SKELETAL FLUOROSIS- AN EPIDIMIO-CLINICO-RADIOLOGICAL STUDY
Dr. Prasanta Kumar Mandal(Asso.Prof)
Dr. Dibakar Ray(Asst.Prof)
Dr. Fagu Ram Majhi(Asst.Prof)
Dr. Somnath Tirkey(Junior Resident)
Dr. Mrinal Kanti Ray(Asst.Prof)
Dr. Surajit Mondal(Junior Resident)
Dept of orthopedics B.S.M.C& H.(Bankura West Bengal India)
Corresponding Address:-
Abstract
Skeletal fluorosis is endemic problem in may parts of world including India as well as West Bengal effecting mainly low socio-economic group of populations. This study is to detect the epidemiological and clinical as well as radiological survey to detect and help to prevent the morbidity and mortality of the people from the so called slow environmental poison.
Keywords ;- Skeletal Fluorosis, Radiological Study
INTRODUCTION
Fluorine is the most abundant element in nature1. It occurs naturally in the Earth’s crust, water and food as the negatively charged ion fluoride (F-). Fluorine is considered to be a trace element because only small amounts are present in the body (about 2.6 gm in adult), and because the daily requirement for maintaining health is only a few milligrams a day. About 96% of total body fluoride is found in the bones and teeth3,5. Although its role in the prevention of dental caries (tooth decay) is well established6, fluoride is not generally considered an essential mineral element because humans do not require it for growth or to sustain life. However, if one considers the prevention of chronic diseases (dental caries, osteoporosis), an important criterion in determining essentiality, then fluoride might well be considered an essential trace element7.
MATERIALS AND METHODS
The Subject :
The study was carried out on the patients after admission in the department orthopaedics, Bankura Sammilkani Medical College and Hospital during the year August 2009 to April 2012.
The Case
An exclusive epidemioclinical survey was done in July 2000 in the village-Nashipur of Birbhum district. The total population including all age groups and sex of the Nashipur village was covered during the survey. From there, 31 patients chosen by systematic random sampling, was admitted in the department of orthopaedics and prospective and retrospective study was done. All skeletal fluorosis cases apparently detected by clinical examination was confirmed by haematological. Biochemical, radiological and pathological investigations.
The Control
A control village Bhabananidpur 5 km away from Nashipur, having all the matching characteristics excepting the skeletal fluorosis was considered for the same study also in order to make valid comparison between the two groups there are sixty patients chosen by systematic random sampling to isolate the aetiological factors towards the development of the disease.
Therefore at the time of study the following issues was considered :---
- Epidemio-clinical study was case control (Analytical) in nature.
- Both skeletal and dental fluorosis was detected clinical in initial time.
- Fluoride content of water in both the villages (i.e. – Nashipur and Bhabanadapur) was determined by Dept. of Chemistry Burdwan University and that was 12-15 ppm and <.8 ppm respectively.
Thirty one cases of both sex and with all age group of skeletal fluorosis was registered for study. Each patient was subjected to thorough history and detailed examination with special emphasis on skeletal system.
A detailed history of duration of exposure or migration, occupation complain of back pain, joint pain, leg pain, stiffness of spine or any other joints, deformity, breathing difficulty, especially on excurtion, weakness on limbs was taken.
Each patient was examined thoroughly for any anemia, jaundice, oedema, chest expansion and mottling.
Thorough examination of spine for kyphosis, tenderness of spinous processes, paraspinal tenderness, nodule, restriction of movements and also each and every joints of both upper limb and lower limb examined for deformity, muscular wasting, tenderness and movements.
The diagnosis was confirmed by clinical, biochemical (fluoride level in blood and bone) radiological and pathological investigations.
The correction of deformity such as genu valgus or genu varus, and preventive measures to inhibit progression of disease to be taken accordingly.
RESULTS AND ANALYSIS
Present study was conducted on 31 skeletal fluorosis patient and 60 properly matched control patients.
Table 1: Proportion of patients belonging to different age groups in both sex.
Age inYears / Sex / Total / Percentage
Male / Female
8-20 / 5 / 5 / 10 / 32.25
21-30 / 2 / 1 / 3 / 9.67
31-40 / 5 / 2 / 7 / 22.58
41-50 / 4 / 1 / 5 / 16.12
51-60 / 2 / x / 2 / 06.45
61-70 / 4 / x / 4 / 12.90
Age :Youngest patient in this present series was a male aged 8 years and oldest patient in this series was a male of 70 years. The maximum no. of patient is in between 8-20 years 32.25%. Average age of the patient was 34.67 years.
