Bajaj et al International Journal of Public Health Dentistry

RESEARCH ARTICLE

Prevalence of dental fluorosis among 12 and 15 year old school going children of
Udaipur city, India
Dimple Bajaj, Shrinath Shetty.

Abstract

Background: Fluoride at optimal level decreases the incidence of dental caries and is also necessary
for maintaining the integrity of oral tissues but at the same time when taken in excess during
developmental stages can cause adverse effects like dental fluorosis and skeletal fluorosis. Aim: To
know the prevalence and degree of dental fluorosis in 12 and 15 years old school going children of
Udaipur city, India. Methods: A total of 1042 children participated in the study. The sample was
divided into 2 groups; Group A, who were using borewater for drinking at home and at school and
Group B where the children, used municipal water supply for drinking both at home and at school.
The data regarding the fluoride content of borewell water of Udaipur city was collected from the office
of wells of India, Udaipur. A survey proforma was prepared based on the World Health organization
(WHO) Oral Health Assessment Form (1997). Karl-Pearson coefficient for correlation and simple
regression analysis was used to measure the correlation between fluoride concentration in drinking
water and community fluorosis index (CFI). Chi-square test was used to evaluate the association
between fluoride levels in drinking water and severity of dental fluorosis. Results: A linear relationship
was observed between the CFI values of 12 and 15 years old children and fluoride concentration in
water (r=0.98). The overall prevalence of dental fluorosis in 12 and 15 year old school going children
of Udaipur city was found to be 29.07%. A significantly high prevalence of dental fluorosis in Group A
(43.99%) was observed as compared to Group B (17.01%) [p<0.05]. Conclusion: The fluoride
concentration in Bore water of all 4 Zones was considerably high as compared to Municipal water.
There was an increase in severity of dental fluorosis as the fluoride concentration increased in the
drinking water. Hence dental fluorosis is considered as a major dental public health problem in
Udaipur city and is related to the high fluoride concentration present in the groundwater.
Keywords: Dental fluorosis; Borewell water; Municipal water; Fluoride.

Introduction Endemic dental fluorosis is a disturbance in

tooth formation caused by excessive intake of
Fluoride is a double -edged sword. Fluoride at
fluoride during the formative period of the
optimal level decreases the incidence of dental
dentition. The degree of severity of the clinical
caries and is also necessary for maintaining
manifestations of this form of chronic fluoride
the integrity of oral tissues but at the same
intoxication depends upon the amount, form
time when taken in excess during
and frequency of fluoride ingestion, the
developmental stages can cause adverse
duration of exposure, the age of the person,
effects like dental fluorosis and skeletal
the bioavailability of the fluoride compound
fluorosis (1).
and possibly other yet unknown factors (2).

