Skeletal fluorosis

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Skeletal fluorosis
Fluorosis victim of the industrial city of Raigarh, Chhattisgarh

Skeletal fluorosis is a bone disease caused by excessive accumulation of fluoride leading to weakened bones.[1] In advanced cases, skeletal fluorosis causes painful damage to bones and joints.

Symptoms and signs

Symptoms are mainly promoted in the bone structure. Due to a high fluoride concentration in the body, the bone is hardened and thus less elastic, resulting in an increased frequency of fractures. Other symptoms include thickening of the bone structure and accumulation of bone tissue, which both contribute to impaired joint mobility. Ligaments and cartilage can become ossified.[2] Most patients suffering from skeletal fluorosis show side effects from the high fluoride dose such as ruptures of the stomach lining and nausea.[3] Fluoride can also damage the parathyroid glands, leading to hyperparathyroidism, the uncontrolled secretion of parathyroid hormones. These hormones regulate calcium concentration in the body. An elevated parathyroid hormone concentration results in a depletion of calcium in bone structures and thus a higher calcium concentration in the blood. As a result, bone flexibility decreases making the bone more susceptible to fractures.[4]


Common causes of fluorosis include inhalation of fluoride dusts or fumes by workers in industry and consumption of fluoride from drinking water (levels of fluoride in excess of levels that are considered safe.[5])

In India, especially the Nalgonda region (Telangana), a common cause of fluorosis is fluoride-rich drinking water that is sourced from deep-bore wells. Over half of groundwater sources in India have fluoride above recommended levels.[6]

Fluorosis can also occur as a result of volcanic activity. The 1783 eruption of the Laki volcano in Iceland is estimated to have killed about 22% of the Icelandic population, and 60% of livestock, as a result of fluorosis and sulfur dioxide gases.[7] The 1693 eruption of Hekla also led to fatalities of livestock under similar conditions.[8]


Skeletal fluorosis Stage II arrows

The diagnosis for Skeletal fibrosis can be done via its radiographic presentation[9]

Skeletal fluorosis phases

Osteosclerotic phase Ash concentration (mgF/kg) Symptoms and signs
Normal Bone 500 to 1,000 Normal
Preclinical Phase 3,500 to 5,500 Asymptomatic; slight radiographically-detectable increases in bone mass
Clinical Phase I 6,000 to 7,000 Sporadic pain; stiffness of joints; osteosclerosis of pelvis and vertebral column
Clinical Phase II 7,500 to 9,000 Chronic joint pain; arthritic symptoms; slight calcification of ligaments' increased osteosclerosis and cancellous bones; with/without osteoporosis of long bones
Clinical Phase III 8,400 Limitation of joint movement; calcification of ligaments of neck vertebral column; crippling deformities of the spine and major joints; muscle wasting; neurological defects/compression of spinal cord


As of now, there are no established treatments for skeletal fluorosis patients.[10] However, it is reversible in some cases, depending on the progression of the disease. If fluorine intake is stopped, the amount in bone will decrease and be excreted via urine. However, it is a very slow process to eliminate the fluorine from the body completely. Minimal results are seen in patients. Treatment of side effects is also very difficult. For example, a patient with a bone fracture cannot be treated according to standard procedures, because the bone is very brittle. In this case, recovery will take a very long time and a pristine healing cannot be guaranteed.[11] However, further fluorosis can be prevented by drinking defluoridated water. It is recently suggested that drinking of defluoridated water from the ″calcium amended-hydroxyapatite″ defluoridation method may help in the fluorosis reversal.[12] Defluoridated water from this suggested method provides calcium-enriched alkaline drinking water as generally fluoride contaminated water has a low amount of calcium mineral and drinking alkaline water helps in eliminating the toxic fluoride from the body.[12]


In some areas, skeletal fluorosis is endemic. While fluorosis is most severe and widespread in the world's two most populous countries – India and China – UNICEF estimates that "fluorosis is endemic in at least 25 countries across the globe. The total number of people affected is not known, but a conservative estimate would number in the tens of millions."[13]

In India, 20 states have been identified as endemic areas, with an estimated 60 million people at risk and 6 million people disabled; about 600,000 might develop a neurological disorder as a consequence.[6]

Effects on animals

knobby hoofed leg
Moroccan cow with fluorosis

The histological changes which are induced through fluorine on rats resemble those of humans.[14]