Table 2: Sex distribution
Sex / No of Cases / PercentageMale / 22 / 70.97
Female / 9 / 29.03
In this study group male out numbers females the total percentage for male was 70.97%, and for female it was 29.03%.
Male : Female ratio is 2.4 : 1
Table 3: Distribution of cases according to their occupation.
Occupation / No of Cases / PercentageStudent / 7 / 22.58
Labourer / 14 / 45.16
Cultivator / 4 / 12.90
Housewife / 6 / 19.35
The table shows that maximum no. of patients (percentage 45.16%) are in the group of labour and who work outside the home and used to drink more water than the student or housewives.
Table 4: Type of Clinical presentation
Sl. No. / Complaints / No. of Cases / Total / PercentageMale / Female
1 / Back Pain / 18 / 7 / 25 / 80.64
2 / Joint Pain & leg pain / 16 / 8 / 24 / 77.41
3 / Stiffness of major joints / 14 / 3 / 17 / 54.83
4 / Deformity / 7 / 3 / 10 / 32.25
5 / Neurodeficit / 5 / X / 5 / 16.12
6 / Visible Nodule / 12 / X / 12 / 38.71
7 / Breathing difficulty / 14 / 4 / 18 / 58.06
8 / Dental fluorosis / 11 / 8 / 19 / 61.29
Maximum no (25) of patient (percentage 80.64) complaints of low back pain. Neurodeficit including quadriplegia is the rarest complain of this study group (only 16.12%).
Table 5: Types of abnormality on General Examination
Sl. No. / Findings / No. of Cases / Percentage1 / Gross Anemia / 7 / 22.58
2 / Jaundice / 1 / 03.2
3 / Oedema / 6 / 19.35
4 / Diminished Chest expansion (< 3 cm) / 31 / 100
Diminished chest expansion <3 cm is present in 100% cases Jaundice is present minimally in 3.2% cases only.
Table 6: Comparison of chest expansion in case and control.
Sl. No. / No. of cases / Mean (X) / SD / P value1 / Control / 60 / 5 / 0.5 / <.001
2 / Case / 31 / 1.92 / 0.152
Calculation : As this study was done with 31 cases and 60 controle
Case No. () = 31
Control No () = 60
So standard error is to be calculated by z value
Z=
=
= =4.076 from the statistical chart p value is <0.001
So chest expansion in the case group is significantly reduced than the control group.
Table 7: Abnormalities on regional clinical examinations
Sl. No. / Region / Abnormalities / No. of patients / Percentage1 / Spine / Kyphosis / 14 / 45.16
Paraspinal tenderness / 18 / 58.06
Restriction of movements / 25 / 80.64
2 / Shoulder / Restricted movement / 13 / 41.93
3 / Elbow / Restricted movement
(Pronation-supination
Deformity / 14 / 45.16
4 / Hip / Fixed flexion deformity
(FFD) () / 15 / 48.38
FAD (adduction) / 1 / 3.22
Restriction of movement / 16 / 51.61
5 / Knee / Restriction of movt / 5 / 16.12
6 / Small joints of Hands & feet / Restriction of movt / 6 / 19.35
Wasting of small muscles / 3 / 9.67
7 / Musculur Wasting (Gross) / 5 / 16.12
From the above table maximum no of patients 25 (percentage 80.64%) suffering from restricted spinal movements and restricted knee movement and muscular wasting is minimum (percentage 16.12) in both the situations.
Table 8: Comparative study of fluoride level in blood in case and control group
Sl. No. / Mean X / SD / P Value1 / Case (-31) / 1.315 / 0.1792 / <0.001
2 / Control (-60) / 0.7 / 0.075
Fluoride level of blood is significantly high in case group than in control group.
Table 9: Comparative study of fluoride level in bone between case and control.
Sl. No. / Mean / SD / P Value1 / Case (-31) / 5395.51 / 2707.66 / <0.001
2 / Control (-60) / 750.00 / 125
Fluoride level of bole in cases is much greater than the control group. The difference is being statistically significant.
Table 10: Distribution of cases according to X-ray findings
Sl. No. / X-ray Changes / No. of Cases / Percentage1 / Mild Osteopenia (OP) / 7 / 22.58
2 / Osteosclerosis (OS) / 24 / 77.41
3 / OS + Diaphyseal widening (DY) / 10 / 32.25
4 / OS + DY + Soft tissue calcification (Stc) / 8 / 25.8
5 / OS + DY + Stc + Osteophyte / 6 / 19.35
The X-ray findings from the above table maximum patients have osteosclerosis. Only six patients have osteophytic changes (19.35%).
