Summation - Skeletal Fluorosis in the U.S.

1) Skeletal fluorosis is an arthritic bone disease caused by excessive, exposure to fluoride. It is a difficult disease to diagnose, and can be readily confused with various forms of arthritis.

2) While there have been several isolated case reports of skeletal fluorosis published in the U.S., there has never been a systematic study in the U.S. of skeletal fluorosis among susceptible subsets of the population (e.g. heavy tea drinkers & people with kidney disease).

3) It is all but certain that some individuals with skeletal fluorosis in the U.S. have been incorrectly diagnosed as suffering from another form of arthritis or bone disease.

4) In the 1960s & 1970s, the use of fluoridated water (1 ppm) in dialysis systems caused an increase in the rate and severity of osteomalacia (a painful bone-softening disease and a common radiological finding in skeletal fluorosis).

Probability for Misdiagnosis - Skeletal Fluorosis in the U.S.:

"Our case report illustrates dramatically that fluorosis can lead to severe disability while closely mimicking a wide variety of other disorders... We believe increased awareness of this unusual disease is needed to enable physicians to make the proper diagnosis."
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 [as arthritis]... 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.

"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.

"It is quite possible that many cases of (skeletal fluorosis) have gone misdiagnosed and unreported over the years... The state of knowledge among practicing physicians, even those in non-fluoride areas, concerning the diagnosis of skeletal fluorosis seems to be deficient and should be more carefully assessed."
SOURCE: Prival MJ. (1972). Fluorides and human health. Center for Science in the Public Interest, Washington D.C.

"Symptoms of fluoride poisoning are actually common in this country. The question is not at all whether they occur, but when and how often they are produced by fluoride... It is true that reports (of skeletal fluorosis in the U.S.) are few. This is both the cause and the effect of the fact that physicians, by and large, are unaware that such a thing exists. It is hardly mentioned in the textbooks or in the medical literature. "
SOURCE: Exner FB. (1957). Fallacies of the fluoridation thesis. In: J Rorty, ed. (1957). The American Fluoridation Experiment. Delvin-Adair Co, New York. pp. 29-153.

Case Reports - Skeletal Fluorosis in the U.S.:

"Tea drinking remains popular in the United States and increasingly is suggested to promote health. We caution that skeletal fluorosis can result from consumption of excessive amounts of instant tea because of substantial fluoride levels in some commercial preparations. A 52-year-old white woman consulted in 1998 for dense lumbar vertebras discovered after twisting her back. Spinal discomfort and stiffness for 5 years reflected “disc disease.”... Skeletal discomfort intensified during the subsequent year, and included new neck and scapular pain and elbow and knee arthralgias. Bone and joint pains, acquired axial osteosclerosis, well water, soap manufacturing, and periodontal disease suggested skeletal fluorosis... Our encounter with this patient calls for better understanding of the amounts and systemic effects of fluoride in various teas."
SOURCE: Whyte MP, et al. (2005). Skeletal fluorosis and instant tea. American Journal of Medicine 118:78-82.

"the fluoride concentration of water from private wells is not routinely measured. In some areas of Arizona, Colorado, Illinois, Iowa, New Mexico, Ohio, Oklahoma, and Texas, high fluoride concentration of the groundwater occurs naturally. Thus, in these areas, as exemplified by the aforementioned patient, it is possible that fluorosis may develop in individuals who obtain their drinking water from private wells."
SOURCE: Felsenfeld AJ, Roberts MA. (1991). A report of fluorosis in the United States secondary to drinking well water. Journal of the American Medical Association 265:486-8.

"The cases presented demonstrate several typical features of skeletal fluorosis. By recognizing this entity early, extensive and costly studies may be avoided and the fluoride source eliminated to prevent further progression and sequelae."
SOURCE: Bruns BR, Tytle T. (1988). Skeletal fluorosis: a report of two cases. Orthopedics 11: 1083-1087.

"A woman with chronic pyelonephritis developed progressive muscular weakness and bone pain. For twenty years she had habitually ingested fluoride-rich soil. Osteosclerosis was found on x-ray examination, and fluorosis was confirmed by bone biopsy. Renal failure augmented skeletal retention of excessive fluoride intake which, in turn, appears to have intensified symptomatic renal osteodystrophy."
SOURCE: Fisher JR, et al. (1981). Skeletal fluorosis from eating soil. Arizona Medicine 38: 833-5.