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Bajaj et al
India is one among the 23 Nations around the
globe where health problems have been
reported due to excessive fluoride in drinking
water. Endemic dental fluorosis is most
prevalent in areas where the drinking water
contains elevated levels of fluoride (3). In
India, Bureau of Indian Standard (BIS) (4) has
set maximum permissible level of fluoride in
water as 1ppm. Since the pioneering studies
of Dean, several attempts have been made to
determine the relationship between the
occurrence of fluorosis and fluoride
concentration in drinking water in numerous
populations throughout the world (5). Fluoride
concentration in Rajasthan's groundwater is
much higher than the permissible limit of 0.6-
1.5 ppm (parts per million) of fluoride
recommended for potable purposes (6).
Therefore in these communities, fluorosis is
very common. Hence, the present study was
planned to know the prevalence and degree of
dental fluorosis in 12 and 15 years old school
going children of Udaipur city.
Materials and Methods
The present study attempted to estimate the
prevalence and severity of dental fluorosis
among 12 and 15 years old school going
children of Udaipur city, Rajasthan State,
India. After conducting a pilot study, the size of
the sample was estimated as 1000, with 250
samples from each Zone. A total of 1042
children participated in the study. The Udaipur
city was divided into 4 zones and the schools
and subjects were selected using random
sampling. Further sample was divided into 2
groups. Group A, who were using borewater
for drinking at home and at school as there
was no municipal water supply and, Group B
30 International Journal of Public Health Dentistry 2013:4(1):29-37. © Publishing Division, Celesta software Private Limited
International Journal of Public Health Dentistry
where the children, used municipal water
supply for drinking both at home and at school.
School based approach was used. Children
were selected from the schools randomly who
satisfied the following inclusion criteria.
a) The school children in the age group of 12
and 15
b) The children who were continuous
residents since birth i.e. those who were
born, reared and living in the same area
except for few weeks (holidays) in the year
and who were using the same source of
drinking water from birth to 10 years of
their life.
c) Children with permanent teeth with at least
more than 50% of the crown erupted and
no fillings on facial surface.
The data regarding the fluoride content of
Borewell water of Udaipur city was collected
from the office of Wells of India, Udaipur. To
confirm these levels of fluoride, further
samples of borewell water were collected from
the area nearby school and analysis was done
at the office of the superintending chemist,
Public Health Engineering Department (PHED)
Laboratory, Udaipur. Before scheduling the
survey an ethical clearance was obtained from
the Ethical committee of Pacific Dental
College, Udaipur. An official permission was
obtained from Deputy Director of Public
instruction, Udaipur.
A survey proforma was prepared based on the
World Health organization (WHO) oral health
assessment form, 1997(7). It consisted of two
st
parts, 1 part consisted of information on
demographic data, permanent residential
address, information on source of drinking
water, aids used for oral hygiene maintenance
nd
(fluoridated or nonfluoridated) and 2 part
Bajaj et al International Journal of Public Health Dentistry

consisted of table for recording fluorosis using Table 1: Distribution of study subjects
the Dean’s Fluorosis index (7). according to age, gender, study area and
Karl-Pearson coefficient for correlation (or source of drinking water
simple correlation) and simple regression Area Source Sex Age Total
analysis was used to measure the correlation
* ** *** 12 15
between fluoride concentration in drinking
water and community fluorosis index (CFI). M 24 6 30
B
Chi-square test was used to evaluate the
F 36 42 78
association between fluoride levels of drinking A
water and severity of dental fluorosis. M 15 18 33
T
Results F 34 59 93

The distribution of the study subjects

M 32 27 59
according to age, gender, source of drinking B
water and study area is presented in Table I. F 41 20 61
B
The percentage of children in 12 years was
M 38 30 68
541(51.92%) and 15 years were T
F 46 16 62
501(48.08%).It was observed that
466(44.72%) of study subjects were using M 69 28 97
Borewell water for drinking whereas B
F 18 45 63
576(55.28%) were using municipal water. The C
mean fluoride concentration in Borewater zone M 21 29 50
T
wise ranged from 0.642-0.927ppm.
F 29 27 56
Table II, shows the distribution of dental
M 14 25 39
fluorosis among the study subjects using
B
municipal and Borewell water, of Udaipur city F 24 15 39
(Zone-A, Zone-B, Zone-C, Zone-D). Graph I D
M 35 76 111
shows the comparison of Dental Fluorosis T
prevalence in Group A (Borewell) and Group B F 65 38 103

(Municipal). The percentage of children

Total Males 248 239 487
affected with fluorosis in Group A was 43.99%
whereas in Group B it was 17.01%. Total Females 293 262 555

Graph II shows the prevalence of dental 541 501

Grand Total (M+F) 1042
fluorosis among 12 and 15 years old children (51.92%) (48.08%)

based on fluoride concentration (in ppm). The

*4 Zones=A,B,C,D;** B= Borewell, T= Tap
percentage of children affected at 12 and 15
(Municipal); ***M=Male, F=Female
years were 26.98% and 31.33% respectively.

