|Year : 2023 | Volume
| Issue : 1 | Page : 1-6
Prevalence of dental fluorosis and dental caries among people consuming water in urban Vadodara: A cross-sectional study
Sangita Vashrambhai Patel1, Rahul D Khokhariya1, Jagruti Rathod2, Deya G Chatterji1, Jesal Patel3
1 Department of Community Medicine, Medical College Baroda, Vadodara, Gujarat, India
2 Gujarat Ecological Society, Vadodara, Gujarat, India
3 GCS Medical College, Ahmedabad, Gujarat, India
|Date of Submission||28-Sep-2022|
|Date of Decision||24-Dec-2022|
|Date of Acceptance||20-Jan-2023|
|Date of Web Publication||30-Mar-2023|
Sangita Vashrambhai Patel
5, Gokul Society, Sindhwaimata Road, Pratapnagar, Baroda - 390 004, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: High fluoride concentration in groundwater can result in endemic fluorosis and is a major public health problem in India.
Aim: To know the association between prevalence of dental fluorosis and dental caries and fluoride level in the water in urban Vadodara.
Methodology: An analytical ecological cross-sectional study was conducted in 4 zones of Vadodara district. Thirty-eight water samples were sent to Gujarat Ecology Society in Vadodara for chemical analysis to test fluoride levels. The data collection was made by house-to-house visit twice during the study involving 2,609 participant interviews. These participants included 449 children belonging to the age group of <15 years. Examination for dental fluorosis and dental caries using Dean's criteria was done. Chi-Square and Mental Hensel Chi-Square were applied for statistical analysis.
Results: The prevalence of dental fluorosis was 17.36% in high-fluoride areas and 22.46% in normal-fluoride areas among children (<15 years of age). There was no statistically significant association in dental fluorosis between high-fluoride areas and normal-fluoride areas (P = 0.2533). The prevalence of dental caries was 29.26% in high-fluoride areas and 75.36% in normal-fluoride areas. There was a statistically significant association in dental caries between high-fluoride areas and normal-fluoride areas (P ≤ 0.0001).
Conclusions: The risk of dental caries was clearly higher in the areas showing normal-fluoride content compared to places with high fluoride levels in drinking water. The risk of dental fluorosis was higher in area with high-fluoride level but the difference was not statistically significant.
Keywords: Cross-sectional study, dental caries, dental fluorosis, fluoride water, India, prevalence rate
|How to cite this article:|
Patel SV, Khokhariya RD, Rathod J, Chatterji DG, Patel J. Prevalence of dental fluorosis and dental caries among people consuming water in urban Vadodara: A cross-sectional study. Environ Dis 2023;8:1-6
|How to cite this URL:|
Patel SV, Khokhariya RD, Rathod J, Chatterji DG, Patel J. Prevalence of dental fluorosis and dental caries among people consuming water in urban Vadodara: A cross-sectional study. Environ Dis [serial online] 2023 [cited 2023 Jun 3];8:1-6. Available from: http://www.environmentmed.org/text.asp?2023/8/1/1/372860
| Introduction|| |
High fluoride concentration in groundwater is known to cause endemic fluorosis, resulting in an acute public health problem in India.
The maximum permissible limit of fluoride in drinking water is 1.5 ppm and the highest desirable limit is 1.0 ppm. Fluoride concentrations above 1.5 ppm in drinking water cause dental fluorosis and much higher concentration skeletal fluorosis.
A. K Susheela mentions crippling role of fluoride in the Indian community. Gujarat ranks 5th in India with high fluoride content in ground water and 18 out of 26 of its districts have water fluoride content more than permissible levels., In the survey conducted by the Ministry of Jal Shakti across all the villages of Gujarat in 2020–21, 13.8% samples reported having fluoride level more than 1.5 mg/L.
Dental fluorosis affects children when their permanent teeth develop with the morbidity being permanent without increasing the risk of mortality. The gradation of dental fluorosis will further help in the assessment of the chronicity of the problem and thereby decide the priority areas for intervention program. Dental fluorosis causes the teeth to be chalky white and also may have white, yellow, brown, or black spots or streaks on the enamel surface. Discoloration is away from the gums and bilaterally symmetrical. Skeletal fluorosis affects the bones and major joints of the body such as neck, back bone, shoulder, hip, and knee joints with severe pain, rigidity, or stiffness in joints. In severe forms, it results in marked disability. Nonskeletal fluorosis is an earlier manifestation of fluorosis and presents as gastrointestinal complaints.
