Skeletal Fluorosis |
Is it true that in India fluoride in water causes severe skeletal deformity due to skeletal fluorosis?
BFS suggested answer
The situation in the UK is completely different from that in remote villages in India. Low levels of fluoride in drinking water in Birmingham and Newcastle have brought huge health benefits in terms of a massive reduction in tooth decay for millions of children for over 30 years.
The safety of low levels of fluoride in drinking water is endorsed by the World Health Organization, the British Medical Association, the British Dental Association and the Royal College of Physicians.
A Guardian article published in July 1995 describes severe skeletal deformity of the limbs of children living in a village in Central India.
Drinking water for the village was heavily contaminated with unsafe levels of natural chemicals including fluoride, arsenic, iron and salts.
The article also claimed that 17% of the population of another village near Delhi, where the drinking water contained between 0.7 and 1.6 ppm, suffered from skeletal fluorosis.
Skeletal fluorosis is undoubtedly a serious problem in parts of India and Pakistan. However, in temperate climates, such as the UK, USA and Canada, there is no evidence that skeletal fluorosis occurs – even in populations where the level of fluoride in drinking water is far in excess of those seen in the UK.
BFS suggested answer refuted
When medical practitioners everywhere also recognize the severity of the problems of chronic fluoride toxicosis, and laws mandating truly safe drinking water are sincerely enforced, the health of millions will dramatically improve.
Dr George L. Waldbott
Get rid of fluoride
In the 1970s and 1980s UN organisations tried very hard to promote water fluoridation in India despite the fact that it was already well known that there were prevailing health problems due to an excess of fluoride. Millions of people in sixteen Indian states are afflicted with skeletal fluorosis, leading to severe conditions such as malformed spine, neck and pelvis, weakened tooth structure and mottled or discoloured teeth. As a consequence, scientific studies of fluoridated water have been performed much more thoroughly in India than in the West. Dr A.K. Susheela of the India Institute of Medical Sciences in New Delhi found that, contrary to what the BFS would have us believe, fluoride severely disrupts the formation of the bone matrix, thereby inhibiting the proper hardening of bones.
According to Susheela, there are twenty nations in the world with serious health problems due to excess fluoride ingestion. They include India, China, and parts of Thailand and Africa; Japan, New Zealand, Australia, Israel, Pakistan, Syria and Turkey are also severely affected; and the problem also exists in Britain, the USA and Canada to a lesser extent. In the Western countries, better nutrition, with more calcium and Vitamin C in the diet, tends to nullify the toxic manifestations to some extent.1
India was the first country in the world to develop protocols for diagnosing fluorosis at an early stage so that prevention of the disease was possible. Radiographs revealing skeletal fluorosis are of no use, because by the time skeletal fluorosis becomes apparent, it is too late to reverse the changes. Fluorosis has no treatment or cure. Prevention is the only solution, and for this, early diagnosis is essential.
For early detection, the two Indian protocols are (1) investigation of all gastrointestinal disturbances and (2) a sensitive blood test. At the same time, Indians are educated through radio, TV and the newspapers about the dangers of fluoride and how to avoid it.
The major problem is that, very often, skeletal fluorosis and non-skeletal fluorosis are misdiagnosed and treated wrongly, as clinicians do not fully understand the manifestations of fluoride poisoning. These are not described adequately in medical and dental textbooks.
Dental fluorosis is quite evident from the discoloration of the teeth. But Professor Susheela is convinced that dentists do not fully understand fluoride action on teeth, because they still promote fluoride among patients who already have dental fluorosis, despite the evidence of what is happening in India. She says: ‘This truly reveals that no organisation or association can be taken for granted. Their intentions while promoting fluoride need to be questioned.’
India’s ethical, up-to-date scientific research on fluoride toxicity contrasts strongly with the West’s authoritarian fluoridation policy, based on low scientific standards and high political opinion.
The British situation
In its suggested answer to this question, the BFS states that the situation in Britain is quite different from that in India. In part, they are right. However, by saying that the Indian drinking water was different in that it ‘was heavily contaminated with unsafe levels of natural chemicals including fluoride, arsenic, iron and salts’, they are quite wrong. British (and Irish) drinking water in fluoridated areas is also contaminated with fluoride, arsenic, iron and salts.