31 International Journal of Public Health Dentistry 2013:4(1):29-37. © Publishing Division, Celesta software Private Limited
Bajaj et al International Journal of Public Health Dentistry

Table 2: Prevalence of dental fluorosis of Municipal (M) and Borewell (B) drinking water
Subjects
Fluoride Subjects with Questionable Very mild Moderate Severe
Mild n(%) CFI
(ppm) examined fluorosis n(%) n(%) n(%) n(%)
n(%)
0.3 (M) 236 22(9.42) 15(6.36) 15(6.36) 2(0.85) 0(0) 0(0) 0.1
0.4 (M) 340 66(19.61) 32(9.41) 28(8.24) 6(1.76) 0(0) 0(0) 0.15
0.642(B) 78 33(42.3) 8(10.26) 16(20.51) 7(8.97) 2(2.56) 0(0) 0.512

0.721(B) 108 47(43.51) 12(11.11) 21(19.44) 11(10.1) 3(2.8) 0(0) 0.537

0.908(B) 120 54(45) 4(3.33) 23(19.16) 21(17.5) 6(5) 0(0) 0.708

0.927(B) 160 71(44.38) 7(4.38) 27(16.88) 29(18.13) 7(4.37) 1(.63) 0.71

Graph 1: Comparison of dental fluorosis prevalence between Group A (Borewell) and Group
B (Municipal)

BOREWELL (GROUP A)

Graph III shows the positive correlation are depicted in Graph I. For each unit change
between fluoride concentration in drinking in fluoride concentration, there was a change
water and Community Fluorosis Index. Karl of 1.022 in Community Fluorosis Index value.
Pearson Correlation Coefficient (r) was 0.98. Discussion
The prediction Equation: CFI= 1.022 (Fluoride Endemic dental fluorosis is most prevalent in
Concentration)-0.212 was derived. For the areas where the drinking water contains
different levels of fluoride concentration the elevated levels of fluoride. The report
estimated community fluorosis index values published by the Rajiv Gandhi National

32 International Journal of Public Health Dentistry 2013:4(1):29-37. © Publishing Division, Celesta software Private Limited
Bajaj et al International Journal of Public Health Dentistry

Graph 2: Prevalence of dental fluorosis among 12 and 15 years old children based on
fluoride concentration (in ppm)

70
Prevalence of Dental
60
50
Fluorosis

40
30
20 12 years
10 15 years
0
0.3 0.4
0.64 0.72
0.91
0.93

Fluoride concentration (ppm)

Graph 3: Correlation and regression between fluoride concentration in drinking water and
community fluorosis index

33 International Journal of Public Health Dentistry 2013:4(1):29-37. © Publishing Division, Celesta software Private Limited
Bajaj et al
Drinking Water Mission, 1994, reported 14
states and the Union Territory Delhi as
endemic for fluorosis (8).
Rajasthan lies in endemic fluoride belt and
extensive use of groundwater accounts for
widespread prevalence of fluorosis (6). Hence
this study was designed to estimate the
fluoride concentration of (Municipal
Borewell) drinking water in Udaipur city and to
assess the prevalence of dental fluorosis in
children who were born and raised in Udaipur
city.
Bardsen et al (9), Norway, reported fluoride
concentration in groundwater in the range of
0.02-9.48 mg/l. Fourteen percent of the wells
contained water with fluoride level ≥ 0.50 mg/l.
Similarly, a study from the Northern Rajasthan,
India, reported fluoride concentration
groundwater in the range of 4.78-1.01 mg/l
(10). The present study too reported high
concentration of fluoride in groundwater as
compared to Municipal water. The fluoride
concentration in groundwater of 4 Zones of
Udaipur city ranged from 0.64-0.93ppm.
Edmunds and Smedley (11) identified three
main factors controlling the natural fluoride
concentration of water; i.e. lithology,
geochemical evolution and residence times of
the water which determines water-rock
interactions and mineral dissolution.
It was noticed in the present study that at 0.3
and 0.4ppm fluoride level, 12.26% and 15.87%
of children were affected with fluorosis. These
findings were consistent with earlier study
conducted by Chandrashekar et al (12), where
at 0.22ppm and 0.43ppm fluoride level, 13.1%
and 13.3% of children were affected with
fluorosis in Davangere district, Karnataka. At
0.642ppm and 0.721ppm fluoride level, 42.3%
and 43.51% of children were affected with
34 International Journal of Public Health Dentistry 2013:4(1):29-37. © Publishing Division, Celesta software Private Limited
International Journal of Public Health Dentistry
fluorosis. Whereas at 0.908ppm and
0.972ppm fluoride level, 45% and 44.38% of
children were affected with fluorosis
respectively.
The prevalence of dental fluorosis in the
present study group corresponds well with the
findings of study conducted by Heller et al (5),
and where at <0.3, 0.3 to <0.7, 0.7-1.2 and
>1.2ppm fluoride level, 13.5%, 21.7%, 29.9%
and 41.4% of children showed dental fluorosis
respectively. Applied to Udaipur conditions,
the relatively higher daily temperature when
compared to temperate regions of the world,
necessitates comparatively increased
consumption of water per day which leads to
an increased ingestion of fluoride (13,14). This
in turn results in higher prevalence of dental
in fluorosis. The relationship between the fluoride
concentration of water and dental fluorosis is
complex. But it was observed that as the
fluoride level increased from 0.3ppm to 0.4,
0.64, 0.72, 0.91 and 0.93ppm, there was
substantial increase in prevalence of dental
fluorosis from 12.26% to 15.9%, 42.3%,
43.51%, 45% and 44.4% respectively.
An increase in percentage of children affected
with dental fluorosis with every unit increase in
fluoride level in drinking water is in close
agreement with other studies conducted by
Dean HT (15), Moller (16), Driscoll (17),
Segreto (18), Reddy and Tewari (4), Akihito
(19), Grobler (20), Banu Ermis (21), and
Wondwossen (22).
Results of the present study showed a linear
relationship between CFI values of 12 and 15
years old children and fluoride concentration in
water (r=0.98).These findings were in close
agreement with that of the studies conducted
by Dean (15), Driscoll (17) and Angelillo (23).
Bajaj et al International Journal of Public Health Dentistry

