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-SEMINAR- DATE-28/01/2014

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ENDEMIC FLUOROSIS

Presented byDr.Sachin ShekdeJR1.

DEPT OF COMMUNITY MEDICINE GMC,LATUR

Guided by Dr.Balaji Ukarande Assist. Professor

CONTENTS• 1.Introduction of fluorine and fluorides.• 2.Worldwide distribution of endemic fluorosis.• 3.Fluorosis in India.• 4.Sources of fluoride.• 5.Definition of fluorosis.• 6.Types of fluorosis.• 7.Prevention and control of fluorosis.• 8.Defluoridation.• 9.Goals of NPPCF.• 10.Guidelines of MoHFW.• 11.Summary.• 12.References.

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INTRODUCTION• Fluorine is the 13th most abundant naturally occurring

element in the Earth’s crust.

• It is the lightest member of the halogens.

• It is the most electronegative and reactive of all the

elements and as a result, elemental fluorine does not occur in nature but found as a fluoride mineral complexes.

• Fluorine is more reactive than chlorine> bromine> iodine.

• Fluorine is essential for mineralization of bones & formation of dental enamels

• 96% of fluoride of body found in bones & teeth.

• Normally small amount of fluoride is required (0.5 to 0.8 mg/lit) in drinking water.

• Fluorine is often called as two-edged sword.

• Prolonged ingestion of fluoride through drinking water in excess of the daily requirement is associated with dental and skeletal Fluorosis.

• Similarly, inadequate intake of fluoride in drinking water is associated with dental caries.

• World Health Organization (WHO) has set the upper limit of fluoride concentration in drinking water at 1.5 mg/l .

• The Bureau of Indian Standards, has therefore, laid down Indian standards as 1.2 mg/l as maximum permissible limit of fluoride with further remarks as “lesser the better” .

• Intake of fluoride higher than the optimum level is the main reason for dental and skeletal fluorosis .

Permissible limit of fluoride in drinking water

Name of organisation Desirable limit (mg/L) Bureau of Indian Standards (BIS) 0.6-1.2

Indian Council of Medical Research (ICMR) 1.0

The Committee on Public Health Engineering Manual and Code

of Practice, Government of India 1.0

World Health Organization (International Standards for

Drinking Water) 1.5

• Fluorosis is an important public health problem

in 24 countries, including India, which lies in the

geographical fluoride belt that extends from

Turkey to China and Japan through Iraq, Iran

and Afghanistan .

• Of the 85 million tons of fluoride deposits on the

earth’s crust, 12 million are found in India .

Hence it is natural that fluoride contamination is

widespread, intensive and alarming in India.

WORLDWIDE DISTRIBUTION

• Worldwide in distribution.• Endemic in 22 countries. • Asia and in Asia,India and China are worst

affected.• Mexico in North and Argentina in Latin

America.• East and North Africa are also endemic.

UNICEF Map of Fluorosis

FLUOROSIS IN INDIA

• Endemic fluorosis is prevalent in India since 1937 .

• It has been estimated that the total population

consuming drinking water containing elevated levels

of fluoride is over 66 million .

• Endemic fluorosis resulting from high fluoride

concentration in groundwater is a public health

problem in India .

• The available data suggest that 15 States in India are endemic for fluorosis (fluoride level in drinking water >1.5 (mg/l) .

• about 62 million people in India suffer from dental, skeletal and non-skeletal fluorosis.

• Out of these; 6 million are children below the age of 14 years .

• Throughout India fluorosis is essentially

Hydrofluorosis except in parts of Gujarat and

U.P. where industrial fluorosis is also seen.

• In worst affected states, maps have been

prepared of geographic pathology on the basis

of fluoride distribution in the drinking water.

