Trop Doct 2008;38:231-233
doi:10.1258/td.2008.070379
© 2008 Royal Society of Medicine Press
Incidence of skeletal deformities in endemic fluorosis
Shashi A
Kumar M
Bhardwaj M
Department of Zoology, Punjabi University, Patiala 147 002, India
Correspondence to: Dr Shashi Aggarwal, Department of Zoology, Punjabi University, Patiala 147 002, India Email: shashiuniindia{at}yahoo.co.in
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SUMMARY
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An investigation was undertaken in three endemic fluorotic areas
of Punjab State, India, to assess the prevalence of skeletal
deformities. The concentration of fluoride in drinking water
varies from 2.3 to 22.5 mg/L. The patients affected with skeletal
fluorosis revealed joint pain in both upper and lower limbs,
numbing and tingling of the extremities, back pains and knock-knees.
Prevalence of skeletal fluorosis was found to be 29% of grade-I,
51% of grade-II and 20% of grade-III and was higher in males
(63%) compared with females (37%).
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Introduction
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A variant of a severe form of skeletal fluorosis, termed
genu valgum (knock-knee syndrome) has been reported from certain
endemic areas including India.
1 Children and adolescents were
found to be the chief victims. A number of scientists have reported
symptoms such as vague pains in hands, feet and knees, numbing
of extremities, tingling sensations, restricted movements of
the trunk, hips and neck, kyphosis, the inability to close the
fist, rigidity of spine, difficulty in walking and crippling
with varied severity.
2 Complaints of abdominal pain, constipation,
intermittent diarrhoea, a bloated feeling, loss of appetite,
a feeling of nausea and mouth sores were reported under the
heading of gastrointestinal disturbances.
3
The present study was undertaken in order to find out the relationship between the prevalence of skeletal fluorosis and skeletal deformities in three fluorotic areas of Punjab, India.
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Patients and methods
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One hundred and three patients with clinically defined skeletal
fluorosis aged between 20 and 80 were selected for the study
from three fluorotic areas of Punjab State, India. The subjects
had been exposed to fluoride (2.3–22.5 mg/L) through drinking
water for more than 15 years. The symptoms and sign of skeletal
fluorosis were classified into three grades according to the
Teotia
et al.4 method. Data was analysed statistically using
SPSS windows, version 10.0.
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Results
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The percentage distribution of skeletal fluorosis was found
to be high in the 30–40 and 50–60 (18%) age groups
and lower in the 70–80 age group (14%).
Z (mode) analysis
(
Z = 5.15) of the data showed that there was significant difference
between males and females observed which indicated that the
percentage of people suffering from skeletal fluorosis was greater
in males than females (Figure
1).
The incidence of the disease was found to be highest in the
low economic group, followed by middle class group and lowest
in the high socioeconomic group. The chi-square analysis. (
2 = 27.40) revealed that the low income class group was most prone
to skeletal fluorosis. The results were statistically significant
(
P < 0.001). Those suffering from skeletal fluorosis were
divided into two groups: normal body mass index and observed
body mass index. Chi-square analysis of the data indicated highly
significant (
P < 0.001) differences between the actual and
the recorded body mass index of the patients. The prevalence
of skeletal fluorosis was higher in males (63%) compared with
females (37%) and was significant at
P < 0.001.
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Clinical skeletal symptoms
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The largest number suffered from:
- lower back pain (73%)
- leg pain (71%)
- arm pain (67%)
- tingling sensations in the hands and feet (48%)
- neck pain (34%)
- muscle weakness (38%)
- loss of appetite (44%)
- feelings of nausea (31%)
- abdominal pain (24%)
- polydypsia (27%)
- polyuria (29%).
Only 19% suffered
from constipation.
The majority of cases were affected by grade-II type skeletal fluorosis (51%; Figure 2), followed by grade-I (29%) and only 20% were suffering from severe grade-III skeletal fluorosis (Figure 3; Table 1).
