Skeletal fluorosis

Symptoms are mainly promoted in the bone structure. Due to a high fluoride concentration in the body, the bone is hardened and thus less elastic, resulting in an increased frequency of fractures. Other symptoms include thickening of the bone structure and accumulation of bone tissue, which both contribute to impaired joint mobility. Ligaments and cartilage can become ossified.[1] Most patients suffering from skeletal fluorosis show side effects from the high fluoride dose such as ruptures of the stomach lining and nausea.[2] Fluoride can also damage the parathyroid glands, leading to hyperparathyroidism, the uncontrolled secretion of parathyroid hormones. These hormones regulate calcium concentration in the body. An elevated parathyroid hormone concentration results in a depletion of calcium in bone structures and thus a higher calcium concentration in the blood. As a result, bone flexibility decreases making the bone more susceptible to fractures.[3]

Common causes of fluorosis include inhalation of fluoride dusts/fumes by workers in industry, consumption of fluoride from drinking water (levels of fluoride in excess of levels that are considered safe[4]), and consumption of fluoride from drinking tea,[5] particularly brick tea. Skeletal fluorosis can be caused by cryolite (Na₃AlF₆, sodium hexafluoroaluminate), and the disease was first recognized among workers processing cryolite.[6]

In India, most in Nalgonda (Telangana), the most common cause of fluorosis is fluoride-laden drinking water which is sourced as groundwater from deep-bore wells. Over half of groundwater sources in India have fluoride above recommended levels.[7]

Fluorosis can also occur as a result of volcanic activity.[8] The 1783 eruption of the Laki volcano in Iceland is estimated to have killed about 22% of the Icelandic population, and 60% of livestock, as a result of fluorosis and sulfur dioxide gases.[9] The 1693 eruption of Hekla also led to fatalities of livestock under similar conditions.[10]

The best way to view the mechanism of action by which fluorine breaks down bones and causes skeletal fluorosis is in a stepwise fashion.

1. Fluoride enters the body by two paths: Ingestion or respiration. Both paths lead to corrosion of exposed tissue in high concentrations. Since the most likely form of fluoride to enter the body is hydrogen fluoride (HF) gas, this is what starts the process. Exposed tissues will be utilized by HF in neutralization reactions.[11]
2. This will leave F⁻
   free to pass further into the body.
3. It reacts with the concentrated HCl in the stomach to form the weak acid, HF.
4. This compound is then absorbed by the gastro-intestinal tract and passes into the liver via the portal vein.
5. The HF is now free to pass into the blood stream and be distributed to all tissues including bones.
6. Bones are largely composed of Ca compounds, particularly carbonated hydroxyapatite (Ca
   ₅(PO
   ₄)
   ₃(OH)); the reaction of Ca²⁺ ions and HF forms an insoluble salt, CaF
   ₂.
7. This salt must be cleared by the body, which concomitantly leaches out some of the calcium that would be part of the bone matrix.
8. This process results in increased density, but decreased strength in bones.[12]

As of now, there are no established treatments for skeletal fluorosis patients.[13] However, it is reversible in some cases, depending on the progression of the disease. If fluorine intake is stopped, the amount in bone will decrease and be excreted via urine. However, it is a very slow process to eliminate the fluorine from the body completely. Minimal results are seen in patients. Treatment of side effects is also very difficult. For example, a patient with a bone fracture cannot be treated according to standard procedures, because the bone is very brittle. In this case, recovery will take a very long time and a pristine healing cannot be guaranteed.[14] However, further fluorosis can be prevented by drinking defluoridated water. It is recently suggested that drinking of defluoridated water from the ″calcium amended-hydroxyapatite″ defluoridation method may help in the fluorosis reversal.[15] Defluoridated water from this suggested method provides calcium-enriched alkaline drinking water as generally fluoride contaminated water has a low amount of calcium mineral and drinking alkaline water helps in eliminating the toxic fluoride from the body.[15]

In some areas, skeletal fluorosis is endemic. While fluorosis is most severe and widespread in the two largest countries – India and China – UNICEF estimates that "fluorosis is endemic in at least 25 countries across the globe. The total number of people affected is not known, but a conservative estimate would number in the tens of millions."[16]

In India, 20 states have been identified as endemic areas, with an estimated 60 million people at risk and 6 million people disabled; about 600,000 might develop a neurological disorder as a consequence.[7]

Moroccan cow with fluorosis

The histological changes which are induced through fluorine on rats resemble those of humans.[17]

• Dental fluorosis
• Fluoride poisoning
• Kaj Roholm