Neuro-medical manifestations of fluorosis in populations living in the Main Ethiopian Rift Valley

Prolonged exposure to higher concentrations of fluoride (> 1.5 mg/L) is associated with dental and skeletal fluorosis. The effects of fluoride on dental and skeletal system have been studied extensively; however, the neurological consequences of fluoride in population-based studies are limited. The study aims to assess the epidemiology of neurological and other manifestations of fluorosis among rural populations living in the Main Ethiopian Rift valley. In this cross-sectional study, we enrolled 316 individuals from 23 rural communities in the Main Ethiopian Rift valley. Fluoride concentration was measured in drinking water samples collected from 23 community wells. Association between fluoride concentrations and clinical features of fluorosis was assessed using student t test, chi square, multivariable regression using adjusted odds ratio (OR). The mean fluoride concentration in the drinking water was 6.8 ± 4.3 mg/L (range: 0.3-15.5 mg/L). At least one clinical sign of skeletal fluorosis was observed in 54.4% (n = 175) of the study participants. Headache and joint pain reported by 67.1% and 56.3% of the participants as the most common neurological manifestation, and skeletal fluorosis symptom, respectively. The mean fluoride level was higher for those individuals who reported paresthesia compared to those with no-paresthesia. Loss of appetite, constipation, and fatigue were reported by 48.0%, 45.6%, and 56.6% of the participants, respectively. Signs of crippling fluorosis were observed in small proportion (1.6%) of the participants. Individuals who reported headache are most likely exposed to higher fluoride concentrations in drinking water compared to those reported no-headache (p < 0.001). The study demonstrates high prevalence of neuro-medical manifestations of fluorosis in population living in the Main Ethiopian Rift valley. Fluoride concentration in drinking water and joint pain were independent predictors of fluorosis.

Association of Dietary Calcium Intake with Dental, Skeletal and Non-Skeletal Fluorosis among Women in the Ethiopian Rift Valley

Fluorosis is a major public health problem in the Rift Valley of Ethiopia. Low calcium (Ca) intake may worsen fluorosis symptoms. We assessed the occurrence of fluorosis symptoms among women living in high-fluoride (F) communities in South Ethiopia and their associations with dietary Ca intake. Women (n = 270) from two villages provided clinical and questionnaire data. Dental fluorosis examination was done using Dean’s Index, and skeletal and non-skeletal fluorosis assessment was carried out using physical tests and clinical symptoms. Daily Ca intake was estimated by a food frequency questionnaire. Food, drinking water and beverage samples were analyzed for F level. Many subjects (56.3%) exhibited dental fluorosis. One-third of the women were unable to perform the physical exercises indicative of skeletal fluorosis; about half had ≥2 symptoms of skeletal/non-skeletal fluorosis. The average F level in drinking water sources was ~5 mg/L. The F content in staple food samples varied from 0.8–13.6 mg/kg. Average Ca intake was 406 ± 97 mg/day. Women having ≤400 mg/day Ca intake had ~3 times greater odds of developing skeletal rigidity with joint pains [AOR = 2.8, 95%CI: 1.6, 5.0] and muscular weakness [AOR = 2.9, 95%CI: 1.3, 6.3] compared to those with higher intakes. No association of calcium intake was seen with dental fluorosis. As low dietary Ca intake was associated with symptoms related to skeletal and non-skeletal fluorosis, this warrants nutritional intervention on calcium intakes in this setting.

Fluoride concentration in ground water and prevalence of dental fluorosis in Ethiopian Rift Valley: systematic review and meta-analysis

BACKGROUND

The concentration of fluoride in ground drinking water greater than the world health organization standard value imposes a serious health, social and economic problem in developing countries. In the Ethiopian Rift Valley where deep wells are the major source of drinking water, high fluoride level is expected. Though many epidemiological studies on fluoride concentration and its adverse effects have been conducted in the region, the result is highly scattered and needs systematically summarized for better utilization.

OBJECTIVE

This research is aimed at estimating the pooled level of fluoride concentration in ground drinking water and the prevalence of dental fluorosis among Ethiopian rift valley residences.

METHODS

Cochrane library, MEDLINE/PubMed and Google scholar databases were searched for studies reporting the mean concentration of fluoride in ground water and prevalence of dental fluorosis in Ethiopian Rift valley. Search terms were identified by extracting key terms from reviews and selected relevant papers and review medical subject headings for relevant terms.

