DIAGNOSIS

• High fluoride contents of the drinking water
• Endemicity of the Fluorosis in the area
• Clinical manifestations of Fluorosis in the population: Dental, Clinical, Skeletal Fluorosis
• Clinical examination: Examination of teeth and three simple diagnostic tests.
  • The individual is made to bend and touch the toes without bending the knees. If there is pain or stiffness in the backbone, hip and joints, this exercise will not be possible.
  • The individual is made to touch the chest with the chin. If there is pain or stiffness in the neck, this exercise will not be possible.
  • The individual is made to stretch the arms sideways, fold the arm and try to touch the back of the head. If there is pain or stiffness in the shoulder joint and backbone, this exercise will not be possible.
• Biochemical evaluation
• Radiological evaluation
• Histopathological evaluations e.g. bone biopsy, muscle biopsy etc.

NOTE: The most diagnostic biochemical evaluation is to estimate Blood, Serum and urinary fluoride.

DIFFERENTIAL DIAGNOSES

All three types of presentations in Fluorosis need to be differentiated from simulating illnesses:

Dental Fluorosis:

Like any other organs in the body; teeth are also affected by various factors leading to diseases. The differential diagnosis of flluorosis should be done for two aspects:

1. Related to the pitting and chipping in Fluorosis
2. Related to discoloration of teeth

Common dental diseases relating to the pitting and chipping in Fluorosis are:

1. Dental caries or decay/ cavity formation.
2. Periodontal disease or pyorrhea
3. Dental Fluorosis

• Caries appear as black spots or cavity in the tooth when decay reaches dentin. Person complains of sensitiveness and acute pain when decay reaches pulp.
• Pyorrhea is caused by action of bacteria present in the mouth on food, resulting in the form of brownish hard deposit on the surface of teeth near gum.
• Periodontal disease is the inflammation of gingival gum and periodontal ligament leads to deposition of inorganic salts known as tartar, it irritates gum resulting in bleeding of gums and bad breath. Tartar cannot be removed by brushing. Periodontal disease is more common amongst persons suffering from diabetes mellitus, nutritional deficiency, especially protein and Vitamin C deficiency.
• Fluorosis affects permanent teeth though decay of temporary teeth is also reported.

Diseases related to discoloration of teeth:

• There may be two types of staining of teeth: a) Internal staining b) external staining
• Fluorosis causes internal staining of teeth, whereas other causes like Brinjal eating, Banana biting, Palm leaf biting, Coconut leaf chewing cause external staining of teeth and may be mistaken for dental Fluorosis.

Skeletal Fluorosis:

• In the early stages of skeletal Fluorosis patients complain of arthritic symptoms, which have to be differentiated from those caused by such diseases as rheumatoid and ankylosing spondylitis. For early diagnosis of skeletal Fluorosis, microradiographic techniques are more helpful than conventional skiagrams. In doubtful cases a bone biopsy (though tedious) for estimation of fluoride content provides conclusive evidence.
• In later stages skeletal Fluorosis is marked by restriction of spine movements and hence can be easily diagnosed.
• In the case of children residing in endemic regions these symptoms need to be differentiated from rickets, and sometimes from renal osteodystrophies, including congenital malformations. In all such cases urinary and serum levels of fluoride and radiographs of skeleton will clinch the diagnosis. When sclerosis of the vertebral column is not marked, calcification of the interosseous membranes in the fore arm clearly indicate the diagnosis of Fluorosis, on radiography.
  

Non Skeletal Fluorosis

The preskeletal stage of fluoride intoxication poses problems for diagnosis. In these cases radiograph of the skeleton will neither show sclerosis or calcification of the ligaments nor significant elevation of urinary levels of fluoride. Moreover the symptoms that are manifested are so varied that they may be identifiable with those of various other diseases. The complaints of the victims in this regard are so common place that they may be easily mistaken for those resulting from other ailments e.g. muscle/neurological involvement in children may be mistaken for Poliomyelitis.