RGUHS Mukherjee A et al.

, RJDS 2021;13(2):48-55

Journal of Dental Sciences

review Article

Fluorosis Mitigation Programmes and its Impact on Health - The Indian

Scenario
Mukherjee Avisek1*, R Yashoda 2, Puranik Manjunath3
1
BDS, (MDS) Post Graduate Student, Department of Public Health Dentistry Government Dental College
and Research Institute, Bangalore.
2
MDS, Associate Professor, Department of Public Health Dentistry, Government Dental College and
Research Institute, Bangalore.
3
MDS, PhD, Professor and Head of the Department of Public Health Dentistry, Government Dental College
and Research Institute, Bangalore.
*Corresponding author:
Dr Avisek Mukherjee, Department of Public Health Dentistry, Government Dental College and Research Institute,
Bangalore. Affiliated to RGUHS. E-mail: avisek.dgp2012@gmail.com
Received date: November 9, 2020; Accepted date: January 19, 2021; Published date: March 31, 2021

Abstract
In India, the availability of safe potable water remains a challenge in rural settings, where 72% of Indian
population reside with high reliance on alternative water sources. In our country, the states having some
circumscribed areas of high fluoride levels (endemic fluoride belts with F content in ground water above
4 ppm). Fluorosis mitigation is therefore necessary. Thus, the objective of this narrative review is to discuss
various fluorosis mitigation programmes in India.Medline was the primary database used in the literature
search. Other databases were also searched for relevant publications. Since the late 1980s, government and
non-governmental agencies launched efforts to control fluorosis. However, most of attempts were mainly on
defluoridation of water, so it cannot be proposed as the only or most effective solution to mitigate fluorosis.
Keywords: Defluoridation, Fluorosis mitigation, Nutritional supplementation,Water

Introduction generally contains high fluoride concentrations, remains

India has only 4% of global water resources in spite of
constituting 16% of the world’s population.1 In India,
the extent of fluoride content in drinking water ranges
from 1.0 to 48.0 mg/L.2 The World Health Organisation
has set the upper limit of fluoride concentration in
drinking water at 1.5 mg/L,3 while the Bureau of Indian
Standards set 1.0 mg/L as the acceptable limit of fluoride
in drinking water, with a remark “the lesser the better.”4
The availability of safe potable water remains a challenge
in rural settings, where 72% of the Indian population
reside, with a high reliance on alternative water sources
posing an increased risk of ingestion of excess fluoride
and fluorosis.5 In the absence of perennial rivers,
surface sources and canal systems, groundwater, which
the main source of drinking water for about 95% of the
population.6
Worldwide, approximately 100 million people are
thought to suffer from fluorosis.7 In India, about
18,197,000 are affected with dental fluorosis and
7,889,000 with skeletal fluorosis.8 Rural populations,
mainly dependent on groundwater for drinking purposes,
are the worst affected. In the early 1930s, fluorosis was
reported only in four states in India, whereas in 2006, it
had been reported in 20 states, indicating the emergence
of endemic fluorosis as one of the public health problems
of the country.9 According to the Ministry of Drinking
Water and Sanitation in 2014, there were 14,132
habitations from 19 states which were yet to be provided