RESULTS

The mean fluoride level in ground water and the prevalence of dental fluorosis were pooled from eleven and nine primary studies conducted in Ethiopian Rift Valley respectively. The pooled mean level of fluoride in ground water therefore was 6.03 mg/l (95% CI; 4.72-7.72, p < 0.001) and the pooled prevalence of dental fluorosis among residents in Ethiopian rift valley was 32% (95% CI: 25, 39%, p < 0.001), 29% (95% CI: 22, 36%, p < 0.001) and 24% (95% CI: 17, 32%, p < 0.001 for mild, moderate and sever dental fluorosis respectively. The overall prevalence of dental fluorosis is 28% (95% CI, 24, 32%, p < 0.001).

CONCLUSIONS

Though, the concentration level varies across different part of the rift valley region, still the level of fluoride in ground drinking water is greater than the WHO standard value (1.5 mg/l). Relatively high-level pooled prevalence of dental fluorosis was also seen in Ethiopian rift valley. Therefore, further studies covering the temperature, exposure time and other intake path ways with large sample size is recommended. Interventional projects should be implemented to decrease the concentration of fluoride in the ground drinking water source.

Geochemical Evolution of Fluoride and Implication for F− Enrichment in Groundwater: Example from the Bilate River Basin of Southern Main Ethiopian Rift

Groundwater is the most important source of drinking water. Fluoride was found in high concentrations in the groundwater from deep wells of the water supply in the southern main Ethiopian rift. The high concentration of fluoride is dominantly geogenic rather than anthropogenic in origin, as the agricultural area was not found to be contaminated with NO3−. Knowledge of fluoride enrichment will help to provide management plans for developing deep groundwater and minimizing the health risks of exposure to fluoride. The chemical processes of fluoride were investigated in the waters in the Bilate River basin using hydrochemical and isotopic tools. The F− concentration ranged from 0.5 to 1.29 mg/L in water from shallow wells and from 0.48 to 5.61 mg/L in water from deep wells. Seventy percent of deep well samples had F− > 1.5 mg/L higher than the World Health Organization potable guideline. The high fluoride concentration in the groundwater was mainly situated in the rift valley of the Bilate River basin, in contrast with low F− groundwater in the highland. The concentration of fluoride was lowest in Ca-Mg-HCO3 type groundwater and highest in Na-HCO3 type groundwater. Moreover, F− was positively correlated with HCO3−, Na+, Na+/Ca2+ and pH in groundwater and Na+/Ca2+ ratios were increased along the flow path. Hydrogeological, hydrodynamic and hydrochemical conditions are responsible for fluoride accumulation in the deep aquifers. Strong dynamic flow in highland areas flush away weathered chemical components (e.g., F−). Thus, surficial weathering is not a major controlling factor for high concentrations of Fluoride in deep groundwater but the combination of silicate hydrolysis and ion exchange mainly control fluoride enrichment in stagnant flow environments.

Beer as a Rich Source of Fluoride Delivered into the Body

Fluoride is an element which in the minimum amount is necessary for the proper construction of the teeth and bones. But on the other hand, it increases the synthesis of reactive oxygen species, inflammatory mediators, and impairs the action of enzymes. Beer is the most popular alcoholic beverage in the world. Due to its prevalence and volume of consumption, it should be considered as a potential source of F- and taken into account in designing a balanced diet. Therefore, the aim of this study was to analyze beer samples in terms of F- levels. The concentrations of fluoride were examined using ion-selective electrode Thermo Scientific Orion and statistical analysis was based on two-way ANOVA and t test. When compared to imported beers, Polish beers were characterized by the lowest mean F- concentration (0.089 ppm). The highest mean F- concentrations were recorded in beers from Thailand (0.260 ppm), Italy (0.238 ppm), Mexico (0.210 ppm), and China (0.203 ppm). Our study shows that beer is a significant source of fluoride for humans, which is mainly associated with the quality of the water used in beer production.