To know the association between the prevalence of dental fluorosis and dental caries and fluoride level in the water in urban Vadodara.
| Methodology|| |
The study was executed after institutional ethical committee approval. A cross-sectional study was carried out at urban Vadodara city. Data were collected using analysis of water samples and by interviewing the people using the same water from the selected water tanks. There are a total of 31 water tanks in Vadodara city with average 8 tanks in each zone. Thirty-eight representative samples were tested for the study which were collected from different parts of the district. Three random samples from tanks selected by computer-generated random number from the four zones: north, south east, and west of the district (12 samples) were taken. Additionally, 24 samples from near and far areas from (2 each) of those water tanks and 2 from main water source of Vadodara (Ajwa and Mahi river) were taken. Standard operating procedure was followed for water collection and transport and samples were sent to Gujarat Ecology Society, Vadodara, for chemical analysis to test fluoride levels. The ion meter (Chemi Line, CL-190) was used to measure the fluoride levels in the water samples. The ion meter was calibrated with the 1 ppm and 10 ppm sodium bicarbonate solution and the fluoride levels in the samples were measured at room temperature.
The Study was carried out from November 2016 to August 2017. Families who used bore well water or living in slum area and flat/apartment area were excluded from the study.
The population of Vadodara city is approximately 16,66,495 according to census 2011. Assuming average household size of 5 persons, it was assumed that the total number of households in Vadodara is about 333,299. Sixty households were randomly selected from the area around the 12 selected water tanks, thus including 720 households and a sample size of 3,600 was calculated. Ultimately, 2,609 participants gave consent to participate in the study including 449 persons belonging to the age group of less than 15 years. Interviews and general examination for dental fluorosis and dental caries using Dean's criteria of persons living in 60 sequential houses from each tank area were done. First house was randomly selected after which the rest of the houses were sequentially selected. If any house was closed, then sequential next house was included.
The field investigator had taken a 1-month training course for examination of patients of dental fluorosis and dental caries in the dental outpatient department of a tertiary care hospital in Vadodara, Gujarat. Dean's Index of Dental Fluorosis was used to classify the cases on examination. Dental caries also known as tooth decay, cavities, or caries, is a breakdown of teeth due to activities of bacteria.
Data collection did not pose any potential risk or harm to the participants. Data safety and confidentiality was maintained by keeping all data in password-protected files which were accessible only to the researchers.
Data entry and analysis
The data were entered in Microsoft Excel worksheet 2007 using strict check files. Water quality parameters were measured in predefined measures. Chi-square and Fisher's exact tests were used for categorical data using Epi info 7. The outcome variables of drinking water quality standards were compared with WHO water quality standards.
| Results|| |
A total of 2,609 participants from 720 households were selected of which 449 were <15 years old of which 233 (52%) of the participants were male. Participants belonged included in the study from among 720 households selected from the 4 zones. Sixty-five (36.74%) participants were <5 years, 125 (27.83%) were between 6 and 9 years. One hundred and fifty-nine (35.41%) participants were between 10 and 14 years, Normal-fluoride value is 1.5 mg/L. Fluoride value was highest in Ajwa water tank followed by Jail Road, Lalbaug, Manjalpur, Vadivadi, T. P. 13, North Harni, Gorwa, Subhanpura, GIDC, Tarsali. All the samples near and far from water tank contain higher fluoride level. The range of the fluoride level is from 0.384 to 2.054 mg/L, as shown in [Table 1].
|Table 1: Fluoride levels of the of main water tanks (3 in each zone) (n=12)|
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As shown in [Table 2], all the samples near and far from water tank contain higher fluoride level. The range of the fluoride level is from 0.625 to 1.954 mg/L.
|Table 2: Fluoride levels of the samples of water at user level (near and far from water tank)|
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[Table 3] shows that the prevalence of dental caries was 29.26% in high fluoride area, while the prevalence of dental caries was 75.36% in normal-fluoride areas. There was a statistically significant association in dental caries between high-fluoride areas and normal-fluoride areas (Chi-square value = 80.824, P ≤ 0.0001).
