|Year : 2017 | Volume
| Issue : 1 | Page : 36-41
Prevalence of Dental Fluorosis Among Adolescents in Schools of Greater Noida, Uttar Pradesh
Monica Chaudhry, Ishan Prabhakar, Bhuvandeep Gupta, Richa Anand, Priyanka Sehrawat, Sahil S Thakar
Department of Public Health Dentistry, I.T.S. Dental College, Hospital and Research Centre, Greater Noida, Uttar Pradesh, India
|Date of Web Publication||14-Mar-2017|
Department of Public Health Dentistry, I.T.S. Dental College, Hospital and Research Centre, 47, Knowledge Park III, Greater Noida, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Drinking water is one of the major sources of fluoride. India is one of those 24 countries where fluorosis is an important public health problem. When excess fluoride is ingested during the years of tooth calcification, it results in fluorosis. Aim: To assess the prevalence of dental fluorosis among adolescents in schools of Greater Noida, Uttar Pradesh. Materials and Methods: A total of 1318 students were examined for dental fluorosis through a stratified sampling technique from four blocks of Greater Noida. Dean’s Fluorosis Index was used to record dental fluorosis and information regarding the source of water till the age of 8 years, usage of fluoridated toothpaste before 2 years of age and other affected family members, which was obtained from their parents. Results: The overall prevalence of dental fluorosis in Greater Noida was found to be 21.0%. A very mild form of dental fluorosis was seen in 27.6% of the adolescents. The source of water consumed by the adolescent till the age of 8 years was found to be significantly associated with dental fluorosis (P = 0.001). Adolescents who consumed water from the hand pump were more likely to develop dental fluorosis. The reporting of an affected family member was seen to vary significantly with the relative score of dental fluorosis observed for that adolescent. The value of Community Fluorosis Index (CFI) was found to be 1.7. Conclusion: Dental fluorosis seemed to be a problem of medium public health significance in Greater Noida as suggested by the observed CFI, which was 1.7. The consumption of water from the handpump by majority of the population was associated with fluorosis.
Keywords: Community fluorosis index, dental fluorosis, fluoride, greater noida
|How to cite this article:|
Chaudhry M, Prabhakar I, Gupta B, Anand R, Sehrawat P, Thakar SS. Prevalence of Dental Fluorosis Among Adolescents in Schools of Greater Noida, Uttar Pradesh. J Indian Assoc Public Health Dent 2017;15:36-41
|How to cite this URL:|
Chaudhry M, Prabhakar I, Gupta B, Anand R, Sehrawat P, Thakar SS. Prevalence of Dental Fluorosis Among Adolescents in Schools of Greater Noida, Uttar Pradesh. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2020 Dec 5];15:36-41. Available from: https://www.jiaphd.org/text.asp?2017/15/1/36/201932
| Introduction|| |
Dental fluorosis is a specific disturbance in tooth formation caused by excessive fluoride intake during the development of teeth. The degree of fluorosis, as well as plasma and bone fluoride levels, is directly related to the concentration of fluoride in drinking water.
Fluoride has always been known as a double-edged sword. When excess of fluoride is ingested during the years of tooth calcification, essentially during the first 7 years of life, it results in fluorosis. When mild or more severe forms of dental fluorosis are found prevalent in a community, steps should be taken to reduce fluoride ingestion during the ages of tooth development. Excessive levels of fluoride in the drinking water can lead to even more serious health problems than dental fluorosis, wherein it may progress to skeletal fluorosis. In its extreme form, skeletal fluorosis is a seriously debilitating disease. Because of excessive intake of fluoride in many parts of the world, skeletal fluorosis affects several millions of people today.,
Drinking water is a major source of fluoride in India. It affects the population of 20 states in India (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. Groundwater is considered as the major source of drinking water in most places on earth. Rajasthan and Gujarat in north India and Andhra Pradesh in south India are the worst affected states. Punjab, Haryana, Madhya Pradesh and Maharashtra are the moderately affected states, whereas the states of Tamil Nadu, West Bengal, Uttar Pradesh, Bihar and Assam are mildly affected.
