Early diagnosis and complete recovery from fluorosis through practice of interventions.

OBJECTIVES: The objective of this communication is to disseminate scientific and technical information for early diagnosis of Fluorosis; recent developments in care and management of patients of Fluorosis. MATERIAL AND METHODS: Body fluids collected from patients suspected of Fluorosis referred by hospitals, samples of drinking water used by them are the materials that have been investigated. Fluoride level in body fluids and water samples are tested by the ion selective electrode (ISE) potentiometry. Forearm X-ray radiograph is taken to assess interosseous membrane calcification. Upon diagnosis of the disease, two corrective measures, namely diet editing and diet counselling are introduced for practice in daily life. In the former, all sources of fluoride ingestion and use are withdrawn whereas in the latter, the patient is encouraged to consume a diet rich in essential nutrients, antioxidants and micronutrients through fruits, vegetables and dairy products. The patients are monitored at intervals to assess fluoride in body fluids. Reduction in fluoride levels has a direct relationship with disappearance of health complaints and subsequent recovery. RESULTS: Eight case studies (5 male + 3 female) are described. Patients'complaints are gastrointestinal discomfort, polyuria, polydipsia, muscle weakness, fatigue and joint pain. Body fluids may have high fluoride with normal or high fluoride level in drinking water.The main source(s) of fluoride entry identified are (i) consuming fluoride contaminated food/snacks/beverages laced with black rock salt; (ii) drinking of untreated ground water; (iii) using fluoridated toothpaste. The duration of recovery varies from patient to patient depending upon their body physiology and the seriousness with which the interventions were practiced. Recurrence of the disease may occur in some patients due to change in life-style, not practicing interventions, entry of fluoride inadvertently. CONCLUSION: This communication provides an overview of Fluorosis, its occurrence, manifestations, diagnostic tests, results, interventions practiced, monitoring and recovery from the disease.

Exposure to fluoride in smelter workers in a primary aluminum industry in India.

BACKGROUND: Fluoride is used increasingly in a variety of industries in India. Emission of fluoride dust and fumes from the smelters of primary aluminum producing industries is dissipated in the work environment and poses occupational health hazards. OBJECTIVE: To study the prevalence of health complaints and its association with fluoride level in body fluids of smelter workers in a primary aluminum producing industry. METHODS: In an aluminum industry, health status of 462 smelter workers, 60 supervisors working in the smelter unit, 62 non-smelter workers (control group 1) and 30 administration staff (control group 2) were assessed between 2007 and 2009. Their health complaints were recorded and categorized into 4 groups: 1) gastro-intestinal complaints; 2) non-skeletal manifestations; 3) skeletal symptoms; and (4) respiratory problems. Fluoride level in body fluids, nails, and drinking water was tested by an ion selective electrode; hemoglobin level was tested using HemoCue. RESULTS: The total complaints reported by study groups were significantly higher than the control groups. Smelter workers had a significantly (p<0.001) higher urinary and serum fluoride level than non-smelter workers; the nail fluoride content was also higher in smelter workers than non-smelter workers (p<0.001). The smelter workers with higher hemoglobin level had a significantly (p<0.001) lower urinary fluoride concentration and complained less frequently of health problems. Only 1.4% of the smelter workers were consuming water with high fluoride concentrations. A high percentage of participants was using substances with high fluoride contents. CONCLUSION: Industrial emission of fluoride is not the only important sources of fluoride exposure--consumption of substance with high levels of fluoride is another important route of entry of fluoride into the body. Measurement of hemoglobin provides a reliable indicator for monitoring the health status of employees at risk of fluorosis.

Reversal of fluoride induced cell injury through elimination of fluoride and consumption of diet rich in essential nutrients and antioxidants.

The objective of the present communication is to address the issues concerning reversal of fluoride induced cell injury and disease (i.e. fluorosis) through the elimination of fluoride and consumption of a diet containing essential nutrients and antioxidants. Humans afflicted with fluorosis, as a result of consuming fluoride contaminated water or food, have been investigated. Hospital based diagnostic procedure for early detection of fluorosis, through retrieval of history, clinical complaints, testing of blood, urine and drinking water for fluoride using ion selective electrode technology, along with X-ray of the forearm have been carried out. Confirmed cases of fluorosis were introduced to an intervention protocol consisting of (1) provision of safe drinking water with fluoride levels less than 1 mg/L and (2) counselling on nutritional supplementation with focus on adequate intake of calcium, vitamins C, E and antioxidants. The patients were monitored at frequent intervals up to one year and the results are reported. With a standardized early diagnosis, elimination of fluoride intake and supplementation of a diet rich in essential nutrients and antioxidants, we have shown that the fluorosis can be reversed.

