|Year : 2022 | Volume
| Issue : 2 | Page : 140-145
Prevalence of dental fluorosis and dental caries in fluoride endemic areas of Rohtak district, Haryana
Reena Rani1, Ruchi Singhal1, Parul Singhal1, Ritu Namdev1, Neha Sikk2, Shruti Jha1, Nancy Goel1
1 Department of Pedodontics, PGIDS, Rohtak, Haryana, India
2 Dental Materials, PGIDS, Rohtak, Haryana, India
|Date of Submission||19-Apr-2022|
|Date of Decision||26-May-2022|
|Date of Acceptance||29-May-2022|
|Date of Web Publication||15-Jul-2022|
Dr. Reena Rani
Department of Pedodontics, PGIDS, Rohtak, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: This study investigates the estimation of the fluoride concentration in drinking water in Rohtak district, Haryana, and quantifies its effect on the prevalence of dental fluorosis and dental caries. Materials and Methods: A cross-sectional survey was conducted among 1262 school children in endemic fluoride areas of Haryana. Using simple random sampling, thirty villages from five blocks of Rohtak districts were selected, and children 6–12 years of age were examined. A questionnaire survey form was filled out to record the demographic details of the samples. Dental caries was recorded according to DMFT (D = Decayed, M = Missing due to caries only, F = Filled, T = Teeth)/deft index (d = decayed, e = extracted due to caries, f = filled, t = teeth). Assessment of Dental Fluorosis was done according to Dean's Fluorosis index, modified in 1942. The data were analyzed using SPSS version 19, and nonparametric tests were used to assess the significance. Results: The study participants included 615 males and 647 females among which Mean DMFT in the area of study ranged from 0.32 to 1.90. Mean deft in the area of study ranged from 0.34 to 1.91. The fluoride concentrations in groundwater are in the range of 0.532–8.802. Out of 1262 children examined, 655 (51.90%) children were having dental fluorosis. 607 (48.10%) of the subjects were free from fluorosis. 16.09%, 13.39%, 9.11%, and 8.16% and 5.15% were having questionable, very mild, mild, moderate, and severe form of fluorosis, respectively. Conclusion: It can be concluded that in Rohtak district, the fluoride levels in drinking water and the prevalence of dental fluorosis are high, so requiring an urgent need to improve the quality of water and institute de-fluoridation of drinking water in affected areas to lower the burden of dental fluorosis in the community.
Keywords: Dean's fluorosis index (modified criteria 1942), dental caries, dental fluorosis, DMFT index, groundwater fluoride concentration
|How to cite this article:|
Rani R, Singhal R, Singhal P, Namdev R, Sikk N, Jha S, Goel N. Prevalence of dental fluorosis and dental caries in fluoride endemic areas of Rohtak district, Haryana. J Indian Soc Pedod Prev Dent 2022;40:140-5
|How to cite this URL:|
Rani R, Singhal R, Singhal P, Namdev R, Sikk N, Jha S, Goel N. Prevalence of dental fluorosis and dental caries in fluoride endemic areas of Rohtak district, Haryana. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Aug 11];40:140-5. Available from: http://www.jisppd.com/text.asp?2022/40/2/140/351043
| Introduction|| |
The role of fluoride in the prevention of dental caries is evident in the literature. The World Health Organization has set the upper limit of fluoride concentration in drinking water at 1.5 mg/l and according to the Bureau of Indian Standards, 1.0 mg/l is the maximum permissible limit of fluoride. Fluoride is a double-edged sword that offers maximum caries protection when used in optimal quantity and judicious manner, whereas injudicious and excessive consumption may cause dental and skeletal fluorosis.
”Dental fluorosis,” A specific disturbance in tooth formation and unesthetic condition, is defined as a chronic, fluoride-induced condition, in which enamel development is disrupted and the enamel is hypomineralized. Clinically, dental fluorosis is characterized by the staining and pitting of tooth/teeth. In severe cases, the entire enamel may also be damaged. The appearance of teeth may be chalky white along with the presence of white, yellow, brown, or black spots or streaks on the surface of the enamel. It occurs during the developmental stages of tooth formation in children who are subjected to increased fluoride consumption.