As you can see from Figure 1, levels of fluoride in the drinking water in most of the areas that suffer endemic fluorosis in India – those marked with a square or a triangle – are lower than 3 ppm – a level the UK government tells us is safe.
The BFS is quite wrong in insisting that conditions such as skeletal fluorosis do not occur elsewhere in the fluoridated world. In Britain and Ireland, the number of cases of osteoporosis has been growing steadily over the past half-century. Osteoporosis now affects almost one in two postmenopausal women, and one in five of them will die as a direct result. It is also increasingly affecting men. One in six orthopaedic hospital beds were occupied by people with broken hips, at a cost to the NHS of £160 million per year by the mid-1980s.2 Osteoporosis is caused by several factors. Many are related to advice given to the population by government: bran (cereal fibre) inhibits the absorption of calcium from diet,3 low-fat diets also reduce calcium intake,4 and fluoride displaces calcium and makes bones more brittle. Osteoporosis is regarded as merely ‘a loss of calcium’, without these other factors being taken into consideration; thus, the true extent of the role they play is obscured. In this way the BFS would have us believe that ‘there is no evidence that skeletal fluorosis occurs’.
Figure 1. Fluoride content of well water in endemic areas in India
Source: WHO Fluorides and human health, Geneva: World Health Organisation, 1970
– More than 3 ppm; 
– Between 1 and 3 ppm; 
– Less than 1ppm. Numerals indicate the number of specimens tested.
Skeletal fluorosis
You would have to be naive in the extreme to believe that fluoride entering the body goes merely to the teeth. Fluorine has a particular affinity for calcium, wherever it is in the body. As calcium is most abundant in bones, fluorine moves rapidly to bones and other hard tissues, where most of it is retained while a fraction is excreted. But not all people are the same, and individual retention and excretion rates vary depending on three factors:
•Total fluoride intake
•Duration of exposure to fluoride
•Normal kidney function (adult males excrete more fluoride than females)
Fluoride’s effects are cumulative: the mineral builds up over time. For this reason, any skeletal changes it causes progress through a number of stages, with the less serious changes occurring early in the natural course of the disease. Whatever may be the type of fluoride exposure, the clinical picture shows that chronic poisoning occurs in the following phased manner:5
1.Preclinical phase: Asymptomatic; slight radio-graphically detectable increases in bone mass
2.Phase I (Musculoskeletal): Sporadic pain; stiffness of joints; osteosclerosis of pelvis and spine
3.Phase II (Degenerative and destructive): Chronic joint pain; arthritic symptoms; slight calcification of ligaments; increased osteosclerosis/cancellous bones; with or without osteoporosis of long bones
4.Phase III (Crippling fluorosis): Limitation of joint movement; calcification of ligaments/neck, spinal column; crippling deformities of spine and major joints; muscle wasting; neurological defects/compression of spinal cord
Fluoride’s effects depend not only on the total dosage and duration of exposure, but also on other factors, such as nutritional status, kidney function, and interactions with other trace elements. But what we really need to know is how much fluoride it takes before it begins to cause us harm.
It is also important to note that these figures are for crippling fluorosis, the last stage. It will take only four years at 10 mg per day, or sixteen years at 2.5 mg per day, before a 100-pound individual can expect to experience Phase I – musculoskeletal fluorosis – with chronic joint pain and arthritic symptoms, with or without osteoporosis.
Based on the figures in the NAS/NRC’s 1993 report, Health Effects of Ingested Fluoride, and on those published by Hodge in 1979, Table 1 shows the minimum daily fluoride intake associated with the development of crippling skeletal fluorosis, according to body weight and years of exposure.
