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ORIGINAL ARTICLE
Year : 2017  |  Volume : 15  |  Issue : 1  |  Page : 42-47

Prevalence of Dental Fluorosis Among 6–12-Year-Old School Children of Mahabubnagar District, Telangana State, India − A Cross-Sectional Study


1 Department of Pedodontics and Preventive Dentistry, Mamata Dental College, Khammam, India
2 Department of Pedodontics and Preventive Dentistry, S.V.S. Institute of Dental Sciences, Mahabubnagar, India
3 Department of Public Health Dentistry, Mamata Dental College, Khammam, Telangana, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Kola S Reddy
Department of Pedodontics and Preventive Dentistry, Mamata Dental College, Khammam, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-5932.201947

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  Abstract 

Introduction: Telangana state in southern India has many areas which have high–low fluoride levels in drinking water, and Mahabubnagar district is one among them, where people are affected with dental and skeletal fluorosis, with the majority belonging to low socio-economic status. Aims: To assess the prevalence of dental fluorosis in school going children of Mahabubnagar district and also to assess fluoride levels in drinking water from different areas of Mahabubnagar district. Materials and Methods: A cross-sectional study was conducted on 2000 children in the age group 6–12 years in different areas of Mahabubnagar district. Dental fluorosis status was assessed by using Modified Dean’s Fluorosis Index. Alizarin visual method was used to estimate fluoride levels in water. The data collected were subjected to statistical analysis. Results: Dental fluorosis in primary and permanent dentition was 15 and 70.3%, respectively. In the northern part of Mahabubnagar district, primary dentition was more affected by fluorosis whereas in southern part, the permanent dentition was more affected. The prevalence of dental fluorosis in primary dentition was more in 6–7-year-old children (35.5%), and in permanent dentition, it was more in 9–10-year-old children (70%). The fluoride level in drinking water was more in Kosghi, Kalwakurthy (2.0 ppm). Conclusion: Dental fluorosis was more in 10-year-old and less in 6-year-old children. It was more in eastern and northern zones of Mahabubnagar district and less in local villages of Mahabubnagar.

Keywords: Children, dental, fluorosis, India, prevalence, schools


How to cite this article:
Reddy KS, Puppala R, Kethineni B, Reddy H, Reddy A, Kalyan V S. Prevalence of Dental Fluorosis Among 6–12-Year-Old School Children of Mahabubnagar District, Telangana State, India − A Cross-Sectional Study. J Indian Assoc Public Health Dent 2017;15:42-7

How to cite this URL:
Reddy KS, Puppala R, Kethineni B, Reddy H, Reddy A, Kalyan V S. Prevalence of Dental Fluorosis Among 6–12-Year-Old School Children of Mahabubnagar District, Telangana State, India − A Cross-Sectional Study. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2019 Nov 15];15:42-7. Available from: http://www.jiaphd.org/text.asp?2017/15/1/42/201947


  Introduction Top


Fluorine is a naturally occurring element found in various minerals. However, release into groundwater due to volcanic activity and weathering processes can cause elevated levels of fluoride in drinking water. Fluoride, although beneficial for the mineralization of hard tissues in the human body, can be toxic to humans with chronic exposure to elevated concentrations.[1] The principal sources of fluorine were drinking water and food such as sea fish, cheese and tea. Small quantity of fluoride is an essential component for normal mineralization of bones and formation of dental enamel. However, excess concentration may result in slow, progressive scourge known as fluorosis.[2] 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.[3]

In India, around 20 million people were severely affected by fluorosis and around 40 million are exposed to its risk. The number of people getting affected, the number of villages, blocks, districts and states endemic for fluorosis have been steadily increasing ever since the disease was discovered in India during 1930s. The reason for the increase in the disease incidence and the sizeable number of locations being identified as endemic zones for fluorosis is due to overgrowth of population, necessitating more and more water, indiscriminate digging of tube wells, resorting to the use of hand pump water, unawareness regarding the importance of checking water quality, especially for fluoride and due to water shortage.[4]

