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ENDEMIC FLUOROSIS with Particular Reference to Dental and Systemic Intoxication AMARJIT SINGH, M.D., M.R.C.P

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ENDEMIC FLUOROSIS with Particular Reference to Dental and Systemic Intoxication AMARJIT SINGH, M.D., M.R.C.P Postgrad Med J: first published as 10.1136/pgmj.38.437.150 on 1 March 1962. Downloaded from POSTGRAD. MED. J. (1962), 38, 150 ENDEMIC FLUOROSIS With Particular Reference to Dental and Systemic Intoxication AMARJIT SINGH, M.D., M.R.C.P. (Lond.) Professor of Medicine SUNDER J. VAZIRANI, B.D.S., D.O.S., M.S., F.I.C.D. Professor of Oral Surgery S. S. JOLLY, M.D. Assistant Professor of Medicine B. C. BANSAL, M.B. Registrar, Central Registration VVith the technical assistance of 0. C. MATHUR, M.Sc.* (Department of Medicine and Dentistry, Medical College, Patiala) THE-studies of the toxic effects of fluoride on the sites of muscular and tendinous insertions are human system have evoked a very lively interest rendered abnormally prominent by excessive peri- throughout the world because the public health osteal reaction with development of multipleby copyright. programmes of fluoridation for the prevention of exostoses which can be clinically palpated in dental caries have always considered the risk of a many cases. The greatest changes are observed remote cumulative intoxication. However, the in the spine, particularly in the cervical region. indices of early intoxication are very poorly de- The vertebrx show altered proportions and fined. The affinity of fluoride for the bones is measurements in all planes, but the striking ab- acknowledged by everybody, but there is no normality is the gross reduction of the antero- universal agreement on its effects on other systems posterior diameter of the spinal canal and inter- of the body-particularly when it has been spread vertebral foramina accounting for the neuro- over a number of years. logical features of a radiculo-myelopathy. In onehttp://pmj.bmj.com/ We have had a unique opportunity of studying of our cases it was reduced to 3 mm. at the level the toxic potentialities of this ion because there of the third and fourth cervical vertebra (Fig. 3). exists an extensive belt of 'endemic fluorosis' in It is evident that with this degree of narrowing the southern parts of Punjab (India) mainly affect- compression of the cord is inevitable. ing the rural population. As already reported, The radiological features of fluorosis are charac- people in these villages get their drinking water teristic and diagnostic (M0ller and Gudjonsson, supply mostly from wells in which the fluorine I932). Sclerosis of bones is observed throughout on September 24, 2021 by guest. Protected content is high (varying from 2.5 to I4 parts per the skeleton, with calcification of ligaments and million-Singh, Jolly and Bansal, I96I; Singh and muscular attachments. Jolly, I96I). The soil of this area is sandy and The most pronounced changes are seen in the the temperature goes pretty high (iI6°-II7° F.) vertebral column with marked osteosclerosis and in the summer. irregular osteophyte formation resulting in beak- The skeletal and neurological features of en- like lipping and a chalky-white ground-glass demic fluorosis have already been described appearance (Fig. 4). (Singh, Jolly and Bansal, I96I; Singh and Jolly, The osteosclerosis and irregular calcification is I96I; Singh, Dass, Hayreh and Jolly, I96I). evident in all the other bones of the body, particu- The bones, due to heavy and irregular fluoride larly along the attachment of muscles and tendons deposition, become grotesque and markedly ir- in the limb bones, in the interosseous membranes regular in their contours (Figs. i and 2). The and around the joint capsules (Fig. 5). It is proposed in this paper to record some of * The biochemical investigations pertaining to this our observations on dental fluorosis and also the work were entirely carried out by Mr. Mathur. systemic effects of fluorine intoxication. Postgrad Med J: first published as 10.1136/pgmj.38.437.150 on 1 March 1962. Downloaded from March I 962 SINGH AND OTHERS: Endemic Flutorosis FIG. i.-The pelvis from a case of fluorosis showing irregular bone deposition with calcification of the acetabulum. FIG. 3 -Fourth cervical vertebra from a case of fluorosis showing a huge exostosis projecting into the spinal by copyright. canal thereby reducing the antero-posterior diameter to only 3 mm. http://pmj.bmj.com/ ; ..e on September 24, 2021 by guest. Protected .I FIG. 2.-Femora from a case of fluorosis showing irregular bone deposition along the insertion of tendons. xk Methods and Material For this purpose we selected Papra, a village in the Sangrur district of Punjab, where the level of fluorine in drinking water was appreciably high (varying from 9.I to io.6 p.p.m.). This village has a total population of 667 individuals living in FIG. 4.