"The finding of adverse effects (skeletal fluorosis) in (kidney) patients drinking water with 2 ppm of fluoride suggests that a few similar cases may be found in patients imbibing 1 ppm, especially if large volumes are consumed, or in heavy tea drinkers and if fluoride is indeed the cause."
SOURCE: Johnson W, et al. (1979). Fluoridation and bone disease in renal patients. pp. 275-293. In: E Johansen, DR Taves, TO Olsen, Eds. Continuing Evaluation of the Use of Fluorides. AAAS Selected Symposium. Westview Press, Boulder, Colorado.

""It is generally agreed that water fluoridation (1ppm) is safe for persons with normal kidneys. Systemic fluorosis in patients with diminished renal function, however, seems a reasonable possibility... We describe herein two patients in whom evidence of systemic fluorosis was related to three factors: (1) diminished renal function, (2) increased quantities of fluoride in drinking and cooking water (1.7-2.6 ppm), and (3) polydipsia secondary to polyuria."
SOURCE: Juncos LI, Donadio JV Jr. (1972). Renal failure and fluorosis. Journal of the American Medical Association 222:783-5.

"The findings of a Papago Indian with the second reported case of fluorotic radiculomyopathy in the United States are presented. Neurological deficits occurring in this entity as a manifestation of spinal cord and nerve root bony compression are decribed. This radiculomypathy is rare but it is of regional importance since fluorosis is endemic in Arizona. The lack of any potential skeletal or neurological hazards from water fluoridation programs for dental caries prevention is stressed."
SOURCE: Goldman SM, et al. (1971). Radiculomyelopathy in a southwestern indian due to skeletal fluorosis. Arizona Medicine 28: 675-677.

"The development of advanced fluorosis in this patient exposed to drinking water with less than 4 ppm of fluoride was unusual and was probably a consequence of his excessive water intake."
SOURCE: Sauerbrunn BJ, et al. (1965). Chronic fluoride intoxication with fluorotic radiculomyelopathy. Annals of Internal Medicine 63: 1074-1078.

"The diagnosis of fluoride osteosclerosis was proved by the history of a long residence in areas of endemic fluorosis (water F = 1.2 - 5.7 ppm) and by fluorine analysis of the patient's bones and teeth... Areas in the United States in which dental fluorosis exists and where the fluorine content of the drinking water is over 3 parts per million should be systematically studied by the public health authorities to determine how widespread the condition of osteosclerosis is. All patients with dental fluorosis and anemia and/or signs of renal impairment should have radiographic examinations of the skeletal systems to rule out the existence of fluoride osteosclerosis."
SOURCE: Linsman JF, McMurray CA. (1943). Fluoride osteosclerosis from drinking water. Radiology 40: 474-484.

No Systematic Studies of Patients with Kidney Disease - Skeletal Fluorosis in U.S. (back to top)

"a fairly substantial body of research indicates that people with kidney dysfunction are at increased risk of developing some degree of skeletal fluorosis... However, there has been no systematic survey of people with impaired kidney function to determine how many actually suffer a degree of skeletal fluorosis that is clearly detrimental to their health."
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.

"In the United States, there have been no reported cases of skeletal fluorosis in persons who drink water containing only one part per million (ppm) of fluoride. However, since no systematic studies have been carried out in patients with renal insufficiency, this possibility cannot be excluded with certainty."
SOURCE: Johnson W, et al. (1979). Fluoridation and bone disease in renal patients. In: E Johansen, DR Taves, TO Olsen, Eds. Continuing Evaluation of the Use of Fluorides. AAAS Selected Symposium. Westview Press, Boulder, Colorado. pp. 275-293.

"It seems probable that some people with severe or long-term renal disease, which might not be advanced enough to require hemodialysis, can still experience reduced fluoride excretion to an extent that can lead to fluorosis, or aggravate skeletal complications associated with kidney disease... It has been estimated that one in every 25 Americans may have some form of kidney disease; it would seem imperative that the magnitude of risk to such a large sub-segment of the population be determined through extensive and careful study. To date, however, no studies of this sort have been carried out, and none is planned."
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.