Fluorosis Management

Evaluation of the Test Report

The report received from the testing laboratory should be critically viewed.

Possibility 1: All samples, (water, urine and serum) show high fluoride content. X-ray Radiograph of fore-arm shows interosseous membrane calcification. Therefore the disease is diagnosed as Fluorosis.

Possibility 2: Among the 3 samples tested, fluoride in water is normal (< 1.0 mg/l); but urine and serum have high fluoride content. Suspect fluoride consumption through food, beverages (black tea without milk, jaljeera etc), use of habit forming substances viz. black rock salt, use of fluoridated toothpaste, or inhalation of fluoride by living in an environment polluted with fluoride. To find out the source of fluoride entry to the body; the patient should be interviewed further to collect additional information to identify the source of fluoride entry to the body.
As fluoride is high in body fluids and interosseous membrane calcification is evident from X-ray radiograph, the correct diagnosis is Fluorosis.

Possibility 3: Test report reveals fluoride high in drinking water and serum; but urine fluoride normal. The patient advised to get Kidney Function tests done. If the results reveal that patient has renal problem, he/she would not excrete high fluoride; fluoride in urine would be normal. Having high fluoride in serum, drinking water and calcification of interosseous membrane in the forearm, though urine fluoride is normal it is case of Fluorosis with Renal disorder.

What are the steps to follow after the Disease is correctly diagnosed

  1. The Doctor  should explain to  the patient  the nature of the disease

  2. It is caused by a poisonous chemical fluoride, which has been consumed for a long period of time as his/her fluoride in serum, urine, drinking water are raised; besides his/her interosseous membrane covering the bones in the forearm is calcified.  It is a confirmation for a case of Fluorosis.

  3. The Doctor need to explain the patient what the level of Fluoride in serum,  urine and drinking water means?

    Serum fluoride is ‘X’ units; Normal reference range
    (0.02 – 0.05) mg/l

    Urine fluoride ‘XX’ units; Normal reference range
    ( 0.1     – 1.0 ) mg/l

    Drinking water F‾ <1.0 mg/L is the upper limit; less the better, as fluoride is injurious to health (BIS).
    However, under extreme circumstances, when there is no safe source of water (BIS), water available with F‾ ranging upto 1.5 mg/L is accepted for consumption. Under such circumstances the calcium intake through diet should be enhanced.

  4. Patient should know that the serum value ‘X’ units should be reduced to the lower limit of the reference range ie. 0.02 mg/l and not the upper limit
    0.05 mg/l, as less the amount of the poison in body fluid, the better for health improvement.

  5. Same is the case with urine fluoride. (0.1mg Fluoride/l should be aimed to achieve).

  6. Drinking / cooking water fluoride, if present > 1.5 mg/l; the source should be immediately changed; as it is unfit for human consumption.

Interventions to Practice for Combating Fluorosis

  • Fluorosis has no treatment or medicine.

  • The disease if diagnosed correctly at an early stage of onset can be prevented easily.

  • The Foundation also offers the Facility for Fluorosis management through interventions. The two Interventions the individual / patient has to practice are:
    1. To stop fluoride entry to the body which may be through consumption of water, food, dental products and / or drugs. By doing so, the progression of the disease is arrested. If water is the source of fluoride, consumption of safe water with fluoride as low as possible but should never exceed 1.0 mg/l of water.
    2. To promote nutrients through diet supplementation, adequate intake of essential nutrients, vitamins and antioxidants instead of pharmaceutical products. By doing so, the repair and maintenance of the damaged parts of the cells, tissues and organs are achieved. The protocol would be varying from individual to individual depending upon the disease status and whether they belong to the lower or higher socio-economic strata. Affordability is an important criterion to ensure sustainability of nutritional intervention. The recipes are designed through discussion with the patient

  • The role of a Diet Counsellor

    1. The Diet Counsellor should go through the health complaints of the patient recorded in the pre-coded format  (History-sheet).  Should note the Non-skeletal fluorosis and the kind of complaints the patient has reported.  Those would decline after practice of interventions.

    2. The Diet Counsellor should inform the patient that he/she should come for Diet Counselling with a female member of the family who normally cooks the food for the family.  This is for compliance/adherence to a revised Dietary regime of the patient.  All members of the family would also get benefited.

    3. The Diet Counsellor  should not provide a ready made diet sheet to the patient, as that is the practise followed in the case of Patients of Diabetes /Cardiovascular / Renal failure, attending various hospitals.

    4. The Diet editing and counselling in Fluorosis is patient specific. Wide variations in health complaints exist between patients.

    5. The Diet Counsellor should provide a Blank sheet of paper (A4 size)  and suggest that from recall of memory, the patient should record what he/she had consumed for 7 days in a week  for :

      1.  Breakfast                           3.  Snacks at Tea time
      2.  Lunch                                4.  Dinner

    6. On the same sheet where the patient has indicated the different iems of food consumed, the Counsellor provides advice on Dos’ and Don’ts for all the 4 meals. Efforts should be made to consume more vegetables, fruits, and dairy products. It is necessary to avoid oily, fried and highly spiced food items

    7. Each step is to be explained well; to inform the benefits to accrue following    Diet editing (correction ie. by withdrawal of fluoride) and Diet counselling (promotion of nutrients) through dairy products, fruits and vegetables, much more than what the family was used to in the past

    8. To point out all items loaded with fluoride available in the market, street food, beverages, etc. so that they are aware and would make a conscious effort to ban such items from consumption.

    For more information refer the Book
    "Fluorosis Mitigation: Guidelines for Program Execution
    For Policy Makers, Health Administrators and Doctors" (2015)

    By Prof. (Dr.) A.K. Susheela

    The essential nutrients for combating Fluorosis:

    Adequate intake of :


    Different recipes for adequate intake of the above nutrients are developed and field tested with excellent results.

    Fluoride contaminated items to be avoided.