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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1.NAME OF THE CANDIDATE AND DR. ARVIND.B.A.
ADDRESS NO 456, 39TH CROSS
2ND BLOCK RAJAJINAGAR
BANGALORE 560010
2.NAME OF THE INSTITUTION M.S. RAMAIAH MEDICAL COLLEGE
BANGALORE-560054
3.COURSE OF STUDY AND SUBJECT M.D.(COMMUNITY MEDICINE)
4.DATE OF ADMISSION TO COURSE 02-05-2008
5.TITLE OF THE TOPIC TO ASSESS THE PREVALENCE OF
DENTAL FLUOROSIS AND GENU
VALGUM AMONG SCHOOL
CHILDREN IN RURAL FIELD
PRACTICE AREA OF M.S.RAMAIAH
MEDICAL COLLEGE
Brief resume of the intended work
6.1. Introduction and need for the study
Fluorine, a member of the halogen family, it is an element believed to be essential for
normal growth, development and maintenance of human health. Fluoride has cariostatic
potential. However, excessive intake of fluoride leads to dental and skeletal fluorosis.
Apart from teeth and bone it also affects other systems of the body leading to an entity
called non-skeletal fluorosis.1
Globally, fluorosis in endemic in atleast 25 countries. The total number of people
affected across the globe is not known, but a conservative estimate would number in the
tens of millions.2 India lies in a geographical fluoride belt, which extends from turkey up
to China and Japan through Iraq, Iran and Afghanistan. Of the 85 million tons of fluoride
deposits found on the earth’s crust, nearly 12 million tons are in India.1 Consequently
fluorosis is an endemic condition prevalent in 19 Indian states and union territories. Thus,
66 million people in our country are at risk of developing fluorosis, including 6 million
children below the age of 14 years, where as 25 million people are already affected by
fluorosis.3
In Karnataka endemic districts for fluorosis are Belgaum, Raichur, Bijapur, Gulbarga,
Chitradurga, Tumkur, Chikmagalur, Mandya, Bangalorerural, Mysore, Mangalore,
Shimoga and Kolar.4 In Kolar more than 80% of the children in the age group of 6-14
suffer from skeletal and severe dental fluorosis.5 Kaiwara, the rural health training centre,
of Department of Community Medicine, M.S.Ramaiah Medical College, which was
previously in Kolar district, now in Chikballapur district is also endemic for fluorosis.
The data on prevalence and severity of fluorosis in Kaiwara is scanty. Preliminary
introspection have revealed a prevalence of 20% dental fluorosis among primary school
children.6 Hence, there is a need to carry out a study to assess the prevalence and severity
of dental fluorosis and genu valgum among the school children in Kaiwara PHC
administrative area.
Research question
What is the prevalence and severity of dental fluorosis and genu valgum among
schoolchildren in rural field practice area of M.S.Ramaiah Medical College?
6.2. Aims and objectives
1) To assess the prevalence and severity of dental fluorosis and genu valgum among
school children in the study area
6.3. Review of literature
In a study done by Saravanan.et.al in Cuddalore district of Tamilnadu, the prevalence of
dental fluorosis among primary school children was found to be 31.4%. Concentration of
fluoride in water in the study area ranged from 0.25ppm to 0.67ppm. Majority of people
in the study area belonged to lower socioeconomic class. They had examined 525
children (255 boys and 270 girls). It was shown that dental fluorosis increased with age
(One possible reason is that most of the teeth in 5-6 year age group are deciduous, and
much of the mineralization process occurs in the intra uterine phase, where placenta
serves as a partial barrier to the transfer of fluoride to the developing primary teeth)
whereas gender difference was not statistically significant. Correlation between water
fluoride content and Community fluorosis index values was noted to be significant. Apart
from concentration of fluoride in water, some additional factors which are important in
development of dental fluorosis are temperature, consumption of fish and tea, the
nutritional status of individuals, the environmental factors and average water intake.1
A study done by Dhar.v et.al in rural areas of Udaipur district of Rajasthan showed that
the overall prevalence of dental fluorosis among school going children as 36.36%. 1587
children (827 boys and 760 girls) in the age group of 5-14 years were examined. The
difference between the age groups (highest prevalence among 11-14 years of age) and
also between boys and girls (37.73% in boys and 34.87% in girls) was statistically
significant.7
A study done by S.S Jolly et.al in Punjab where 46000 children (belonging to 358
villages) aged 5-17 years were examined for dental fluorosis. In 210 villages (maximum
fluoride concentration - 1.4 ppm) incidence of dental mottling was 0-10%. In 96 villages
(maximum fluoride concentration - 2.3 ppm) incidence of dental mottling was 10-30%. In
52 villages (max fluoride concentration > 2.3 ppm) incidence of mottling was >30%. In
10 villages, in-depth study of skeletal fluorosis was done where children and adults were
examined. They showed the incidence of skeletal fluorosis as practically nil at mean
fluoride concentration of 1.4ppm but rises with the increase of fluoride concentration.