The scarce published literature on the prevalence of dental fluorosis among the school children in the fluoride endemic area of Uttar Pradesh prompted us to undertake this study. The aim of this study was to determine the prevalence of dental fluorosis in the adolescents aged 12–18 years attending schools in Greater Noida, Uttar Pradesh and to evaluate the association of possible risk factors such as age, gender, type of school and use of fluoride toothpaste.
| Materials and Methods|| |
An observational study was conducted, which also involved a small survey, for over a period of 6 months from June 2015 to November 2015 among the school children in Greater Noida, Uttar Pradesh. Ethical clearance was obtained from the institutional ethical committee.
For the estimation of the sample size, a pilot study was conducted in a school, which involved the screening of 64 adolescents for dental fluorosis. A prevalence of 33% was observed. Taking the prevalence of dental fluorosis as 33% with 95% confidence interval, a sample of 1299 children was considered to be appropriate for the study considering the α value as 3%.
The examiner was trained and standardised to the study protocols in the Department of Public Health Dentistry at the college under the supervision of the staff members. Participants were selected and examined for different scores of dental fluorosis. These participants were re-examined on successive days using the same diagnostic criteria to check the repeated measurement reliability. A kappa value of 0.8 was observed, which indicated good agreement.
The children were included provided that their child was born and brought up in Greater Noida particularly for the first 8 years of their life. Children with on-going fixed or removable orthodontic therapy, as well as missing or carious anterior teeth, were excluded from the study.
Greater Noida is divided into four developmental blocks namely Dadri, Dankaur, Visrakh and Jewar. To enroll participants for a sample size of 1299 from these four blocks, stratified sampling technique was used. In each block, schools were selected randomly to obtain a sample of a minimum of 325 adolescents to reach a total sample with at least 1299 participants (because 1299/4 = 324.75).
A list of schools in each block was obtained from the Department of Education and was matched with the area under Greater Noida. From the entire list of schools in Gautam Buddh Nagar district, only the secondary and higher secondary schools located in Greater Noida were selected to be a part of the sampling frame. Thus, the sample frame comprised a total of 47 schools. It was decided that at least four schools would have to be examined from each development block in Greater Noida to achieve the required sample considering the fact that each school in the sample list comprised of a minimum of 100 students who belonged to the targeted age group. In case the four schools could not complete the required sample (because of absenteeism), the examiner was supposed to move select a 5th school randomly. A school was randomly selected from one block by lottery method, and children aged 12–18 years were examined in that school. After this, the investigator moved to another school in the same block (selected again by lottery method) until a minimum sample of 324 students was completed from each of the blocks. As it was required that each and every student should have an equal chance to be selected in the study, it was noted that the entire class was examined, and the examiner did not stop just on the 325th student; hence, a greater number of students were examined than the minimum required for the study. In this manner, the study was conducted in 19 schools of Greater Noida, Uttar Pradesh. Four schools were selected from Jewar, and five schools each were selected from the rest of the three blocks. This resulted in screening of 329, 331, 330 and 328 adolescents from the blocks of Dadri, Dankaur, Visrakh and Jewar, respectively, leading to a sum total of 1318 adolescents.
For each of these 1318 children, demographic data and Dean’s Index were recorded. Examination was conducted under natural light conditions. Each participant was made to sit on a chair with the examiner standing in front of the chair and were assessed using Dean’s Index (1942)., Teeth were not dried, but excess plaque was removed with gauze for a clear view for Dean’s Index coding. Other demographic details such as the participant’s name, age, sex and area of residence for the first 8 years, source of drinking water, history of usage of fluoride toothpaste and history of fluorosis in family members for each participant were collected through the participant’s parents. Community Fluorosis Index (CFI) was calculated for the population of Greater Noida.,
The data obtained were compiled systematically, transformed from a pre-coded proforma to a computer and a master table was prepared using Microsoft Excel program. The data were analysed using the Statistical Package for the Social Sciences version 21.0 software. Chi-square test was applied (P ≤ 0.05).
