Prolonged, excessive exposure to fluoride can cause a debilitating bone disease known as skeletal fluorosis. The disease develops insidiously and can be difficult to distinguish from a number of other bone and joint diseases. Research shows that individual susceptibility to fluorosis varies greatly across the population, both with respect to the doses and duration of exposure that can cause the disease, and the skeletal manifestations and symptoms that result. Although skeletal fluorosis used to be considered a non-issue in the United States and other western countries, recent research suggests that many people — particularly heavy tea drinkers and those with kidney impairment — may unknowingly be suffering from some form of the disease.
Skeletal Fluorosis: A “Diagnostic Riddle”
One of the reasons doctors fail to detect skeletal fluorosis is because — whether in its early or late stages — the symptoms and appearance of fluorosis can closely resemble other, more commonly known, bone and joint diseases.
In the initial stages of fluorosis, known as the ”pre-skeletal“ phase, a patient may suffer a variety of symptoms in the absence of any detectable bone changes, including joint pains, joint stiffness, and gastric distress. (Czerwinski 1988; Cook 1971). The absence of bone changes makes this pre-skeletal phase difficult to diagnose, because the symptoms are indistinguishable from common forms of arthritis, such as osteoarthritis and rheumatoid arthritis.
Even when bone changes do develop, correct diagnosis can remain elusive. This is because the bone changes in skeletal fluorosis mimic the bone changes in other diseases, including osteoarthritis, renal osteodystrophy, spondylosis, DISH, Paget’s Disease, and osteopetrosis. In 2011, for example, a team of U.S. scientists reported that a Georgia woman with crippling skeletal fluorosis, as evident by her severe hunchback (“kyphosis”), had to wait up to 18 years before doctors were able to diagnosis her condition as being caused by fluoride. (Whyte 2011). Other U.S. studies have reported similar results. (Sauerbrunn 1965). If a doctor cannot diagnose fluorosis when it reaches the crippling stage, it is doubtful that he or she will be able to detect the earlier, subtler forms of the disease.
For over 40 years, U.S. health authorities insisted that skeletal fluorosis can not develop unless a person ingests 20 milligrams of fluoride per day for over 10 years. U.S. health authorities now concede, however, that skeletal fluorosis can occur at doses as low as 10 mg/day. (NRC 1993; Whitford 1996; IOM 1997; ATSDR 2003). This revised estimate, however, is itself outdated. This is evident, for example, by the following data from a large-scale study in China which found that average doses of just 6.2 to 6.5 mg/day were sufficient to cause stage 1 skeletal fluorosis (a form of fluorosis in which bone changes are detectable on x-ray). Since arthritic symptoms can occur prior to the bone changes of stage 1 fluorosis, the doses that can cause arthritic symptoms would appear to be less than 6 mg/day.
Another error underlying U.S. safety standards is the notion that skeletal fluorosis does not occur at water fluoride levels below 8 ppm. (IOM 1997; EPA 1985). Studies in India and China have repeatedly documented skeletal fluorosis at levels as low as 0.7 to 1.5 ppm fluoride. Even studies in the United States — despite being very small in scope — have reported advanced skeletal fluorosis in kidney patients at 1.7 ppm, (Johnson 1979) and crippling skeletal fluorosis at just 2.2 to 3.5 ppm. (Sauerbrunn 1965).
Individual susceptibility to fluorosis varies greatly across the population
The claim that skeletal fluorosis cannot occur if an individual consumes less than 10 mg/day of fluoride obscures the individual variability, and complexity, of fluorosis. As with any other toxic substance, individual susceptibility to fluoride varies considerably across the population. Research has documented, for example, that:
- some individuals can develop skeletal fluorosis despite having “safe” levels of fluoride in their bones and without any known excessive exposure to fluoride; (Sandberg 1985)
- individuals receiving the same dose of fluoride can exhibit dramatically different bone responses; (Chachra 2010)
- individuals with pre-skeletal fluorosis can suffer excruciating pain, while individuals with advanced fluorosis can remain symptom-free; (Franke 1975)
- although U.S. health authorities claim that fluorosis only develops after 10 or more years of exposure, children can develop the disease in as little as 6 months, (Teotia 1998), and some adults have developed it in as little as 2 to 7 years (Gerser 1983; Fratzl 1995; Felsenfeld 1991).
