Environ Monit Assess (2015) 187:497 DOI 10.1007/s10661-015-4723-z
Neighbourhood fluorosis in people residing in the vicinity of superphosphate fertilizer plants near Udaipur city of Rajasthan (India) Shanti Lal Choubisa & Darshana Choubisa
Received: 5 May 2015 / Accepted: 1 July 2015 # Springer International Publishing Switzerland 2015
Abstract Chronic industrial fluoride toxicosis in the forms of dental, skeletal and non-skeletal fluorosis was investigated in 162 villagers (94 males and 78 females) above 15 years of age living in the vicinity of superphosphate fertilizer plants located approximately 12 km south of Udaipur city of Rajasthan, India. Out of these villagers, 90 (55.5 %) and 29 (18.0 %) were found to be afflicted with mild to severe dental and skeletal fluorosis, respectively. Dental fluorosis characterized with light to deep-brownish bilaterally striated horizontal lines, pits or patches and fine dots or granules was noted on incisor teeth of villagers. Irregular wearing, excessive corrosions (abrasions), dark-brownish pigmentation of exposed cementum and dentine material, diastem as between teeth, pronounced loss of tooth supporting bone with recession and bulging of gingiva (gum) were also present in subjects of older age group (>55 years). Among 29 (18.0 %) individuals, mild to moderate manifestations of skeletal fluorosis such as crippling, kyphosis, invalidism and genu-varum syndrome were found. In these fluorotic subjects pain/rigidity in major joints viz. neck, back, hip, knee and shoulder was also found. S. L. Choubisa (*) Parasitology and Toxicology Research Laboratory, Post Graduate Department of Zoology, Government Meera Girls College, Udaipur 313001 Rajasthan, India e-mail: [email protected] D. Choubisa Department of Prosthodontics, Pacific Dental College and Research Centre, Bhilo Ka Bedla, Pratap Pura, Udaipur 313001 Rajasthan, India e-mail: [email protected]
None of the fluorotic subjects showed evidence of genuvalgum syndrome. Other signs of chronic industrial fluoride intoxication in soft tissues (non-skeletal fluorosis) included colic, intermittent diarrhoea or constipation, bloating, polyuria and polydipsia. These findings indicate that surrounding environment of superphosphate fertilizer plants is contaminated with fluoride emission, which in turn is causing diverse ill health effects in humans which are discussed. Keywords Dental fluorosis . Fluoride . Neighbourhood fluorosis . Skeletal fluorosis . Toxicosis . Superphosphate fertilizer plants . Udaipur. Rajasthan (India)
Introduction Prolonged fluoride exposure through water, food, soil and air causes diverse adverse health effects (fluorosis) in both man and domestic animals. If these effects appear due to drinking of fluoridated water, then these are collectively referred to as hydrofluorosis which is natural, more prevalent and wide spread in nature. In contrast, neighbourhood and industrial fluorosis are anthropogenic, relatively less prevalent and restricted to a particular area and location/place and are caused by the long-term exposure to fluoride/fluorine emission from various industrial operations. Different types of coal burning and industrial activities such as power generating stations and the manufacturing or production of steel, iron, aluminium, zinc, phosphorus, chemical fertilizers, bricks, glass, plastic, cement, hydrofluoric acid,
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etc. generally release fluoride/fluorine in both gaseous and particulate/dust forms into their surrounding environments (W. H. O. 1970). The chronic inhalation or exposure of fluoride from such contaminated or polluted environment causes dental, skeletal and non-skeletal disorders or adverse changes in industrial workers as well as in the residents living in the vicinity of such industries (W. H. O. 1970). Chronic industrial fluoride intoxication was recognized for the first time in Danish cryolite workers by Moller and Gudjonsson (1932). Following the identification and thorough investigations of several cases of osteo-dental fluorosis due to the inhalation of fluoride dusts by Roholm (1937), then industrial fluorosis was reported from many countries (W. H. O. 1970; Franke et al. 1975; Carnow and Conibear 1981; Barriga et al. 1997; Wu et al. 2004; Susheela et al. 2013). But studies on neighbourhood fluorosis or industrial fluoride poisoning in people living in the surrounding areas of various industries are limited (Murray and Wilson 1946; Murray 1950). In India, most of the studies have been conducted on hydrofluorosis in both man and domestic animals belonging to different geographical provinces with varying grade of fluoride concentration in drinking water sources (Choubisa et al. 1996a, 2011a; Choubisa 1997, 1998, 1999a, b, 2000, 2007, 2012a; Choubisa and Mishra 2013). Despite having a number of different types of industrial activities in the country, only few reports on neighbourhood fluorosis (Bhavsar et al. 1985; Desai et al. 1988; Samal and Naik 1988; Sharma and Pervez 2004; Mishra and Pradhan 2007) are available. Therefore, a preliminary investigation was undertaken to ascertain the toxic effects such as dental, skeletal and nonskeletal changes (fluorosis) of chronic industrial fluoride exposure in villagers living in the vicinity of superphosphate fertilizer plants that are the source of fluoride.
