Fluoride Contamination in Ground Water – The Problem and its Integrated Management 

1. Fluoride Contamination in Ground
Water – The Problem and Integrated
Management
Dr.Ashok Ghosh
Dept. of Environment & Water Management
A. N. College, Patna
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2. FLUOROSIS IS NOT
TREATABLE
BUT
FLUOROSIS IS
PREVENTABLE
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3. Fluorine
• Fluorine is the most electronegative element,
distributed ubiquitously as fluorides in nature. Water is
the major medium of fluoride intake by humans.
• Fluoride can rapidly cross the cell membrane and is
distributed in skeletal and cardiac muscle, liver, skin
and erythrocytes.
• Fluorosis is a major public health problem resulting
from long-term consumption of water with high fluoride
levels.
• It is characterized by dental mottling and skeletal
manifestations such as crippling deformities,
osteoporosis, and osteosclerosis.
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4. World Wide Fluoride Distribution
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5. Fluoride Contamination -India
Fluoride Contamination in
Ground Water
Most Affected:
• Rajasthan
• Gujarat
• Andhra Pradesh
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6. State Number of Districts
Assam 02
Andhra Pradesh 17
Bihar 09
Delhi 04
Gujarat All Except 1
Haryana 12
Number of
Districts Known to Jammu & Kashmir 01
be Endemic For Karnataka 03
Fluorosis in Kerala 03
Different States of
Maharashtra 10
India
(Source:Dr.Raja Reddy,2009) Orissa 03
Punjab 13
Rajasthan All Except 1
Tamil Nadu 08
Uttar Pradesh 07
West Bengal 04
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7. FLUORIDE IN GROUND WATER
• About 203 districts in 20 states of the country are
affected with fluoride contamination.
• Around 66.62 million people in these states (six
million children below the age of 14) live under this
ominous shadow
• Those suffering from fluorosis complain of fatigue
and typically the bones of the backbone, neck,
hands or legs of the affected person become fragile
and lead to deformity. It becomes difficult to stand,
run, walk or carry a load.
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8. FLUORIDE CONTAMINATION IN
BIHAR
Fluoride contaminated aquifers in dry areas of following
Districts of Bihar is confirmed:–
• Gaya
• Nawada
• Rohtas
• Katihar
• Munger
• Bhagalpur
• Jehanabad
• Aurangabad
• Jamui
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9. Clinical Outcomes of Endemic
Fluorosis
• Dental Fluorosis in Children
• Skeletal Fluorosis in Adults
• Non Skeletal Fluorosis
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10. Fluoride poisoning and the biological response
leading to ill effects depend on the following factors:
• Excess concentration of fluoride in drinking water.
• Low Calcium and high alkalinity in drinking water.
• Total daily intake of fluoride
• Duration of exposure to fluoride
• Age of the individual
• Expectant mothers and lactating mothers are the most
vulnerable groups as, fluoride crosses the placenta because
there is no barrier and it also enters maternal milk.
• Derangement in hormonal profile either as a result of fluoride
poisoning or as a cause, aggravate the disease. Important
hormones for healthy bone formation and bone function are
clacitonin, parathormone, vitamin - D and cortisone.
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11. Different fluoride doses (long term ingestion
through water) and their effects on human body
Fluoride (mg/l) Effects on human body
Below 0.5 Dental Caries
0.5 to 1.0 Protection against dental
caries. Takes care of bone
and teeth
1.5 to 3.0 Dental fluorosis
3 to 10 Skeletal fluorosis (adverse
changes in bone structure)
10 or more Crippling skeletal fluorosis
and severe osteoclerosis
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12. Dental Fluorosis
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13. Very mild fluorosis :
Opaque, paper-white areas scattered
irregularly over the tooth.
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14. Moderate fluorosis :
The enamel surfaces of the teeth show
marked wear and brown stain is frequently
a disfiguring feature.
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15. Severe fluorosis
worn areas and brown stains are wide
spread; the teeth often have a corroded
appearance.
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16. The 3 Stages of Skeletal Fluorosis
 Phase 1: sporadic pain; stiffness of joints;
osteosclerosis of pelvis and vertebral column
 Phase 2: chronic joint pain; arthritic symptoms; slight
calcification of ligaments; increased
osteosclerosis/cancellous bones; with/without
osteoporosis of long bones.
 Phase 3: Crippling Skeletal Fluorosis: limitation of joint
movement; calcification of ligaments/neck and
vertebral column; crippling deformities of spine and
major joints; muscle wasting; neurological defects/
compression of spinal cord
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17. Skeletal Fluorosis -Children of
Kachariya Dih, Nawada,Bihar
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18. Skeletal Fluorosis -Children of Kachariya Dih......
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19. Trauma of Kachariya Dih, Nawada ,Bihar
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20. Radiologic changes in bone - Fluorosis
Jaw bone shows prominent
marrow spaces
Skull bone showing thicken inner
and outer table
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Barrowing of long bone Source: Rawlani et al,2010

21. LM IMAGE
Non-skeletal Fluorosis
• Muscle degeneration is especially
interesting.
• Effect on red blood cells due to
fluoride intoxication.
