"This patient presented with chronic symmetrical arthralgia with accompanying
gastrointestinal disturbance, raising the possibility of enteropathic
arthritis. The diagnosis of skeletal fluorosis was surprising, with fluoride levels being high in body fluids and drinking water.
SOURCE: Gupta R, Kumar AN, Bandhu S, Gupta S. (2007) Skeletal fluorosis mimicking seronegative arthritis. Scandanavian Journal of Rheumatology 36(2):154-5.
"‘Skeletal fluorosis’ is a condition associated with prolonged accumulation
of fluoride resulting in fragile bones having low tensile strength.
It affects the joints as well as the bones. It
is not easily recognizable till advanced stage. In its early stages,
its symptoms may resemble those of arthritis. In
its most severe stages it becomes a crippling disability that
has a major public health and socio-economic impact, affecting
millions of people in various regions of Africa, China and India."
SOURCE: Ayoob S, Gupta AK. (2006). Fluoride in Drinking Water: A Review
on the Status and Stress Effects. Critical
Reviews in Environmental Science and Technology
36:433–487.
"The authors describe a 50-year-old man with previously
treated cancer who was using tray-applied topical fluoride gel.
He complained of gastric
symptoms, difficulty in swallowing, leg
muscle soreness and knee joint soreness... The
patient's fluoride regimen was altered, and within a short period
his urinary fluoride levels returned to normal and his symptoms
resolved."
SOURCE: Eichmiller FC, Eidelman N, Carey CM. (2005). Controlling
the fluoride dosage in a patient with compromised salivary function.
Journal of the American Dental
Association 136:67-70.
"[A]rthopathy and arthritis affected
a significant number of the (fluorosis) patients, resulting in
functional disability... The physical signs of brick tea-type
skeletal fluorosis were elbow,
shoulder and knee articular dysfunction, which was the most common
pathology. X-ray examination revealed that the interosseous
membrane ossification, tendon attachment calcification and articular
degeneration were the causes of these functional disorders."
SOURCE: Cao J, et al. (2003). Brick tea
fluoride as a main source of adult fluorosis. Food and Chemical
Toxicology 41:535-42.
"The radiological severity of knee
osteoarthritis was greater in the endemic fluorosis group
than in controls... [E]ndemic fluorosis may increase the severity
of osteoarthritis in the knees."
SOURCE: Savas S, et al. (2001). Endemic
fluorosis in Turkish patients: relationship with knee osteoarthritis.
Rheumatology International 21: 30-5.
"Early signs
[of skeletal fluorosis] are vague pains and arthralgia.
This generally progresses to backache, pain in the spine,
and signs of stiffness and rigidity..."
SOURCE: Littleton J. (1999). Paleopathology
of skeletal fluorosis. American Journal of Physical Anthropology
109: 465-483.
"The initial symptoms usually were headache and weakness.
These were followed by multiple joint pains,
mostly in the feet, knees, and back. Spinal stiffness and
kyphosis developed in a few patients."
SOURCE: Wang Y, et al. (1994). Endemic fluorosis
of the skeleton: radiographic features in 127 patients. American
Journal of Roentgenology 162: 93-8.
"Symptoms of pain, stiffness and diffuse
aches may be dismissed as functional, but may in fact be
early signs of fluoride damage to tendinous insertions and ligaments
as well as joint capsules."
SOURCE: Anand JK, Roberts JT. (1990). Chronic
fluorine poisoning in man: a review of literature in English (1946-1989)
and indications for research. Biomedicine & Pharmacotherapy
44: 417-420.
"Clinical Phase 1 Fluorosis: Sporadic
pain; stiffness of joints; osteosclerosis of pelvis &
vertebral column. Clinical Phase 2 Fluorosis: Chronic
joint pain; arthritic symptoms; slight calcification of ligaments..."
SOURCE: Department of Health and Human Services. (1991). Review
of fluoride: benefits and risks.
Report of the Ad Hoc Subcommittee on Fluoride. Washington, DC.
"Vague, diffuse aches and stiffness
of joints with decreased range of motion are common initial symptoms.
