"The
radiological severity of knee
osteoarthritis was greater
in the endemic fluorosis group than in controls...
[S]ome radiological findings such as osteosclerosis,
interosseous membrane calcification, or ligament calcification,
which are accepted as hallmarks of skeletal fluorosis were not
found as frequently as in the literature." (NOTE from FAN:
In this group of fluorosis patients, only 3.6% had radiological
evidence of osteosclerosis in the spine, and only 9% had evidence
of calcification in the interosseous membrane of the forearm.
Hence, the exacerbation of osteoarthritis
occurred in most patients before the fluorosis was detectable
on x-ray.)
SOURCE: Savas S, et al. (2001). Endemic fluorosis in Turkish patients:
relationship with knee osteoarthritis. Rheumatology International
21: 30-5.
"Radiographs of the skeleton and bone scintigraphy showed
degenerative osteoarthritis...
Interestingly, laboratory findings, skeletal
radiographs and bone densitometry, gave no indication for abnormalities
of bone metabolism or mineralization. Without bone biopsy we would
have failed the correct diagnosis (of skeletal fluorosis)."
SOURCE: Roschger P, et al. (1995). Bone mineral structure after
six years fluoride treatment investigated by backscattered electron
imaging (BSEI) and small angle x-ray scattering (SAXS): a case
report. Bone 16:407.
"Assessment of the fluoride-induced
changes from x-ray results is often difficult, especially in the
initial stages commonly encountered."
SOURCE: Czerwinski E, et al. (1988). Bone and joint pathology
in fluoride-exposed workers. Archives of Environmental Health
43: 340-343.
"Ironically, two crucial criteria
of fluorosis, i.e., osteosclerosis and bone pattern alteration,
are the most questionable in the (x-ray) assessment. Perhaps
this is one reason why such great discrepancies in the frequency
of fluorosis are found among various authors."
SOURCE: Czerwinski E, et al. (1988). Bone and joint pathology
in fluoride-exposed workers. Archives of Environmental Health
43: 340-343.
"A wide variety of vague, subtle
symptoms 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.
"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.
"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. Since more stringent regulations in many
countries have resulted in reduced exposure to fluorides, it
is reasonable to examine workers and watch for these findings
instead of waiting for dense bone to appear which is related
to massive exposure to fluoride."
SOURCE: Carnow BW, Conibear SA. (1981). Industrial fluorosis.
Fluoride 14: 172-181.
"Similar findings of musculoskeletal
changes without classical x-ray signs of fluorosis in
workers exposed to high levels of fluorides have appeared in
a number of other studies. Of special importance is the large
prospective study by Zislin and Girskaya (1974). They followed
2738 workers from the time they first came to work in an aluminum
smelter and compared them with 1700 others employed in a nonfluoride
producing industry. They found that nonspecific
bone changes, musculoskeletal symptoms and other findings antedate
the classic x-ray changes of fluorosis
in the bones by five to seven years and concluded that the changes
of fluorosis described by Roholm represent the late stage of
the disease."
SOURCE: Carnow BW, Conibear SA. (1981). Industrial fluorosis.
Fluoride 14: 172-181.
"In our opinion it is often difficult
to appreciate the bone density because too many variables are
involved such as radiograph penetration, influence of overlying
soft tissues, etc."
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.
Among the elderly, arthritis of the spine is an especially common
ailment that is customarily attributed to 'aging.' Since fluoride
retention in bones increases as a person grows older, how can
we disregard the possibility that this 'old age' disease might
be linked with fluoride intake? 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.
"to our knowledge, [skeletal fluorosis]
has not been described in the literature prior to the onset
of the typical bone changes. This is not surprising since the
intital stage, like that of many other kinds of chronic poisoning,
develops slowly and insidiously with ill-defined complaints
that are difficult to attribute to their cause.