| Results|| |
A total of 1318 school children were examined, and it was found that 278 were affected by varying severity of dental fluorosis. The prevalence was calculated as 21.0%. Dankaur (23.8%) and Visrakh (22.7%) had the highest prevalence of dental fluorosis. Dadri and Jewar closely followed with 21.7 and 13.9% prevalence, respectively [Table 1].
|Table 1: Distribution of the study population according to blocks in Greater Noida|
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A very mild form of dental fluorosis (27.6%) seemed to be the most common grade of severity of dental fluorosis. Severe dental fluorosis had the lowest prevalence of 8.2% [Figure 1].
|Figure 1: Distribution of the study population having dental fluorosis according to Dean’s Fluorosis Index score|
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Although the prevalence of dental fluorosis was marginally higher in females (51.7%), the variation was not statistically significant (P = 0.071). The variation of the presence of dental fluorosis against various age groups showed that among all, as much as 36% were of the age 13 years [Figure 2]. It was also observed that the prevalence of dental fluorosis varied significantly with age (P = 0.001).
Out of the 278 children who had dental fluorosis, 3.9% consumed well water, 31.2% had it from tap and 64.9% from the hand pump. Source of water consumed by the child till the age of 8 years was found to be significantly associated with dental fluorosis [P = 0.01, [Table 2] and also with its severity [P < 0.001, [Table 3], which inferred that children who consumed water from the hand pump were more likely to develop dental fluorosis.
|Table 2: Association between dental fluorosis and the source of drinking water|
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|Table 3: Association of Dean’s fluorosis score with the source of drinking water|
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Out of the 1318 students examined, 26.5, 36 and 37.5% were from government, private aided and private unaided schools, respectively. Although the percentage of children suffering from dental fluorosis was very low in the government schools (10.2%) as compared to private aided (42.5%) and private unaided schools (46.3%), no significant association was seen between the type of school the child studied in and dental fluorosis (P = 0.061) [Table 4].
Out of the total number of students who suffered from dental fluorosis, 79.8% reported another family member having a similar condition. It was seen that the reporting of an affected family member varied significantly with the score of dental fluorosis [P < 0.001, [Table 5]. It was observed that as the Dean’s fluorosis score increased, the frequency of reporting of an affected family member by the participants also increased [P < 0.001, [Table 6].
|Table 5: Association between dental fluorosis and history of affected family member with dental fluorosis|
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|Table 6: Association between Dean’s fluorosis score and history of a family member affected with dental fluorosis|
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Out of those who used a toothpaste before the age of 2 years, 94.7% had dental fluorosis; on the other hand, among the ones who began using it after the age of 2 years, 95.1% did not have dental fluorosis [Figure 3]. A statistically highly significant association was observed (P = 0.001).
|Figure 3: Prevalence of dental fluorosis with usage of fluoridated toothpaste before the age of 2 years|
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CFI was calculated to be 1.7, which indicated ‘medium’ public health significance for dental fluorosis in the population of Greater Noida.
| Discussion|| |
Fluorosis is an endemic disease prevalent in 20 states out of the 36 states and Union Territories of the Indian Republic. In India, 40–70% districts are affected in Bihar, National Capital Territory of Delhi, Haryana, Jharkhand, Karnataka, Maharashtra, Madhya Pradesh, Odisha, Tamil Nadu and Uttar Pradesh. The fluoride levels of the drinking water in Uttar Pradesh range from 0.2 to 25.0 mg/L, the maximum level of which is well above the normal range of 1.5 mg/L as stated by World Health Organization. In other parts of India, the prevalence of dental fluorosis has been recorded as 16.8% in Kerala, 17.75% in Gujarat, 36.3% in Udaipur and 92.7% in Haryana. The apparent variation in the prevalence of dental fluorosis can be attributed to the source of drinking water. In most parts of India, groundwater is found to be the major source of drinking water. Fluoride level depends primarily on the groundwater level; the deeper the underground level from where the water is derived, higher is the fluoride level.