48
 Mukherjee A et al., RJDS 2021;13(2):48-55

with safe drinking water in India. The total population
at risk of fluorosis in habitations with high fluoride in
drinking water is estimated to be 11.7 million.10
In our country, the states having some circumscribed
areas of high fluoride levels (endemic fluoride belts
with F content in ground water above 4 ppm) include
Punjab, Haryana, Rajasthan, Gujarat, Madhya
Pradesh, Andhra Pradesh, Tamil Nadu, among others.11
However, fluoride intake from other sources needs to
be additionally considerable, especially from food.
Traditionally, fluorosis has been directly correlated to
the fluoride intake in water, however, studies in Madhya
Pradesh have brought out the fact that nutritional habits
play an important role in endemic fluorosis. Jolly et
al highlighted the role of nutritional factors relative to
different clinical patterns of fluorosis seen in India.12
Liang et al showed a 43.8% prevalence of skeletal
fluorosis in those with adequate nutrition, and 69.2% in
those with malnutrition.13
The objective of this narrative review was to discuss
various fluorosis mitigation programmes in India based
on a comprehensive approach of water management
solutions, including provision of alternate water,
defluoridation of water, rainwater harvesting, nutritional
supplementation and integrated fluorosis mitigation.
Methods
Medline was the primary database used in the literature
search. Web of Science, Google Scholar, WHO and other
Department of Health (National and State) websites
were also searched for relevant publications.
1. Fluorosis Mitigation Programmes – The Global
Scenario
If some form of fluoride mitigation is considered
necessary, one or more of the following options may
be applicable,14 including the provision of new or
alternative source of water containing acceptable levels,
blending of the existing water supply with another one
containing lower level of fluoride, provision of bottled
water, treating the water level at the point-of-use at
domestic level in small treatment devices i.e. domestic
defluoridation unit, treatment of water at the community
level i.e. conventional treatment or hand pump attached
package treatment, and resettlement of community.14
Globally, there are various fluorosis mitigation programs
that have been conducted using defluoridation units.
They include the defluoridation unit in Ngurdoto
village, Tanzania by bucket defluoridator using bone
char,15 fluorosis mitigation project in Ban Sankayom
village in Thailand using bone char defluoridator,16
and the ICOH Mobile Bus Unit Project in Thailand,17
which emphasized creating awareness among the people
regarding the health effects of excessive consumption of
fluoride, helping them with on-site analysis of fluoride
content of water samples and solve the problem using
possible alternatives.
2. Fluorosis Mitigation Programmes - The Indian
Scenario
Over the last few decades, several government and
non-governmental agencies have launched efforts
to control fluorosis.1 A brief overview of fluorosis
mitigation programmes in India is as shown in
Table 1.

Table 1: A Brief overview of Fluorosis Mitigation Programmes in India

Programme
State Technique Used Outcome Cost
Name and Year

Project Precipitation mechanism Significant relief from

Rajasthan -
SARITA 1996 of defluoridation non-skeletal symptoms.

5600 rainwater harvesting

Sachetana plus structures were constructed. Beneficiaries - 5600
drinking water Karnataka Rainwater harvesting families
project,2006 Creation of artificial catchment Cost - 14.34 Crore.
and recharge of borewells.
Nuapada
EQMG, Domestic Cost - Rs.29,19,000 for
District, Orissa.
Orissa defluoridation kits, 6995 beneficiaries 6995 beneficiaries, Rs.417
Fluorosis
Rainwater harvesting. per beneficiary.
Mitigation, 2005
Sonbhadra,
Uttar Pradesh. 2146 household Cost - Rs 80,70,000.00
EQMG
Fluorosis Uttar Pradesh 970 children. Cost per beneficiary-
Mitigation Project, Nutritional intervention.
Rs 632
2004.

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 Mukherjee A et al., RJDS 2021;13(2):48-55