|Table 3: Distribution of dental caries among children (<15 years of age) according to fluoride level (n=449)|
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[Table 4] shows that the prevalence of dental fluorosis was 17.36% in high-fluoride areas, while the prevalence of dental fluorosis was 22.46% in normal-fluoride areas. All the cases observed were of mild variety on examination. There was no statistically significant association in dental fluorosis between high-fluoride areas and normal-fluoride (Chi-square value = 1.305, P = 0.2533).
|Table 4: Distribution of dental fluorosis among children (<15 years of age) according to fluoride level (n=449)|
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[Table 5] shows that the prevalence of dental fluorosis of the entire study sample of 2,609 has been compared in high-fluoride and normal-fluoride areas. The prevalence rate of dental fluorosis in high-fluoride area was 4.22% while 4.48% in normal-fluoride areas, and the difference was statistically not significant between high-fluoride areas and normal-fluoride areas (P = 0.8547).
|Table 5: Distribution of dental fluorosis in high-fluoride and normal-fluoride areas (n=2609)|
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| Discussion|| |
The fluoride levels were normal in 3 areas (Tarsali, Panigate, GIDC), while it was marginally higher in rest of areas. The range of the fluoride level was from 0.384 to 2.054 mg/L fluoride levels of the of the 12 main water tanks. The range of the fluoride level was from 0.625 to 1.954 mg/L of the samples of water at user level (near and far from water tank). The fluoride levels were marginally higher in most of the areas [Table 1] and [Table 2].
The prevalence of dental caries in children below 15 years of age was 29.26% in high-fluoride areas, while the prevalence of dental caries was 75.36% in normal-fluoride areas [Table 3]. There was a statistically significant association in dental caries between high-fluoride areas and normal-fluoride areas.
The prevalence of dental fluorosis in children below 15 years of age was 17.36% in high-fluoride areas, while the prevalence of dental fluorosis was 22.46% in normal-fluoride areas [Table 4]. There was no statistically significant association in dental fluorosis between high-fluoride areas and normal-fluoride areas. A study in Haryana by Shyam et al. among 11–14-year-old schoolchildren showed 96.6% prevalence of dental fluorosis in endemic fluoride areas with mild-to-moderate level of dental fluorosis. A study conducted in Sundanin 2020 by Mahmoud Ali et al. showed that the prevalence of dental fluorosis was 68.3% of which majority of students were diagnosed with very mild (23.2%) and mild (26.5%) forms.
In a descriptive cross-sectional survey conducted on 653 fishermen from the Kutch District, Gujarat, the prevalence of skeletal fluorosis was 30.3%, out of which, the majority of the subjects had mild skeletal fluorosis (18.4%). This condition was found to be significantly associated with age and gender.
The prevalence of dental fluorosis in the study population was 4.29%. The prevalence rate of dental fluorosis in high fluoride area was 4.22% while 4.48% in normal-fluoride areas [Table 5]. The difference was statistically not significant between high-fluoride areas and normal-fluoride areas. In our study, we did not find association between high-fluoride level and dental fluorosis because fluoride levels in the water samples were marginally high.
Fluoride content in our study ranged from 0.384 to 2.054 mg/L. The study conducted by Kotecha et al. showed that at Vadodara district, the incidence of dental fluorosis was 1.51 times higher in high-fluoride areas as compared to normal-fluoride areas (confidence interval [CI] 17.59%–22.57% respiratory rate [RR] = 1.51). The prevalence of dental caries was lower in high-fluoride areas compared to normal-fluoride areas, indicating protective effect of water fluoride on dental caries (CI 6.16% to 11.18%, RR = 0.82).,
A significant association between dental caries and dental fluorosis was observed in age group 10–12 years in a study conducted by Sakshi et al. in Mewat district, Haryana. It was found that the DMFT score was high in students having fluorosis mainly in age group 13–15 years, which shows a direct relationship among caries prevalence and fluorosis.
The prevalence of dental caries was significantly higher among students having no signs of fluorosis compared to those who did and similar findings were seen in a study conducted by Parul Mangal in Rajasthan. Dental fluorosis develops only when a child is exposed to high-fluoride level during childhood between 0 and 6 years of age when dentition develops. Once fluorosis develops, it is permanent and cannot be halted.