In our study, the prevalence of dental fluorosis in Greater Noida, Uttar Pradesh was recorded as 21.0%. Studies on dental fluorosis in other parts of Uttar Pradesh have recorded a prevalence of 28.6% in Unnao District, 29.35% in Lucknow and 33.37% in Barabanki district.
Milder forms of fluorosis were more common than its severe forms in this study. This was in accordance with the findings of Srivastava et al. and Naidu et al. No significant difference was observed in the prevalence of dental fluorosis among both the genders. This finding was in accordance with the ones observed in other studies.,,, Universally, in the literature, no tendency towards developing dental fluorosis has been reported by either of the genders.
The prevalence of dental fluorosis varied significantly with age. This was found to be in accordance with the study of Arif et al. However, it was found to be in disagreement with the study of Sukhabogi et al. Variation of dental fluorosis with age indicates change in the source of drinking water. In this study, the older children had higher grades of dental fluorosis. Earlier, hand pumps were the only source of water in Greater Noida. However, in the recent years, tap water supply is available.The prevalence of dental fluorosis was higher in the children who consumed water from the hand pump. This variation of dental fluorosis with the source of drinking water was found to be statistically significant. This finding was in agreement with two previously conducted studies., On the other hand, Gopalakrishnan et al. found no association between the source of drinking water and the occurrence of dental fluorosis.
The use of fluoridated toothpaste before the age of 2 years was found to be associated with occurrence of dental fluorosis. This was found to be in agreement with the studies of Beltrán-Valladares et al., Azevedo et al., Skotowski et al., Mascarenhas and Burt and Davies et al. However, the results were in disagreement with the study of Gopalakrishnan et al.
CFI was 1.7 in this study. This value was similar to another study (1.76). However, according to Karthikeyan et al., CFI values in three different areas of Tamil Nadu ranged from 0.63 to 3.56 in children.
One of the limitations of this study is that the prevalence of dental fluorosis has not been related to water fluoride level in this study. In addition, the obtained results can also be because of recall bias. Considering the mentioned limitations, further research is required in this field.
Health care and public health professionals can counsel parents and caregivers regarding dental fluorosis and the use of fluoride toothpaste by young children. Regular testing, especially of groundwater sources, should be done, and the community should be notified if there are any elements above the permissible limits. Consumer product industries and health agencies should label the fluoride concentration of bottled water and promote the use of a small amount of fluoride toothpaste for children younger than 6 years. Caregivers can inform the concerned authorities if similar conditions such as dental fluorosis have been seen in the community.
| Conclusion|| |
Dental fluorosis can be considered a problem of medium public health significance in Greater Noida as the CFI recorded was 1.7. This can be attributed to not just the fluoride in the drinking water but also the usage of fluoridated toothpaste before the age of 2 years by children.
Because of the central importance of physical appearance to a young person’s self-esteem, the disfiguring stains of severe fluorosis have significant psychological consequences to which the adolescent age group is highly vulnerable. Dental fluorosis is, however, not just confined to cosmetic concerns but has health implications as well.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arlappa N, Aatif Qureshi I, Srinivas R. Fluorosis in India: An overview. Int J Res Dev Health 2013;1:97-102.
Peter S. Essentials of Community Dentistry. 4th ed. New Delhi: Arya Publishers; 2013.
Dean HT. Classification of mottled enamel diagnosis. J Am Dent Assoc (1922) 1934;21:1421-6.
Jayaprakash K. A Short Textbook of Preventive and Community Dentistry. New Delhi: Jaypee Brothers Medical Publishers Pvt Ltd; 2004.
Gopalakrishnan P, Vasan RS, Sarma PS, Nair KS, Thankappan KR. Prevalence of dental fluorosis and associated risk factors in Alappuzha district, Kerala. Natl Med J India 1999;12:99-103.