Fluorosis 38% of decrease of urinary

Mitigation in Rainwater harvesting fluoride, 6% increase of serum
Nalgonda district Andhra
Pradesh Bone char defluoridation calcium, 5% increase of serum -
2004 techniques. phosphorus, 8% increase in
serum alkaline phosphatase.
Removal of Hand pumps
which were source of
Dhar district, high fluoride water
Madhya Pradesh, Madhya content. Implemented in 24 clusters
-
2008. A Pilot Pradesh identified from 8 panchayats.
study. Providing Safe water
through collaborative
effort with EQMG.
Jhabua district, Reversal of skeletal fluorosis.
Madhya Pradesh. 86% reduction in grade
Madhya Integrated Fluorosis
Integrated I fluorosis, 77% reduction in
Pradesh Mitigation
Fluorosis grade II fluorosis, 60% reduction
Mitigation, 2005. in grade IV fluorosis.
Dharmapuri and
Krishnagiri Health delivery outlets, Installation- Rs 1,928.80
district, Tamilnadu, Tamil Crore.
schools and community-
Hogenakkal water Ongoing Project
Nadu based approaches. Maintenance annually - Rs
supply and
fluorosis mitigation 63.67 Crores
project, 2008.
Prasanti Costs - Rs 35,000.
Technology Andhra Adsorption (Activated Evidence of improvement within servicing and regeneration
using Activated Pradesh Alumina) a short period of a few weeks of the alumina - of Rs 350
Alumina,1978 per unit
Phase 1 - Rs. 410/ unit
250 per-household unit
UNICEF in By June 2003, 60 dealers in AP
Rs. 50 per unit to SC/ ST.
India using Andhra and 20in Karnataka.
Household based Pradesh, Adsorption (Activated Phase 2 - Rs.1000/unit,
Alumina) By mid-2003, 24000 DDUs
defluoridation Rajasthan distributed in 5 districts of Rs.250 / unit -(BPL)
1996-2002 Rajasthan. families Rs. 400/ unit
(APL) families. Phase 3
same cost-Phase 2.
Magnesium oxide
Fluoride Removal Can be scaled up to treat fluoride 1 litre of fluoride water
based, precipitation- with 2-5 ppm by IISc
by IISc method contaminated water at
Karnataka sedimentation- method- 7 paisa/litre
at Kolar, community level (500-2000
filtration technique of
Karnataka.2005 litres/day). DDU -Rs.2000/unit.
defluoridation

Fluoride, turbidity, colour, Annual cost at 40 litres /

odour, pesticides, and organic capita / day is Rs.20/- for
Nalgonda Andhra Precipitation substances are removed. domestic treatment.
Technique,1961 Pradesh (Activated Alumina)
Bacterial contamination is Rs.85/- for community
also reduced. treatment.

2.1 Initiatives Taken by the Government of India
2.1.1 Nalgonda Technique, Andhra Pradesh (1961)
In 1961, in Kadri town of Nalgonda district in Andhra
Pradesh, the first community defluoridation plant
was constructed by the National Environmental
Engineering Research Institute (NEERI), Nagpur.
The technique involves the addition of aluminium
salts, lime, and bleaching powder, followed by rapid
mixing, flocculation, sedimentation, filtration, and
disinfection.17 The technology is excellent, provided the
daily operations are entrusted to a trained, conscientious
operator. However, it is less preferred due to water
scarcity and daily disposal of sludge.18
2.1.2 National Drinking Water Mission (1986)
In 1986, Government of India (GOI) set up the National
Drinking Water Mission to provide safe drinking water
to its people and to combat the fluorosis problem.19

