemicfluorideshelpincirculatingfluoridesinthebloodstreamandis
incorporatedintodevelopingteeth.Butstillsystemicfluoridesareyetnot
widespreadinIndia,thereforetoensureadditionalgainsinoralhealth
practicesfluoridetoothpastesshouldbeusedwidely.

141. Sources of f-
•Fluoride is the thirteenth most abundant element in the Earth's crust.
•It rarely occurs as the element but normally is found as the fluoride ion or as a
number of inorganic and organic fluorides.
•It occurs in varying concentrations in rocks, soil, water, air, plants and animals
both naturally and as a consequence of human activity such as agricultural or
industrial processes.
AyyasamyPdukkaduMunusamyet al Adv. Appl. Sci. Res., 2014, 5(2):173-185

142. Principal source of human fluoride ingestion is water
•Present in nearly all ground water
•Derived from plants, marine animals and even dust particles
•Tea
•Certain types of fishes, dried salmon-84.5 ppm
•Potatoes-6.4 ppm
Essentials of public health dentistry by sobenpeter, 5
th
edi

143. DIETARY ITEMS FOR FLUORIDE CONTENT (Tandon and Thomas 2000)
Items Dry wt. of substance (g)
Fluoride (ppm) in dry
wt. of substance
Fluoride in 100 g
sample(micrograms
)
Vegetables
group
Beans 2.50 2.38 59
Tomato 1.80 1.56 28
Brinjal (local) 2.70 2.21 60
Cucumber 1.40 0.98 14
Ladies finger 1.03 0.86 9
Green chillies 1.30 1.14 15
Pumpkin 1.10 0.54 6

144. Fruits
Dry wt. of
substance (g)
Fluoride (ppm) in dry wt. of
substance
Fluoride in 100 g
sample(micrograms)
Orange 0.86 31.0 9
Pineapple 1.40 1.03 14
Green grapes 1.04 0.55 6
Banana 2.46 0.39 10
Apple 1.30 0.32 4
Guava 1.70 0.43 7
DIETARY ITEMS FOR FLUORIDE CONTENT (Tandon and Thomas 2000
)

145. Animal
foods
Dry wt. of substance
(g)
Fluoride (ppm) in dry
wt. of substance
Fluoride in 100 g
sample(microgra
ms)
Chicken 4.60 0.92 42
Whole egg 4.10 4.62 189
Pork 3.80 1.17 45
Mutton 2.20 1.80 40
Sea foods
Fresh water
fish
2.10 0.58 12
Dried sea
fish
8.20 165.44 135.70
DIETARY ITEMS FOR FLUORIDE CONTENT (Tandon and Thomas 2000)

146. •Dry tea leaves-97 ppmof fluoride
•Both green and black tea contain fluoride, although green tea contains twice the
amount of f-than black.
DIETARY ITEMS FOR FLUORIDE CONTENT (Tandon and Thomas 2000)

147. Average fluoride content of tea
Brand of tea
Quantity of tea
and sugar used
tea without milk
content in 1 cup
tea withmilk
(200ml)
Approx.
fluoride
with milk &
sugar
(Fluoride content in ppm) (micro gms)
CTC tea leaves 1 tsp 1.710 1.54 200
Commercial tea
(Brooke
Bond, Lipton green
label,
TajMahal)
1 tsp 1.00-1.19 0.928-1.11 190-222
DIETARY ITEMS FOR FLUORIDE CONTENT (Tandon and Thomas 2000)

148. •Buffaloes milk-0.499 ppm
•Human breast milk has low fluoride content, less than 0.02mg/L
•The fluoride content in cow’s milk is reported to be 0.02-0.05 mg/L
CovisJ,HargreavesJA.Fluorideintake from beverage consumption. Community Dent Oral Epiemiol1988;16:11-15

149. •The f-concentration in various foods reflects the f-conc in the water used in food
processing.
•Mineral water usually contains considerably higher conc. From1.5-7ppm, dependindon
the geological location of the sourses.
•Water, naturally or artificially fluoridated, is the most imp single sourseof f-
•When 1liter of fluoridated water containing 1ppm f-is consumed, most of the f-is
absorbed, whereas only 1/3 to ½ of f-in foods is assimilated.
Essentials of public health dentistry by sobenpeter, 5
th
edi