According to the World Health Organization, the maximum acceptable concentration of fluoride ions in drinking water is 1.5 mg/l to prevent tooth and bone problems.[5] The available data suggest that 15 states in India are endemic for fluorosis (fluoride level in drinking water >1.5 mg/l), and about 62 million people in India suffer from dental, skeletal and non-skeletal fluorosis. Out of these, six million are children below the age of 14 years.[6]

Mahabubnagar district of Telangana state consists of areas with various levels of fluoride in drinking water, starting from below-optimum to optimum and above-optimum levels. People who consume groundwater have higher chances of developing dental fluorosis because of higher level of fluoride in deep groundwater of the city as reported by the water department of Mahabubnagar district.[7]

No study showing the prevalence of dental fluorosis has been conducted so far in this region; hence, a study was done with an aim to assess the prevalence of dental fluorosis in 6–12-year-old school going children of different regions of Mahabubnagar district. The objectives of the studies were to assess prevalence of dental fluorosis in both primary and permanent dentitions according to various age group children in different areas of Mahabubnagar district and to estimate the fluoride level in drinking water in these respected areas.


  Materials and Methods Top


A cross-sectional study was conducted in Mahabubnagar district among school children in the age group of 6–12 years. It contains about four revenue divisions, 64 mandals, 1541 villages, four municipalities and 4689 schools of which 3133 were primary schools, 889 were upper primary schools, 658 were high schools and nine were higher secondary schools.[8] Before starting the study, ethical clearance was taken from the Ethical Committee of Institution, Mahabubnagar. An official permission was obtained from the district educational officer (DEO), Mahabubnagar. An informed consent was obtained from the respective school headmasters and parents of the children.

Training and recording procedure were standardized by repeated sections of calibration between the examiner and chief supervisor in the Department of Pedodontics and Preventive Dentistry, in the institution before starting the actual recording on children. The draft of the questionnaire used in the study was reviewed by a panel of experts, which included faculty members from Pedodontics and Preventive Dentistry, Public Health Dentistry, school teachers and headmasters, and thereafter, the draft was finalized.

A pilot study was conducted on a convenient sample of 50. The prevalence of dental fluorosis was found to be 49.71%. On this basis, the sample size was decided with n = 1849 with consideration of 3% precision and 99% confidence level. The final sample was rounded to 2000. Hence, a total of 2000 school going children from rural and urban areas of 6–12 years old were enrolled in this study. The sampling procedure involved multistage stratified sampling[9] where whole Mahabubnagar district is divided into five strata, viz. Mahabubnagar central, southern, northern, eastern and western parts. In each stratum, the following areas were selected:



  • Mahabubnagar central: Boyapalli, Jainallipur, Ramaiah Bowli, Mettugadda.


  • Mahabubnagar southern part: Kollapur, Utkoor, Bijinipally, Wanaparthy.


  • Mahabubnagar eastern part: Kalwakurthy, Thadoor, Uppununthala, Kollur.


  • Mahabubnagar northern part: Kotthur, Badepalli, Balanagar, Nawabpeta.


  • Mahabubnagar western part: Kosghi, Narayanpet, Bomaraspet, Makthal.


In each area, one school was selected by simple random sampling (lottery) method and on the whole, about 20 schools were selected from the above-mentioned areas. Eligible children were selected randomly from a list obtained from school records. Age eligibility requires that the subjects fall into the appropriate age at the time of sampling. All 6–12-year-old children present on the day of clinical examination, school children who were lifelong residents of Mahabubnagar district, children with permanent teeth with at least more than 50% of the crown erupted and no filling on facial surface and individuals who were willing and cooperative for the study are included in the study. Children without fluorosis stains and children with orthodontic brackets or crowns are excluded from the study.