50

2.1.3 National Rural Drinking Water Program (NRDWP)
(2009)
In 2009, GOI launched NRDWP, with a goal to provide
every rural person with adequate safe water for drinking,
cooking, and other domestic basic needs on a sustainable
basis. It also aimed to provide potable drinking water
(55 litres per capita per day) by piped water supply to
50% of rural population, of which only 18% of the rural
population have been provided till date. It also sought
to provide household connections to 35% of rural
households, of whom only 17% of rural households
were benifitted.19
2.1.4 National Programme for Prevention and Control
of Fluorosis (NPPCF) (2008-09)
Government of India initiated the National Programme
for Prevention and Control of Fluorosis (NPPCF) as a
new health initiative during the 11th Five Year Plan in
2008-09 in a phased manner. The programme covered 100
districts of 17 States during the 11th Plan and additional
95 new districts were covered in a phased manner during
the 12th Plan. In the 12th Plan the programme has been
brought under the NCD flexi-pool of the National Health
Mission (NHM).20 Under the programme, assistance
to the states for strengthening manpower in endemic
districts, purchase of equipment for lab including an ion
meter, training at various levels, health education and
publicity, treatment including reconstructive surgery,
and rehabilitation to benefit the people in the affected
districts.20
2.2 Initiatives by State Governments
2.2.1 The Government of Gujarat identified a few long-
term schemes, some of which are as follows:
Dharoi Reservoir Dependent Scheme: A total of 68.86
million liters of water per day under group water supply
to 371 villages belonging to Kheralu, Sidhpur, Visnagar
and Patan taluks, at an estimated cost of Rs. 140 crores.21
Sabarmati River Dependent Scheme: Water drawn
from the river Sabarmati to the 109 villages from Vijapur
taluk at an estimated cost of Rs. 36 crores.21
Narmada Canal Dependent Scheme: Construction of
necessary storage tanks and filtration plants, water from
Narmada main canal to the 111 villages belonging to
Chanasma Taluka, 118 villages belonging to Kadi Taluka
and most villages belonging to Sami and Harij Taluka.21
2.2.2 Hogenakkal Integrated Drinking Water Project
(2008)
Government of Tamil Nadu, with funding from Japan
Bank for International Cooperation (JBIC) undertook
Mukherjee A et al., RJDS 2021;13(2):48-55
the Hogenakkal Integrated Drinking Water Project using
Tamil Nadu’s share of the Cauvery river water.22 The
total cost in 2010 was Rs.1,928.80 crores for installation
and Rs. 63.67 crores for annual maintenance.22
2.2.3 Mission Bhagiratha (2016)
This project was undertaken by Government of Telangana
in 2016 to provide safe drinking water to thousands of
households long affected by fluorosis sourced from river
Godavari and river Krishna in Nalgonda district through
150 water treatment plants.23
2.3 Initiatives Taken by Private Sector
2.3.1 People Science Institute, Uttarakhand, India
through its Environmental Quality Group (EQMG),
monitors environmental pollution. EQMG’s activities
include monitoring water quality of rivers, fluorosis
mitigation programme and providing technical support
services to organizations, along with several other small
public interest projects and activities.
EQMG has also proposed plans for provision of safe
drinking water to victims of fluorosis in many areas of
Dhar (Madhya Pradesh), Nuapada district (Orissa), and
Sonbhadra (Uttar Pradesh).
2.3.1.1 Dhar, Madhya Pradesh (2008)
In 2008, Vasudha Vikas Sansthan undertook fluoride
testing and fluorosis mitigation programme in Tirala,
Dharampuri and Umarban blocks of Dhar district with the
assistance of WaterAid and with the technical Support of
Peoples’ Science Institute, Dehra Doon. The interventions
included awareness about fluoride mitigation, removal
of hand pumps (source of high fluoride water content)
and providing safe water through collaborative effort.
The programme assessed the impact of EQMG after six
months of intervention in 2009. There was a significant
difference in fluoride concentration in the urine samples
of the subjects before and after intervention in the
villages. The increase in urinary fluoride values observed
in the non-implementation village should serve as an
alarm for decision makers, implementation agencies and
other concerned organisations.24
2.3.1.2 Orissa (2005)
In 2005, Peoples’ Science Institute and Sahbhagi Vikash
Abhiyan workers chalked out a detailed fluorosis
mitigation programme to check the water quality and
assess the prevalence of fluorosis within the selected
villages followed by an awareness campaign for the
villagers in four districts (Nuapada, Kalahandi, Bolangir,
and Burger) of western Orissa. The plans included
conversion of dug wells into safe sanitary wells,