• Membrane degeneration induced by SEM Image
fluoride turns erythrocytes into
“echinocytes” with a shrunken
membrane (amoeba shaped) and a
much shorter lifespan, capable of
causing severe anaemia.
• Recently it has been confirmed that
high fluoride content in body lowers
RBC cell wall changes
the IQ of children (Echinocytes)
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22. Prevention of Fluorosis
• Early detection
• Detection of source of fluoride
• Identification of factors responsible for severity
of fluorosis
• Integrating fluorosis prevention program in
health care program
• Withdraw the source of Fluoride / provision of
safe drinking water(Progression of the disease
arrested)
• To promote, supplementation of diet with
essential nutrients, vitamins & antioxidants
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23. Social cycle of disease
prevention
Implementation Survey
Fluoride
Planning Analysis
Advocacy Dissemination
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24. Community
Diagnosis
First indicator DF survey in school
 DF in Children for fluorosis mapping
 Water fluoride Followed by
 Industrial activity
 Dietary habits Water fluoride testing
Monitoring indicator for
 DF prevalence Establishing cause
 SF prevalence and effect relation
&
 Urinary fluoride prevention through
 Water fluoride safe water
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25. INTREGRATED
FLUOROSIS
MANAGEMENT AND
PREVENTION
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26. Prevention of Fluorosis
 Placing fluorosis on health agenda
 Early detection
 Detection of source of fluoride
 Identification of factors responsible
for severity of fluorosis
 Integrating fluorosis prevention
program in health care program
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27. WATER
PANCHAYAT HEALTH
f
AGRICULTURE EDUCATION
INDUSTRY
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28. HEALTH
SERVICES
Intra MEDICAL
IEC
SERVICES
sectoral
MEDICAL
EDUCATION
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29. Provision of safe drinking water
Possibility I
Safe and unsafe drinking water co-existing and
how to go about?
Possibility II
Only unsafe water / fluoride contaminated water
existing and then how to go about.
Other possibilities:
• If a perennial river flowing through the
state, infiltration wells can be dug in the river
bed – location based strategy (Water Supply
Agencies deal with such issues)
• Rain Water Harvesting
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30. Hi-tech de-fluoridation plant…….kaput
as usual
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31. Water supply
• Water conservation and recharging
• Water chemistry monitoring
• Early detection and timely sustained
action
• Planning with irrigation and
agriculture
• Planning with industry
• Converge with health activities
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32. Alternate Source for Fluoride Free Water –
Open Water Bodies – Ponds,Lakes,etc
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33. Construction of Rain Water Harvesting
Structures for:
• Roof top rainwater harvesting (for domestic consumption)
• Artificial rainwater harvesting (to increase recharge to dilute
groundwater)
• Recharge of bore wells (to dilute groundwater)
• Direct aquifer recharge (to dilute groundwater)
• Farm ponds (to increase recharge to dilute groundwater)
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34. Rain Water Harvesting
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35. Rain Water Harvesting
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36. Artificial Catchements
The colour of water is the colour of sky !!!!!!!
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37. Artificial Farm Ponds
The colour of water is the colour of the earth
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38. Open Dug Well
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39. Defluoridation of Water
2
A Terracotta domestic
1 filter for removal of
fluoride
(Activated Alumina System )
Nalgonda – Bucket treatment
• From the existing safe water sources in
the village, the water can also be stored 3
in an overhead reservoir.
• From the reservoir water can be supplied
through a central stand post with
multiple taps.
4 Reverse Osmosis though expensive is available
as Domestic Filters
Reverse Osmosis Technology (RO Filter) is the only technology
5 which would remove fluoride and other chemical contaminants
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40. 4 Stage Adsorption Filteration
4 stage
Adsorption Water
filters remove
fluoride, chlorine
and heavy
metals using
KDF carbon GAC
and activated
alumina.
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41. 5 Stage RO Domestic Filter
• 5 Stage Reverse Osmosis Water
Filter with a storage tank.
• It can purify 50 gallons of water/day
• This filter removes chlorine and
heavy metals such as chromium and
cadmium.
• The storage tanks are very useful
because it can be filtering your water
constantly so that you don’t run out.
• When the storage tank is full, it has
an automatic close off valve that
stops the filtering process so water
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42. Double Reverse Osmosis System
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43. These Do NOT Remove Fluoride
• Brita, Zero B, Aquaguard, and most other filters.
• Some websites about fluoride removal state
otherwise, but I checked the products in my lab to
confirm that fluoride is left in the water.
• Boiling Water -This will concentrate the fluoride
rather than reduce it.
• Freezing Water - Freezing water does not affect
the concentration of fluoride.