With disease progression, kyphosis with limited spinal
mobility, flexion contracture of lower extremities, and restricted
chest wall expansion occur."
SOURCE: Fisher RL, et al. (1989). Endemic
fluorosis with spinal cord compression. A case report and review.
Archives of Internal Medicine 149: 697-700.
"Although skeletal fluorosis has been studied intensely
in other countries for more than 40 years, virtually
no research has been done in the U.S. to determine how many people
are afflicted with the earlier stages of the disease, particularly
the preclinical
stages. Because some of the clinical symptoms mimic arthritis,
the first two clinical phases of skeletal fluorosis could be easily
misdiagnosed... Even if a doctor is aware of the disease, the
early stages are difficult to diagnose. "
SOURCE: Hileman B. (1988). Fluoridation
of water.Questions about health risks and benefits remain after
more than 40 years. Chemical and Engineering News August
1, 1988, 26-42.
"The most frequent symptoms in those exposed >6 yr were
low back pain, painful knee, elbow, and
hip... Analysis of workers' complaints showed no specific
pain or other symptom that we could refer only to fluorosis...The
only characteristic feature would be multiple-joint
involvement in the case of fluorosis. This
would differentitate fluorosis from monoarticular osteoarthritis
(OA), but unfortunately not from multiple-joint
osteoarthritis or rheumatoid
arthritis (RA)."
SOURCE: Czerwinski E, et al. (1988). Bone
and joint pathology in fluoride-exposed workers. Archives of
Environmental Health 43: 340-343.
"According to our survey, clinical manifestations of fluoride
injury were systemic. A wide variety of
vague, subtle symptoms (i.e. backache, restricted joint movement,
abdominal pain)
occurred either prior
to or simultaneously with the development of bone changes
similar to those reported previously. Nonskeletal symptoms, therefore,
are important for early diagnosis."
SOURCE: Zhiliang Y, et al. (1987). Industrial
fluoride pollution in the metallurgical industry in China. Fluoride
20: 118-125.
"The clinical picture was characterized by new bone formation,
musculo-skeletal dysfunction leading to
arthralgia, arthritis, fixed flexion deformities, peripheral
neuropathy and incapacitation."
SOURCE: Krishnamachari KA. (1986). Skeletal
fluorosis in humans: a review of recent progress in the understanding
of the disease. Progress in Food and Nutrition Sciences
10:279-314.
"[I]t is postulated that fluoride activates the calcification
of cartilage... Thus it would be interesting
to investigate the effect of fluoride on the evolution of joint
alterations in rheumatoid
arthritis and osteoarthrosis."
SOURCE: Bang S, et al. (1985). Distribution
of fluoride in calcified cartilage of a fluoride-treated osteoporotic
patient. Bone 6: 207-210.
"Arthritis of spine and small joints
of hands and fingers develops early in the course of the disease
with or without demonstrable
radiological changes."
SOURCE: Bhavsar BS, Desai VK, Mehta NR,
Vashi RT, Krishnamachari KAVR. (1985). Neighborhood Fluorosis
in Western India Part II: Population Study. Fluoride 18:
86-92.
"Early bone fluorosis is not clinically obvious; often the
only complaints of young adults are vague pains in the small joints
of the hands, feet, and lower back. Such cases may be misdiagnosed
as rheumatoid arthritis
or ankylosing spondylitis."
SOURCE: Smith GE. (1985). Repetitive Strain
Injury, or Incipient Skeletal Fluorosis? (Letter.) New Zealand
Medical Journal 98:328.
"Our findings demonstrate a highly significant relationship
between the frequency of back and neck surgery, fractures, symptoms
of musculoskeletal disease and a
past history of diseases of the bones and joints.
In the absence of so-called classic fluorosis, a disease complex
was established which involves much more than merely the radiologic
appearance of dense bone."
SOURCE: Carnow BW, Conibear SA. (1981).
Industrial fluorosis. Fluoride 14: 172-181.