150. Fluoride drops
•Fluoride drops are prescribed to prevent cavities in primary and permanent teeth while
the teeth are in formation stage.
•Drops are often recommended for children who live in areas where the water supply is
not fortified with fluoride.
All About Fluoride Drops for Infants | Colgate® Oral Care

151. Dispensing Fluoride Drops
•To prescribe a fluoride supplement, a dentist or doctor must first find out the amount of
fluoride present in a child's drinking water.
•Fluoride ion concentration is measured in parts per million for both drinking water and
supplemental dosage, but drops will usually be pre-mixed and measured in milligrams
[Acc to ADA]
•fluoride drops can be given to a child with or without food, and sometimes diluted with
water or juice.
All About Fluoride Drops for Infants | Colgate® Oral Care

152. •Most pharmacists recommend a baby or toddler wait two hours after medication is taken
to eat, drink or take other medications.
•If an excess amount is ingested it could cause stomach pain , indigestion or diarrhea
(National Centers for Poison Control.)
All About Fluoride Drops for Infants | Colgate® Oral Care

153. Sodium f-drops
•Sodium Fluoride Drops 0.5 mg/mL
•Other Ingredients: Glycerin, purified water, xylitol, propylene glycol, natural flavor,
sucralose, methyl paraben, propyl paraben.
Sodium Fluoride Drops 0.5 mg/mL, Sancilio& Company Inc, march 2018

154. Sodium Fluoride Drops 0.5 mg/mL, Sancilio& Company Inc, march 2018

155. •While prescription fluoride is proven to be effective in decreasing cavities, it’s also
important to practice good oral hygiene with child.
•Parents should Start consulting a dentist when baby is around 6 months old or as soon
as their first tooth erupts.
Sodium Fluoride Drops 0.5 mg/mL, Sancilio& Company Inc, march 2018

157. Feasibility of water fluoridation
COST-EFFECTIVENESS
Following estimates are required for conducting a cost-effectiveness analysis of CWF:
(Capital Costs Fluoridation schemes require capital expenditure to)
•Establish a plant and equipment
•Consultant engineering fees
•To replace and upgrade those facilities when necessary.
Operating Costs (Annual running costs)
•Fluoride materials
•Labor
•Maintenance
Rathore, et al.: Cost-Effectiveness of Community Water Fluoridation International Journal of Scientific Study | July
2015 | Vol 3 | Issue 4

158. Factors reported to influence the per capita cost include:
• Size of the community (the larger the population reached, the lower the per capita cost)
• The level of tooth decay in population
• Age and treatment of the water treatment works
• Number of fluoride injection points in the water supply system
• Amount and type of system feeder and monitoring equipment used
• Amount and type of fluoride chemical used, its price, and its cost of transportation and
storage
• Expertise of personnel at the water plant.
Rathore, et al.: Cost-Effectiveness of Community Water Fluoridation International Journal of Scientific Study | July
2015 | Vol 3 | Issue 4

159. Rathore, et al.: Cost-Effectiveness of Community Water Fluoridation International Journal of Scientific Study | July
2015 | Vol 3 | Issue 4

160. Defluoridationof water

161. Definition
•Downward adjustment of concentration of fluoride ion in public water supply in such a
way, that the concentration of fluoride in water is maintained constantly at1ppm
OR
•It is the process of removing excess fluoride present in drinking water supply in order to
prevent dental fluorosis or more severedisability.
Essentials of public health dentistry by sobenpeter, 5
th
edi

162. Defluoridationof water
•Several methods have been suggested
i.Based upon ion exchange process or adsorption and
ii.Based upon addition of chemicals to water during treatment.
In India, the first work on defluoridationwas done by the National Environmental
Engineering Research Institute (NEERI) at Nagpur in 1961.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