The examination was done by three dentists; they were assisted by three dental assistants over a period of 1 year for recording data. A questionnaire was used to fill out personal data such as name, age, gender and occupation and income status of the parent, permanent address and source of drinking water, oral hygiene methods and diet chart. Standard infection control guidelines were applied. All the recordings were done in the daylight and the child was made to sit in ordinary chair facing away from a direct sunlight.[10] The oral examination of study subjects was conducted in respective schools using a plane mouth mirror under natural light. Dental fluorosis was assessed using Modified Dean’s Fluorosis Index (1942).[11]

Collection of water samples was done based on methodology followed in National Oral Health Survey and Fluoride Mapping 2002–2003.[12] Sufficient numbers of plastic bottles were carried to the schools. Water was collected from drinking source which was used by children, and all the bottles were labelled. The water samples were sent to the laboratory of ‘Rural water supply’, Mahabubnagar to confirm the fluoride levels in the water before commencement of clinical examination. Water fluoride analysis was done using Alizarin visual method.[13]

Statistical analysis was performed using the Statistical Package of Social Science (version 17; SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to describe the prevalence and severity of dental fluorosis. Frequency tables were computed.


  Results Top


Out of 2000 children examined, 1021 were males. Among male school children, majority (15.87%) belonged to 8–9-year-old age group and among female school children, majority (18.59%) belonged to 10–11-year-old age group [Table 1]. Among male school children, majority (55.50%) belonged to western group and among female school children, majority (59.25%) belonged to eastern region [Table 2].
Table 1: Sample distribution according to age and gender

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Table 2: Sample distribution according to region

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The prevalence of dental fluorosis was more in 6–7-year-old children (35.5%) and less in 11–12-year-old children in primary dentition (3.0%) [Table 3]. The prevalence of dental fluorosis was more in 9–10-year-old children (69.7%) and less in 6–7-year-old children (24.7%) [Table 4].
Table 3: Dental fluorosis in primary dentition

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Table 4: Dental fluorosis in permanent dentition

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The prevalence of dental fluorosis in primary dentition was more in northern part of Mahabubnagar district (28.4%) and less in central part of Mahabubnagar district (9.5%) [Table 5]. The dental fluorosis in permanent dentition was more in eastern and northern parts of Mahabubnagar district (58%). The least affected was Mahabubnagar central (50.6%) [Table 6]. The highest water fluoride level was found in Kalwakurthy and Nawabpet (2 ppm). The lowest water fluoride level was found in Uppununthala, Balanagar and Kottur (0.6 ppm) [Table 7].
Table 5: Region-wise prevalence of dental fluorosis in primary dentition

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Table 6: Region-wise prevalence of dental fluorosis in permanent dentition

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Table 7: Water fluoride levels of selected regions in Mahabubnagar district

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  Discussion Top


When compared to other similar studies in India, that is, Naidu et al.,[14] Ravi Kiran et al.[15] and Narayanamurthy et al.,[16] our sample size was more. These school children were selected by stratified random sampling. Same sampling procedure was followed in the study done by Sudhir et al.[9] The Modified Dean’s Fluorosis Index was used for examining dental fluorosis because of its simplicity and uniformity of use in many previous studies. It is also the recommended index for use when the water fluoride level is below 5 ppm.[17]

Dental fluorosis in primary dentition was more in 6–7-year-old children and it was low in 11–12-year-old children. The probable reason could be that children who had continuously resided in an area with elevated water fluoride content for the 1st 5 years of their life showed more dental fluorosis when compared with those who resided in a similar area between 5 and 10 years of their life. This is in accordance with the fact that most permanent teeth including permanent incisors and first molars undergo crown formation within the 1st 5 years of life.[18]

The dental fluorosis in permanent dentition was found mostly in 9–10-year-old children (70%). Compared with children of higher ages, this result differs from the one obtained by Choubisa et al.,[19] who found no correlation between age and the occurrence of dental fluorosis. This may be due to differences in the frequency of fluoride intake at different ages that would have corresponded with the development of certain teeth. It may also be due to variations in the water fluoride level where the children resided during the development of their permanent teeth.