Villages with practically same fluoride concentration showed different incidence of
fluorosis, thus showing that the concentration of fluoride alone is not responsible for the
incidence of skeletal fluorosis.8
A study done by Pushpa Bharati et.al in Gadag and Bagalkot districts of Karnataka
revealed that among the 832 subjects (532 and 300 from Mundargi and Hungund Taluks
respectively) surveyed 328 (61.65%) and 194 (64.67%) patients exhibited the symptoms
of either dental or skeletal or both types of fluorosis. Browning of teeth was the most
common symptom of dental fluorosis observed among subjects of Mundargi Taluk
(64.29%) followed by pain and pus in teeth (58.79%) whereas, lack of luster was the
most common symptom of dental fluorosis in Hungund Taluk (77.42%) followed by
browning of teeth (54.84%). The skeletal symptoms including tingling and numbing of
extremities, pain in back and bent stature were high among females of both the talukas
whereas shoulder pain and neck pain were also observed to a higher extent among
females of Mundargi Taluk. The fluoride content of drinking water in Mundargi Taluk
ranged from 4.0 ppm to 10.5 ppm that in Hungund taluk ranged from 2.04 ppm to 3.20
ppm.9
Dean’s index is used to measure the severity of dental fluorosis:
1. Normal
2. Questionable - A few white flecks to occasional white spots
3. Very mild - Less than 25% of the tooth surface covered by small white opaque
areas
4. Mild - 50% of the tooth surfaces covered by white opaque areas
5. Moderate - Nearly all the tooth surface are involved, with minute pitting and
brown or yellowish stains
6. Severe - Smoky white appearance of all the teeth with hypoplasia, chipping and
large brown stains which vary from chocolate brown to black. There is discreet
and confluent pitting, often accompanied by attrition.10
A new form of fluorosis characterized by genu valgum and osteoporosis of the lower
limbs has been reported in recent years in some district’s of Andhra Pradesh and
Tamilnadu. The syndrome was observed among people whose staple was sorghum
(jowar). Further studies showed that diets based on sorghum promoted a higher retention
of ingested fluoride than do diets based on rice.11 Study done among young children in
Kachariadih village of Nawada district in Bihar state, where the fluoride level in water
ranged from 3.5 ppm to 14.5 ppm, the prevalence of genu valgum was 14%. These bone
deformities occurred in early age upto 9 years and more predominant in 1 to 5 year old
children. It has been concluded that the clinical and radiological changes of bone in
young children may be due to secondary vitamin-D deficiency.12
The degree of genu valgum is measured by the distance between the medial malleoli at
the ankle when the child stands or lies down with the knees touching each other and
accordingly it is graded as Mild (<5cm), Moderate (5-10cm) and Severe (>10cm).13
7. Materials and methods
Study area – Kaiwara, the rural field practice area of Department of Community
Medicine, M.S.Ramaiah Medical College.
Study population – Primary School children in the study area.
Inclusion criteria:
Primary school children in the age group of 6to12 years of age (from 1st
standard to 7th standard).
Exclusion criteria:
Children having local deposits on their teeth like debris will be excluded
from the study.
Children having orthopaedic deformities of the lower limb, which interfere
with measurement of genu valgum will be excluded.
Study design - Cross sectional study
Sampling method – Sampling frame will be the list of all primary schools. A school is
a sampling unit in the study. Randomly schools will be selected until the sample size
required is met.
Sample size - By pilot study, the prevalence of dental fluorosis was found to be 20%
n = {1.96}2 p q / r2
= {1.96}2 * 20 * 80 / 22
= 1536.64 = 1537
Study period - Period of six months
Statistical analysis - Descriptive statistics will be used to describe the prevalence of
dental fluorosis and genu valgum. Chi-square test will be used to test the statistical
association of Sociodemographic factors with fluorosis.