Material and methods Study area Industrial area near Umarda village located approximately 12 km south of Udaipur city of Rajasthan (India) was chosen for the study where superphosphate fertilizer plants are functioning and emitting fluoride fumes/gases in the surrounding environment. Earlier from this industrial area, chronic industrial fluorosis in cattle (Bos taurus), buffaloes (Bubalus bubalis) and
Environ Monit Assess (2015) 187:497
recently in domesticated goats (Capra hircus) has already been reported (Patra et al. 2000; Choubisa 2015). Fluoride concentrations in the environmental samples of this area: fodder (534.4 ± 74.9 mg kg−1), pond water (1.19 ± 0.29mgl−1) and tube well water (0.479 ± 0.351mgl−1) collected from within 1 km of the fertilizer plants have also been estimated earlier (Patra et al. 2000). These sources are enough to indicate the persisting fluoride pollution in the vicinity of phosphate fertilizer plants. In the present study, due to our certain limitations, we could not estimate fluoride/fluorine emitted from the superphosphate fertilizer plants in the surrounding atmosphere or air as well as in the vegetables and food grains of study area. Mode of survey and identification of dental, skeletal and non-skeletal fluorosis A cross-sectional survey (2014–2015) was performed during day-time for evidence of chronic fluoride toxicosis in the forms of dental, skeletal and non-skeletal fluorosis in villagers inhabiting surrounding area of superphosphate fertilizer units. A total of 162 individuals (94 males and 78 females) above 15 years of age were clinically examined for evidence of osteo-dental fluorosis. Criteria for the identification of dental and skeletal fluorosis were followed as earlier (Choubisa and Sompura 1996; Choubisa et al. 1997, 2001; Choubisa 2001). These subjects were also asked for medical history or complaints as for colic, diarrhoea, constipation, abdominal pain, bloating, skin allergy, polyuria, polydipsia, impaired reproductive functions, etc. for evidence of non-skeletal fluorosis. Similar study was also performed in 165 subjects (96 males and 69 females) above the age of 14 years living in the non-industrial area or village namely Barapal located approximately 10 km away from the present superphosphate fertilizer industrial area. The mean fluoride concentration of drinking water sources (hand pumps and dug wells) of this village was found to be less than 1.0 ppm (estimated by Orion ion specific electrode). In both the survey areas, only native villagers were considered for clinical examination for evidence of chronic fluoride intoxication. The villagers of both studied areas have very poor nutritional status. In general, they intake maize, barley, rice, onion with or without pulses and vegetables. Other food stuffs like milk, curd, ghee and fruits are very rare
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in their diets. Most of them are habitual for daily intake of local wine, tea and smoking. In the present investigation, fluoride concentration in urine and blood was not estimated in the fluorotic individuals. Identification of chronic industrial fluoride effects in these villagers was based on clinical findings only.