163. Deflouridation
technique
Ionexchange
Precipitation
Electro
chemical
Reverse
osmosis
Adsorption
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164. Adsorption technique of defluoridation
•This technique functions on the adsorption of fluoride ions onto
the surface of an active agent.
•Activated alumina, activated carbon and bone char were among
the highly tested absorbing agents.
❖Activated Alumina
❖Bone char
❖Brick piece column
❖Mud pot
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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165. Activated Alumina
▪Application of domestic defluoridationplant, based on activated
alumina, was launched by UNICEF in rural India
▪The disadvantages with activated alumina are; Adsorption of
fluoride is possible only at specific pH range, needing pre-and post-
pH adjustment of water.
▪Frequent activation of Alumina is needed, which make the
technique expensive.
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166. ❖Bone char (calcium phosphate exchange)
▪the process of Defluoridation by bone char as the ion exchange and
adsorption between fluoride in the solution.
▪The efficacy of the plant depends upon temperature and pH of raw
water; duration for which the bone-char is in contact with raw
water.
▪It is a highly economic technique with a defluoridationpercentage
of 62 to 66
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

167. ❖Bone char (calcium phosphate
exchange)
▪Disadvantage :
✓The bone char harbors
bacteria and hence
unhygienic.
✓It is a technique sensitive
procedure,
✓the use of bone-char
may invite cultural and
religious objections
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

168. ❖Brick pieces column
▪The basic principle of functioning of Brick piece column is the
same as that of activated alumina.
▪The soil used for brick manufacturing contains Aluminium oxide.
❖Mud pot
▪The fluoride removal capacity will vary with respect to the
alumina content
▪The major advantages of mud pots are they are economic and
readily acceptable for the rural communities .
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on DefluoridationTechniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

169. ❖Natural adsorbents
▪Many natural adsorbents from various trees were tried as defluoridation
agents.
▪Seeds of the Drumstick tree, roots of Vetivergrass and Tamarind seeds were
few among them.
▪Researchers at “M. S. SwaminathanResearch Foundation‟ (MSSRF) had
shown drumstick seeds to have remarkable defluoridationefficiency, which
was higher than that of activated alumina.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on DefluoridationTechniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

170. Defluoridation by Ion-Exchange technique
•Synthetic chemicals,

171. CationExchange Resins
These are commercially produced resins which are expensive and uneconomical in most circumstances
a)Defluoron1 : sulphonatedraw dust + 2 % alum solution.
b)Carbion: Used on sodium & hydrogen cycles
c)Magnesia: It removed the excess fluoride but pH of treated water was beyond
10 and its correction by -acidification
-recarbonation.
d) Defluoron2: 1)developed in 1968
2)to over come the problem of defluoron
3) sulphonatedcoal + aluminiumsolution.
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172. •The two major drawbacks of Ion-exchange and adsorption techniques are:
❑There is often difficult to arrange where there is no piped water system
supply.
❑gradual exhaustion of the active agent is not easily detected.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

173. Defluoridation by Precipitation technique
•Precipitation methods are based on the addition of chemicals
(coagulants and coagulant aids) and the subsequent
precipitation of a sparingly soluble fluoride salt as insoluble
fluorapatite
•The best example for this technique is the famous
Nalgondatechniqueof defluoridation.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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174. Nalgondatechnique
•National Environmental Engineering Research Institute (NEERI), Nagpur
has evolved an economical and simple method for removal of fluoride
which is referred to as “Nalgonda Technique” ( in 1974 and reported by
bulushuin 1988)
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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175. •Involves addition of readily available chemicals
•sodium aluminate or lime + bleaching powder + filter alum to the fluoride water
followed by
•flocculation>sedimentation > filtration.
•Useful-a) domestic and
b) community water supplies.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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176. Domestic defluoridationfilters
❖Stainless steel candle filters adopting Nalgonda technique
❖Consists of water filters of any size and make fitted with candle filters and an
additional mixing device