Dental fluorosis is a major public health problem in India in which approximately 19 states with 230 districts of India are affected by the burden of dental fluorosis. Its prevalence is predominant in the states of Bihar, Tamil Nadu, Andhra Pradesh, Gujarat, Rajasthan, Punjab, and Haryana, mainly because of the consumption of drinking water containing a high concentration of fluoride. In India, the majority of the population is dependent on groundwater for drinking purposes, which predisposes them to dental fluorosis. In Haryana state, almost all districts except six (Panchkula, Yamunanagar, Ambala, Kurukshetra, Kaithal, and Panipat) have groundwater with a medium-to-high fluoride concentration. Rohtak district is included in Haryana's high fluoride belt area, which is subdivided into five blocks. With the increasing number of patients suffering from dental fluorosis and reporting in dental outpatient department of the pedodontics department, PGIDS necessitates this study to be done for evaluating the endemic areas in the Rohtak district. Previous studies had included limited areas of the Rohtak district. Hence, the present study was done to overcome the shortcomings of previous studies by covering all five blocks of Rohtak district and sampling both the rural and urban school children. The present study was designed to estimate the fluoride concentration in drinking water in Rohtak district, Haryana, and quantify its effect on the prevalence of dental fluorosis and dental caries.
| Materials and Methods|| |
A cross-sectional study was conducted on 6–12-year-old school children of district Rohtak, Haryana. Rohtak district is one of the 21 districts of Haryana state in Northern India. The district consists of two tehsils-Rohtak and Meham which are further subdivided into 5 blocks Rohtak, Kalanaur, Sampla, Meham, and Lakhan-Majra. From these five blocks, villages were selected by simple random sampling. Each village was given a specific code for the ease of marking on the map. Before conducting the study, approval was obtained from the institutional review board, PGIDS, Rohtak. Official permission was sought from the District Education Officer as well as the concerned school authorities. Written informed consent was taken from the parents/guardians of the students. A total of 1262 children in the age group of 6–12 years were randomly selected from different schools in five blocks of Rohtak district, Haryana. Only those children who were continuous residents of that area were selected to ensure they have been using the local drinking water since birth. Age was recorded as age at last birthday (rounded off to 6 months) and this information was taken from the school records. A questionnaire survey form was filled out to record the demographic details of the samples. Dental caries was recorded according to DMFT (D = Decayed, M = Missing due to caries only, F = Filled, T = Teeth)/deft index (d = decayed, e = extracted due to caries, f = filled, t = teeth). Assessment of Dental Fluorosis was done according to Dean's Fluorosis Index, modified in 1942. Standardization of the recording procedures was done to achieve reasonable consistency to avoid intra-examiner and inter-examiner variability. All the drinking water samples were collected from the water sources used for domestic purposes. The water samples were collected in 100 cc plastic bottles, which were washed with distilled water and dried before the collection of samples. These bottles were labeled according to the area and source of drinking water. The specific code of each area was mentioned on the respective bottle. After getting the results, the bottles were decoded. This was done to minimize the biasing of the results. All water samples collected were analyzed by Ion Selective Electrode Method using ION check 45 m. The machine was calibrated using TISAB (Total Ionic Strength Adjustment Buffer) with a total of five standards – 0.5 mg/L, 1.0 mg/L, 2.0 mg/L, 5.0 mg/L, and 10 mg/L for water samples. After calibration, the electrode was directly inserted into the water samples and fluoride estimation was done. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 19 (IBM corporation, Chicago, USA) software program. Appropriate descriptive and inferential statistics were applied. The statistical tests used were the Correlation matrix, Chi-square, and student t-test.