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Figure 2 A 50-year-old woman with grade-II skeletal fluorosis with knock-knee and bow legs. The joints of legs were sclerotized. The patient had stiffness and rigidity in her muscles and a tingling sensation in her hands and feet
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Figure 3 A 65-year-old man with grade-III skeletal fluorosis. The symptoms were bone and joint pain, stiffness and rigidity, restricted movements of spine and joints, aches and stiffness of muscles, muscle weakness, neck pain and knock-knee. His hands showed major deformities. He was unable to flex his fingers
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Discussion
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The present study revealed the prevalence of skeletal deformities
in relation to the fluoride concentration in drinking water
(2.3–22.5 mg/L) in the three fluorotic areas of Punjab
State, India.
The prevalence of skeletal fluorosis was higher among men (63%) than women (37%) in the fluorotic areas. The results are in agreement with those reported by Krishnamachari and Krishnaswamy1 among residents of Nalgonda and Praksasam in Andhra Pradesh. The overall ratio between males and females affected was 10% among the children and 20% among the adolescents and young adults. Bharati and Rao5 observed that the prevalence of skeletal fluorosis was significantly higher in males (66%) compared with females (57.94%) in Dharwad District, Karnataka. The severity of disease as indicated by the fluorotic score was also higher in males (9.04) in comparison with females (5.85). Watanabe et al.6 also noted the incidence of skeletal fluorosis was higher in males (66%) than females (30%) in southwestern China. Earlier studies have indicated that the incidence and severity of chronic fluoride intoxication are greatly influenced by socioeconomic status, climatic and nutritional status.1,2,4 During the present investigation the low income patients were more prone to skeletal fluorosis than the middle and high income patients. The results were statistically significant (2 = 27.40).
The relationship between the levels of fluoride in drinking water and skeletal fluorosis vary from place to place. Zhu et al.7 reported endemic fluorosis in Shaanxi Province in western China at fluoride levels from 1.17 to 4.00 mg/L. Major skeletal deformities observed in various studies of fluorosis were bowed legs (genu varum), knock-knee (genu valgum) and stiffness of the cervical and lumber spine.1 Our study also revealed skeletal fluorosis with crippling bone deformities and skeletal syndromes, such as aching and stiffness of the muscles, muscle weakness, a tingling sensation in hands and feet, a numbness of the extremities, back pain and bent posture were higher among males.
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References
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- Krishnamachari KAVR, Krishnamswamy K. Genu valgum and osteoporosis in an area of endemic fluorosis. Lancet 1973;2:887–9[Medline]
- Bharati P, Kubakaddi A, Rao M, Nack RK. Clinical symptoms of dental and skeletal fluorosis in Gadag and Bagalkot districts of Karnataka. J Hum Ecol 2005;18:105–7
- Susheela AK, Kumar A, Bhatnagar M, Bahadur R. Prevalence of endemic fluorosis with gastrointestinal manifestations in people living in some North-Indian villages. Fluoride 1993;26:97–104
- Teotia SPS, Teotia M, Singh DP. Bone static and dynamic histomorphometry in endemic fluorosis. In: Fluoride Research: Studies in Environmental Science. Amster-dam: Elsevier Science Publisher, 1985;27:347–55
- Bharati P, Rao M. Epidemiology of fluorosis in Dharwad district, Karnataka. J Hum Ecol 2003;14:37–42
- Watanabe T, Kondo T, Asanuma S, Ando M, Tamura K, Sakuragi S, Rongdi J, Choake L. Skeletal fluorosis from indoor burning of coal in southestern China. Fluoride 2000;33:135–9
- Zhu C, Bai G, Liu X, Li Y. Screening high fluoride and high arsenic drinking water and surveying endemic fluorosis and arsenism in Shaanxi province in western China. Water Res 2006;40:3015–22[Medline]
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SUMMARY
Introduction