Observations and discussion Dental fluorosis Bilateral moderate to severe form of dental mottling (Fig. 1) was found in 90 of 162 subjects (55.5 %) living in the vicinity of superphosphate fertilizer plants. But none of the subjects residing in non-industrial village (Barapal) revealed any signs of dental mottling. In the fluorosed subjects, dental fluorosis appeared bilaterally in the form of light to deep-brownish irregular pits or patches, fine dots and horizontal striations. However, light to deep-brownish fine dots and patches on enamel were more prevalent as compared to the striated horizontal lines. In older people, irregular wearing, excessive corrosion or abrasions, recession and bulging of gingiva and diastema (gaps) between teeth were found. Such findings have also been reported in both man (Choubisa 2012b) and domestic animals (Choubisa 2008, 2010a, b, 2013a, b) exposed with fluoride. The appearance of dental fluorosis in the form of light to deep-brownish fine dots and patches distributed irregularly on enamel of teeth is probably due to irregular or discontinuous fluoride exposure. Such forms of
Fig. 1 Moderate form of dental fluorosis in a 16-year-old child showing bilateral irregular distribution of light to deep-brownish patches/spots and fine dots on enamel and also irregular wearing of teeth
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dental fluorosis have also been observed in goats of the same industrial area (Choubisa 2015). Instead of brownish striated horizontal lines, the appearance of a single large spot/patch located linearly on each incisor teeth of cattle living in the vicinity of aluminium and fertilizer units in Kerala has also been reported recently (Kumar and Aravindakshan 2015). Appearance of such unique pattern of dental fluorosis distinguishes it from hydrofluorosis and can probably be considered as biomarkers for chronic industrial fluoride poisoning or pollution. In India, a variable prevalence of dental fluorosis has been reported from the industrial fluoride polluted provinces. The highest prevalence, 55.2 % of dental fluorosis in children living in the vicinity of the aluminium factory in Orissa (India) has been reported by Samal and Naik (1988). In another study conducted recently in western Orissa, 14 to 22 % incidence of dental fluorosis has also been reported (Mishra and Pradhan 2007). In a large scale survey having sample size of 7059 individuals, conducted in an industrial area of western India, 1202 (17.02 %) individuals revealed the evidence of toxic signs of neighbourhood fluorosis (Bhavsar et al. 1985). In this study, 1655 (23.58 %) individuals of either sex were found to be afflicted with dental fluorosis with varying grades. From the state of Gujarat (India), 35.3 % tribals residing nearby the fluorspar mines were also found to be afflicted with mild to severe dental fluorosis (Desai et al. 1988). In the present study, 55.5 % villagers of both sexes showed the evidence of dental fluorosis which is a relatively higher prevalence than observed in the earlier studies. The variation and severity of dental fluorosis or chronic fluoride intoxication in man and animals living in any geographical province can be attributed to a number of factors such as duration of fluoride exposure and its concentration and intake frequency, habits, nutrition, besides the individual susceptibility, biological response and genetics of an individual (Choubisa et al. 2007, 2009, 2010, 2011b; Choubisa 2010c, 2012b, c, 2013a, b, c, 2014). But authors believe that variation in the prevalence and severity of neighbourhood dental fluorosis is greatly dependent on the distance between the source of fluoride emission and the subject. The distance from F emission source definitely reduces the frequency or chances of fluoride exposure which in turn decreases the prevalence and severity of fluorosis. Such observations have also been made by Desai and her co-investigators (1988) in their study conducted in the mining areas of Gujarat. Height
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of chimney and weather condition, such as the persistence of the prevailing wind (pattern and direction) and amount of rainfall, are also important contributory determinants for genesis and severity of neighbourhood fluorosis. Skeletal fluorosis Out of 162 subjects, 29 (18.0 %) revealed evidence of mild to moderate form of skeletal fluorosis. Of these, 19 (11.72 %) were men and 10 (6.17 %) were women. Severe form of skeletal fluorosis or chronic industrial fluoride effects such as kyphosis, invalidism, genuvarum (Fig. 2) were observed only in older subjects (>50 years of age). In these subjects, complaint of pain in major joints viz. neck, back, hip, knee and shoulder was also found. Secondary neurological complications such as paraplegia and quadriplegia were not seen in any fluorosed individual. In the present study area, none of
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the villagers were found to be afflicted with genuvalgum syndrome or knock-knees deformity (legs angled inward at the knee). Individuals of non-industrial village (Barapal) did not show any signs of skeletal fluorosis. The incidence and severity of skeletal fluorosis was higher in the older age group, which is certainly due to longer exposure and increasing industrial fluoride toxicity. In earlier studies, such findings have also been observed in the older age group (Choubisa et al. 1996a, 1997; Choubisa 2001, 2012b). In the present study, no case of genu-valgum syndrome was noted, in contrast to some of the southern (Andhra Pradesh, Karnataka and Tamil Nadu) and central (Madhya Pradesh) Indian states where hydrofluorosis is also endemic and cases of genuvalgum syndromes along with osteoporosis of long bones have been reported (W. H. O. 1970; Choubisa 2001, 2012b). In the state of Rajasthan where hydrofluorosis is hyper endemic in several areas but such deformity has yet not been detected and reported (Choubisa 1996; Choubisa et al. 1996b, 1997; Choubisa 2001, 2012b, d). How fluoride causes genu-valgum syndrome is still uncertain and inconclusive. However, level of some micronutrients may be responsible for this deformity (W. H. O. 1970).