Fluoride Levels in Indian States• Andhra Pradesh: 0.4 - 29.0 mg/L• Assam : 1.6 - 23.4 mg/L• Bihar: 0.2 - 8.32 mg/L• Chhattisgarh: information awaited• Delhi: 0.2 - 32.0 mg/L• Gujarat: 1.5 - 18.0 mg/L• Haryana: 0.2 - 48.32 mg/L• Jammu & Kashmir: 0.5 -4.21 mg/L• Jharkhand: 0.5 - 14.32 mg/L• Karnataka: 0.2 - 7.79 mg/L

Fluoride Levels in Indian States

• Kerala: 0.2 - 5.40 mg/L• Madhya Pradesh: 1.5 - 4.20 mg/L• Maharashtra: 0.11 - 10.00 mg/L• Orissa: 0.6 - 9.2 mg/L• Punjab: 0.4 - 42.0 mg/L• Rajasthan: 0.10 - 10.0 mg/L• Tamil Nadu: 0.1 - 7.0 mg/L• Uttaranchal: information awaited• Uttar Pradesh: 0.2 - 25.0 mg/L• West Bengal : 1.1 - 14.47 mg/L

• Rajasthan and Gujarat in North India and Andhra

in South India are worst affected.

• Punjab, Haryana, M.P. and Maharashtra are

moderately affected.

• T.N.,W.B.,U.P.,Bihar and Assam are mildly

affected.

• 70-100% districts are affected in Andhra Pradesh, Gujarat and Rajasthan.

• 40-70% districts are affected in Bihar, National Capital Territory of Delhi, Haryana, Jharkhand, Karnataka, Maharashtra, Madhya Pradesh, Orrisa, Tamil Nadu and Uttar Pradesh

• 10-40% districts are affected in Assam, Jammu & Kashmir, Kerala, Chhattisgarh and West Bengal. While the endemicity for the rest of the states is not known.

• Maharashtra : The 10 districts endemic for Fluoride / Fluorosis are:

• Bhandara • Chanderpur• Buldhana • Jalgaon • Nagpur • Akola • Amravati • Nanded • Solapur • Yavatmal

Fluorosis affected Districts in the State

Sources of Fluoride

• Contaminated ground water is the main source.

• Contaminated drinking & cooking water, agricultural & food products, drugs and industrial emissions & pollutants

• The main source of fluoride in groundwater is the rocks which are rich in fluoride.

• Most of the people affected by high fluoride concentration in groundwater live in the tropical countries where the per capita consumption of water is more because of the prevailing climate.

Sources of fluoride for human exposure

Main sources of fluoride :

• Water

• Food

• Air

• Medicament

• Cosmetic

Fluoride Rich Dental Products

• Fluoridated toothpaste

• Mouth rinse

• Varnish

• Sodium fluoride tablets

• Primarily it is Fluoride which is present in

drinking water .

• when F in water is more than 1.5 mg per

litre, it is toxic to health .

• pH in terms of alkalinity of water promotes

the absorption of F .

AGENT FACTORS

• calcium in the diet reduces the absorption of F .

• Hard water rich in Calcium reduces the F toxicity .

• Fresh Fruits and Vit.C reduces the effect of F .

• Trace elements like Molybdenum enhances the effect of F .

• In School going children seen as dental

fluorosis.

• In third and fourth decade of life seen as

Skeletal Fluorosis.

• Males suffer more than females.

• Illiterates suffer more frequently in the

fluorotic belts.

Host Factors

• High Annual Mean Temperature.

• Low Rainfall.

• Low humidity.

• F rich Natural subsoil rocks.

• Vegetables from high F belts.

• Fluoridated tooth paste particularly when used by

children.

• Tropical climate.

• Developing Countries.

Environmental Factors

Fluoride Concentration (mg/l)Fluoride ( mg/l) Source Effects0.002 Air Effect on plants

1.00 Water Prevention of Dental caries

>=2 Water Effect dental enamel >=8 Water Effect Bones and

muscles

>50 Food, Water Changes in Thyroid

(>100 Food, Water Defective development

>120 Food, Water Changes in Kidney

What is Fluorosis ?

• Fluorosis is a major public health problem caused by intake of excess amount of fluorides over a long period resulting permanent and irreversible damages.

• Fluorosis is a disease caused by deposition of fluorides in the hard and soft tissues of the body.

• It is not merely caused by excess intake of fluoride but there are many other attributes and variables which determine the onset of fluorosis in human population.

• It is usually characterized by discoloration of teeth and crippling disorders.

Types of Fluorosis

Dental Skeletal Non Skeletal

DENTAL FLUOROSIS

• Tooth enamel is principally made up of hydroxyapatite (87%) which is crystalline calcium phosphate .

• Fluoride which is more stable than hydroxyapatite displaces the hydroxide ions from hydroxyapatite to form fluoroapatite.