See also


  1. Whitford GM (1994). "Intake and Metabolism of Fluoride". Advances in Dental Research. 8 (1): 5–14. doi:10.1177/08959374940080011001. PMID 7993560.
  2. Kalia LV, Lee L, Kalia SK, Pirouzmand F, Rapoport MJ, Aviv RI, Mozeg D, Symons SP. Thoracic myelopathy from coincident fluorosis and epidural lipomatosis. Canadian Journal of Neurological Sciences. 2010 March; 37(2):276–278.
  3. Gönnewicht, Daniela (2005). "Untersuchung eines Zusammenhanges von Fluoridkonzentrationen in privaten Trinkwasserversorgungsanlagen und Kariesentwicklung im Raum Ascheberg (Südliches Münsterland/Westfalen)" (PDF). Dissertation. Universität Münster, Fachbereich Medizinische Fakultät. Archived from the original (PDF) on 2017-11-07. Retrieved 2021-08-17.
  4. Teotia SP, Teotia M (March 1973). "Secondary hyperparathyroidism in patients with endemic skeletal fluorosis". Br Med J. 1 (5854): 637–40. doi:10.1136/bmj.1.5854.637. PMC 1588649. PMID 4692708.
  5. "CDC – National Research Council (NRC) Report – Safety – Community Water Fluoridation – Oral Health". Archived from the original on 2021-04-27. Retrieved 2013-09-04.
  6. 6.0 6.1 Reddy DR (2009). "Neurology of endemic skeletal fluorosis". Neurol India. 57 (1): 7–12. doi:10.4103/0028-3886.48793. PMID 19305069. Archived from the original on 2021-11-05. Retrieved 2021-08-17.
  7. Thordarson, Thorvaldur; Self, Stephen (2003). "Atmospheric and environmental effects of the 1783–1784 Laki eruption: A review and reassessment" (PDF). Journal of Geophysical Research. 108 (D1): 4011. Bibcode:2003JGRD..108.4011T. doi:10.1029/2001JD002042. Archived (PDF) from the original on 2020-06-24. Retrieved 2021-08-17.
  8. "Eruption History". Archived from the original on 2017-08-06. Retrieved 2021-08-17.
  9. Sellami, Meriem; Riahi, Hend; Maatallah, Kaouther; Ferjani, Hanen; Bouaziz, Mouna Chelli; Ladeb, Mohamed Fethi (1 March 2020). "Skeletal fluorosis: don't miss the diagnosis!". Skeletal Radiology. 49 (3): 345–357. doi:10.1007/s00256-019-03302-0. ISSN 1432-2161. Archived from the original on 11 November 2021. Retrieved 10 November 2021.
  10. Whyte MP, Essmyer K, Gannon FH, Reinus WR (January 2005). "Skeletal fluorosis and instant tea". Am. J. Med. 118 (1): 78–82. doi:10.1016/j.amjmed.2004.07.046. PMID 15639213.
  11. Grandjean P, Thomsen G (November 1983). "Reversibility of skeletal fluorosis". Br J Ind Med. 40 (4): 456–61. doi:10.1136/oem.40.4.456. PMC 1009220. PMID 6626475.
  12. 12.0 12.1 Sankannavar, Ravi; Chaudhari, Sanjeev (2019). "An imperative approach for fluorosis mitigation: Amending aqueous calcium to suppress hydroxyapatite dissolution in defluoridation". Journal of Environmental Management. 245: 230–237. doi:10.1016/j.jenvman.2019.05.088. PMID 31154169.
  13. "UNICEF – Water, environment and sanitation – Common water and sanitation-related diseases". Archived from the original on 2021-04-10. Retrieved 2007-09-17.
  14. Franke J, Runge H, Fengler F, Wanka C (1972). "[Experimental bone fluorosis]". Int Arch Arbeitsmed (in Deutsch). 30 (1): 31–48. doi:10.1007/bf00539123. PMID 5084923.

Further reading

  • Fluorosis from drinking very large amounts of tea: Naveen Kakumanu, M.D. & Sudhaker D. Rao, M.B., B.S. (2013-03-21). "Skeletal Fluorosis Due to Excessive Tea Drinking". New England Journal of Medicine. 368 (12): 1140. doi:10.1056/NEJMicm1200995. PMID 23514291.{{cite journal}}: CS1 maint: multiple names: authors list (link)

External links