construction of sand wells in ponds with low fluoride
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 Mukherjee A et al., RJDS 2021;13(2):48-55
concentration, domestic defluoridation kits and rainwater
harvesting. The physical works and defluoridation kits
amounted to about Rs. 29,19,000 for 6995 beneficiaries,
with an approximate cost of Rs. 417/- per beneficiary.25
2.3.1.3 Sonbhadra, Uttar Pradesh (2004)
In Sonbhadra district, with the assistance of BSA
(Banwasi Seva Ashram) and PSI (Peoples’ Science
Institute), a study conducted by EQMG presented
the findings of the water quality tests, accompanying
health surveys and the community-based activities for
fluorosis mitigation planning in 2004, which led to the
preparation of fluorosis mitigation plans for 21 villages,
including conversion of an existing safe dug well and
concrete well into sanitary wells, as well as hand pump
with attached AA kit, AA domestic kit, individual roof
rainwater harvesting, and community roof rainwater
harvesting. Out of total 3875 households within the 21
targeted villages, a total 2146 households were covered.
The estimated cost of Rs. 80,70,000.00 amounted to a
cost of Rs. 632 per beneficiary, as compared to Rs. 417
per beneficiary of the project undertaken in Nuapada
district, Orissa.26
2.3.2 Prasanti Technology using Activated Alumina,
Andhra Pradesh (1978)
Prasanti technology developed by Satya Sai University
for Higher Learning, Puttaparthy used activated alumina
for defluoridation based on adsorption. Each plant costs
approximately Rs 35,000.27
2.3.3 UNICEF in India using household based
defluoridation, Andhra Pradesh and Rajasthan (1996-
2002)
Pilot projects were undertaken by UNICEF along
with Water Environment Sanitation Section (WESS)
Department of Chemistry, IIT Kanpur in Andhra Pradesh
and Rajasthan, 1996-2002. Hand pump attached
Defluoridation Units and Domestic Defluoridation Units
were developed by using indigenously manufactured
activated alumina. The advantages of this domestic
defluoridation units included lower cost for treatment as
only a limited volume of water required (for cooking and
drinking) treatment, which lowered requirement of need
of chemicals and generated lower volume of sludge.
The project was implemented in three phases in Andhra
Pradesh.28
2.3.3.1 Fluorosis Mitigation in Dungarpur, Rajasthan
(SARITA) (1996)
A pilot project was launched by SARITA in Dungarpur
district of Rajasthan under the sponsorship of UNICEF,
52
which included defluoridation using activated alumina
filters, Nalgonda based drum sets and community
awareness activities. A total of 800 households of five
villages adopted both the techniques daily for the last
four years to observe significant relief in several non-
skeletal symptoms of fluorosis.29
2.3.4 Fluoride removal by IISc method at Kolar,
Karnataka (2005)
A simple-to-use domestic defluoridation unit that relied
on magnesium oxide based, precipitation-sedimentation-
filtration technique was developed by Indian Institute of
Science (IISc) to reduce fluoride concentrations in water
to permissible levels (< 1.5 ppm) at Kolar, Karnataka.
The IISc method includes the cost of DDU at Rs. 2000/
unit and cost of treating one litre of fluoride water (2-5
ppm) by 7 paise/litre, which was lesser in comparison to
the activated alumina method at 40 paisa per liter.30
2.4 Initiatives Taken by Public-Private-Partnership
2.4.1 Sachetana plus drinking water project, Karnataka
(2006)
In Karnataka, more than 6% of districts are affected by
dental fluorosis. Bharatiya Agro Industries Foundation
Institute of Rural Development (BIRD-K) along with
Rural Development and Panchayat Raj, Government of
Karnataka implemented a 5-year Fluorosis Mitigation
Project to ensure safe drinking water through innovative
technologies and to eradicate fluorosis in Tumkur, Gadag
and Kolar District in 2006. Rainwater harvesting was the
method of choice. Beneficiaries were 5600 families and
the implementation cost was Rs 14.34 crores.31
2.4.2 Mitigation of Fluorosis in Nalgonda District
Village, Andhra Pradesh (2004)
The Government of Andhra Pradesh along with Sai
Oral Health Foundation adopted a strategy of fluorosis
mitigation by providing low fluoride water in affected
villages in Nalgonda district using rainwater harvesting
systems and bone char based domestic defluoridators.
There was significant decrease in urinary fluoride levels,
burning sensation during urination, relief in gastric
problems, improvement in body movements and increase
in serum alkaline phosphatase (KA units/L) among the
residents of both villages.32
2.4.3 Integrated fluorosis mitigation, Madhya Pradesh
(MP) (2007)
In 2007, NEERI and UNICEF undertook an Integrated
Fluorosis Mitigation programme in Jhabua district, MP
that included understanding health impacts of excessive
fluoride intake through information, education and