Other symptoms or toxic signs
Fig. 2 Less severe form of skeletal fluorosis in a 56-year-old woman showing common deformities: kyphosis, invalidism, crippling and genu-varum syndrome (legs angled outward at the knee)
According to the information given by the villagers, other signs of chronic industrial fluoride intoxications such as intermittent diarrhoea or constipation, abdominal pain, flatulence, polyuria and polydipsia were found in the fluorosed subjects. Such complaints have also been reported not only in humans (W. H. O. 1970; Choubisa 2001, 2012b) but also in diverse species of domestic animals (Choubisa et al. 2012; Choubisa 2013a, b, c) inhabiting areas with varying concentration of fluoride in drinking waters. However, in the area under present survey, cases of repeated abortions, sterility, reluctance to reproductive functions and erectile dysfunction in male individuals were not detected. It may be possible due to a small sample size in the present preliminary investigation and irregular fluoride exposure due to discontinue rain fall and change in air direction. Although, such reproductive dysfunctions are found in those areas where hydrofluorosis is hyper endemic or fluoride exposure is regular (Choubisa 2010a, b, 2012a, b; Choubisa et al. 2012).
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In conclusion, the present findings indicate evidently that surrounding areas of the superphosphate fertilizer plants are contaminated or polluted with fluoride emission. Interestingly, most of the villagers in study area are unaware about the industrial fluoride pollution as well as cause of dental and skeletal fluorosis and other industrial health hazards. Therefore, to prevent industrial fluoride intoxication in community, general awareness and preventive measures are highly suggestive. To study/ ascertain the health status of industrial workers/ employees and community living in an industrial fluoride polluted area, more health surveys are required in different parts of the country, which help in making of health policy for man and animals at national level. Though present study is at preliminary level and has small sample size, but these findings can also be seen as contributing significantly to our existing knowledge of neighbourhood fluorosis. Acknowledgments The authors are grateful to the University Grants Commission, New Delhi, India for financial assistance [No.34-466/2008 (SR)]. They also wish to thank Dr. Zulfiya Sheikh, Associate Professor of Zoology, Government Meera Girls College, Udaipur and Pushkar Mali (Project Fellow) for their cooperation.
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Choubisa, S. L., Choubisa, D. K., Joshi, S. C., & Choubisa, L. (1997). Fluorosis in some tribal villages of Dungarpur district of Rajasthan, India. Fluoride, 30(4), 223–228. Choubisa, S. L., Choubisa, L., & Choubisa, D. K. (2001). Endemic fluorosis in Rajasthan. Indian Journal of Environmental Health, 43(4), 177–189. Choubisa, S. L., Choubisa, L., Sompura, K., & Choubisa, D. (2007). Fluorosis in subjects belonging to different ethnic groups of Rajasthan. Journal of Communicable Diseases, 39(3), 171–177. Choubisa, S. L., Choubisa, L., & Choubisa, D. (2009). Osteodental fluorosis in relation to nutritional status, living habits and occupation in rural areas of Rajasthan, India. Fluoride, 42(3), 210–215. Choubisa, S. L., Choubisa, L., & Choubisa, D. (2010). Osteodental fluorosis in relation to age and sex in tribal districts of Rajasthan, India. Journal of Environmental Science & Engineering, 52(3), 199–204. Choubisa, S. L., Mishra, G. V., Sheikh, Z., Bhardwaj, B., Mali, P., & Jaroli, V. J. (2011a). Toxic effects of fluoride in domestic animals. Advances in Pharmacology and Toxicology, 12(2), 29–37. Choubisa, S. L., Mishra, G. V., Sheikh, Z., Bhardwaj, B., Mali, P., & Jaroli, V. J. (2011b). Food, fluoride, and fluorosis in domestic ruminants in the Dungarpur district of Rajasthan, India. Fluoride, 44(2), 70–76. Choubisa, S. L., Modasiya, V., Bahura, C. K., & Sheikh, Z. (2012). Toxicity of fluoride in cattle of the Indian Thar Desert, Rajasthan, India. Fluoride, 45(4), 371–376. Desai, V. K., Saxena, D. K., Bhavsar, B. S., & Kantharia, S. L. (1988). Epidemiological study of dental fluorosis in tribal residing in fluorspar mines. Fluoride, 21(3), 137–141. Franke, J., Rath, F., Runge, H., Fengler, E., Auermann, E., & Lenart, G. (1975). Industrial fluorosis. Fluoride, 8(2), 61–83. Kumar, P. S., & Aravindakshan, C. M. (2015). Industrial fluorosis and its effects on serum biochemistry and haemogram in