Fluoride Content in Alcoholic Drinks

The aim of the study was to determine the role of alcoholic drinks as a potential source of dietary fluoride by means of measuring fluoride levels in selected alcoholic drinks available on the Polish market that are also diverse in terms of the percentage content of ethanol. The study was conducted on 48 types of drinks with low, medium, and high alcohol content available on the Polish market and offered by various manufacturers, both Polish and foreign. Fluoride concentrations in individual samples were measured by potentiometric method with a fluoride ion-selective electrode. The highest fluoride levels were determined in the lowest percentage drinks (less than 10 % v/v ethanol), with the lowest fluoride levels observed in the highest percentage drinks (above 40 % v/v ethanol). In terms of types of alcoholic drinks, the highest fluoride levels were determined in beers and wines, while the lowest levels were observed in vodkas. These data confirm the fact that alcoholic beverages need to be considered as a significant source of fluoride delivered into the body.

Groundwater fluoride enrichment in an active rift setting: Central Kenya Rift case study

Groundwater is used extensively in the Central Kenya Rift for domestic and agricultural demands. In these active rift settings groundwater can exhibit high fluoride levels. In order to address water security and reduce human exposure to high fluoride in drinking water, knowledge of the source and geochemical processes of enrichment are required. A study was therefore carried out within the Naivasha catchment (Kenya) to understand the genesis, enrichment and seasonal variations of fluoride in the groundwater. Rocks, rain, surface and groundwater sources were sampled for hydrogeochemical and isotopic investigations, the data was statistically and geospatially analyzed. Water sources have variable fluoride concentrations between 0.02-75 mg/L. 73% exceed the health limit (1.5mg/L) in both dry and wet seasons. F(-) concentrations in rivers are lower (0.2-9.2mg/L) than groundwater (0.09 to 43.6 mg/L) while saline lake waters have the highest concentrations (0.27-75 mg/L). The higher values are confined to elevations below 2000 masl. Oxygen (δ(18)O) and hydrogen (δD) isotopic values range from -6.2 to +5.8‰ and -31.3 to +33.3‰, respectively, they are also highly variable in the rift floor where they attain maximum values. Fluoride base levels in the precursor vitreous volcanic rocks are higher (between 3750-6000 ppm) in minerals such as cordierite and muscovite while secondary minerals like illite and kaolinite have lower remnant fluoride (<1000 ppm). Thus, geochemical F(-) enrichment in regional groundwater is mainly due to a) rock alteration, i.e. through long residence times and natural discharge and/or enhanced leakages of deep seated geothermal water reservoirs, b) secondary concentration fortification of natural reservoirs through evaporation, through reduced recharge and/or enhanced abstraction and c) through additional enrichment of fluoride after volcanic emissions. The findings are useful to help improve water management in Naivasha as well as similar active rift setting environments.

Fluoride exposure from groundwater as reflected by urinary fluoride and children's dental fluorosis in the Main Ethiopian Rift Valley

This cross-sectional study explores the relationships between children's F(-) exposure from drinking groundwater and urinary F(-) concentrations, combined with dental fluorosis (DF) in the Main Ethiopian Rift (MER) Valley. We examined the DF prevalence and severity among 491 children (10 to 15 years old) who are life-long residents of 33 rural communities in which groundwater concentrations of F(-) cover a wide range. A subset of 156 children was selected for urinary F(-) measurements. Our results showed that the mean F(-) concentrations in groundwater were 8.5 ± 4.1 mg/L (range: 1.1-18 mg/L), while those in urine were 12.1±7.3 mg/L (range: 1.1-39.8 mg/L). The prevalence of mild, moderate, and severe DF in children's teeth was 17%, 29%, and 45%, respectively, and the majority (90%; n=140) of the children had urinary F(-) concentrations above 3 mg/L. Below this level most of the teeth showed mild forms of DF. The exposure-response relationship between F(-) and DF was positive and non-linear, with DF severity tending to level off above a F(-) threshold of ~6 mg/L, most likely due to the fact that at ~6 mg/L the enamel is damaged as much as it can be clinically observed in most children. We also observed differential prevalence (and severity) of DF and urinary concentration, across children exposed to similar F(-) concentrations in water, which highlights the importance of individual-specific factors in addition to the F(-) levels in drinking water. Finally, we investigated urinary F(-) in children from communities where defluoridation remediation was taking place. The lower F(-) concentration measured in urine of this population demonstrates the capacity of the urinary F(-) method as an effective monitoring and evaluation tool for assessing the outcome of successful F(-) mitigation strategy in relatively short time (months) in areas affected with severe fluorosis.