Gastroduodenal manifestations in patients with skeletal fluorosis.

A prospective case-controlled study was performed to evaluate the gastrointestinal symptoms and mucosal abnormalities occurring in patients with osteofluorosis. Ten patients with documented osteofluorosis and ten age- and sex-matched healthy volunteers were included in the study. Clinical evaluation, real-time ultrasound, and upper gastrointestinal endoscopy and biopsy from the gastric antrum and duodenum were performed in all subjects. The biopsies were subjected to a rapid urease test and light and electron microscopic examinations. Ionic fluoride levels were estimated in the drinking water, serum, and urine using an ION 85 ion analyzer. All patients with osteofluorosis had gastrointestinal symptoms, the most common being abdominal pain. Endoscopic abnormalities were found in seven patients with osteofluorosis. In all 7 of these patients, chronic atrophic gastritis was seen on histology. Electron microscopic abnormalities were observed in all 10 patients with osteofluorosis. These included loss of microvilli, cracked-clay appearance, and the presence of surface abrasions on the mucosal cells. None of the control subjects had any clinical symptoms or mucosal abnormalities. It was concluded that gastrointestinal symptoms as well as mucosal abnormalities are common in patients with osteofluorosis.

Circulating testosterone levels in skeletal fluorosis patients.

OBJECTIVE: The present study focuses on serum testosterone concentrations in patients with skeletal fluorosis, in order to assess the hormonal status in fluoride toxicity. METHODS: Serum testosterones were compared for patients afflicted with skeletal fluorosis (n = 30) and healthy males consuming water containing less than 1 ppm fluoride (Control 1, n = 26) and a second category of controls (Control 2, n = 16): individuals living in the same house as the patients and consuming same water as patients but not exhibiting clinical manifestations of skeletal fluorosis. RESULTS: Circulating serum testosterones in skeletal fluorosis patients were significantly lower than those of Control 1 at p < 0.01. Testosterone concentrations of Control 2 were also lower than those of Control 1 at p < 0.05 but were higher than those of the patient group. CONCLUSIONS: Decreased testosterone concentrations in skeletal fluorosis patients and in males drinking the same water as the patients but with no clinical manifestations of the disease compared with those of normal, healthy males living in areas nonendemic for fluorosis suggest that fluoride toxicity may cause adverse effects in the reproductive system of males living in fluorosis endemic areas.

Safety of ciprofloxacin therapy in children: magnetic resonance images, body fluid levels of fluoride and linear growth.

We evaluated the safety of ciprofloxacin administered in a dose of 15-25 mg/kg for 9-16 days, in a case series of 58 children who were between 8 months and 13 years of age. No arthropathy was observed during therapy and follow-up. Blinded evaluation of 22 pairs of nuclear magnetic resonance scans obtained before and between day 10 and 15 of therapy did not reveal any cartilage damage. After the first dose of ciprofloxacin (10 mg/kg), serum fluoride levels increased at 12 h in 15 of 19 (79%) patients; 24-h urinary fluoride excretion was higher on day 7 compared with basal values in 16 of 18 (88.9%) patients. Height z scores of 53 patients at a mean of 22.5 months of follow-up were not significantly different from basal scores (p = 0.12). In conclusion, ciprofloxacin may be recommended for use in children for short duration when effective alternative antibacterials are unavailable. However, there is a need for further studies to evaluate the tissue accumulation of fluoride and its potential to cause toxic effects.

Effects of chronic fluoride toxicity on the morphology of ductus epididymis and the maturation of spermatozoa of rabbit.

This study used light and scanning electron microscopy to observe the effect of chronic fluoride toxicity on the structure of the ductus epididymis, testis and spermatozoa in rabbit. The rabbits were treated with 10 mg NaF/kg body weight/day for 20 and 23 months. Serum fluoride was estimated by the fluoride ion-specific electrode method. Fluoride levels in the sera of both 20 and 23-month treated rabbits were significantly increased (P < 0.001). Loss of stereocilia, significant decrease (P < 0.001) in the height of the pseudostratified columnar epithelium and significant increase (P < 0.001) in the diameter of both the caput and cauda ductus epididymis were observed only in the 23-month fluoride treated rabbits. The decreases in the epithelial cell height (P < 0.01) and the tubular diameter (P < 0.001) of the testis were significant only in 23-month treated animals. Spermatozoa in the lumen of the testis of both treated groups of animals and in the caput and cauda ductus epididymis of 20-month treated animals appeared normal, but spermatozoa in the caput and cauda ductus epididymis of 23-month treated animals were fragmented. In the 23-month fluoride treated rabbits, the weights of the caput and cauda epididymis were significantly reduced (P < 0.025) and there was also a reduction in the number of secretory granules in these organs. The structural changes observed in the caput and cauda ductus epididymis might adversely affect the maturation of spermatozoa.