"Although a few subjects had no symptoms, the
fluoride exposed workers had a higher frequency of joint pain
and stiffness than the control group. This joint pain resulted
in disability in some cases."
SOURCE: Boillat MA, et al. (1980). Radiological
criteria of industrial fluorosis. Skeletal Radiology 5:
161-165.
"[E]xtensive research from India has revealed severe
arthritic changes and crippling neurological complications
even where the fluoride concentration in water naturally is as
low as 1.5 ppm...Even though extensive bone deformities may not
be found on a large scale from fluoride in water at the 1 ppm
concentration, some of the early signs of
the disease, such as calcifications of ligaments, joint capsules,
and muscle attachments, are likely to occur. Indeed these
conditions are characteristic of osteoarthritis,
in which the formation of microcrystals of apatite (known to be
promoted by fluoride) has now been clearly demonstrated... For
example, Pinet and Pinet described in detail
X-ray changes encountered in skeletal fluorosis in North Africa
that are in every respect identical with those present in the
arthritic spine of the elderly
elsewhere."
SOURCE: Waldbott GL, Burgstahler AW, and
McKinney HL. (1978). Fluoridation: The Great Dilemma. Coronado
Press, Inc., Lawrence, Kansas.
"Understandably, it is not uncommon
to find reference to arthritic changes, if for no other reason
than the difficulty of distinguishing them from certain fluoride
effects on bone."
SOURCE: Hodge HC, Smith FA. (1977). Occupational
fluoride exposure. Journal of Occupational Medicine 19:
12-39.
"In our material we noted
degenerative
changes in the lumbar spine in 95% of cases, which suggests
that fluoride accelerates these changes. In addition to
pain in the lower spine which is associated with radiological
changes, patients with negative x-ray findings
also complain of pain in the lumbar-sacral area, an indication
that symptoms precede
changes demonstrable by x-ray."
SOURCE: Czerwinski E, Lankosz W. (1977).
Fluoride-induced changes in 60 retired aluminum workers. Fluoride
10: 125-136.
"Most often the patients complained
of back pain. Pains in the shoulders, elbows, forearms and lower
legs were common. These pains differed in intensity and
occurred constantly or periodically with no clear relationship
to effort."
SOURCE: Czerwinski E, Lankosz W. (1977).
Fluoride-induced changes in 60retired aluminum workers. Fluoride
10: 125-136.
"The investigation of a high incidence of arthritis in 21
dairy herds disclosed elevated fluorine levels in bone samples...
There was a statistical correlation between
a high incidence of damage to peri-articular structures, resulting
in debility and loss of production, and elevated bone fluorine."
SOURCE: Griffith-Jones W. (1977). Fluorosis
in dairy cattle. The Veterinary Record 100: 84-89.
"In early stages, fluorosis is usually associated only with
stiffness, backache, and joint pains which
may suggest the diagnosis of rheumatism, rheumatoid
arthritis, ankylosing spondylitis
and osteomalacia. At this stage the radiological
findings of skeletal fluorosis may not be evident and therefore
most of these cases are either misdiagnosed
for other kinds of arthritis or the patients are treated symptomatically
for pains of undetermined diagnosis (PUD). The majority of our
patients had received treatment for rheumatoid
arthritis and ankylosing
spondylitis before they came under our observation."
SOURCE: Teotia SPS, et al. (1976). Symposium
on the Non-Skeletal Phase of Chronic Fluorosis: The Joints. Fluoride
9: 19-24.
"In the initial stages, the complaints of the patients are
not remarkable. At first they experience
vague rheumatic pains, then the pains become localized in the
spine, especially in the lumbosacral region. Later, a sensation
of stiffness in the lumbar and cervical spine develop. However,
we also found patients with slight
radiological changes who complained of intense pains in the
spine and in the large joints. On the other hand, some
patients whose fluorosis was radiologically distinct were almost
without complaints."
SOURCE: Franke J, et al. (1975). Industrial
fluorosis. Fluoride 8: 61-83.
"Many workers complained of pains
at night and while resting, but movement caused them to
disappear."