177. STEPS IN NALGONDA TECHNIQUE
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178. Mechanism
•The unit holds 22 litresof water, which is filled into the upper
chamber.
❖Rapid mix:
▪Rapid mixing is an operation by which the coagulant is rapidly and
uniformly dispersed through out a single or multiple phase system.
▪It is rapidly mixed for a period of 30 to 60 sec with speed of 10 to 20
rpm so that the coagulant is rapidly and uniformly dispersed.
▪This help in the formation of micro flocsand result in proper utilization
of chemical coagulant.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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179. ❖Flocculation :
▪It is the 2
nd
stage of the formation of settable particles(flocs)
from destabilized colloidal size particles.
▪It is achieved by gentle and prolonged mixing for a period of 10
to 15 min with the speed of 2 to 4 rpm.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

180. ❖Sedimentation
▪It is the separation from the water by gravitational setting of
suspended particles that are heavier than water.
▪Factors that affect sedimentation are:
a)Size,shape,densityand nature of particles
b)Viscosity,densityand temperature of water.
c)Surface over flow rate.
d)Velocity of flow.
e)Effective depth of settling zone.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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181. ❖Filtration:
▪It is the process of separating suspended and colloidal impurities from
water by passes through a porous media.
▪The flocculated water is allowed to settle and filter through fullers
earth candle overnight.
▪Treated water will be available for drinking and cooking with desire
level of fluoride.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

182. •Absence of acceptable, alternate low fluoride source within transportable
distance.
•Total dissolved solids below 1500 mg/l.
•Total hardness is below 600 mg/l.
•Raw water fluorides ranging from 1.5 -20 mgF/l.
Essentials of public health dentistry by sobenpeter, 5
th
edi
Indication of Nalgonda Technique

183. Advantages of Nalgondatechnique
•Regeneration of media is not required.
•No handling of caustic acids and alkalies.
•The chemicals required are readily available and are used in conventional
municipal water treatment.
•Adaptable to domestic use.
•Economical
•Simplicity -design ,construction,operationand maintainence.

184. •Can be used to treat water in large quantities for community usage.
•Highly efficient removal of fluorides from high levels to desirable levels.
•Little wastage of water and least disposal problem.
•mimimummechanical and electrical equipment.
•No energy except muscles power for domestic equipment.
•Local semi-skilled workers can be readily employed.
Essentials of public health dentistry by sobenpeter, 5
th
edi

185. •Simultaneous removal of color, odor, turbidity, bacteria and organic
contaminants.
•Normally, associated alkalinity ensures fluoride removal efficiency.
•Provides de-fluoridated water of uniform acceptable quality.
Essentials of public health dentistry by sobenpeter, 5
th
edi

186. Disadvantages of Nalgondatechnique
•Desalination may be necessary when the total dissolved solids exceed 1500
mg/l.
•Hardness of the raw water in the range of 200 mg/l to 600 mg/l requires
precipitation softening and beyond 600 mg/l becomes a cause for rejection or
adoption of desalination.
•Generation of higher quantity of sludge compared to electrochemical
defluoridation
•The large amount of alum needed to remove fluoride.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

187. Maintenance of Nalgondafilters
•The package plant installed on hand pump scheme costing Rs
1.6 lakh to serve 250 population.
•To serve population of 250, 50 stainless steel filters are
required and the cost of 50 filters is approx. Rs35000.
•The main advantage will be its low cost of investment and low
cost of maintainence.
Essentials of public health dentistry by sobenpeter, 5
th
edi

188. Modifications for Nalgonda technique.
INCLUSION CRITERIA
Poly Aluminium Chloride:
It is evident that for higher
concentrations of fluoride,
the removal efficiency of
fluoride is higher with Poly
Aluminium Chloride (PAC)
when compared with
Alum.
Poly Aluminium Hydroxy
Sulphate(PAHS):
A polymeric aluminum
compound, poly-
aluminium-hydroxy-
sulphate(PAHS) is found to
require less flocculation
time and settling time.