Environ Monit Assess (2015) 187:497 cattle of Kerala, India. Proceedings of National Academy of Sciences, India Section B: Biological Sciences, doi:. doi:10. 1007/s40011-015-0524-y. Mishra, P. C., & Pradhan, K. (2007). Prevalence of fluorosis among school children and cattle population of Hirakud town in Orissa. The Bioscan, 2(1), 31–36. Moller, P. F., & Gudjonsson, S. V. (1932). Massive fluorosis of bones and ligaments. Acta Radiologica (Stockholm), 13, 269–294. Murray, M. M. (1950). Industrial fluorosis. British Medical Bulletin, 7(1–2), 87–89. Murray, M. M., & Wilsion, D. C. (1946). Fluorine hazards with special reference to some social consequences of industrial processes. Lancet, 2, 821–824. Patra, R. C., Dwivedi, S. K., Bhardwaj, D., & Swarup, D. (2000). Industrial fluorosis in cattle and buffalo around Udaipur, India. Science of the Total Environment, 253, 145–150. Roholm, K. (1937). Fluorine intoxication: a clinical-hygienic study, with a review of the literature and some experimental investigations. London:H. K. Lewis and Co.. Samal, U. N., & Naik, B. N. (1988). Dental fluorosis in school children in the vicinity of an aluminium factory in India. Fluoride, 21(3), 142–148. Sharma, R., & Pervez, S. (2004). Study of dental fluorosis in subjects related to phosphatic fertilizer plant environment in Chhattisgarh state. Journal of Scientific and Industrial Research, 63, 985–988. Susheela, A. K., Mondal, N. K., & Singh, A. (2013). Exposure to fluoride in smelter workers in a primary aluminum industry in India. The International Journal of Occupational and Environmental Medicine, 4, 61–72. W. H. O. (1970). Fluorides and human health. Geneva:World Health Organization. Wu, D., Zheng, B., Wang, A., & Yu, G. (2004). Fluoride exposure from burning coal-clay in Guizhou province, China. Fluoride, 37(1), 20–27.
Neighbourhood fluorosis in people residing in the vicinity of superphosphate fertilizer plants near Udaipur city of Rajasthan (India) Shanti Lal Choubisa & Darshana Choubisa
Received: 5 May 2015 / Accepted: 1 July 2015 # Springer International Publishing Switzerland 2015
Abstract Chronic industrial fluoride toxicosis in the forms of dental, skeletal and non-skeletal fluorosis was investigated in 162 villagers (94 males and 78 females) above 15 years of age living in the vicinity of superphosphate fertilizer plants located approximately 12 km south of Udaipur city of Rajasthan, India. Out of these villagers, 90 (55.5 %) and 29 (18.0 %) were found to be afflicted with mild to severe dental and skeletal fluorosis, respectively. Dental fluorosis characterized with light to deep-brownish bilaterally striated horizontal lines, pits or patches and fine dots or granules was noted on incisor teeth of villagers. Irregular wearing, excessive corrosions (abrasions), dark-brownish pigmentation of exposed cementum and dentine material, diastem as between teeth, pronounced loss of tooth supporting bone with recession and bulging of gingiva (gum) were also present in subjects of older age group (>55 years). Among 29 (18.0 %) individuals, mild to moderate manifestations of skeletal fluorosis such as crippling, kyphosis, invalidism and genu-varum syndrome were found. In these fluorotic subjects pain/rigidity in major joints viz. neck, back, hip, knee and shoulder was also found. S. L. Choubisa (*) Parasitology and Toxicology Research Laboratory, Post Graduate Department of Zoology, Government Meera Girls College, Udaipur 313001 Rajasthan, India e-mail: [email protected] D. Choubisa Department of Prosthodontics, Pacific Dental College and Research Centre, Bhilo Ka Bedla, Pratap Pura, Udaipur 313001 Rajasthan, India e-mail: [email protected]
None of the fluorotic subjects showed evidence of genuvalgum syndrome. Other signs of chronic industrial fluoride intoxication in soft tissues (non-skeletal fluorosis) included colic, intermittent diarrhoea or constipation, bloating, polyuria and polydipsia. These findings indicate that surrounding environment of superphosphate fertilizer plants is contaminated with fluoride emission, which in turn is causing diverse ill health effects in humans which are discussed. Keywords Dental fluorosis . Fluoride . Neighbourhood fluorosis . Skeletal fluorosis . Toxicosis . Superphosphate fertilizer plants . Udaipur. Rajasthan (India)
Introduction Prolonged fluoride exposure through water, food, soil and air causes diverse adverse health effects (fluorosis) in both man and domestic animals. If these effects appear due to drinking of fluoridated water, then these are collectively referred to as hydrofluorosis which is natural, more prevalent and wide spread in nature. In contrast, neighbourhood and industrial fluorosis are anthropogenic, relatively less prevalent and restricted to a particular area and location/place and are caused by the long-term exposure to fluoride/fluorine emission from various industrial operations. Different types of coal burning and industrial activities such as power generating stations and the manufacturing or production of steel, iron, aluminium, zinc, phosphorus, chemical fertilizers, bricks, glass, plastic, cement, hydrofluoric acid,