SOURCE: Franke J, et al. (1975). Industrial
fluorosis. Fluoride 8: 61-83.
"All the patients had typical diagnostic features: skeletal
pains, backache, stiffness, rigidity and restricted movements
of the spine and other joints."
SOURCE: Faccini JM, Teotia SPS. (1974).
Histopathological assessment of endemic skeletal fluorosis. Calcified
Tissue Research 16: 45-57.
"Schlegel presented data on 61 cases of skeletal fluorosis
among workers of a Swiss aluminum factory... Their
major symptoms were arthritic changes in the joints, especially
in the spine... In contrast to non-industrial fluorosis,
the author noted excessive involvement of the
elbow joint which is presumably due to habitual use of
the arms... The author also emphasizes the difficulty
in differentiating spontaneous arthrosis from fluorotic arthritis."
SOURCE: Schlegel HH. (1974). Industrial skeletal fluoroses: preliminary
report on 61 cases from aluminum smelter. Sozial
und Praventivmed. 19:269-74. (Abstracted
in: Fluoride
1975; 8:177)
"Arthritis of the spinal
column develops early in the disease with or without demonstrable
radiological changes."
SOURCE: Waldbott GL. (1974). The pre-skeletal phase of chronic
fluorine intoxication. Fluoride
7:118-122.
"In spite of this distinctive clinical picture of advanced
fluorosis, the earlier stages of the disease are more difficult
to recognize. The initial symptoms are quite
non-specific and not obviously linked to fluoride. The onset of
fluorosis leads to tingling sensations in the hands and feet,
pain similar to arthritic pain in the joints and the lower back,
stiffness, and motor weakness. The first reliable diagnostic
sign is increased bone density in X-ray examination, but in some
early cases early bone changes are not radiologically detectable."
SOURCE: Groth, E. (1973). Two Issues of
Science and Public Policy: Air Pollution Control in the San Francisco
Bay Area, and Fluoridation of Community Water Supplies.
Ph.D. Dissertation, Department of Biological Sciences, Stanford
University, May 1973.
"This case supports the premise that
some forms of arthritis are related to sub-clinical
fluorosis, i.e. fluorosis which is not sufficiently advanced
to show the characteristic skeletal changes radiologically."
SOURCE: Cook HA. (1972). Crippling fluorosis
related to fluoride intake (case report). Fluoride 5: 209-213.
"Possibly some cases of pain diagnosed
as rheumatism or arthritis may be due to subclinical fluorosis
which is not radiologically demonstrable."
SOURCE: Cook HA. (1971). Fluoride studies in a patient with arthritis.
The Lancet 1: 817.
"The onset of chronic fluorosis is
insidious and may be confused with chronic debilitating diseases
such as osteoarthritis,
trace-element toxicosis, and trace-element deficiencies."
SOURCE: Shupe JL. (1970). Fluorine toxicosis
and industry. American Industrial Hygiene Association Journal
31: 240-247.
"Whereas dental fluorosis is easily recognized, the skeletal
involvement is not clinically obvious until the advanced stage
of crippling fluorosis... Such early cases are usually in young
adults whose only complaints are vague pains
noted most frequently in the small joints of the hands and feet,
in the knee joints and in the joints of the spine. These cases
are frequent in the endemic area and may be misdiagnosed as rheumatoid
or osteo arthritis."
SOURCE: Singh A, Jolly SS. (1970). Chronic
toxic effects on the skeletal system. In: Fluorides
and Human Health. World Health Organization. pp. 238-249.
"Most authors agree that chronic fluorosis
can cause musculoskeletal discomfort and pain, despite
the fact that well documented cases of fluorosis in patients without
any clinical symptoms have been published...
All but one of the 17 patients complained of vague pains and stiffness
in the lower and upper extremities, shoulders, neck and lower
back. In none of the cases could another disease of the
bone or of the joints be found, except arthrotic lesions... If
signs of fluorosis are present, they may lead to symptoms of the
osteoarticular system."
