Fluoride Action Network


When safe and adequate exposure of an essential trace element is exceeded it becomes potentially toxic. Fluoride is one classic example of such a double edged sword which both plays a fundamental role in the normal growth and development of the body for example the consumption of levels between 0.5–1.0 ppm via drinking water is beneficial for prevention of dental caries but its excessive consumption leads to development of fluorosis.

Purpose of Review

The abundance of fluorine in the environment as well as in drinking water sources are the major contributors to fluorosis. It is a serious public health concern as it is a noteworthy medical problem in 24 nations including India yet the threat of fluorosis has not been rooted out. The review focuses on recent findings related to skeletal fluorosis and role of oxidative stress in its development. The fluoride mitigation strategies adopted in recent years are also discussed.

Recent Findings Based on Case Studies

Recent findings revealed that consumption of fluoride at concentrations of 1.5 ppm is majorly responsible for skeletal fluorosis. The sampling from rural areas showed that 80% villages are having fluoride concentrations more than the WHO permissible limits and people residing in such areas are affected by the skeletal fluorosis and also in the regions of Africa and Asia endemic fluorosis have been accounted in the majority of the region affecting approximately 100 million people. Various mitigation programmes and strategies have been conducted all over the world using defluoridation.


Fluorosis is a slow and progressive malady affecting our body and a serious concern to be taken into consideration and to be dealt with effectively. The fluoride toxicity although reversible, is a slow process and the side effects lack treatment options. The treatment options available are either not approachable or affordable in the rural areas commonly suffering from the fluoride toxicity. No specific treatments are available to date to treat skeletal fluorosis affectively; therefore, prevention is one of most safest and best approach to fight fluorosis. The current review lays emphasis on the skeletal fluorosis and its prevalence in recent years. It also includes the recent findings as well as the current strategies related to combat skeletal fluorosis and provides findings that might be helpful to promote the research in the field of effective treatment for fluorosis as well as development of easy and affordable methods of fluoride removal from water.


1.Swapnila C, Flora SJ. Arsenic and fluoride: two major ground water pollutants. Indian J Exp Biol. 2010;48:666–78.

2. Pranesh MB, Arjundas G, Kalyanaraman S, Bharati RS. Autopsy study of a case of skeletal fluorosis. Neurology India. 2019 May 1. 1977;67(3):643. The paper presents a detailed autopsy report of a patient with crippling skeletal and neurological fluorosis.

3. Mohammadi AA, Yousefi M, Yaseri M, Jalilzadeh M, Mahvi AH. Skeletal fluorosis in relation to drinking water in rural areas of West Azerbaijan, Iran. Scientific reports. 2017;7(1):17300. The study demonstrates a significant relationship between the fluoride concentrations in the water and the prevalence of skeletal fluorosis in an endemic fluorosis area.

4. Kurdi MS. Chronic fluorosis: the disease and its anaesthetic implications. Indian journal of anaesthesia. 2016;60(3):157–62.

5. Joshi S, Hlaing T, Whitford GM, Compston JE. Skeletal fluorosis due to excessive tea and toothpaste consumption. Osteoporos Int. 2011;22(9):2557–60. Article

6. Misra UK. Endemic skeletal fluorosis. Neurol India. 2010;58(2):338.

7. Krishnamachari KA. Skeletal fluorosis in humans: a review of recent progress in the understanding of the disease. Prog Food Nutr Sci. 1986;10(3–4):279–314. PubMed

8. Kleerekoper M. Fluoride and the skeleton. Crit Rev Clin Lab Sci. 1996;33(2):139–61. Article

9. Cohn PD. A brief report on the association of drinking water fluoridation and the incidence of osteosarcoma among young males. New Jersey Department of Health.Environ. Health Service. 1992;8:1–17.

10. Richards A, Moskilder L, Sogaard CH. Normal age-related changes in fluoride content of vertebral trabecular bone-relation to bone quality. Bone. 1994;15(1):21–6. Article

11. Barbier O, Arreola-Mendoza L, Del Razo LM. Molecular mechanisms of fluoride toxicity. ChemBiol Interact. 2010;188(2):319–33. Article

12. Flora SJ, Pachauri V, Mittal M, Kumar D. Interactive effect of arsenic and fluoride on cardio-respiratory disorders in male rats: possible role of reactive oxygen species. Biometals. 2011;24(4):615–28. Article

13. Chouhan S, Lomash V, Flora SJ. Fluoride-induced changes in haem biosynthesis pathway, neurological variables and tissue histopathology of rats. J Appl Toxicol. 2010;30(1):63–73. Article

14. Reddy GB, Khandare AL, Reddy PY, Rao GS, Balakrishna N, Srivalli I. Antioxidant defense system and lipid peroxidation in patients with skeletal fluorosis and in fluoride-intoxicated rabbits. Toxicol Sci. 2003;72(2):363–8. Article

15. Shivarajashankara YM, Shivashankara AR, Rao SH, Bhat PG. Oxidative stress in children with endemic skeletal fluorosis. Fluoride. 2001;34(2):103–7.

16. Chouhan S, Tuteja U, Flora SJ. Isolation, identification and characterization of fluoride resistant bacteria: possible role in bioremediation. Appl Biochem Microbiol. 2012;48(1):43–50. Article

17. WHO. Guidelines for Drinking-water Quality. Health criteria and other supporting information, vol. 2. 2nd ed. Geneva: World Health Organization; 1996. p. 796–803.

18. Meena KS, Meena K, Gunsaria RK. Skeletal fluorosis in populace of Deoli Tehsil (Tonk District), Rajasthan, India. Journal of Water Pollution & Purification Research. 2018;4(3):24–8.

19. Haritash AK, Aggarwal A, Soni J, Sharma K, Sapra M, Singh B. Assessment of fluoride in groundwater and urine, and prevalence of fluorosis among school children in Haryana, India. Applied water science. 2018;8(2):52. The study suggests a correlation between the concentration of fluoride in groundwater, and urine of school children.

20. Khairnar MR, Dodamani AS, Jadhav HC, Naik RG, Deshmukh MA. Mitigation of fluorosis-a review. J Clin Diagn Res. 2015;9(6):ZE05–9. This review provides information about the available treatment/ modalities for fluorosis, available technologies for fluoride removal from water and the recent development for fluorosis mitigation program.

21. Dahi, E., Mtalo, F., Njau, B. and Bregnhj, H., 1996. Defluoridation using the Nalgonda technique in Tanzania.

22. NEERI. Defluoridation. Technology mission on drinking water in villages and related water management. Nagpur: National Environment Engineering Research Institute; 1987.

23. Lathaa SS, Ambika SR, Prasad SJ. Fluoride contamination status of groundwater in Karnataka. Curr Sci. 1999;76(6):730–4.

24. Rawlani S, Rawlani S, Rawlani S. Assessment of skeletal and non-skeletal fluorosis in endemic fluoridated areas of Vidharbha region, India: a survey. Indian journal of community medicine: official publication of Indian Association of Preventive & Social Medicine. 2010;35(2):298. Article

25. Flourides H.F. Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine. Atlanta, GA: U.S.Department of Health and Human Services, Public Health Service. 2003.

26. Kohn W.G, Maas WR, Malvitz DM, Presson S.M, Shaddix K.K. Recommendations for Using fluoride to prevent and control dental caries in the United States. 2001 ;50.