-Radiograph of the lumbar spine showing I12 houses. An effort was made to examine all osteosclerosis with calcification of inter-vertebral the residents who -were available at the time of ligaments and irregular bone deposition in the survey. The study comprised of complete dental transverse processes. Postgrad Med J: first published as 10.1136/pgmj.38.437.150 on 1 March 1962. Downloaded from 152 POSTGRADUATE MEDICAL JOURNATL March i962 the accuracy of 'mottled enamel' as an index of endemic fluorosis. !. ..:..9.. .-. To evaluate the exact incidence of dental fluorosis and its relation to skeletal fluorosis a careful field survey of the human population was carried out in the above village where the fluorine content of the water from ....... ....... drinking ranges 9.I2 ........ .. to io.68 p.p.m. Results of the Present Survey ..,.... A total of 302 individuals was examined, out of which I5 were edentulous and are not included a................. in the subsequent analysis. Of the remaining 287 persons, 170 were males and II7 females of W .-'. different age-groups, as shown in Table i. The population was grouped into residents (257) and non-residents (30), and into those having a deciduous (49) or permanent (238) dentition. By residents we mean those persons who were born and brought up in the endemic area. Non-residents were those who either migrated as refugees or as brides into the village after the age of 14 or IS years. Deciduous denti- tion age ranged from o-5 years and permanent dentition 6 years and above. FIG. 5.-Roentgenograph of the chest showing a chalky- The dental changes were grouped into threeby copyright. white bony cage in contrast to the radio-translucent grades, and in order to standardize our study we lungs. followed the same grades as described by Siddiqui (1955): Grade I: White opacities or patches on the and systemic examination, roentgenographic enamel; very faint yellow line across the studies of skeleton and teeth and biochemical enamel. studies, wherever indicated. Grade II: A distinct brown stain. Grade III: Besides the well-established brown Dental Fluorosis line, considerable pitting all over the enamelhttp://pmj.bmj.com/ Mottled enamel or dental fluorosis is a well- sometimes with chipped-off edges. recognized entity. It has been shown that if a The population was examined with the mouth person resides in an area having a fluoride content mirror and probe in the daylight. of more than i p.p.m. during the period of eruption of his teeth, he will most probably Incidence of Mottled Enamel in Children develop mottled enamel. On the other hand, if Forty-eight children (I7.I% of the total popu- an individual were to move to an endemic locality lation) in the age-group of 0-5 years were exam- after the period of development of the enamel of ined. They were all residents of the village. Out on September 24, 2021 by guest. Protected his teeth, there will be no mottling. Thus mottling of these, 40 (8i.6%) showed mottled enamel, of dental enamel has become one of the first and whereas the remaining 9 (i8.4%) had none. Out, earliest visible signs of chronic fluorine intoxi- of the 40 positive cases, 80% were in grade -I cation; it is usually regarded as a sensitive diag- 2 5% in grade II, and I7.5% in grade III dental nostic criterion and has been accepted as an index fluorosis. of fluorosis (Day, I940; Dean, I936 and I943; McKay, I9I6). Incidence of Mottled Enamel in Adults In our recent paper (Singh and others, ig6ib) The permanent dentition group, i.e. aged 6 on skeletal fluorosis and its neurological compli- and above, consisted of 238 persons, out of which cations, it was observed that in 25% of the 46 30 were non-residents. Among 2o8 residents, cases showing obvious skeletal signs of serious 204 (98.I%) were suffering from mottled enamel fluoride intoxication, there was no evidence of and only 4 (44..%) were free from dental fluorosis. dental mottling even though the fluorine content The mottling was most evident on the labial ofi the- drinking water- was as much- as- I4 p.p.m. surface of the upper and anterior teeth- Out of In view of this report, Holman (i96i) questioned these 204 adults I9.2% were in grade I, z6.S% Postgrad Med J: first published as 10.1136/pgmj.38.437.150 on 1 March 1962. Downloaded from March I962 SINGH AN! OTHERS: Endemic Fluorosis T53 in grade II, and 54% in grade III, as shown in Table I. TABLE I GRADING OF DENTAL PIGMENTATION Grade Grade Grade Deciduous Total I II III Age o-5 years 40 32 7 Permanent 204 39 55 110 Age Group 9 9 32 ..... 6-io 50 ... I11-20 56 3 II 42 21-30 38 I I 15 I2 31-40 27 12 9 6 41-50 I6 2 8 6 5I-60 12 2 3 7 FIG. 6. Teeth from a case of fluorosis showing irregular 61-70 5 .; bone deposition near the roots of the teeth.
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