• Fluorosis of dental enamel occurs when excess fluoride is ingested during the years of tooth calcification essentially during the first 7 years of life .

• It is characterised by "mottling" of dental enamel, which has been reported at levels above 1.5 mg/L intake.

• The teeth loose their shiny appearance and chalk-white patches develop on them.

• This is the early sign of dental fluorosis.

• Later the white patches become yellow and sometimes brown or black.

• In severe cases, loss of enamel gives the teeth a corroded appearance. Mottling is best seen on the incisors of the upper jaw.

• It is almost entirely confined to the permanent teeth only during the period of formation.

• In endemic zones, people lose their teeth at an early age and may become edentate.

• Several classifications have been proposed to assess the severity of dental fluorosis.

• Dean’s based his classification on the clinical appearance of the enamel, and it varied from normal to severe.

DENTAL FLUOROSIS SCALE(Dean’s index)

• Normal Enamel (0): Enamel smooth, glossy, pale creamy white translucency

• Questionable fluorosis (0.5): Slight aberrations from translucency with occasional white fleck or spots

• Very mild fluorosis (1) :Small, opaque, paper-white areas involving less than 25% of the surfaces of the two most affected teeth; may acquire brown stains in adulthood

• Mild fluorosis (2) :More extensive dull white opacities involving less that 50% of the surfaces of the two most affected teeth

• Moderate fluorosis (3): All enamel surfaces affected; distinct brown staining frequent

• Severe fluorosis (4): Teeth show marked hypoplasia , attrition and pitting; brown or black staining widespread.

DENTAL FLUOROSIS

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Brown wavy striations on teeth/sever mottling

DENTAL FLUOROSIS

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• To determine the severity of dental

fluorosis as a public health problem, Dean

devised a method of calculating the

prevalence and degree of severity in a

community, which he termed the

community fluorosis index (CFI).

• The Community Fluorosis Index (CFI) is a way of measuring the burden of dental fluorosis in a population.

• Instead of just measuring the overall prevalence of fluorosis (i.e., what percentage of people have fluorosis ).

• The CFI is thus a measurement of both prevalence and severity.

How the CFI Is Calculated ?

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

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

• When the CFI was <0.4, Dean’s considered it of

little or no public health concern.

• while indices between 0.4 and 0.6 were

borderline, and the removal of excess fluoride

was indicated when the CFI was >0.6.

• Hence, a CFI of 0.6 sets the upper limit of fluoride

concentration for aesthetic reasons. Dean's index

is based upon the clinical appearance only.

SKELETAL FLUOROSIS

• Associated with lifetime daily intake of 3.0 to 6.0 mg/l or more.

• It affects young as well as old.

• The symptoms include severe pain and stiffness in

the backbone,joints and/or rigidity in hip bones.

Common Causes of skeletal Fluorosis

• Fluoridated Water for Kidney Patients• Excessive Tea Consumption• High-Fluoride Well Water (more likely to be a

factor among deep wells)• Industrial Fluoride Exposure• Fluorinated Pharmaceuticals (Voriconazole &

Niflumic Acid)• Indoor coal burning (a common practice in

China).

SKELETAL FLUOROSIS

• When a concentration of 10 mg/L is exceeded, crippling

fluorosis can ensue. lt leads to permanent disability.

• X-ray examinations of the bones reveals thickening and

high density of bones.

• In some patients with calcium deficiency osteomalacia

type changes are seen.

• Constriction of vertebral canal and intervertebral foramen

- pressure on nerves leads to paralysis.

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• There may be sclerosis of spine, pelvis and limbs. The ligaments of spine may be calcified, producing a ‘poker back’.

• The tendinous insertion of muscles may be ossified, producing the characteristic ‘rose thorn’ shadow in the X-Ray.

Stages: Skeletal Fluorosis

Preclinical Stage : • the patient feels no symptoms • but changes have taken place in the body• Biochemical abnormalities occur in the blood

and in bone composition • Histological changes can be observed in the

bone in biopsies

Second clinical stage

• Constant pains in the bones, ligaments begin to calcify.

• Osteoporosis may occur in the long bones, and

• early symptoms of osteosclerosis Bony spurs may appear on the limb bones, especially around the knee, the elbow, & on the surface of tibia and ulna.

Advanced skeletal fluorosis

• Extremities become weak and moving the

joints is difficult.