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44. Health Department
• Sensitization workshop for Policy makers
• Skill development- trainings
• Development of diagnostic facility
• Fluorosis Mapping – school Health
• Fluoride Mapping-Water supply
• High endemic area - Calcium supplementation - along
with Diet counseling
• Diagnosis and treatment of cases at treatment facility
• IEC and BCC
• Monitoring
• Intersectoral co ordination
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45. Supplementation
• Supplementation of Calcium to Pregnant
and breast feeding women
• During 7th, 8th and 9th month of pregnancy
and 1st month of PP
• Calcium tablet 500 mg per day
Iodised salt to ANC and BF women
Vit.A supplement to PNC
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46. Information Education Communication/ Behavior
Change Communication (IEC/ BCC)
• State health IEC action plan includes Fluorosis
• Health and water board – common message
• Mass media to inter personal communication
• Fluorosis manifestations
• Sources of fluoride
• Prevention of fluorosis
• Dietary precautions
• Importance of supplementation for Antenatal
Care (ANC) & Postnatal Care (PNC)
• Centers with diagnostic and treatment
facilities
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47. School Intervention (Education
Department)
• Detection through health check up
• Mapping of problem
• Safe drinking water supply at schools
• Nutrition counselling at schools
• Supplementation at schools (Calcium
& Vit.C)
• Safe water supply (Processed) for
Village
• Training of school children
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48. Agriculture and Irrigation
intervention
• (Primary Prevention)
Use of low fluoride containing water for
irrigation
• Drip irrigation promotion
• Soil chemistry study and Calcium ,Ph
balancing
• Monitoring
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49. Health Indicators of Effective
Fluorosis Control
• Children born after program are free from DF
• No new case of crippling SF
• Community gets relief from pains, aches and stiffness of
joints
• Physical efficiency improves
• Foetal wastage rate declines
• Renal stone rate declines
• Bone fracture rate declines
• Cardiac problem indicative of artery blockage rate
declines
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50. Treatment of Fluorosis !
• Using DF as a epidemiological warning
• NSF (Nephrogenic Systemic Fibrosis) diagnosis through
systematic screening
• Early skeletal fluorosis detection
• Adequate Calcium, Vitamin C & Anti oxidant intake can
protect from early and severe form of skeletal fluorosis
• Ortho corrections
• Surgical corrections are some times possible but that is
not a treatment it is a relief
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51. Treatment of Skeletal Fluorosis !
• Skeletal fluorosis is irreversible and
un treatable
• If early detection is done further progress
can be prevented
• Surgical corrections are some times possible
but that is not a treatment it is a relief
• Adequate calcium intake can protect from
early and severe form of skeletal fluorosis
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52. Diet and Nutrition Education
All level of Prevention
• Education about high Fluoride containing food
articles
• Education about inclusion of food articles rich
in Calcium and antioxidents
• Educating for food fluoride in Ready to eat /
packed food
• Education for need of Iodised salt in Fluorosis
affected regions
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53. Why antioxidants are promoted?
Antioxidants are phytochemicals
Scavengers and removes free radicals
Protects the body from diseases
Pharmaceutical products are not
recommended; Antioxidant intake through
dietary sources are promoted
Recovery is rather rapid
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54. To consume more of calcium and iron rich
items:Dairy products and vegetables
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55. Vitamin C
• Amla
• Amrud
• Lemon
• Oranges,
• Tomato,
• Coriander leaf &
other GLV
• Sprouted pulses
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56. Vegetables and fruits rich in antioxidants :
(1) Papaya, (2) Carrot, (3) Pumpkin, (4)Palak and
other leafy vegetables, (5) Garlic, (6) Spring onion,
(7) Chilly (8) Pepper, (9) Apple, (10) Cherry, (11)
Oranges (12) Ginger etc
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57. List of antioxidants
1. β – carotene in: ● Papaya ● Carrot ● Pumpkin ●Mango and ● Sweet
Potato.
2. Glutathione: Spinach (palak) and other leafy vegetables
3. Quarcetin: White Onion
4. Allicin: ● Garlic, ● Onion, ● Spring Onion ● Leek
5. Capasaicin: ● Chilly, ● Pepper
6. Ellagic acid: ● Apple, ● Cherry, ● Orange, ● Strawberrie
7. Gallic acid and Epicatechin: Cocoa.
8.*Lycopene : ● Tomatoes , ● Pink Guava, ● Watermelon, ● Red
papaya and ● Palm oil * [ Protects osteoblasts ]
9. Sulphoraphane: ● Broccoli, ● Cabbage, ● Brussels sprouts and
● Cauliflower [ideal for breast cancer patients
also]
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58. 58
Snacks with rock salt
Daalmoth
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59. Steps to Reduce Fluoride Exposure
• Don't take fluoride supplements.
• Read labels on bottled beverages -Unless they are made
using distilled or reverse-osmosis water, they are
probably made with fluoridated public water.
• Consider using unfluoridated toothpaste.
• Avoid drinking black or red tea -There are many health
benefits associated with chemical compounds found in
tea, but this may be a beverage to avoid if you need to
reduce your fluorine intake. Black and red tea come
from two different types of plants, but both leaves
naturally contain high amounts of fluorine.

60. Steps to Reduce Fluoride Exposure……..
• Be wary of tinned fish and canned food items -
Fluoride may be used as a preservative.
• Avoid black or red rock salt or items containing black
or red rock salt.
• Avoid using chewing tobacco.
• Avoid long term use of medication that contains
fluorine.
• Certain antidepressants and medications for
osteoporosis contain fluorine.

61. Thanks