| Results|| |
A total of 1262 school children were examined from 30 villages in the Rohtak district. [Table 1] indicates the distribution of children according to the area, prevalence of dental caries (mean DMFT and mean deft), and fluorosis and their groundwater fluoride concentration. Areas were categorized into four groups according to groundwater fluoride concentration (in ppm)-low fluoride area (>0.7 ppm), optimum fluoride area (0.7–1.5 ppm), high fluoride area (1.5–4 ppm), and very high fluoride area (>4 ppm) [Table 1] and [Figure 1]. Mean DMFT in the area of study ranged from 0.32 to 1.90. Mean deft in the area of study ranged from 0.34 to 1.91. The fluoride concentrations in groundwater are in the range of 0.532–8.802. Out of 1262 children examined, 655 (51.90%) children were having dental fluorosis. 607 (48.10%) of the participants were free from fluorosis. 16.09%, 13.39%, 9.11% and 8.16%, and 5.15% were having questionable, very mild, mild, moderate, and severe form of fluorosis, respectively [Table 2]. [Table 3] indicates the distribution of dental caries and dental fluorosis according to age showing the highest prevalence of both dental caries and dental fluorosis in 9 years age group (25.51% and 27.78%, respectively) and the lowest in 6 years' age group (5.91% and 1.83%, respectively). No statistically significant association was found between the prevalence of dental caries and age (DMFT and age r = 0.653, P = 0.112), (deft and age r = 0.219, P = 0.637). The prevalence of dental fluorosis among males is 49.49% and in females is 54.10%. However, this difference was found to be statistically insignificant (P > 0.005), Chi-square value 0.017, and the prevalence of dental caries among males is 48.62% and in females is 53.17% [Table 4]. A negative correlation was found between groundwater fluoride concentration and DMFT/deft, whereas a positive correlation was evident between groundwater fluoride concentration and dental fluorosis. Dental fluorosis and DMFT/deft showed a negative correlation [Table 5]. Various esthetic treatment options such as etch bleach seal, night guard or in-office bleaching, veneers, and crowns were advised to the participants according to the extent and severity of dental fluorosis. Restorative, endodontic pulp therapy or extractions were advised as per severity and extent of dental caries [Table 6].
|Table 1: Distribution of children according to the area, the prevalence of dental caries (mean Decayed, Missing due to caries only, Filled, Teeth and mean decayed, extracted due to caries, filled, teeth) and dental fluorosis and the groundwater fluoride concentration|
Click here to view
|Figure 1: Distribution of villages according to groundwater fluoride concentration (ppm)|
Click here to view
|Table 3: Distribution of dental caries and dental fluorosis according to the age of children|
Click here to view
|Table 4: Distribution of dental caries and dental fluorosis according to gender|
Click here to view
| Discussion|| |
Many studies have been done to identify the prevalence of dental caries and fluorosis in different parts of India; however, limited data have been reported in the literature of the Rohtak district of Haryana. Out of 30 different areas, 25 places in rural areas and 5 places in urban areas were selected for this study. This predominant selection of rural areas was because most of the population of Haryana state resides in rural areas.
The temperature of this area in the summer season from April to July generally remains between 30°C and 40°C, occasionally going up to 48°C for a few days. The consumption of drinking water is much more compared to areas with low temperatures. Therefore, drinking water would play an important role in the prevalence of dental caries and fluorosis. Keeping in view the above factor, the estimation of fluoride concentration in drinking water was considered an important factor and was taken into account. Although the municipal water supply is present in most of the areas of study, still groundwater consumption was frequently observed due to limited timing of municipal water supply and availability of tubewells and hand pumps, especially in rural areas. Other risk factors affecting dental caries were not included in the study which may be a shortcoming of the present study.
The age range of 6–12 years was selected for the present study, as there is the transition from primary to mixed dentition with the eruption of the lower incisor and first molar at 6 years of age, and 12 years is considered a global monitoring age for caries to study disease trends and for international comparison since by this age, all permanent teeth except the third molar erupt.
