|Year : 2010 | Volume
| Issue : 1 | Page : 1-6
Dental fluorosis and its association with the use of fluoridated toothpaste among middle school students of Delhi
Poornima Tiwari, Suminder Kaur, Alka Sodhi
Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
|Date of Web Publication||31-Jan-2012|
Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
Introduction: Fluorosis can manifest as dental fluorosis (seen mostly in secondary dentition), skeletal fluorosis, and systemic fluorosis. Groundwater with high fluoride concentrations, diet rich in fish and tea, indoor air-pollution, and use of fluoride toothpastes may contribute considerably to total exposure. Objective: To assess the prevalence of dental fluorosis and associated factors particularly fluoridated toothpastes, among middle school children of a resettlement colony in Delhi. Materials and Methods: This survey was conducted among the middle school students (VI th -VIII th ) studying in three government schools of Sangam Vihar, South Delhi. Students were examined for dental fluorosis by experts. A pre-structured questionnaire was used to obtain data regarding age, source of drinking water, toothpaste used, etc. Height, weight, and hemoglobin were recorded. Two repeat visits were made. Out of 432 students enrolled in these schools, 413 students were examined. Statistics: Descriptive and chi-square statistics were used. Results: Dental fluorosis was prevalent in 121 (29.3%) study subjects. It was significantly more in children of age 13 years or above, in those who used fluoridated toothpaste for dental cleaning (P=0.033) and in anemic children (P<0.001). However, there was no significant association of disease with gender (P=0.02), source of drinking water (P=0.417), and with BMI (P=0.826). Conclusion: As dental fluorosis is very common (in about one-fourth) among the middle school children, in this resettlement colony of Delhi, various control measures e.g. discouraging the fluoridated toothpastes, educating parents about fluorosis, de-fluoridation of water in the high risk areas, etc may help to tackle this situation.
Keywords: Dental fluorosis, fluoridated toothpaste, middle school
|How to cite this article:|
Tiwari P, Kaur S, Sodhi A. Dental fluorosis and its association with the use of fluoridated toothpaste among middle school students of Delhi. Indian J Med Sci 2010;64:1-6
|How to cite this URL:|
Tiwari P, Kaur S, Sodhi A. Dental fluorosis and its association with the use of fluoridated toothpaste among middle school students of Delhi. Indian J Med Sci [serial online] 2010 [cited 2013 May 18];64:1-6. Available from: http://www.indianjmedsci.org/text.asp?2010/64/1/1/92481
| ¤ Introduction|| |
The term "Fluorosis" describes a state of toxicity of the trace element, fluorine within an organism. Fluorosis in ancient peoples was limited to Active Volcanic Areas, Coastal Areas, and Arid Areas. From the late 18th century onwards, the history of fluorosis in the ecosystem becomes less and less "natural."  Groundwater with high fluoride concentrations can be found in many areas of the world, including large parts of Africa, China, Mexico, the Middle East, and southern Asia (India, Sri Lanka). 
The City of Delhi - capital of India - is also suspected as endemic for fluorosis. This is because as against the permissible limit of 1.00 ppm, the level of fluoride in drinking water ranges from 1.1 to 32.46 ppm. The incidence of fluorosis may be high in South, South-West, West, and North-West Districts of Delhi.  With one-third of Delhi's groundwater laced with excessive fluorides, the number of people falling prey to fluoride poisoning is increasing.  In specific areas, diet containing fish and tea, indoor air-pollution, and use of fluoride toothpastes may contribute considerably to total exposure. 
Generally speaking, human fluoride toxicity will manifest as any combination of dental fluorosis: the most obvious and easily diagnosed form of fluorosis by a characteristic bilateral white mottling of the dentition caused by over-exposure to fluoride when the dental enamel is actively mineralizing during early childhood (seen mostly in the secondary dentition), skeletal fluorosis, and systemic fluorosis.  Changes induced in teeth as well as bones are irreversible and they do not resolve on removing in cause or by any other treatment, once they have manifested. Therefore, the crux of the problem is early detection. 
There have been very few studies of fluorosis in Delhi. So, the present study was planned to assess the prevalence of dental fluorosis and associated factors particularly fluoridated toothpastes, among middle school children of a resettlement colony in Delhi.
| ¤ Materials and Methods|| |
This survey was conducted among the middle school students studying in three government schools located in Sangam Vihar, which is a resettlement colony in the South district of Delhi.  As secondary dentition starts developing by 6 years of age and is almost complete by 12 years of age,  middle school children (class VI-VIII, i.e. approximate age 12-14 years) were selected as study subjects for this survey on dental fluorosis.
Permission was taken from the principals of the three schools. The teachers were informed about the visit. Clearance was taken from the ethical committee of the institution.
On the day of the visit, the students in the classes (VI th to VIII th ) were examined in broad day light for the presence of dental fluorosis. The examination was carried out by experts, specially trained for the diagnosis of dental fluorosis at the dental OPD of a tertiary hospital in Delhi for 2 days.