Table 11: Distribution of the patients according to the Grading on the basis of fluoride level of bone (mg F/kg of ASH concentration)
Sl. No. / Grading / No. of cases / Percentage1 / Preclinical (Pc) / 12 / 38.72
2 / II. Clinical phase I (cPI) / 8 / 25.80
3 / III Clinical phase II (cP-II) / 4 / 12.90
4 / IV Clinical phase III / 7 / 22.58
Discussion
Fluorosis is a clinical condition characterized by mottling of teeth (Dental Fluorosis), increased density of bone (Skeletal Fluorosis) and it is demonstrated in adult radiographically and histopathologically due to excess fluoride intake which interferes with collagen formation in the osteoblasts and chondroblasts (cells that lay down bone and cartilage). Consumption of excess fluoride results in the body’s inability to discriminate between which tissues should be mineralised and which tissues should not. In other words, the mineralization of tissues such as bone (which should be mineralized) is disrupted while tendons, ligaments, muscles and other soft tissues (which should not be mineralized) start to become mineralized by interfering with collagen mineralization. Cumulative damage to these cells leads to arthritis, arteriosclerosis, brittle bones, wrinkled skin, and scleroderma. Fluoride’s disruptive effects on collagen of soft tissues may also set off other diseases such as muscular dystrophy, rheumatoid arthritis, lupus etc.
India is among the 23 nations around the globe, where health problems occur due to consumption of fluoride contaminated water. An estimated 62 million people in India, in 17 out of states are affected with dental, skeletal and/or non skeletal fluorosis. The extent of fluoride contamination of water in India varies from 1.0-48 mg/L (A.K. Susheela 1997).
In July 1999 an exclusive door to door epidemiological and clinical survey was done in 12,000 populated village Nashipur of Birbhum District. From that survey we got 620 patient of fluorosis (Dental, skeletal).
The present study was conducted with 31 patients of both sex and all age group selected by systemic random sampling from the survey in the village Nashipur of Birbhum district. They were admitted in the Bankura Medical College and Hospital in the department of orthopaedics. Sixty patients from the village Bhabanandapur of the same district 5 km away from the concerned village Nashipur, admitted in the different departments of Bankura Medical College and Hospital, and Burdwan Medical College and Hospital for some other reasons are taken as a control group. The information of admission was collected from volunteer appointed from those villages.
After admission, each and every patient was examined exclusively, detailed history of and examination findings was written in a proforma.
Name, age, sex, address was taken for their identification, occupation of each and every case was carefully noted, then chief complain including duration, noted, past history of any major illness including hospitalization was also noted. Family history including individuals name, age, affection of dental or skeletal fluorosis was also noted, then personal history including water consumption, food habit was also noted general survey, including anemia, jaundice, cyanosis, neck vein, neck glands, decubitus of choice, any visible subcutaneous nodules, oedema, pulse, respiration blood pressure was also taken carefully.
Detailed examination of back and spine for deformity, swelling, visible nodule, tenderness, neurodeficit and movements including flexion, extension, lateral bending and rotation noted carefully.
Each and every joints of upper limb and lower limb examined carefully and noted in the proforma.
Then patient was investigated for routine blood including TC, DC, ESR Hb% serum bilirubin, urea, creatinine, serum level of fluoride and fluoride level of bone (taken from biopsy) was detected. Biopsy specimen also send for histopathological study. X-rays taken from cervical spine, L.S. Spine, D.L. Spine, Chest, Pelvis, femur including knee, both bone leg including ankle, shoulder, humerus, including elbow, both bone ferearm including wrist, for skeletal survey. Diagnosis was confirmed by clinical methods, X-rays, blood and bone level of fluoride, and histopathological findings.
From the table 1 we can observe that 10 patients (32.25%), 5 male, 5 female are in the age group of 8-20 years, 3 patients, 2 male, 1 female in the age group of 21-30 years. 7 patients, 5 male, 2 female (22.58%) 5 patients (16.12 %) 4 male, 1 female, 2 patients (6.45%) both males, and 4 patients (12.90%) all males, are in the age group of 31-40 years 41-50 years, 51-60 years and 61-70 years respectively. One interesting finding is here there was no female patient in the age group of 51-60 years and 61-70 years. The youngest patient is 8 years old male oldest patient in 70 years old male with average age of 34.6 years the observation strongly supports the fact that skeletal fluorosis can involve all the age group starting from first decade as observed by Zipkin (1959).
From table-2 the sex distribution can be assessed. We can see in our study there were 22 male patient and 9 female patient. The percentage of males were 70.91 % and that of females were 29.03 %. Male patient out of number than female that was also true in all age group distribution this may be due to small study sample actual sex distribution in fluorosis patient can only be assessed by community survey.