189. Other techniques of defluoridation
physical methods that are tested for defluoridationof water.
•Though they are effective in removing fluoride salts from water, there are certain
disadvantages that limit their usage on a large scale.
Reverse
osmosis
Electrolysis
and electro
dialysis
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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190. ❖Reverse Osmosis
▪In reverse osmosis, the hydraulic pressure is exerted on one side
of the semi permeable membrane which forces the water across
the membrane leaving the salts behind.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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191. ❖Electro dialysis
-Membranes allow the ions to pass but not the water.
-The driving force is an electric current which carries the ions through the membranes
-Highly energy intensive
-Expensive.
-Both processes are very complicated
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on Defluoridation Techniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

192. ❖Defluoridation by electrolysis:
▪The basic principle of the process is the adsorption of fluoride
with freshly precipitated aluminumhydroxide, which is
generated by the anodic dissolution of aluminumor its alloys
in an electro chemical cell.
❑Advantages :
•Does not require addition of chemicals.
•No need to pre & post-treatments .
•Low volume of sludge.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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193. •Units can be designed for any capacity.
•Units are designed for specific locations & fluoride content of water. But can be operated
with varying fluoride concentrations by slightly altering the operating parameters.
•The electrochemical reactor occupies less floor space.
•Operator friendly
•Requires less electric energy (0.3 to 0.6kwh/1000 lts)
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
Review on DefluoridationTechniques of Water, -piddennavarRenuka, krishnappaPushpanjali.

194. Current status of defluoridationin India.
•UNICEF has worked closely with the Government and other partners in defluoridation
programmesin India, where excessive fluoride has been known for many years to exist in
much of the nation's groundwater.
•Government of India launched a massive programme, namely „Technology Mission on
Safe Drinking Water‟ in 1986 wit the goal of providing potable water to the people living
in rural India.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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195. •UNICEF's focus in the Indian programmehas been on strengthening the systems for
monitoring water quality, facilitating water treatment by households, and advocating
alternative water supplies when necessary.
•Under national drinking water scheme of Govt. of India, 16 villages belonging to
Siddhpur, Kheralu, Visnagar, Patan, Chanasmaand Kaditalukas of Mehsana district,
Gujarat were provided with defluoridationplants at the cost of Rs. 106 lakh.
•However, due to high cost of (approximately Rs1.5 lakh/year) maintenance and
repairing, most of the plants are nonfunctional.
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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196. •Other plants are,
•DharoiReservoir Dependent Scheme:
371 villages belonging to Kheralu, Sidhpur, Visnagarand Patantaluka will be provided with
the 68.86 MLD of water under group water supply scheme, at an estimated cost of Rs. 140
Crore.
•Sabarmati River Dependent Scheme:
109 villages from VijapurTaluka will be provided with water drawn from Sabarmati river at
an estimated cost of Rs. 36 Crore
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197. •Narmada Canal Dependent Scheme:
•111 villages belonging to ChanasmaTaluka, 118 villages belonging to KadiTaluka and a
large number of villages belonging to Sami and Harijtaluka will be provided with the
water from Narmada main canal by constructing necessary storage tanks and filtration
plants.
•The experience of villagers with several existing regional water supply schemes is,
however, not very satisfactory for two reasons;
(i) the water supply is generally erratic and
(ii) the water supply scheme is not under the control of the village community
The International Journal Of Engineering And Science (Ijes) Volume2 ,Issue3,2013
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198. Toxicity ofFluorides
•Fluoridesareextensivelyusedin thepracticeof Dentistry to reduce the
incidence of Dentalcaries.
•Usedinexcessivequantities,F.canproducetoxicandevenlethaloutcomewhen
ingested,inhaledorabsorbedintothebody.
•safety tolerated dose (STD) –8-16mg of f-/kg body wt
•Certainly lethal dose (CLD) –32-64mg of f-/kg body wt
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

199. Toxicity ofFluoride
AcuteToxicity Chronictoxicity
A single largedose
2.5 -5mg
Dental fluorosis
2 -8ppm
(0 year to10year)
Skeletalfluorosis
More than 8 ppm for 10 -20yrs of
anyage
Morethan optimum level
for longerduration
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

200. Symptoms of FluorideToxicity
Fluoride acts in Four generalways
1)WhenfSaltscontactwithmoistskinormucousmembrane,Hydrofluoricacid
formscausechemicalburn.
2)Itisgenerallyprotoplasmicpoisonthatactstoinhibitenzymesystem.
3)It binds calcium that isneededfornerveaction.
4)Ahyperkalemiaoccursthatcontributetocardiotoxicity.
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