A pre-structured questionnaire was used to obtain data regarding age, source of drinking water, use of toothpaste, etc. The height and weight of each child was recorded simultaneously by the examiner. Height was measured to the nearest 1 cm by using a standardized measuring scale put against a straight wall. Weight was measured by use of a standardized weighing machine to the nearest 0.5 kg. Then, body mass index (BMI) was calculated.
After this, a lab technician collected blood sample by finger prick under aseptic conditions from each student and performed hemoglobin (Hb) estimation by using Sahli's hemoglobinometer. Those with Hb level below 12 gm% were classified as anemic. 
Two repeat visits were made on the following days to each class so as to examine those who were absent during previous visits. A total of 432 students were enrolled in these three schools and the number of students who were examined in this study was 413, i.e. 95.7%. All the students diagnosed to be having dental fluorosis or anemia or low body weight, were referred to the tertiary hospital in Delhi. Health education was also provided to them in the school by the health educator. Iron and Folic acid tablets were distributed among those found to be anemic.
The master-sheets were prepared and data was sorted out. Descriptive and chi-square statistics were used.
| ¤ Results|| |
The age of the students was 10 years, 11 years, 12 years, 13 years, 14 years of 118 (28.5%), 87 (21.1%), 102 (24.7%), 60 (14.5%), and 46 (11.1%) students, respectively. About two third of the respondents (254; 61.5%) were male and the remaining (159; 38.5%) were females.
The source of drinking water was tap in the household of 221 (53.5%) children and was tube well water in 192 (46.5%) children. A majority (377; 91.3%) of the students used some brand of fluoridated toothpaste for cleaning teeth, while 36 (8.7%) students were using either indigenous tooth powder (dunt manjan) or Daatun. Maximum students (356; 86.3%) were underweight (BMI < 18.5) and only 57 (13.7%) had normal weight (BMI between 18.5 and 24.9). None of the students was overweight. About one-fourth students (114; 27.6%) were detected to have anemia (by Sahli's method). Anemia was found to be present among 49 (30%) of the girls and among 65 (26%) of the boys. All, except one, had tea daily. None reported consuming tobacco in any form.
Prevalence of fluorosis
Dental fluorosis was found to be present in 121 (29.3%) study subjects.
As shown in [Table 1], dental fluorosis was significantly more in children of age 13 years or above. [Table 2] shows that dental fluorosis was significantly more in the respondents whose agent used for dental cleaning was some fluoridated toothpaste as compared to those using non fluoridated agents (P=0.033). Dental fluorosis was also significantly more associated with the presence of anemia in respondents (P<0.001). However, there was no significant association of the disease prevalence with gender (P=0.02), source of drinking water (P=0.417), and with BMI (P=0.826).
|Table 1: Age wise distribution of dental fluorosis in the study population|
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|Table 2: Prevalence of dental fluorosis according to various characteristics|
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| ¤ Discussion|| |
The prevalence rate of dental fluorosis in this area was found to be 29.3%. A high prevalence of dental fluorosis among children of higher age group has been reported in the present study and also in other studies. , This might be due to the increasing number of permanent teeth with age. Normally the complete secondary dentition (excepting the third molar) is in place by the end of the 12 th year,  which accounts for the similar prevalence in 13 and 14 year olds. In the present study, positive association was seen of dental fluorosis with use of fluoridated toothpaste. The use of fluoridated toothpaste may be further pushing up the risk.  Dental fluorosis was also found to be associated with anemia. It has been suggested that one of the toxic manifestations of fluoride may be anemia. ,
Dental fluorosis was not found to be associated with the source of drinking water; however, other studies have reported an association with consumption of ground water as compared to tap water. ,, The reason for the difference may be that as the study area has no authorized water supply. In this area, the private suppliers supply water from tube wells only, even when it is obtained from taps.  No association was found between dental fluorosis and BMI. Similar results were seen in another study in Brazil.  No difference was seen in the prevalence of dental fluorosis with gender and similar results have been found in other studies also. ,,
This study has some limitations. The direct information of the source of supply of water in the houses was not retrieved in this study, as the children could not provide us this information, which is a limitation of this study. Also, the study is school based and not community based. All factors known to be associated with fluorosis were not studied. However, the strength of the study is that the diagnosis of fluorosis was done by experts after proper training.
| ¤ Conclusion|| |
It can be concluded that dental fluorosis is very common among the children in middle school. Use of fluoridated toothpaste is significantly associated with the disease. So, various control measures e.g., discouraging the fluoridated toothpastes, educating parents about fluorosis, de-fluoridation of water in the high risk areas, etc may help to tackle this problem. There is also a need for more studies focusing on the benefits of such interventions at the community level.
| ¤ Acknowledgement|| |
We are highly thankful to Dr. Saudan Singh, Head of the Department for their support in this research work and also to the Central microbiology lab for the permission given.
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[Table 1], [Table 2]