Methodology – A pre-designed semi structured questionnaire will be developed, pilot
study will be done using it. Following pilot study questionnaire will be standardized and
will be used for main study. To obtain consent, letters will be sent to Block Education
Officer-Chintamani, to headmasters of the school which are selected for study, to
Kaiwara ashrama and to panchayat heads. Following this dates will be fixed for the
schools and on those days school children will be examined. Sociodemographic details of
children will be obtained from school records with the help of teachers.
Nutritional assessment by clinical examination will be made in broad day light using the
proforma designed by National Institute of Nutrition. Anthropometric measurements will
be done as per the established standards.
WEIGHT MEASUREMENT-Bathroom scale will be used for weighing. Instrument will
be standardized using known weights. Instrument will be placed on flat surface. The child
will be weighed with minimal clothing and will be made to stand on scale looking
straight ahead and the weight will be recorded to the nearest quarter Kg .three
consecutive weight measurement will betaken at short intervals and the average of the
three measurement will be taken as the weight of the children.
HEIGHT MEASUREMENT- measuring tape will be placed against the smooth vertical
wall. Children will be made to stand with feet together on a flat surface, arms by the side,
heels buttocks and upper back will be in contact with the wall, they will be asked to look
straight ahead. Distance from the floor to the maximum point on the head will be
measured. Height will be recorded to the nearest half centimeter.
Dental examination will be done in daylight with the help of self-illuminated hand held
magnifying lens. Dean’s index is used to grade the severity as mentioned in literature
review. Genu valgum is measured as mentioned in literature review with the help of
divider and plastic scale. Mid day meal provided to the children will be reviewed. At the
end of the study fluoride content of water of all the villages will be reviewed.
8. REFERENCES.
1) Saravanan. S, Kalyani. C et.al (2008). Prevalence of dental fluorosis among primary
school children in rural areas of Chidambaram Taluk, Cuddalore district, Tamilnadu,
India, Indian journal of community medicine, vol.33, issue 3, pg146-150.
2) http://www.nihfw.org/pdf/NIHFW_newsletter_jan-march07.pdf as accessed on
31/10/2008
3) WHO - SEAR, Fluoride and fluorosis jeopardizing your health, New Delhi, Meenakshi
Sharma et.al.
4) http://www.fluorideandfluorosis.com/endemicdistricts.html as accessed on 2/07/2008
5) http://fluoride.ecobytes.net/alert/india/fluorosis-playing-havoc-in-kolar as accessed on
31/10/2008
6) Personal communication from Prof.N.Kochupillai, Director-Medical Research,
M.S.Ramaiah Medical College
7) Dhar V., Jain A, et.al. (2007). Prevalence of gingival disease, malocclusion and
fluorosis in school going children of rural areas in Udaipur district, Journal of
Indian society of pedodontics and preventive dentistry, June 2007, pg103-105.
8) Jolly.S.S., Singh.B.M. et.al (1968). Epidemiological, clinical, and biochemical study
of endemic dental and skeletal fluorosis in Punjab, British Medical Journal, 1968, 4,
pg 427-429.
9) Pushpa Bharathi, Annapoorna Kubakaddi et.al (2005). Clinical symptoms of dental
and skeletal fluorosis in gadag and bagalkot district of Karnataka, Journal of human
ecology, 18(2), pg105-107.
10) J.Fawell et al.(2006). Fluoride in drinking water. IWA publishing, London, U.K.
11) Park.K. Text Book of Preventive & Social medicine. 19th Edition, Banarsidas Bhanot
publishers, Jabalpur.
12) National Institute of Nutrition, Annual report 2003-2004, Fluorosis in young children
in village of Bihar state.
13) M.Natarajan.Textbook of Orthopedics and Traumatology.5th edition,
M.N.Orthopaedic hospital publishers, Chennai, pg 137-138
9.Signature of the candidate
10.Remarks of the guide:
11.Name and Designation of
(In block letters)
11.1. Guide: Dr. Pruthvish.S. M.D.,D.N.B.
Professor and I/C head,
Dept of Community Medicine
MSRMC, Bangalore-54
11.2 Signature
11.3. Co-Guide Dr.Arjunan Isaac. M.D
Lecturer,
Dept of Community Medicine
MSRMC, Bangalore-54
11.4. Signature
11.5.Head of the Department Dr. Pruthvish.S. M.D.,D.N.B.
Professor and I/C head,
Dept of Community Medicine
MSRMC, Bangalore-54
11.6. Signature
12. Remarks of chairman & Principal
12.1 Signature