Table-3 reveals that maximum no 14 (45.16 %) of patients were labourer by occupation, 4 patients were cultivator (12.90 %), 7 patients were student (22.58%) and 6 patients (19.35 %) were housewives. From this table it is obvious that persons used to work or stay outside home (14+4+7)=25, (80.64%) need more water and are more commonly affected. Findings are more or less matched with observation by SS Jolly 1961.
From table-4 mode of presentation reveals that low back pain is the commonest problem by the patients. Here we can see maximum 25 (80.64 %) patients complaining of back pain then 24 patients (77.41 %) presented with major joint pain including leg pain, 19 patients (61.29 %) with mottling, 18 patients (58.06 %) with breathing difficulty on excursion, 17 patients (58.83 %) with stiffness of major and minor joints, 12 patients (38.71 %) with visible subcutaneous nodule, 10 patients (32.25 %) with genu valgus or genu varus deformity and 5 patients (16.12 %) presented with neurodeficit including paraparesis, paraplegia, quadriparesis, in order of frequency. One patient was with bedsores. The cases with deformity (genu varus or genu valgus) was treated by valgus or varus osteotomy. Out of ten in one case the deformity had recurred in 2.5 years follow up.
These mode of presentation is more or less, similar to findings by S.S. Jolly 1961 and Susheela AK 1996. Teotia M et. al. – 2000.
Table 5-6 shows hundred percent association with diminished chest expansion which was <3 cm in comparison to control which was 5 cm with Mean 1.92 0.152 P value <0.001 means statistically significant. In other words chest expansion is reduced in skeletal fluorosis cases than the control group which is statistically significant. Findings correlates with previous workers Sing et. al. 1969. Where are 7 cases (22.58 %) with anemia and only one case of jaundice (Bilirubin leel is 2 mg/dl) Hemoglobin level were <8 gm% in each. The cause of anemia in cases was not explained otherwise.
There are 6 cases of oedema feet (19.35 %) which are pitting in type. The cause can not be explained other wise. The finding correlates with previous workers Mwanil DL et. al. 1994.
Table 7 showing the abnormalities in different joints. From the table it is obvious that spine is the most common affection. The kyphotic deformity was present in 14 cases (45.16 %), paraspinal tenderness in 18 patients (58.06 %) and maximum findings restriction of spinal movement in 25 patients (80.64%). All movements was affected, particularly flexion-extension movement. Spinal movement grossly restricted in 11 cases (35.48 %) of which 5 cases had no movement at all. On the other hand the spine behaves like a single plate of bone.
Movement was possible but restricted in 13 cases 41.93 % of which 3 cases passive movement was painful.
In 1 case (3.22 %) the spinal movement was terminally restricted the study findings correlates with previous investigation Zipkin-1959 Susheela A.K. 1996.
Shoulder movement particularly abduction and external rotation was restricted in 13 cases (41.93 %) of which terminal movement restricted in 6 cases 19.35 %, moderately restricted in 4 cases (12.9 %). Grossly restricted in 3 cases 9.6 % of which all were painful like frozen shoulder.
In elbow no cases of deformity no tenderness, flexion-extension movements were almost full but pronation-supination movement was restricted in 14 cases 45.16 % of which 4 cases mildly, 12.9 % 5 cases moderately and 5 cases grossly restricted and painful (16.12 %) respectively.
Similarly restriction of movement of wrist is present only in 3 cases which includes 1 quadriparesis patient. In Hip fixed flexion deformity of variable degree starting from 100 to 450 were present in 15 patients (48.38 %). There was one case of fixed adduction deformity, which was 200. Not a single case of fracture of hip or shortening of limb was found which is a contradictory finding to previous investigator Dr. S.J. Jacobson 1990.
The hip movement was restricted to various degree in 16 patients (51.61 %) of which grossly, moderately and terminally restricted in 5,3 and 8 cases respectively.
There were 10 cases of knee deformity either Genu valgus (6 cases) or genu Varus (4 cases) as stated earlier. No bony tenderness was found. Restriction of movement was found only in 5 cases, (16.12 %) of which 1 case has no movement possible at all but other 4 cases have moderate restriction of movement.
In small joints of hands and feet, restriction of movements were found only in 6 patients (19.35 %) wasting of small muscles of hands and feet were found in 3 cases. The findings are corroborative to previous investigator AgarwalND-19693.
Muscular wasting of hip regions and leg in comparison to control group was found only in 5 cases (16.12 %). The observation correlates with findings of previous investigator9,25 Witford, GM - 1996.
From table 8 comparative study of fluoride level of blood in case and control we can see the mean fluoride level were 1.315 with 0.1792 standard derivation (SD) and 0.7 with 0.075 SD respectively. As the no of patients =31 and =60 both more than 30 standard error should be calculated from the Z value
Z=