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Health diagnosis for fluorosis can be done by following the steps given here. INREM utilizes local public health facilities and laboratories spread across the country.

The ethical aspects of health is observed by INREM’s institutional ethics committee.

Water quality: fluoride in all sources of water

pink yellow
Testing for fluoride with field kit
pink (safe) yellow (unsafe)

The safe permissible limit for fluoride is 1 mg/l. This can be checked using field kits and in laboratory also.

Water quality testing of all sources is done in participation with community using field kits and laboratory analysis with Ion electrode. Results from 5 villages of Jhabua show that handpumps have greater fluoride levels than dug wells (see graph below).

Most of the water samples collected from dug wells have fluoride levels less than 1 mg/l. Samples collected from handpumps have fluoride levels even up to 12 mg/l in some cases. Consumption of such high fluoride water leads to fluorosis – mainly Dental and Skeletal.

Collecting water samples

Overall, on average, handpumps have higher fluoride than dug wells. But this graph shows that some dug wells have high fluoride and some handpumps have low fluoride also.


Dental and Skeletal fluorosis symptoms

Our survey of 40 Jhabua schools in August-September 2010 for Dental Fluorosis (DF) shows that 22% of children have some symptom of DF

Many children are also affected with Skeletal Fluorosis with range of symptoms such as bowed legs,  Genu valgum, etc

Summary of Dental Fluorosis (DF) survey in 40 schools of Jhabua
No DF Mild DF Medium DF Severe DF Total
Male Female Male Female Male Female Male Female Male Female
1775 1493 405 264 157 79 32 21 2369 1857
958 out of 4226  (22%) surveyed children have DF symptoms

Food analysis: for fluoride and nutrition

Food analysis: for fluoride and nutrition
2 out of 102 food samples collected from families

The staple food in Jhabua is Makai (Maize). Nutrition content analysis of Maize samples show that they do have significant amount of Calcium, Magnesium and Iron.

However, consuming Maize Roti provides for only 10% of daily requirement for Calcium.

There is low to nil consumption of milk and dairy products. Also, nutrition for infants being very poor, child malnutrition is very high in Jhabua. As a result, we have many cases of Juvenile Fluorosis which is caused by a combination of high Fluoride in water and poor consumption of Calcium.

Fluoride in food samples from 2 villages of Jhabua




Miyati Jashoda Khunji All Miyati Jashoda Khunji All




3.55 1.45 3.55
Jowar 3.22



3.22 0.78 3.22


0.66 0.92 2.78 0.86 2.78
Paddy 2.59 0.63 1.61




Tuwar Dal


1.24 2.62







0.81 1.97


Wheat 1.17


0.95 2.68


Nutrition content of Maize samples
  Maize (Sample no. 1110) Maize  (Sample no. 1111) Maize (Sample no. 1112)
Calcium (mg/kg)




Magnesium (mg/kg)




Iron (mg/kg)




Crude protein (%)




Blood and Urine fluoride analysis

Monitoring of blood serum and urinary fluoride is very important. Whereas urinary fluoride levels shows us how much fluoride is being ejected from the body, the blood serum fluoride levels can inform us about fluoride present in the body.

There are very few facilities in India which can do testing of blood serum for fluoride. We have tested our samples at the laboratory managed by Dr. A. K. Susheela in New Delhi.

Urinary fluoride reduction:

19 out of 20 children (sample group) who were part of mitigation programme show significant reduction in blood serum fluoride

All 3 children (control group) who had to leave midway for higher studies show increase in blood serum fluoride

These significant results give proof for the twin mitigation strategy of fluoride-free water (by using INREM’s filter) and appropriate nutrition of Calcium, Magnesium and Vitamin C.

X-ray of arms and legs


X-ray of fore-arms and legs of patients were conducted at Jhabua district hospital and these were analyzed by radiologists at Apollo hospitals, Hyderabad. The analysis showed that these children suffer also from juvenile osteoporosis along with fluorosis.

As shown by blood serum fluoride results, the patient has high fluoride in blood ( > 0.05 mg/l). This along with observation of Osteoporosis confirms Skeletal Fluorosis for this patient.

This analysis also showed that Juvenile fluorosis is a combination of both fluoride excess and calcium deficiency.

Photos from different angles of a Skeletal Fluorosis patient, age 13, village Miyati, Jhabua  

X-ray of Leg and right fore-arm | X-ray report from Radiology department, Apollo hospitals, Hyderabad

We recommend that for suspected fluorosis patients, one should always take a Digital X-ray of right fore-arm and any other limb which appears to have deformity.


We monitor patients and families following their adoption of mitigation procedures.

Height and Weight Monitoring Testing Filter Water

Medical report card

Weekly: We look at any problems  the family has had with use of filter and nutrition.  We look at usage of  the nutrition items that are provided and any problems related to that

The fluoride removal filter is checked to see if it is working properly with the help of a field kit.

Monthly: Patient height and weight are observed to calculate change in Body Mass Index (BMI)

Once every 8-9 months: For some selected patients, blood and urine samples are monitored for fluoride and other parameters


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