201. •FollowingingestionofFluoride,nauseaandvomitingcanoccur.Itisdue
toProductionofHydrofluoricacidintheacidenvironmentofstomach,
causesirritationofthestomachwall.
Localorgeneralsignsofmuscletetanyensuredueto the drop of
blood calcium.
Thiscanbeaccompaniedbyabdominalcrampsand pain.
•Finally, hypocalcemiaand hyperkalemiaintensityresults in either
coma, convulsions or cardiacarrhythmia's.
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

202. Essentials of public health dentistry by sobenpeter, 5
th
edi

203. FLUOROSIS
•A non-reversible, disease weakening skeletal structures caused by high level of
fluorides inwater.
•skeletal fluorosis
•Dentalfluorosis
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

204. SkeletalFluorosis
•A water fluoride level over8ppm
•Characterizedby
–Increased x-ray density of trabecular bone (spine, pelvis)
–Increased thickness of long bone cortices due to endosteal and periosteal
apposition
•In more advancedcases
–Calcification of ligaments
→Ankylosingspondylitis
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

205. SkeletalFluorosis
•Other effectsare-
–Gastriccomplaints
–Osteosclerosis
–Exostosis of long bones, vertebrae, jaw bones, & other
flatbones.
Misdiagnosed as Rheumatoid or OsteoArthritis
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

206. SkeletalFluorosis
Early cases—vague pain in small joints, knee and
joints ofspine
Latercases---stiffness of spine &
limitation ofmovement
Advanced cases---KYPHOSIS—difficulty in walking partly
duetostiffness&partlydueto
neurological lesions
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

207. DentalFluorosis
•Definitions
1.Hypo-mineralization of tooth enamel or dentin by the long continued
ingestion of excessive amounts of fluorides during toothdevelopment
-Dean1934
2.A specific disturbance of tooth formation caused by excessive intake of fluoride
during formation period ofdentition
-Murray1986

208. DentalFluorosis
3.Disturbance in tooth enamel formation caused by fluoride being present in
tissue fluid over a prolonged period during toothdevelopment
-fejerskov1988
4.Permanent hypo mineralization of enamel characterized by greater surface
and subsurface porosity than in normal enamel, resulting from excess fluoride
reaching the developing tooth during developmentalstages
-fejerskov1990

209. Possible mechanism ofdental fluorosis
•Inhibit Protein synthesis and reduce secretory enamel(reducesamino
aciduptake)
•InMineralization:
–Irreversibly affects the existing mineralizing matrix, (more rapid
deposition and disruption of crystalgrowth)
–Interferes with deposition of crystals in new matrix
–reduce the available ionic calcium, resulting in reduced
proteolyticactivity
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

210. •Interferes Protein removal from thematrix
–Amelogenin is hydrolyzed and removed from the matrix
–A dose dependent delay in hydrolysis and removal of
amelogenin is caused byfluorides
delay growth of enamelcrystals
tooth erupts with incompletely mineralizedenamel
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

211. Distribution of fluorosisin permanentdentition
•Posterior teeth are more affected than anteriorin
both maxilla andmandible
•Fluorosis occurs symmetrically within thearch
•Premolar>2
nd
molar>max incisor>canine>1
st
molar> mandibular
incisors
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

212. Distribution of fluorosisin primarydentition
•Exhibit less fluorosis than their permanent successors, but distribution within
the dentition follows similarpattern
•Assessment of fluorosis is difficult in primary dentitionbecause:
–Thinner enamel-→ more whitishappearance
–Incremental lines of retzius is often lacking or less pronounced than permanent
teeth
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

213. •Reasons for less appearance of fluorosis in primarydentition:
–Placenta as selective barrier
–Most of calcification of primary teeth occurs before birth
–Duration of enamel maturation isshorter
–Thinnerenamel
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

214. Post eruptive changes in dental fluorosis
•Changes are determined by degree ofsubsurfaceporosity
•Pitting occurs shortly after eruption depending on initialhypo-mineralization
•Very susceptible to enhancedattrition
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