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etc. generally release fluoride/fluorine in both gaseous and particulate/dust forms into their surrounding environments (W. H. O. 1970). The chronic inhalation or exposure of fluoride from such contaminated or polluted environment causes dental, skeletal and non-skeletal disorders or adverse changes in industrial workers as well as in the residents living in the vicinity of such industries (W. H. O. 1970). Chronic industrial fluoride intoxication was recognized for the first time in Danish cryolite workers by Moller and Gudjonsson (1932). Following the identification and thorough investigations of several cases of osteo-dental fluorosis due to the inhalation of fluoride dusts by Roholm (1937), then industrial fluorosis was reported from many countries (W. H. O. 1970; Franke et al. 1975; Carnow and Conibear 1981; Barriga et al. 1997; Wu et al. 2004; Susheela et al. 2013). But studies on neighbourhood fluorosis or industrial fluoride poisoning in people living in the surrounding areas of various industries are limited (Murray and Wilson 1946; Murray 1950). In India, most of the studies have been conducted on hydrofluorosis in both man and domestic animals belonging to different geographical provinces with varying grade of fluoride concentration in drinking water sources (Choubisa et al. 1996a, 2011a; Choubisa 1997, 1998, 1999a, b, 2000, 2007, 2012a; Choubisa and Mishra 2013). Despite having a number of different types of industrial activities in the country, only few reports on neighbourhood fluorosis (Bhavsar et al. 1985; Desai et al. 1988; Samal and Naik 1988; Sharma and Pervez 2004; Mishra and Pradhan 2007) are available. Therefore, a preliminary investigation was undertaken to ascertain the toxic effects such as dental, skeletal and nonskeletal changes (fluorosis) of chronic industrial fluoride exposure in villagers living in the vicinity of superphosphate fertilizer plants that are the source of fluoride.
Material and methods Study area Industrial area near Umarda village located approximately 12 km south of Udaipur city of Rajasthan (India) was chosen for the study where superphosphate fertilizer plants are functioning and emitting fluoride fumes/gases in the surrounding environment. Earlier from this industrial area, chronic industrial fluorosis in cattle (Bos taurus), buffaloes (Bubalus bubalis) and
Environ Monit Assess (2015) 187:497
recently in domesticated goats (Capra hircus) has already been reported (Patra et al. 2000; Choubisa 2015). Fluoride concentrations in the environmental samples of this area: fodder (534.4 ± 74.9 mg kg−1), pond water (1.19 ± 0.29mgl−1) and tube well water (0.479 ± 0.351mgl−1) collected from within 1 km of the fertilizer plants have also been estimated earlier (Patra et al. 2000). These sources are enough to indicate the persisting fluoride pollution in the vicinity of phosphate fertilizer plants. In the present study, due to our certain limitations, we could not estimate fluoride/fluorine emitted from the superphosphate fertilizer plants in the surrounding atmosphere or air as well as in the vegetables and food grains of study area. Mode of survey and identification of dental, skeletal and non-skeletal fluorosis A cross-sectional survey (2014–2015) was performed during day-time for evidence of chronic fluoride toxicosis in the forms of dental, skeletal and non-skeletal fluorosis in villagers inhabiting surrounding area of superphosphate fertilizer units. A total of 162 individuals (94 males and 78 females) above 15 years of age were clinically examined for evidence of osteo-dental fluorosis. Criteria for the identification of dental and skeletal fluorosis were followed as earlier (Choubisa and Sompura 1996; Choubisa et al. 1997, 2001; Choubisa 2001). These subjects were also asked for medical history or complaints as for colic, diarrhoea, constipation, abdominal pain, bloating, skin allergy, polyuria, polydipsia, impaired reproductive functions, etc. for evidence of non-skeletal fluorosis. Similar study was also performed in 165 subjects (96 males and 69 females) above the age of 14 years living in the non-industrial area or village namely Barapal located approximately 10 km away from the present superphosphate fertilizer industrial area. The mean fluoride concentration of drinking water sources (hand pumps and dug wells) of this village was found to be less than 1.0 ppm (estimated by Orion ion specific electrode). In both the survey areas, only native villagers were considered for clinical examination for evidence of chronic fluoride intoxication. The villagers of both studied areas have very poor nutritional status. In general, they intake maize, barley, rice, onion with or without pulses and vegetables. Other food stuffs like milk, curd, ghee and fruits are very rare
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in their diets. Most of them are habitual for daily intake of local wine, tea and smoking. In the present investigation, fluoride concentration in urine and blood was not estimated in the fluorotic individuals. Identification of chronic industrial fluoride effects in these villagers was based on clinical findings only.