DMFT and deft index were used to record dental caries in the present study which is simple, rapid, versatile, and universally accepted. The overall prevalence of dental caries was found to be 50.95%. The mean DMFT was found to be 0.96 and the mean deft was 1.01. The reason for the comparatively less prevalence of dental caries in the present study could be explained by the cariostatic effect of fluoride. Hydroxyapatite in teeth enamel is formed from calcium, magnesium, and phosphate compounds and is susceptible to decay induced by acid-producing bacteria. Fluoride interacts with hydroxyapatite to form fluorapatite, which is less susceptible to erosion by acid-producing oral bacteria.
The mean value of DMFT and deft in females was found to be 0.99 and1.07, respectively. The value of mean DMFT and deft in males was found to be 0.93 and 1.01. In this study, it was observed that deft/DMFT scores were more in females in both permanent and primary dentition as compared to their counterparts. This finding is consistent with the study conducted by Sukhabogi et al. and Singh and Singh. Earlier eruption of teeth, snacking during food preparation, hormonal influences, and amelogenin contribution to caries susceptibility are the few known factors for the higher caries prevalence among females.
In the present study, no statistically significant association was found between the prevalence of dental caries and age which was in concurrence with the other authors,,, who have also reported no association between dental caries and age.
In the present study, dental fluorosis was present in 655 children out of a total of 1262 (51.90%). The prevalence rate of fluorosis was higher in the present study because Rohtak district is considered an endemic area of fluorosis with high fluoride concentration in most of the areas. In the present study, the percentage of dental fluorosis was found to be 49.49% in males and 54.10% in females. However, this difference was found to be statistically insignificant (P > 0.005) 7 representing similar prevalence in both sexes. This is in concurrence with the study conducted by Tiwari et al. where no significant association between dental fluorosis and gender (P = 0.02) was observed.
Aggarwal et al. found a total prevalence of dental fluorosis as 27.28% in school children of Rohtak city, out of which 27.91% was in boys and 25.98% in girls, the difference between males and females was not statistically significant. There was no significant increase in the prevalence of dental fluorosis with age.
The prevalence of dental fluorosis is directly related to the fluoride concentration in drinking water, as the fluoride content increases, there is a continuous rise in dental fluorosis. The results were statistically significant. The present findings are concurrent with the findings of the authors,,, described above.
In the present study, a gradual continuous decline in dental caries was found to be associated with an increase in fluoride content in drinking water. The present study findings are similar to authors described above.,,,
In the present study areas, it was observed that areas of high fluoride in groundwater had more cases of enamel hypoplasia, mottled enamel with brown discoloration along with pit and enamel wear due to poor mineralization and increased sensitivity, but the prevalence of dental caries was low in these areas. There was a gradual decline in dental caries with an increase in dental fluorosis. DMFT and fluorosis (r = −0.930, P < 0.001) deft and fluorosis (r = −0.932, P < 0.001). The results were found to be statistically significant which was in accordance with the findings of Jackson et al. and Driscoll et al.
Thus, various treatment approaches have been recommended for dental fluorosis patients depending on the severity of the disease. Treatment options include micro/macro abrasion, bleaching, etch bleach seal, composite restorations, composite or ceramic veneers, and full crowns.
| Conclusion|| |
The risk of dental fluorosis was significantly higher in the areas showing more fluoride content in drinking water. However, with the increase in fluoride content, the prevalence of dental caries decreased. There is an urgent need to improve the quality of water and institute de-fluoridation of drinking water in affected areas to lower the burden of dental fluorosis in the community either by making alternative sources available or providing water with an optimal concentration of fluoride. Awareness about the sources and ill effects of fluoride has to be spread in the population through health education. These measures can go long way in reaping caries by preventing the benefits of fluoride while simultaneously avoiding dental fluorosis as much as possible in these areas.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shyam R, Manjunath BC, Kumar A, Narang R, Rani G, Singh S. Prevalence of dental fluorosis and treatment needs among 11-14 years old school children in endemic fluoride areas of Haryana, India. Indian J Dent Res 2021;32:110-4.