Serum haptoglobin and C-reactive protein in human skeletal fluorosis.

Circulating levels of haptoglobin and C-reactive protein were studied in patients of skeletal fluorosis and compared with two types of controls. The first type of control included normal healthy individuals consuming water containing permissible levels of fluoride (up to 1 mg/L). The second type of control included individuals consuming water contaminated with fluoride (1.2-14.5 mg/L) but not exhibiting clinical manifestations of skeletal fluorosis. A significant increase in the levels of haptoglobin (p < 0.01) and C-reactive protein (p < 0.01) as well as a raised erythrocyte sedimentation rate were seen in patients of skeletal fluorosis as compared to both types of controls. The present study suggests the possibility of a subclinical inflammatory reaction occurring in patients with skeletal fluorosis.

Ultrastructural studies of spermiogenesis in rabbit exposed to chronic fluoride toxicity.

OBJECTIVE: To address the role of fluoride in causing defects to spermatids and epididymal spermatozoa. METHODS: Male rabbits were treated with 10 mg NaF/kg body weight daily for 18 months and maintained under identical laboratory conditions along with the control rabbits not given NaF. Testis and epididymis (caput) were investigated for ultrastructural details of spermatids and spermatozoa. RESULTS: A wide variety of structural defects were observed in the flagellum, the acrosome, and the nucleus of the spermatids and epididymal spermatozoa of fluoride-treated rabbits. Abnormalities included absence of outer microtubules, complete absence of axonemes, structural and numeric aberrations of outer dense fibers, breakdown of the fibrous sheath, and structural defects in the mitochondria of the middle piece of the flagellum. Detachment and peeling off of the acrosome from the flat surfaces of the nucleus were also observed. CONCLUSION: The abnormalities observed render the sperm nonfunctional and ineffective, and thus there is a possible role of fluoride in causing infertility.

Toxic effects of chronic fluoride ingestion on the upper gastrointestinal tract.

In a prospective case controlled study, we evaluated the adverse effects of long-term fluoride ingestion on the gastrointestinal tract. Ten patients with otosclerosis who were receiving sodium fluoride 30 mg/day for a period of 3-12 months, and 10 age- and sex-matched healthy volunteers were included. They were all evaluated clinically and subjected to a real time ultrasound examination, upper gastrointestinal endoscopy, and biopsies from the gastric antrum and duodenum. The biopsies were subjected to a rapid urease test as well as light and electron microscopic examinations. Ionic fluoride was estimated in the serum, urine, and drinking water using an ION 85 Ion Analyzer. Seven subjects (70%) ingesting fluoride had abdominal pain, vomiting, and nausea. Petechiae, erosions, and erythema were seen on endoscopy in all the subjects, but not in the controls. Histological examination of the gastric antral biopsy showed chronic atrophic gastritis in all the subjects but in only one (10%) healthy volunteer. Scanning electron microscopic examination showed "cracked-clay" appearance, scanty microvilli, surface abrasions, and desquamated epithelium in the subjects ingesting fluoride, but not in the controls. We conclude that long-term fluoride ingestion is associated with a high incidence of dyspeptic symptoms as well as histological and electron microscopic abnormalities.

Effect of long-term administration of sodium fluoride on plasma calcium level in relation to intestinal absorption and urinary excretion in rabbits.

The present study was undertaken to determine the effect of chronic fluoride toxicity on calcium metabolism. Rabbits (n = 10) were orally administered an aqueous solution of 10 mg NaF/kg body wt daily for 18 months. Equal numbers (n = 10) of age-, sex- and weight-matched rabbits kept under identical laboratory conditions, but not treated, with NaF solution, served as control. The fasting plasma calcium concentrations of fluoride-treated rabbits were significantly lower (P < 0.001) than those of control animals. In contrast to the decrease in plasma calcium level, and increase in intestinal radioactive calcium (45Ca) absorption was observed (P < 0.001) in all fluoride-treated animals. However, urinary calcium excretion levels were found to be reduced (P = not significant) in fluoride-treated rabbits. It is therefore concluded that long-term fluoride poisoning alters the calcium homeostatic mechanism, thereby affecting calcium metabolism.