Dean (15) stated that CFI values less than 0.4 water of all 4 Zones was considerably high as
is not of public health concern. In present compared to Municipal water. The prevalence
study it was observed, that, for all the study of dental fluorosis increased from 9.42% at
groups consuming Borewell water the CFI 0.3ppm fluoride level to 45% at 0.908ppm.
values were more than 0.4. There was an increase in severity of dental
The overall prevalence of dental fluorosis in 12 fluorosis as the fluoride concentration
and 15 year old school going children of increased in the drinking water. Hence dental
Udaipur city was found to be 29.07% . This fluorosis is considered as a major dental public
finding of our study is highly supported by the health problem in Udaipur city and is related to
observations reported by National Oral Health high fluoride concentration present in
Survey Fluoride Mapping 2002-2003 groundwater.
(Rajasthan) (6). The Survey reported 32% and Affiliations of the authors: 1. Dr. Dimple
29.6% of 12 and 15 year old having fluorosed Bajaj, Senior Lecturer, Department of Public Health
Dentistry, Y.M.T Dental college and hospital,
teeth in urban area. Mumbai, Maharashtra, India 2. Dr.Shrinath
Shetty, Ex-Professor and Head, Pacific
Further, the present study demonstrated a Dental College and Hospital, Department of
high prevalence of dental fluorosis in Group A Public Health Dentistry Udaipur, Rajasthan
India.
(43.99%) as compared to Group B (17.01).
Akpata et al (24) reported that over 90% of the
Conflict of Interest:
The author(s) declared no conflict of interests.
12-15 year aged rural children in Saudi Arabia
drinking well water (0.5-2.8 ppm of fluoride) Source of Funding: Nil.
had fluorosed teeth. The findings of the References
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Villari P. Caries and fluorosis
prevalence in communities with Corresponding author
different concentrations of fluoride in Dr. Dimple Bajaj,
Senior Lecturer, Department of Public Health
the water. Caries Res 1999; 33:114- Dentistry, Y.M.T Dental College and Hospital,
122. Mumbai, Maharashtra, India.
e-mail: dr.dimplebajaj@hotmail.com

37 International Journal of Public Health Dentistry 2013:4(1):29-37. © Publishing Division, Celesta software Private Limited