SOURCE: Vischer TL, et al. (1970). Industrial
fluorosis. In: TL Vischer, ed. (1970). Fluoride
in Medicine. Hans Huber, Bern. pp. 96-105.
"Joint changes or fluoric arthrosis
may be very severe especially in the hip, knee and elbow joints."
SOURCE: Soriano, M. (1968). Periostitis
deformans due to wine fluorosis. Fluoride 1: 56-64.
"Fluoric Arthropathies: Around joints,
thick marginal osteophytes develop. In some instances,
they grow to such an extent as to block joint movement ('blocking
arthrosis'). The joint block can also be induced by calcification
of the periarticular ligament. The most
common sites of articular involvement are the hips, the sacroiliac,
elbow and knee joints. In older persons, the vetebral column is
commonly affected. Advanced stages of the disease show atrophy
and ulceration of joint cartilage."
SOURCE: Soriano, M. (1968). Periostitis
deformans due to wine fluorosis. Fluoride 1: 56-64.
"Another frequent finding was the calcification of ligaments
and muscle attachments ...Approximately
three quarters of those later found to have radiological evidence
of skeletal involvement did complain of pains mainly in the back,
chest, and legs."
SOURCE: Latham MC, Grech P. (1967). The
effects of excessive fluoride intake. American Journal of Public
Health 57: 651-660.
"In general, the metabolic patterns of osteoblasts, ameloblasts,
odontoblasts, and chrondoblasts are sufficiently similar so that
disturbances of cartilage might be expected...
To date, any osteoarthritis
observed in fluoride-treated cattle has been regarded as an unrelated
process. However, excessive remodeling of the subchondral plate
and cancellous end of the bone, such as occurs in osteofluorosis,
will eventually lead to remodeling of the articular cartilage.
Excessive cartilage remodeling leads to osteoarthritis
of normal joints. Therefore, both the mechanical effects of fluoride
induced remodeling and the direct action of fluoride on cartilage
cells might alter cartilage. The fluoride levels and remodeling
circumstances necessary to produce cartilage alteration in cattle
- if it occurs - remain to be established."
SOURCE: Johnson LC. (1965). Histogenesis
and mechanisms in the development of osteofluorosis. In: H.C.Hodge
and F.A.Smith, eds : Fluorine chemistry, Vol. 4. New York, N.Y.,
Academic press (1965) 424-441.
"The ligamentous calcification [of
skeletal fluorosis] is often periarticular and shows as osteoarthritis
of the spine and hip joints as well as of the sacro-iliac joints."
SOURCE: Kumar SP, Harper RA. (1963). Fluorosis
in Aden. British Journal of Radiology 36: 497-502.
In the early stages of skeletal fluorosis, the "only complaints
are vague pains noted most frequently in
the small joints of hands and feet, the knee joints and those
of the spine. Such cases are frequent in the endemic area and
may be misdiagnosed as rheumatoid
or osteoarthritis. Such
symptoms may be present prior to the development of definite radiological
signs. A study of the incidence of rheumatic
disorders in areas where fluoridation has been in progress for
a number of years would be of interest."
SOURCE: Singh A, et al. (1963). Endemic
fluorosis. Epidemiological, clinical and biochemical study of
chronic fluoride intoxication in Punjab. Medicine 42: 229-246.
"The onset was insidious, and stiffness
of the back and legs was a universal complaint. Almost
all the patients complained of vague fleeting
pains all over the body, particularly in the spine and in the
knee-joints."
SOURCE: Singh A, et al. (1961). Skeletal
fluorosis and its neurological complications. Lancet 1:
197-200.
"It is quite possible that endemic
centres [of skeletal fluorosis] exist but that the cause of the
disabling spondylitis or
other joint affections has not been determined, and a diagnosis
of chronic arthritis has resulted. Few cases in Canada or the
United States will be found to be as dramatic as that recorded
here from Southwest China, but by calling attention to the advanced
stage of this condition help may be afforded to the diagnosis
of early cases."
SOURCE: Kilborn LG, et al. (1950). Fluorosis
with report of an advanced case. Canadian Medical Association
Journal 62: 135-141.