Fluoride toxicity: a biochemical and scanning electron microscopic study of enamel surface of rabbit teeth.

The present study has been carried out to investigate the effect of fluoride toxicity on the morphology as well as inorganic chemical constituents of rabbit teeth. Rabbits were administered sodium fluoride at a dose of 10 mg NaF/kg body weight every 24 h for 18 and 23 months. The incisor and molar teeth (whole tooth) were investigated for fluoride, calcium and phosphorus content in 18- and 23-month treated animals. The enamel surfaces of incisor teeth of 23-month treated animals were examined under scanning electron microscope. A significant increase in fluoride levels and significant decrease in calcium content was found following fluoride administration for 18 and 23 months as compared to control. Ca/P ratio was significantly increased only in 23-month treated animals. The scanning electron micrographs revealed hypoplastic, rough, uneven, pitted and cracked enamel surfaces covered with granular deposits as a result of excessive intake of fluoride. It can be concluded that long term fluoride administration leads to severe structural alterations on the enamel surface, possibly through defective mineralization.

Fluoride as a possible aetiological factor in non-ulcer dyspepsia.

A prospective case controlled study was conducted to evaluate the role of fluoride as a possible aetiological factor for non-ulcer dyspepsia (NUD). Twenty patients with NUD and 10 age and sex matched healthy controls were subjected to clinical evaluation, upper gastrointestinal endoscopy and biopsies from the gastric antrum and duodenum. The antral and duodenal mucosa was subjected to a rapid urease test for Helicobacter pylori and histological and electron microscopic examinations. Fluoride levels in the drinking water, serum and urine were estimated using a ION 85 ion-analyser. These levels were significantly higher in patients with NUD than in controls (P less than 0.05). Histological abnormalities in the antral and duodenal mucosa were seen in 14 patients (70%) with NUD and 1 control subject (10%) (P less than 0.05). Electron microscopic abnormalities in the mucosal cells were seen in all patients with NUD but in none of the controls (P less than 0.01). The fluoride levels in serum and urine correlated with the symptoms, histological and electron microscopic abnormalities (P less than 0.05). It was concluded that chronic exposure to fluoride may result in NUD and should be considered in patients where other known cause of dyspepsia have been excluded.

A study of the effect of high concentrations of fluoride on the reproductive organs of male rabbits, using light and scanning electron microscopy.

Fluoride was orally administered to rabbits at 10 mg NaF/kg body weight for 18 or 29 months. The animals were then killed and the structure of the testis, epididymis and vas deferens studied under light and scanning electron microscopes. In animals treated for 29 months, the spermatogenic cells in the seminiferous tubules were disrupted, degenerated and devoid of spermatozoa. In animals treated for 18 or 29 months, loss of cilia on the epithelial cells lining the lumen of the ductuli efferentes of the caput epididymidis and of stereocilia on the epithelial cells lining the lumen of the vas deferens was observed. In some regions of the epithelial lining of the lumen of the ductuli efferentes and vas deferens, the boundaries of the cells were not clear and appeared to be peeled off. Mucus droplets were abundant in the vas deferens of control animals, but absent in both the treated groups. Spermatogenesis ceased only in animals treated for 29 months. The difference in the structural changes observed in the testes of the 2 treated groups may have been due to the blood-testis barrier. It is concluded that ingestion of high concentrations of fluoride has harmful effects on the male reproductive system.

Aortic calcification in chronic fluoride poisoning: biochemical and electronmicroscopic evidence.