Susheela AK. Dental fluorosis. In: Susheela AK, editor. A Treatise on Fluorosis. 2nd ed. Delhi: Fluorosis Research and Rural Development Foundation; 2003. p. 54.
Dhar V, Jain A, Van Dyke TE, Kohli A. Prevalence of gingival diseases, malocclusion and fluorosis in school-going children of rural areas in Udaipur district. J Indian Soc Pedod Prev Dent 2007;25:103-5.
] [Full text]
Dahiya S, Kaur A, Jain N. Prevalence of fluorosis among school children in rural area, district Bhiwani: A case study. Indian J Environ Health 2000;42:192-5.
Srivastava AK, Singh A, Yadav AS, Mathur A. Endemic dental and skeletal fluorosis: Effects of high ground water fluoride in some North Indian Villages. Int J Oral Maxillofac Pathol 2011;2:7-12.
Nanda RS. Observations on fluoride intake in Lucknow. J Indian Dent Assoc 1972;44:177-81.
Singh M, Saini A, Saimbi CS, Bajpai AK. Prevalence of dental diseases in 5- to 14-year-old school children in rural areas of the Barabanki district, Uttar Pradesh, India. Indian J Dent Res 2011;22:396-9.
] [Full text]
Naidu GM, Rahamthullah SA, Kopuri RK, Kumar YA, Suman SV, Balaga RN. Prevalence and self perception of Dental Fluorosis among 15 year old school children in Prakasham district of south India. J Int Oral Health 2013;5:67-71.
Arif M, Husain I, Hussain J, Kumar S. Assessment of fluoride level in groundwater and prevalence of dental fluorosis in Didwana block of Nagaur district, Central Rajasthan, India. Int J Occup Environ Med 2013;4:178-84.
Sarvaiya BU, Bhayya D, Arora R, Mehta DN. Prevalence of dental fluorosis in relation with different fluoride levels in drinking water among school going children in Sarada tehsil of Udaipur district, Rajasthan. J Indian Soc Pedod Prev Dent 2012;4:317-22.
Choubisa SL, Choubisa L, Choubisa D. Osteo-dental fluorosis in relation to age and sex in tribal districts of Rajasthan, India. J Environ Sci Eng 2010;52:199-204.
Sukhabogi Jr, Parthasarathi P, Anjum S, Shekar B, Padma C, Rani A. Dental fluorosis and dental caries prevalence among 12 and 15-year-old school children in Nalgonda district, Andhra Pradesh, India. Ann Med Health Sci Res 2014;4(Suppl 3):245-52.
Beltrán-Valladares PR, Cocom-Tun H, Casanova-Rosado JF, Vallejos-Sánchez AA, Medina-Solís CE, Maupomé G. Prevalence of dental fluorosis and additional sources of exposure to fluoride as risk factors to dental fluorosis in school children of Campeche, Mexico. Rev Invest Clin 2005;57:532-9.
Azevedo MS, Goettems ML, Torriani DD, Demarco FF. Factors associated with dental fluorosis in school children in southern Brazil: A cross-sectional study. Braz Oral Res 2014;28:1-7.
Skotowski MC, Hunt RJ, Levy SM. Risk factors for dental fluorosis in pediatric dental patients. J Public Health Dent 1995;55:154-9.
Mascarenhas AK, Burt BA. Fluorosis risk from early exposure to fluoride toothpaste. Community Dent Oral Epidemiol 1998;26:241-8.
Davies RM, Ellwood RP, Davies GM. The rational use of fluoride toothpaste. Int J Dent Hyg 2003;1:3-8.
Bhat PK, Kumar A. Prevalence and severity of dental fluorosis in an endemically afflicted district of Karnataka, South India. Int J Contemp Dent 2011;2:96-100.
Karthikeyan G, Pius A, Apparao BV. Contribution of fluoride in water and food to the prevalence of fluorosis in areas of Tamil Nadu in South India. Fluoride 1996;29:151-5.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]