• The vertebrae partially fuse together, crippling

the patient.

A VICTIM OF SKELETAL FLUOROSIS WITH STIFFNESS OF NECK AND SPINE

Skeletal Fluorosis

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Skeletal Fluorosis

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Skeletal Fluorosis

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GENU VALGUM

• A new form of fluorosis characterised by genu valgum and

osteoporosis of the lower limbs has been reported in recent

years in some districts of Andhra Pradesh and Tamil Nadu.

• The syndrome was observed among people whose staple

was sorghum (jowar).

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GENU VALGUM

TESTS FOR SKELETAL FLUOROSIS• COIN TEST: The subject is asked to lift a coin

from the floor without bending the knee. A fluorotic subject would not be able to lift the coin without flexing the large joints of lower extremity.

• CHIN TEST: The subject is asked to touch the anterior wall of the chest with the chin. If there is pain or stiffness in the neck, it indicates the presence of fluorosis.

• STRETCH TEST:

The individual is made to stretch the arm sideways fold at elbow and touch the back of the head. When there is pain and stiffness, it would not be possible to reach to the occiput indicating presence of Fluorosis.

NON-SKELETAL FLUOROSIS

• There are convincing evidence of involvement

of skeletal muscles, erythrocytes, G-I mucosa,

ligaments and spermatozoa on consuming more

than optimal intake of fluorides.

• Detection of Fluorosis at early stage is possible

by understanding the soft tissue manifestation.

• In the fluorosed muscles,actin and myosin

filaments are destroyed and mitochondria lose

their structural integrity thereby providing

evidence of depletion of muscle energy.

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• The erythrocyte membrane loses its calcium content

in presence of high fluoride.

• Non-ulcer dyspeptic complaints are manifested by

consuming high F in water and food.

• Infertility due to oligospermia and azoospermia is

commonly seen in fluorotic belts.

Non Skeletal fluorosis

Neurological Manifestations

1. Nervousness & Depression

2. Tingling sensation in fingers and toes

3. Excessive thirst and tendency to urinate

Frequently ( Polydypsia and polyurea )

4. Control by brain appears to be adversely affected.

2. Muscular manifestations

• Muscle Weakness & stiffness

• Pain in the muscle and loss of muscle power

3. Urinary tract manifestations

• Urine may be much less in volume Yellow red in colour

• 3. Allergic manifestation Skin rashes Perivascular inflammation. Pinkish red or bluish red spot, round or

oval shape on the skin that fade and clear up within7-10 days.

5. Gastro - intestinal problem • Acute abdominal pain • Diarrhoea • Constipation • Blood in Stool • Bloated feeling (Gas) • Tenderness in Stomach • Feeling of nausea

PREVENTION AND CONTROL

• Flurosis Can be prevented or minimized.. by using alternative water sources. • by removing excessive fluoride from drinking

water. • by improving the nutritional status of

populations at risk.

Alternative water sources

• These include surface water, rainwater, and low-fluoride groundwater.

• Surface water : Surface water should not be used for drinking without treatment and disinfection.

Rainwater• Rainwater is usually a much cleaner water

source and may provide a low-cost simple solution.

• The problem, however, is limited storage capacity in communities or households.

• Large storage reservoirs are needed because annual rainfall is extremely uneven in tropical and subtropical regions. Such reservoirs are expensive to build and require large amounts of space.

• Low-fluoride groundwater:• Fluoride content can vary greatly in wells in the

same area, depending on the geological structure of the aquifer and the depth at which water is drawn.

• The fact that fluoride is unevenly distributed in ground water, both vertically and horizontally, means that every well has to be tested individually for fluoride in areas endemic for fluorosis:

DE-FLUORIDATION

• “De-fluoridation is the process of removal of excess fluoride from water.”

• The defluoridation methods are divided into three basic types depending upon the mode of action :

• Based on kind of chemical reaction with fluoride: Nalgonda technique .

• Based on adsorption process: Bone charcoal, processed bone, tricalcium phosphate, activated carbons, activated magnesia, tamarind gel, serpentine, activated alumina, plant materials .

• Based on ion-exchange process: Anion/Cation exchange resins

• Filtration:• Reverse Osmosis Filtration• Activated Alumina Defluoridation Filter• Distillation Filtration

• There are basically two approaches for treating water supplies to remove fluoride:

• Flocculation• adsorption.