Fluoride is known to cause ectopic calcification. The biochemical mechanism(s) involved in the initiation of calcification is not understood and the accompanying ultrastructural changes remain to be elucidated. Therefore, certain relevant parameters have been investigated in the aorta of rabbits administered fluoride, 10 mg NaF/kg body wt, every 24 hr for 17 and 24 months. The significant findings are: (i) degeneration of smooth muscle fibers in the tunica media of the aorta, (ii) presence of electron-dense granules in the mitochondria and on the inner surface of the plasma membrane of smooth muscle cells, (iii) presence of matrix vesicles with electron-dense deposits, (iv) enhanced calcium content and the Ca/P ratio, and (v) increased total glycosaminoglycan (GAG) content with reduced dermatan sulfate. The presence of electron-dense granules in the mitochondria, on the plasma membrane and matrix vesicles is suggestive of the process of calcification. The enhanced calcium content as well as the Ca/P ratio supports the view that the aorta is undergoing mineralization. The total GAG is enhanced, possibly due to an increase in the content of GAGs other than isomers of chondroitin. The observation that conveys an important message is that the dermatan sulfate normally known to exist in high concentrations in soft tissues begins to decrease as the process of calcification sets in. This perhaps would hold true and may serve as an index in the process of ectopic calcification.

Circulating levels of sialic acid and glycosaminoglycans: a diagnostic test for ankylosing spondylitis.

The circulating levels of sialic acid (N-acetylneuraminic acid) and glycosaminoglycans (GAGs) were measured in 69 patients with spinal disorders of orthopaedic interest (ankylosing spondylitis 17, osteofluorosis 6, idiopathic backache 10, osteoarthrosis 16, osteoporosis 20). The serum GAG levels showed no statistically significant change from control values in the five disorders investigated in the present study. Although osteoporosis and osteoarthrosis showed a decrease in serum sialic acid (SA) levels, the mean ratio (SA/GAG) demonstrated no change from control values. Idiopathic backache showed no difference in any of the parameters studied when compared with control values. Ankylosing spondylitis and osteofluorosis had a remarkable similarity in their clinical and radiological features, but a divergent mean value of ratio was noted. The mean ratio of both the conditions also showed a statistically significant difference from the control value. This suggests that the SA/GAG ratio can be used as a diagnostic test in ankylosing spondylitis.

Fluoride-induced changes in the tooth glycosaminoglycans: an in vivo study in the rabbit.

Effect of high fluoride ingestion on the tooth matrix glycosaminoglycans was studied in rabbits administered 10 mg NaF/kg body weight orally at 24-h intervals for a period of 9 months. Fluoride-treated tooth showed a significant reduction in glycosaminoglycan content as compared to the normal tooth. Sephadex G-75 chromatography and DEAE-cellulose ion exchange chromatography revealed the presence of small molecular weight glycosaminoglycan molecules and an increase in the charge density heterogeneity in the sulphated glycosaminoglycans of the fluoride-treated rabbit tooth as compared to the controls. These changes may be related to the dedifferentiated tooth matrix and an increase in the dermatan sulphate content in the fluoride-treated tooth matrix reported earlier.

Chronic fluoride toxicity: a scanning electron microscopic study of duodenal mucosa.

The effects of chronic fluoride toxicity on duodenal mucosa of rabbits were investigated using scanning electronmicroscope on materials obtained from rabbits subjected to oral administration of sodium fluoride at the dose of 10 mg/kg body weight per day for a period of 24 months. Significant morphological abnormalities were observed in the mucosa of all the fluoride treated animals [n = 9] when compared to that of control rabbits. The surface of the microvilli of duodenal epithelium revealed a "cracked-clay" appearance in fluoride treated rabbits. Besides, abrasion on the villus surface due to epithelial cell degeneration was also noticed. Mucus probably coating the degenerated cells formed strands over the villi in fluoride treated animals.

Effect of fluoride on molecular weight, charge density and age related changes in the sulphated isomers of glycosaminoglycans of the rabbit cancellous bone.

The effect of fluoride on the composition, molecular weight and charge density of the glycosaminoglycan isomers in the cancellous bone of the iliac crest region of the pelvic girdle was studied in rabbits treated with fluoride for 3, 9 and 16 months and the corresponding age-matched controls. With advancing age the chondroitin-6-sulphate concentration was found to increase in the fluoride-treated as well as the control animals. The concentration of dermatan sulphate was found to decrease with advancing age in the control groups. However, the fluoride-treated groups showed increasing concentrations of dermatan sulphate as the age and the duration of fluoride treatment advanced. The glycosaminoglycans in the fluoride-treated group showed the presence of low-molecular-weight molecules which were not found in the corresponding control group, and also showed an increased charge-density heterogeneity as compared to the corresponding control group. The data presented provide evidence to suggest that glycosaminoglycans of cancellous bone undergo age-related changes in their isomeric profile. The increase in dermatan sulphate and the presence of low-molecular-weight, highly charged molecules in the adult fluorosed bone may be related to the cartilagenous loci formation as reported earlier.