For instance, in lead poisoning the characteristic
hallmarks are 'lead line' of gums and radial nerver paralysis;
in chronic cadmium poisoning, one sees softening of bones. However,
they are always precded or accompanied by a variety of subtle,
inconspicuous symptoms of the kind encountered in incipient,
chronic fluoride poisoning. Actually, subclinical poisoning
can harm vast numbers of people before obvious clinical symptoms
appear. These mulitple, hidden effects of slow poisoning pose
a strong challenge to our current concepts of 'safe limits'
of toxic substances in our environment."
SOURCE: Waldbott GL, Lee JR. (1978). Toxicity from repeated
low-grade exposure to hydrogen fluoride - Case report. Clinical
Toxicology 13: 391-402.
"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.
"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(1):
19-24.
"we also found patients with slight
radiological changes (subtle signs or O-I) 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.
"In several patients we failed to
notice evidence of typical sclerosis in the radiogram.
Instead, the picture of so-called 'hypertrophic atrophy' was
found... It is likely that a previously existing osteoporosis
is superimposed upon fluorosis or the predominance of the fluoride-induced
bone resorption in conjunction with thickening of the statically
loaded bone structure may be responsible."
SOURCE: Franke J, et al. (1975). Industrial fluorosis. Fluoride
8: 61-83.
"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 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...
The lack of a clear clinical picture of the early stages of
fluorosis makes this disease easy to overlook or to misdiagnose,
even in its relatively advanced stages."
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.
"It should also be noted that chronic fluorosis is not
easily diagnosed, and that few physicians
have ever seen a case. Three of the cases reported in the U.S.
literature were not diagnosed until post-mortem examination
revealed excessive fluoride content in the bone. It is possible
that the disease may be occurring to some extent without having
been recognized."
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.
"There has been very little (research)
done, especially in the realm of 'borderline' or subclinical
toxicity. And yet, it is precisely in this area that knowledge
of most importance to man could be brought to light.
To this day, many investigators still think of fluorosis
exclusively in terms of osteosclerosis, whether crippling or
non-crippling. This attitude is no longer valid, because osteosclerosis
is only one of many skeletal abnormalities that can be induced
by fluoride."
SOURCE: Marier JR, Rose D. (1971). Environmental fluoride. National
Research Council of Canada, Publication No. 12,226, Ottawa.
"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). Fluorides and Human Health.
World Health Organization. pp 239-240.
"The frequent lack of increased density
or derangement of trabecular structure of bone in our cases
and the nonspecificity of the alterations of thie spine make
both of these changes bad criteria for the diagnosis of fluorosis.
The more peripheral findings of exostosis, apposition
of new bone, ossification of ligaments and tendon insertions
and metastatic, aberrant growth of new bone seem much more specific
and constant."
SOURCE: Vischer TL, et al. (1970). Industrial fluorosis. In:
TL Vischer, ed. (1970). Fluoride in Medicine. Hans Huber, Bern.
pp. 96-105.
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.
"It is apparent that
small grossly recognizable deposits, areas of hyperplasia and
perhaps beginning exostoses can be produced in the bones of
small animals without their being detected by roentgenographic
methods. That this may be equally
true in the case of human beings cannot be claimed, but the
point seems worthy of mention because in some instances
X-ray photography is the only means used to detect evidence
of industrial exposure to fluorides on the part of workmen.
It seems probable that changes comparable to those seen in the
animals may have escaped detection. It
remains to be determined whether disability or limitation of
movement in certain parts of the body may also occur before
bone changes are demonstrable on the X-ray plate."
SOURCE: Largent EJ, Machle W, Ferneau IF. (1943). Fluoride ingestion
and bone changes in experimental animals. Journal
of Industrial Hygiene and Toxicology 25: 396-408.
"incipient changes (1st phase) may
be difficult to distinguish (via x-ray) from physiological variations."
SOURCE: Roholm K. (1937). Fluoride intoxication: a clinical-hygienic
study with a review of the literature and some experimental
investigations. London: H.K. Lewis Ltd.
Skeletal fluorosis may produce adverse symptoms (e.g.