Observations and discussion Dental fluorosis Bilateral moderate to severe form of dental mottling (Fig. 1) was found in 90 of 162 subjects (55.5 %) living in the vicinity of superphosphate fertilizer plants. But none of the subjects residing in non-industrial village (Barapal) revealed any signs of dental mottling. In the fluorosed subjects, dental fluorosis appeared bilaterally in the form of light to deep-brownish irregular pits or patches, fine dots and horizontal striations. However, light to deep-brownish fine dots and patches on enamel were more prevalent as compared to the striated horizontal lines. In older people, irregular wearing, excessive corrosion or abrasions, recession and bulging of gingiva and diastema (gaps) between teeth were found. Such findings have also been reported in both man (Choubisa 2012b) and domestic animals (Choubisa 2008, 2010a, b, 2013a, b) exposed with fluoride. The appearance of dental fluorosis in the form of light to deep-brownish fine dots and patches distributed irregularly on enamel of teeth is probably due to irregular or discontinuous fluoride exposure. Such forms of
Fig. 1 Moderate form of dental fluorosis in a 16-year-old child showing bilateral irregular distribution of light to deep-brownish patches/spots and fine dots on enamel and also irregular wearing of teeth
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dental fluorosis have also been observed in goats of the same industrial area (Choubisa 2015). Instead of brownish striated horizontal lines, the appearance of a single large spot/patch located linearly on each incisor teeth of cattle living in the vicinity of aluminium and fertilizer units in Kerala has also been reported recently (Kumar and Aravindakshan 2015). Appearance of such unique pattern of dental fluorosis distinguishes it from hydrofluorosis and can probably be considered as biomarkers for chronic industrial fluoride poisoning or pollution. In India, a variable prevalence of dental fluorosis has been reported from the industrial fluoride polluted provinces. The highest prevalence, 55.2 % of dental fluorosis in children living in the vicinity of the aluminium factory in Orissa (India) has been reported by Samal and Naik (1988). In another study conducted recently in western Orissa, 14 to 22 % incidence of dental fluorosis has also been reported (Mishra and Pradhan 2007). In a large scale survey having sample size of 7059 individuals, conducted in an industrial area of western India, 1202 (17.02 %) individuals revealed the evidence of toxic signs of neighbourhood fluorosis (Bhavsar et al. 1985). In this study, 1655 (23.58 %) individuals of either sex were found to be afflicted with dental fluorosis with varying grades. From the state of Gujarat (India), 35.3 % tribals residing nearby the fluorspar mines were also found to be afflicted with mild to severe dental fluorosis (Desai et al. 1988). In the present study, 55.5 % villagers of both sexes showed the evidence of dental fluorosis which is a relatively higher prevalence than observed in the earlier studies. The variation and severity of dental fluorosis or chronic fluoride intoxication in man and animals living in any geographical province can be attributed to a number of factors such as duration of fluoride exposure and its concentration and intake frequency, habits, nutrition, besides the individual susceptibility, biological response and genetics of an individual (Choubisa et al. 2007, 2009, 2010, 2011b; Choubisa 2010c, 2012b, c, 2013a, b, c, 2014). But authors believe that variation in the prevalence and severity of neighbourhood dental fluorosis is greatly dependent on the distance between the source of fluoride emission and the subject. The distance from F emission source definitely reduces the frequency or chances of fluoride exposure which in turn decreases the prevalence and severity of fluorosis. Such observations have also been made by Desai and her co-investigators (1988) in their study conducted in the mining areas of Gujarat. Height