Skeletal fluorosis looks different in different individuals
Skeletal fluorosis is a far more complex disease than is generally perceived. This fact is highlighted by the very different forms the disease can take based on an individual’s nutritional status, health status, age, genetics, and exposure to aluminum. Whereas the dominant feature of skeletal fluorosis is generally considered to be hyper-dense bone in the spine (axial osteosclerosis), research has documented that:
- some fluorosis victims can suffer primarily from osteoarthritis without noticeable osteosclerosis in the spine,
- other fluorosis victims can suffer primarily from osteomalacia, osteoporosis, and/or secondary hyperparathyroidism without prominent osteosclerosis.
To the extent that doctors rely on osteosclerosis in the spine as the telltale marker of fluorosis, victims will continue to fall through the cracks.
Common Causes of Fluorosis
- Fluoridated Water for Kidney Patients
- Excessive Tea Consumption
- High-Fluoride Well Water (more likely to be a factor among deep wells)
- Industrial Fluoride Exposure
- Fluorinated Pharmaceuticals (Voriconazole & Niflumic Acid)
- Indoor coal burning (a common practice in China).
Fluorosis Bends Rural Gujurat at the Knees
Fluoride, Arthritis, and the Specter of Misdiagnosed Skeletal Fluorosis in the US
It has been known since the 1930s that ingesting too much fluoride can cause stiff and painful joints. According to scientists who have studied this condition (commonly referred to as skeletal fluorosis), the joint damage caused by fluoride may mimic other, more common, forms of “arthritis,” making it easy to
Study finds link between tea, fluoride, and weak bones
The authors identified 5 patients in their practice who developed skeletal fluorosis as a consequence of drinking tea (primarily darjeeling tea) over a course of 10 to 25 years. The skeletal fluorosis in these patients was the osteomalacic variety of the disease, in which the bones become softened and weak. As a result of the “fluoride-related osteomalacia”, the patients suffered “spontaneous bone fractures” where their bones fractured without external trauma.
Ministry of not-so-funny walks
The fluorosis problem is "enormous, unbelievable," says Andezhath Susheela of the Fluorosis Research and Rural Development Foundation in Delhi. She has been unravelling the national story for a decade during which time her estimate of the number of people leading "a painful and crippled life" from fluorosis has risen from one million to 25 million and now to 60 million -- six million of them children.
Fluoride & Osteoarthritis
While the osteoarthritic effects that occurred from fluoride exposure were once considered to be limited to those with skeletal fluorosis, recent research shows that fluoride can cause osteoarthritis in the absence of traditionally defined fluorosis. Conventional methods used for detecting skeletal fluorosis, therefore, will fail to detect the full range of people suffering from fluoride-induced osteoarthritis.
Skeletal Fluorosis & Individual Variability
One of the common fallacies in the research on skeletal fluorosis is the notion that there is a uniform level of fluoride that is safe for everyone in the population. These "safety thresholds" have been expressed in terms of (a) bone fluoride content, (b) daily dose, (c) water fluoride level, (d) urinary fluoride level, and (e) blood fluoride level. The central fallacy with each of these alleged safety thresholds, however, is that they ignore the wide range of individual susceptibility in how people respond to toxic substances, including fluoride.
Fluoride & Spondylosis; Spondylitis
Among individuals with skeletal fluorosis, the fluoride-induced changes to the spine, and the accompanying symptoms, can bear a close resemblance to spondylosis and spondylitis (as well as DISH). Spondylosis is a (non-inflammatory) degenerative disease of the spine marked by bony outgrowths (spurs) which can produce nerve cord compression. Spondylitis, by contrast, is an inflammatory form of arthritis that causes inflammation in the joints between the vertebrae. Whereas spondylosis is generally asymptomatic, spondylitis generally causes significant pain and stiffness in the spine.
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