According to the region-wise distribution of dental fluorosis in primary dentition, the northern part of Mahabubnagar is mostly affected (28.4%) when compared with other parts of Mahabubnagar district, as the fluoride concentration in drinking water was between 0.6 and 2.0 ppm. Mahabubnagar central region was least affected (9.7%) in primary dentition where the fluoride concentration was between 0.8 and 1.2 ppm. In permanent dentition, both the eastern and northern parts of Mahabubnagar district were the most affected (58%) whereas the least affected was Mahabubnagar central (50.6%). This is because of high fluoride content in the drinking water ranging from 0.6 to 2 ppm, in eastern and northern parts whereas in Mahabubnagar central, the fluoride content was 0.8–1.2 ppm.

The increasing prevalence and severity of dental fluorosis with increasing fluoride concentration may be explained by the fact that dental fluorosis is a developmental defect which occurs because of exposure to water containing high fluoride concentrations. This relation between water fluoride concentration and severity of dental fluorosis is dose-dependent with increasing concentration leading to higher risk.[20]

In the present study, it was seen that the dental fluorosis in children has been found to be 70.3% at the range of 0.6–2.2 mg/l of fluoride concentrations in drinking water. Similar observation was made in Nelakondapalli mandal (65.4%) in Khammam district[21] and close to this finding in Sarada Tehsil (69.4%) in Udaipur district, Rajasthan[22] and Prakasham district (82.4%) of Andhra Pradesh.[14] Sudhir et al.[9] and Manji et al.[23] recorded 100% dental fluorosis among the children of 5–14-year-old age groups in Nalgonda district of Telangana state and Kenya. This is in contrast to a study done in urban slum area of Nalgonda district, Telangana state whereas low dental fluorosis rate, 30.6%, was reported by Nirgude et al.[24] The study conducted by Dubey et al.,[25] Bhalla et al.[26] and Gitte et al.[27] showed prevalence of dental fluorosis as 54.5, 18 and 23.10% which is less when compared to the present study.

However, the actual prevalence of dental fluorosis, especially in permanent dentition, was higher (55.3%) than in primary dentition (15%), similar to other studies like in a study done by Salman.[28]

Mineralization of primary teeth occurs in intrauterine phase only. During this phase, placental barrier exists which prevents transfer of fluoride to the developing primary teeth. Hence, fluorosis is less prevalent in primary dentition.[29] Moreover, the duration of exposure to fluoride of the enamel during formation of primary teeth is shorter.[30] Other reasons are the thinner enamel of primary teeth as compared to permanent teeth[30] and the rapid fluoride absorption in growing foetus, making it less available for primary teeth.[31] On the contrary, the greater physical size and activity and kind of nutrients intake lead to a higher intake of water, and hence a higher prevalence in older age groups.[32]

Although the present study has comprehensively assessed the prevalence of dental fluorosis among school children of Mahabubnagar district, no correlation was made with the levels of fluoride in the water and the type of drinking water, as it was a cross-sectional study.

So, there is a need for further epidemiological studies with wider geographical base and greater number of study subjects. Further studies are also required to analyze the association of other oral health disorders affecting childhood and the quality of life of the children affected with dental fluorosis.

Adequate health education measures should be taken to inform the school children about the prevention of common oral diseases by providing suitable education materials and by engaging school children in health promotion activities. The dental public health professionals should interact with them in a mutually beneficial manner and there is a great need for inclusion of oral health promotion in the curriculum of the school children.


  Conclusion Top


The overall prevalence of dental fluorosis was found to be 70.3%. The prevalence of dental fluorosis in primary dentition was more in 6–7-year-old children and in northern region of Mahabubnagar. In permanent dentition, dental fluorosis was more in 9–10-year-old children and was more in eastern and northern parts of Mahabubnagar district. This study establishes relationship between the fluoride levels in drinking water and dental fluorosis. There is increasing prevalence and severity of dental fluorosis with increasing fluoride concentration in drinking water.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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