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of chimney and weather condition, such as the persistence of the prevailing wind (pattern and direction) and amount of rainfall, are also important contributory determinants for genesis and severity of neighbourhood fluorosis. Skeletal fluorosis Out of 162 subjects, 29 (18.0 %) revealed evidence of mild to moderate form of skeletal fluorosis. Of these, 19 (11.72 %) were men and 10 (6.17 %) were women. Severe form of skeletal fluorosis or chronic industrial fluoride effects such as kyphosis, invalidism, genuvarum (Fig. 2) were observed only in older subjects (>50 years of age). In these subjects, complaint of pain in major joints viz. neck, back, hip, knee and shoulder was also found. Secondary neurological complications such as paraplegia and quadriplegia were not seen in any fluorosed individual. In the present study area, none of
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the villagers were found to be afflicted with genuvalgum syndrome or knock-knees deformity (legs angled inward at the knee). Individuals of non-industrial village (Barapal) did not show any signs of skeletal fluorosis. The incidence and severity of skeletal fluorosis was higher in the older age group, which is certainly due to longer exposure and increasing industrial fluoride toxicity. In earlier studies, such findings have also been observed in the older age group (Choubisa et al. 1996a, 1997; Choubisa 2001, 2012b). In the present study, no case of genu-valgum syndrome was noted, in contrast to some of the southern (Andhra Pradesh, Karnataka and Tamil Nadu) and central (Madhya Pradesh) Indian states where hydrofluorosis is also endemic and cases of genuvalgum syndromes along with osteoporosis of long bones have been reported (W. H. O. 1970; Choubisa 2001, 2012b). In the state of Rajasthan where hydrofluorosis is hyper endemic in several areas but such deformity has yet not been detected and reported (Choubisa 1996; Choubisa et al. 1996b, 1997; Choubisa 2001, 2012b, d). How fluoride causes genu-valgum syndrome is still uncertain and inconclusive. However, level of some micronutrients may be responsible for this deformity (W. H. O. 1970).
Other symptoms or toxic signs
Fig. 2 Less severe form of skeletal fluorosis in a 56-year-old woman showing common deformities: kyphosis, invalidism, crippling and genu-varum syndrome (legs angled outward at the knee)
According to the information given by the villagers, other signs of chronic industrial fluoride intoxications such as intermittent diarrhoea or constipation, abdominal pain, flatulence, polyuria and polydipsia were found in the fluorosed subjects. Such complaints have also been reported not only in humans (W. H. O. 1970; Choubisa 2001, 2012b) but also in diverse species of domestic animals (Choubisa et al. 2012; Choubisa 2013a, b, c) inhabiting areas with varying concentration of fluoride in drinking waters. However, in the area under present survey, cases of repeated abortions, sterility, reluctance to reproductive functions and erectile dysfunction in male individuals were not detected. It may be possible due to a small sample size in the present preliminary investigation and irregular fluoride exposure due to discontinue rain fall and change in air direction. Although, such reproductive dysfunctions are found in those areas where hydrofluorosis is hyper endemic or fluoride exposure is regular (Choubisa 2010a, b, 2012a, b; Choubisa et al. 2012).
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In conclusion, the present findings indicate evidently that surrounding areas of the superphosphate fertilizer plants are contaminated or polluted with fluoride emission. Interestingly, most of the villagers in study area are unaware about the industrial fluoride pollution as well as cause of dental and skeletal fluorosis and other industrial health hazards. Therefore, to prevent industrial fluoride intoxication in community, general awareness and preventive measures are highly suggestive. To study/ ascertain the health status of industrial workers/ employees and community living in an industrial fluoride polluted area, more health surveys are required in different parts of the country, which help in making of health policy for man and animals at national level. Though present study is at preliminary level and has small sample size, but these findings can also be seen as contributing significantly to our existing knowledge of neighbourhood fluorosis. Acknowledgments The authors are grateful to the University Grants Commission, New Delhi, India for financial assistance [No.34-466/2008 (SR)]. They also wish to thank Dr. Zulfiya Sheikh, Associate Professor of Zoology, Government Meera Girls College, Udaipur and Pushkar Mali (Project Fellow) for their cooperation.
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