Flocculation• National Environmental Engineering Research Institute

(NEERI), Nagpur has evolved an economical and simple method for removal of fluoride which is referred as NalgondaTechnique.

• Nalgonda Technique involves addition of Aluminium

salts, lime and bleaching powder followed by rapid mixing, flocculation, sedimentation, filtration and disinfection.

NALGONDA Technique Water Treatment

• water mixed with aluminium sulphate (alum), lime or sodium carbonate ( 1/20 th of alum) and bleaching powder ( 3 mg/l) .

• Stir water slowly for 10-20 minutes and allow to settle for nearly one hour.

• Supernatant is withdrawn.

• Discard the sludge.

Adsorption• The other approach is to filter water down

through a column packed with a strong adsorbent, such as activated alumina (Al2O3), activated charcoal, or ion exchange resins.

• This method, too, is suitable for both community and household use.

Better nutrition:• adequate calcium intake is clearly associated

with a reduced risk of dental fluorosis. • Vitamin C may also safeguard against the risk.

Fluoride Containing Items to be avoided:

• Dental Products• Fluoridated Toothpaste • Fluoridated Mouth rinses • Fluoridated Varnish • Fluoridated swabs

Fluoride Containing Items to be avoided• Drugs• Antidepressants viz, Citalopram, Escitalopram, Paraxetine and

Prozac . • Antiinfective drugs viz.Fluoroquinolones (Ciprofloxacin,

Moxifloxacin, and Gatifloxacin). • Anti-cholesterol drugs require fluorinated intermediates for their

synthesis viz. Atorvastatin and Fluvastatin. • Sodium fluoride by itself is also prescribed for Otosclerosis and

Osteoporosis.

• Homeopathy drugs also contain fluoride.

Fluoride Containing Items to be avoided

Industrial Emission / Occupational Exposure• Hydrofluoric acid, fumes and fluoride dust

from industries.• Working with Lasers (laser equipment) • Working in Libraries, Archives where sodium

fluoride sprayed to save books from insects.

Steps to Reduce Fluoride

• Avoid Fluoride Rich Food Substances • Black tea and Lemon tea (tea with milk is safe);• Black rock salt ( kala namak ); • Black rock salt lased pickles, Garam masala ,

salty snacks, Chaat and Chaat masala Canned fruit juices

• Chewing of tobacco Supari ( arccanut ) and “ Hajmola ” and other “ Churan ” containing rock salt.

Fluoride Containing Items to be avoided

GOAL OF NPPCF

• Goal of National Programme for Prevention and Control of Fluorosis (NPPCF):

To prevent and control fluorosis cases in the country.

Objectives of NPPCF

• To collect & use baseline survey data of

fluorosis.

• Comprehensive management of fluorosis in

endemic areas.

• Capacity building for prevention, diagnosis &

management of fluorosis cases.

Mitigation of Fluorosis

• Closing contaminated water source.

• Arranging alternative safe water source.

• Rain & surface water harvesting for agriculture & household.

• Supply of pipeline river water from water treatment plant.

Mitigation of Fluorosis

• Enhanced surveillance, early detection, proper treatment &

rehabilitation Training of field level health personnel.

• Capacity building of District Hospitals & Medical Colleges.

• Laboratory support development in District Hospitals &

Medical Colleges.• Health education, dietary counseling & nutrition.

• Dietary supplementation of calcium, vitamin C, D3 & iron

GUIDELINES FOR COMPREHENSIVE MANAGEMENT OF FLUOROSIS CASES

• Early Detection –a) Dental Changesb) Pain & Stiffness of peripheral jointsc) Deformities of lower limb• Prompt Intervention –a) Health Educationb) Preventive Measuresc) Treatmentd) Rehabilitation

DISTRICT LEVEL ACTIVITIES

• Training of MO for Management of Cases.

• Training of Dist staff, ICDS & Educational Personnel.• Fully Equipped Lab.

• Diagnostic support for all kinds of Fluorosis.• Monitoring.

• Basic medical, surgical & rehabilitative activities for diagnosed cases by dist level specialist.

• Referral of difficult cases to near by Medical College.