communication. Quantitative Chemical Risk Assessment
(QCRA), was used to establish tolerable levels of risk
to human health, followed by development of specific
strategies for fluorosis mitigation, such as water
management solutions, domestic level defluoridation of
drinking water and nutritional supplementation, all of
which caused reversal of fluorosis.1
2.5 Mitigation Through Nutritional Supplementation
Like other diseases, nutrition and diet of an individual
play an important part in prevention of fluorosis.
Chinoy et al indicated that nutrient supplementation has
a beneficial effect on reducing fluoride induced liver
toxicity and is necessary in recovering from fluoride
toxicity.33 Studies have also shown that an individual’s
calcium status modifies the type of bone changes seen in
fluorosis. Clinical trials with therapeutic supplementation
of micronutrients in fluorosis affected children in
Rajasthan showed beneficial effects on skeletal
deformities. Reversal of fluoride induced cell injury
through nutritional supplementation of calcium, vitamin
C and antioxidants have been reported from Delhi.1
In an epidemiological study carried out by RMRCT
Jabalpur in 1995, fluorosis was found to be the cause of
endemic genu valgum. Following this, an intervention
was initiated with nutritional supplementation and safe
drinking water in 1997.1 Nutritional supplementation
was given mainly through change in the diet pattern.
Micronutrient rich foodstuffs like Cassia Tora (chakoda
bhaji) was advocated for increased use.1 Evaluation
carried out in 2004 revealed a complete reversal of the
bone deformities due to fluorosis in mild cases and partial
reversal in severe cases. The reversal was not only in
clinical pictures but also in biochemical and radiological
parameters.1
Chakma et al observed reversal of fluorosis after the
consumption of chakoda bhaji.34 Consumption of
chakoda bhaji is promoted as part of integrated fluorosis
mitigation due to the following reasons, including high
content of calcium, iron, vitamin C and other nutritional
elements. Chakoda bhaji can be grown by using treated
greywater in rural households without any additional
requirement of fertilizer.1
2.6 Recent Approaches (2019)
Integrated Fluorosis Mitigation (IFM) Programme in
selected fluorosis endemic villages of Nawada district,
Bihar was launched in 2019, in a collaborative socio-
scientific research programme of the Centre for Fluorosis
Mukherjee A et al., RJDS 2021;13(2):48-55
Research, Anugrah Narayan College, Patna, CSIR-
NEERI, Nagpur, NIRTH, Jabalpur, PHED, Government
of Bihar and UNICEF, Patna. This programme
included mitigation measures such as provision for an
uninterrupted supply of fluoride-safe water to the entire
population in the study villages, nutritional interventions
in the form of some plants, calcium, vitamin C, vitamin
D, iron and extensive awareness-cum-interaction
programmes with the villagers for educating them about
the ill effects of ingestion of fluoride-contaminated
drinking water for prolonged periods, and the benefits
of consumption of fluoride-safe water coupled with the
regular use of nutritional supplements. The villagers
were provided with hand pump attachable adsorbent
based defluoridation units for the regular availability of
fluoride-safe drinking water, which was made available
by CSIR-NEERI, Nagpur.35
Role of the Dentist in Fluorosis Mitigation
Dentists, especially public health dentists, are positioned
to address the heart of the matter. In their routine clinical
practice, dentists can educate and motivate patients
to adapt to practices regarding safe drinking water.
Through routine surveys or during dental camps, public
health dentists can utilize their knowledge and various
education materials in educating people and making
them aware about the hazards of fluorosis, emphasizing
on the importance of drinking safe water. Public health
dentists can play a very important role by helping the
government in policy making, implementing various
projects like NRHM, NRDWP, etc.36
Conclusion
Although mitigation programmes are effective
approaches for fluorosis mitigation, its validation
through pilot studies and full-scale projects under
different conditions, possibly in various parts of the
world, will be useful to further strengthen this approach
for maximum benefits.
Implementation of a project involving public private
partnership should be need based, with proper planning,
monitoring, and regular reinforcement. Failure in any
one aspect will lead to the project working only on
paper but not reaching the intended beneficiaries. Lack
of communication programs and a lack of awareness
among people have made combating fluorosis on a mass
scale a distant dream till date. Mass media or social
media can play an important role in preventing and
limiting problem of fluorosis.
53
 Mukherjee A et al., RJDS 2021;13(2):48-55
Conflict of Interest
None
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