] [Full text]
Sharma A, Kumar N, Sharma R. Prevalence and association of dental caries and dental fluorosis in fluoride endemic region of Mewat district, Haryana, India. Int J Oral Health Dent 2019;5:27-31.
Mascarenhas AK. Risk factors for dental fluorosis: A review of the recent literature. Pediatr Dent 2000;22:269-77.
Rawat R, Gunjan SA, Dinesh FS, Vishwanath G, Soumya V. Dental fluorosis and its burden in India-revisiting a forgotten chapter. Int J Community Med Public Health 2020;7:3730-4.
Shyam R, Bhadravathi Chaluvaiah M, Kumar A, Pahwa M, Rani G, Phogat R. Impact of dental fluorosis on the oral health related quality of life among 11- to 14-year-old school children in endemic fluoride areas of Haryana (India). Int Dent J 2020;70:340-6.
Singh A, Laura JS, Rana A. Fluoride distribution in groundwater and prevalence of dental fluorosis among school children in villages of Jind district, Haryana (India). Int J Curr Res 2013;5:998-1002.
Peckham S, Awofeso N. Water fluoridation: A critical review of the physiological effects of ingested fluoride as a public health intervention. ScientificWorldJournal 2014;2014:293019.
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:S245-52.
Singh DK, Singh RP. Prevalence of dental caries in school going children of Patna. J Indian Dent Assoc 1981;53:267-31.
Saravanan S, Kalyani C, Vijayarani M, Jayakodi P, Felix A, Nagarajan S, et al.
Prevalence of dental fluorosis among primary school children in rural areas of Chidambaram Taluk, Cuddalore district, Tamil Nadu, India. Indian J Community Med 2008;33:146-50.
] [Full text]
Jackson RD, Kelly SA, Katz BP, Hull JR, Stookey GK. Dental fluorosis and caries prevalence in children residing in communities with different levels of fluoride in the water. J Public Health Dent 1995;55:79-84.
Solanki J, Dundappa J, Babu K. Prevalence of dental fluorosis in school children of Jodhpur city. IJDA 2011;3:563-7.
Haikel Y, Cahen PM, Turlot JC, Frank RM. Dental caries and fluorosis in children from high and low fluoride areas of Morocco. ASDC J Dent Child 1989;56:378-81.
Kaur H, Basran SS, Nandi S, Chana S. Prevalence of dental fluorosis in 10-16 year old school children of Mewat district, Haryana: A cross sectional survey. Int J Res Dent 2012;2:18-23.
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.
] [Full text]
Aggarwal A, Singh B, Kharbanda OP, Shukla DK, Goswami K, Gupta S. Dental fluorosis in rural school children in Haryana – A brief report. Indian J Prev Soc Med 2001;32:113-5.
AlDosari AM, Akpata ES, Khan N. Associations among dental caries experience, fluorosis, and fluoride exposure from drinking water sources in Saudi Arabia. J Public Health Dent 2010;70:220-6.
Sharma A, Gupta S. Dental caries prevalence in endemic fluoride areas of Haryana state, India. J Indian Dent Assoc 1998;69:97-9.
Driscoll WS, Horowitz HS, Meyers RJ, Heifetz SB, Kingman A, Zimmerman ER. Prevalence of dental caries and dental fluorosis in areas with optimal and above-optimal water fluoride concentrations. J Am Dent Assoc 1983;107:42-7.
Park K. Parks Textbook of Preventive and Social Medicine. 18th
ed. Jabalpur: Banarasi Das Bhanot Publishers; 2005.
Dean TH, Arnold FA, Elvolve E. Additional studies of the relation of fluoride domestic waters to dental caries experience in 4,425 white children aged 12 to 14 years, of 13 cities in 4 states. Public Health Rep 1942;57:1156-79.
Shahroom NS, Mani G, Ramakrishnan M. Interventions in management of dental fluorosis, an endemic disease: A systematic review. J Family Med Prim Care 2019;8:3108-13.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]