The fluoride concentrations in water were in the range of 0.532–8.802 in Rohtak district of Haryana. During a study, 1,262 children examined, of which 655 (51.90%) children had dental fluorosis. This study had higher fluoride levels compared to those of our study. It was also observed that the prevalence of dental caries was lower in areas having high-fluoride levels compared to normal-fluoride levels. Similar findings were observed in our study.
In a longitudinal study by Saldarriaga et al., the mean age at the beginning of the study was 9.71 ± 1.2 years and was later 13.7 ± 1.4 years old in the second evaluation. Among them, 53.2% were females. 97.8% of the children had at least one tooth with DF during the first evaluation.
A door-to-door survey was done in seven villages that were randomly selected from seven districts of Chhattisgarh. Water samples were analyzed and fluoride content of each source was mapped along with the medical history of the affected households in each hamlet of the surveyed villages. Out of total children, 740 (21.8%) were aged less than 5 years. The prevalence of dental fluorosis was 21.4%. In the surveyed area, the fluoride levels ranged between 0.1 and 9.0 ppm with mean (standard deviation) of 2.2 (2.1) ppm in drinking water. The prevalence of manifestation of skeletal fluorosis and dental fluorosis was lower than other provinces in India and the possible reasons were due to the habit of frequently changing the drinking water sources by the children.
Another study in Haryana was done on underground water samples at eight sites during premonsoon and postmonsoon season to understand the impact of water recharging and its interaction with rocks. The fluoride level in the samples varied from 0.19 to 2.87 ppm with a mean of 1.06 ppm in water samples and more than 38% of samples did not meet the permissible limit. Assessment using Dean's index showed that 49% of the children suffered from various levels of dental fluorosis with higher occurrences among male children. They recommended distribution of calcium/ascorbic acid food supplement to school children.
Testing the fluoride concentration in hand pump (Hp) water and tubewell water from a few blocks in Jaipur Rajasthan ranged from 2.1 to 15 ppm and 0.7 to 6.2 ppm, respectively. The prevalence of skeletal fluorosis ranged between 8% and 12% and significantly increased fluoride levels in drinking water had positive correlation with skeletal fluorosis.
Prevalences of dental caries, dental fluorosis, and skeletal fluorosis among students of rural areas of Bankura District, West Bengal, India, were 32.7%, 72.3%, and 11.3%, respectively, which was statistically significant (χ2 = 22.265; P < 0.001).
Within Gujarat itself, different villages of Patan district of North Gujarat estimated the burden of dental and skeletal fluorosis to be 30% and 8%–10%, respectively. In the semi urban area of Patan, fluorosis was more common in lower socio-economic class.
Dental fluorosis can have multiple confounders such as eating practices specially with fluoride content in the local foods and oral hygiene, which can cause structural and chemical changes of the enamel. However, higher-level fluoride (≥0.7 ppm vs. <0.7 ppm) in the drinking water was associated with lower dental caries according to a cross-sectional study which analyzed the data from the National Lithuanian Oral Health Survey.
The generalizability of the above study data is applicable to the whole Vadodara Municipal Corporation area. Before testing the fluoride levels in the sample, the standardization of instruments used for measurements was done to reduce measurement bias. All tests were conducted in the same lab by the same lab personnel. This reduces intra and inter observer error. This cross-sectional study gives the effect of cohort design because once the dental fluorosis develops, it remains permanent with no mortality.
The National Programme for Prevention and Control of Fluorosis of the Government of India aims to prevent and control fluorosis cases in the country and includes strategies such as surveillance of fluorosis in the community, capacity building, establishment of diagnostic facilities, and management of cases including treatment surgery, rehabilitation, and providing health education for prevention and control of fluorosis cases.
| Conclusions|| |
Fluoride values were marginally high in all the areas except Tarsali, Panigate, and GIDC. High fluoride in water has no association with dental fluorosis in our study. But, high fluoride in water has a protective effect on dental caries in children below 15 years of age.
Special thanks to Gujarat Ecological Society, Vadodara, for testing water samples collected free of cost.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]