215. •Porous enamel may take upstains
–The shape usually follows the position of upperlip
–Continuous drying out of max incisors in combination with
immediate exposure of these teeth to any sort of staining from
food makes them particularly susceptible todiscoloration
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

216. •the severity of fluorosis:-
(i)Fluoride concentration in drinkingwater,
(ii)Period ofexposure,
(iii)Climatic factors (for example Temperature),
(iv)Fluoride ingestion through other sources,
Nutritionalstatus,
(v)Chemical constituent of drinking waterother
than fluoride,and
(vi)Occupation.
Rizwan ullah, potential fluoride toxicity from oral medications; a review
Iran J BasicMedsci,2017;20:841-848

217. Classification systems of fluorosis
•Dean’sindex:
–Trendly H. Dean in1934
–Initially this index categorized dental fluorosis on a seven point
ordinal scale:-
Normal, questionable, very mild, mild, moderate, moderately
severe,severe
–In1939Deancombinedmoderatelysevereandsevereasonly
severeandthusmodifieditinto6pointscale
Essentials of public health dentistry by sobenpeter, 5
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218. Criteria ofscoring:-
0 –Normal –enamel represents usualtranslucent
semivitriform, surface is smooth, glossy & pale creamy whitecolor
1–Questionable –slight aberrations from the translucency ranging
from white flecks tooccasional
whitespots
Essentials of public health dentistry by sobenpeter, 5
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edi

219. 2–Very Mild –small opaque paper white areascattered
irregularly over the tooth showing no more than 1-2mm of
whiteopacity
3–Mild–whiteopaqueareasintheenamelaremoreextensivebut
donotinvolveasmuchas50%ofthetooth
Essentials of public health dentistry by sobenpeter, 5
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edi

220. 4–Moderate –all enamel surface are affected &surfaces
subjected to attrition show marked wear, brown stains are frequently
a disfiguringfeature
5–Severe –all enamel surface are affected & surface hypoplasia is so
marked that the general form of the tooth may be altered . discrete
or confluent pitting . Brown stains are widespread & give a
corroded appearance
Essentials of public health dentistry by sobenpeter, 5
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221. •Community fluorosisindex:-
Trendly H Dean In
1935 –criteria
Normal 0
Questionable 0.5
Verymild 1
Mild 2
Moderate 3
Severe 4
Essentials of public health dentistry by sobenpeter, 5
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222. In 1942 –Community index of dentalfluorosis
sum of ( no. of individuals x statisticalwt)
CFI
no. of individualsexamined
Essentials of public health dentistry by sobenpeter, 5
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223. In 1946 –Public Health significance of CFIscore
0.0 –0.4 –Negative
0.4 –0.5 –Borderline
o.5 –1.0 –Slight
1.0 –2.0 –Medium
2.0 –3.0 –Marked
3.0 –4.0 –Verymarked
Essentials of public health dentistry by sobenpeter, 5
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224. Differentialdiagnosis
characteristicsDentalfluorosis Enamelopacities
Areaaffected
all surfaces, often enhanced on or neartips
of cusps or incisaledges
Usually centered in smoothsurface
of limitedextent
Lesionshape
Line shading in pencil sketch whichfollow
incremental lines OR cloudy appearance
OR snow capping at cusptips
Round or oval
Demarcation
Diffuse distribution of varyingintensityClearlydifferentiated
Color
Paper white ,frosted appearance, stainat
time oferuption
Creamy yellow to darkreddish
orange at the time oferuption
Teeth affected
Always homologous teeth. Premolars&
2
nd
molars mostlyaffected
Labial surface of singletooth,
mostlyincisors

225. Effective treatment ofdentalfluorosis
•Bleaching
•Crown
•Veneers &laminates
•Compositerestorations
Essentials of public health dentistry by sobenpeter, 5
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226. Fluorosis inIndia

227. Prevention offluorosis
1.Change the source of drinking water to the water containing
optimum amount offluorides
2.Defluoridation
Essentials of public health dentistry by sobenpeter, 5
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228. THANK YOU