COMMUNITY (VILLAGE LEVEL ACTIVITIES)

• Provisional community diagnosis• Verification of Community Diagnosis by PHC

Doctors.• Line listing of sources reduction activity,

Reconstructive Surgery Cases, Rehabilitative Intervention activities, local action & referral.

• Appropriate IEC.• Inter-sectoral Co-operation.• Measures for prevention and health promotion.

ACTIVITIES UNDER NPPCF CELL

• IEC material Development.

• Suggestions for abandoning Fluoride affected drinking

water sources.

• Urine analysis going on of suspected cases in affected

villages.

• Training Programme.

• Fluorosis confirmatory diagnosis camp at RH in

respective blocks.

To do…

• Cooperation & coordination of all- District Health Officer, District Health Lab, Water quality department, Village panchayat, Taluka Health Officers, Medical Officers, Paramedical staff to prevent this irreversible diseases by detection, diagnosis, referral and management of affected community people.

LATUR DISTRICT SCENARIO• 2005-06 Report found 21 fluoride

contaminated sources. • All sources has alternates available at present

& are below 1.5 ppm.• 2012-2013 Chemical water analysis campaign

at District health lab revealed - Out of 3373 Samples tested, 17samples have fluoride level >1.5 ppm

• Ahmadpur = 6, Nilanga=1, Renapur=2, Udgir=8

Sr. No. Taluka Target Received TestFloride Above 1.5

Ionometer Results above 1.5

1 Ahmadpur 940 351 351 21 6

2 Ausa 975 368 359 0 0

3 Chakur 635 419 419 18 0

4 Deoni 386 165 165 0 0

5 Jalkot 335 230 230 3 0

6 Latur 1071 413 413 7 0

7 Nilanga 1247 360 359 5 1

8 Renapur 794 383 383 25 2

9 Shirur A 412 161 157 1 0

10 Udgir 757 523 522 37 8

Total 7552 33733358 117 17

Taluka wise List of drinking water source status having Fluoride Above Permissible Limit

TAKE HOME MESSAGES

• Fluorosis is preventable disorder• Fluorosis is not an infectious disease and it’s clinical effects are seen after a long period of high fluoride consumption. • Checking drinking water source is essential for good general health and proper development• Dietary management is easiest and cost effective way for Fluorosis cases to reduce fluoride level. • Dental fluorosis is easy to detect & helps us to arrest the further skeletal effects with interventions. • Health Education & promotion are important at community level.

THESE METHODS DO NOT REMOVE FLUORIDE

• 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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SUMMARY

• Fluorosis is a public health problem caused by excess intake of fluroide >1.0 ppm through drinking water/food products/industrial pollutants over a period of time.

• It is permanent and irreversible harmful disease effect on the health of an individual and the community,which in turn has an impact on growth, development, economy and manpower of the country.

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• There has been remarkable increase in the incidence of fluorosis in the entire country.

• There is no effetive treatment for the fluroide related disorders, prevention and control is the most effective measures for the same.

Please Save water and Use it Appropriately for us and our next

generations

THANK YOU 108

references• 1) Parks textbook of Preventive and Social Medicine by k.park.22nd edition p.595-96• 2) J. Kishore National Health Programmes of India 10th edition p-586-87• 3) I J Res Dev Health, April 2013vol.1(2)(ijrdh) by Arlappa N et al .(www.IJRdh.com)• 4) The National Medical Journal of India vol.12 no 3 ,1999 by S.P.S Teotia . Dept of

medicine ,L.L.R.M medical college , Meerut. U.P• 5)Susheela A.K. Fluorosis : India scenario : A treatise on fluorosis . Fluorosis research and

rural development foundation : New Delhi India.• 6) Journal of Chemical and Pharmaceutical Research 2009,1(1):31-37. by Tiwari et. al.• 7) http://article novapublishers.com /catalouge/product_info php? Product id-15895.• 8) Guidelines for surveillance of fluorosis in community by dept. of health and family

welfare, Govt of India, 2012-2013.• 9) Indian journal of Paediatrics. Sept 2013: 80(9)713-715 by A.K. Susheela.• 10)Textbook of public health and community medicine.A.F.M.College.pune P.768-

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Dental Fluorosis

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Skeletal Fluorosis

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Skeletal Fluorosis

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Skeletal Fluorosis

Skeletal Fluorosis

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Skeletal Fluorosis

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