The American chemist Bette Hileman was scathing of the lack of studies into skeletal fluorosis carried out in her own country, saying:
Although skeletal fluorosis has been studied intensely in other countries for more than 40 years, virtually no research has been done in the US 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. Skeletal fluorosis is not even discussed in most medical texts under the effects of fluoride; indeed, a number of texts say the condition is almost nonexistent in the US. Even if a doctor is aware of the disease, the early stages are difficult to diagnose.6
 |
||
Body weight (lb) |
Minimum mg/day |
Minimum mg/day |
|
||
229 |
20.77 |
5.19 |
220 |
19.96 |
4.99 |
210 |
19.05 |
4.76 |
200 |
18.14 |
4.54 |
190 |
17.24 |
4.31 |
180 |
16.32 |
4.08 |
170 |
15.42 |
3.86 |
160 |
14.52 |
3.63 |
150 |
13.6 |
3.4 |
140 |
12.7 |
3.18 |
130 |
11.79 |
2.95 |
120 |
10.89 |
2.72 |
110 |
9.98 |
2.49 |
100 |
9.07 |
2.27 |
|
||
Note: Intake figures by body weight for 44 years are shown here for purposes of comparison only.
Source: Health effects of ingested fluoride. Subcommittee on Health Effects of Ingested Fluoride, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission on Life Sciences, US National Research Council, August 1993.
Table 1. Minimum daily fluoride intake associated with Phase III skeletal fluorosis
Bone changes observed in human skeletal fluorosis are structural and functional, with a combination of osteosclerosis, osteomalacia, osteoporosis, and exostosis formation, as well as secondary hyperparathyroidism in a proportion of patients.
About 10 per cent of bone tissue is broken down and replaced each year. At this stage, any ingested fluoride is incorporated in the new bone structure. Because of fluoride’s affinity for calcium, in 1961 Dr C. Rich originated a treatment for osteoporosis, administering large doses of fluoride in the belief that the fluoride would assist the formation of new bone substance, strengthening it and preventing fracture. At first it looked as if the scheme might be successful: as expected, the bones of women who took the fluoride supplements looked considerably denser on X-rays and bone scans. But although the bones looked denser, they were weaker. Women treated with fluoride supplements had significantly more fractures. Five years after he began, Rich also warned that there were other side effects: gastric pain, calcification of the arteries, osteoarthritis and visual disturbances.7 The treatment was abandoned.
But the weakening of bones doesn’t happen only with supplements. All fluoride weakens bones. For this reason, it can be predicted that as people ingest more fluoride in water or food, so the rate of osteoporotic fractures will increase. And so it proves to be. Numbers of hip fractures have risen dramatically among both women and men since water fluoridation began.
In 1978 scientists at Yale University reported that fluoride in strengths as little as the ‘optimal’ 1 ppm decreased bone strength and elasticity.8 Workers at the Roswell Park Memorial Institute also showed that fluoride accelerated the process of osteoporosis.9 In 1992, a study of elderly patients in Utah found ‘a small but significant increase in the risk of hip fracture in both men and women exposed to artificial fluoridation at 1 part per million’.10 The relative risk of hip fracture in the higher-fluoride group, compared with the lower-fluoride group, was 27 per cent greater for women and 41 per cent greater for men. Figure 2 shows the data for men from this study. Dr John R. Lee concluded from this study that ‘[f]luoride is toxic to bones and increases risk of fracture at all levels of exposure including fluoridation at 1 ppm. Regardless of any other consideration, this is reason enough to discontinue fluoridation immediately.’11
Source: Danielson et al. J Am Med Assoc 1992; 268: 746–8.
Figure 2. Hip fractures, rate per 1,000, men
The total quantity of fluoride ingested is the single most important factor in determining the clinical course of skeletal fluorosis; the severity of symptoms correlates directly with the level and duration of exposure.12 The WHO recognised this thirty years ago, which is why the WHO called for all sources of fluoride to be considered before decisions to fluoridate are taken. In 1970 the WHO said:
At higher levels of ingestion – from 2 to 8 mg daily, skeletal fluorosis may arise . . . Whereas dental fluorosis is easily recognized, the skeletal involvement is not clinically obvious until the advanced stage of crippling fluorosis . . . early cases may be misdiagnosed as rheumatoid or osteoarthritis.13
With fluoride in food (whether due to pesticides or to the use of fluoridated water in food processing), water, toothpaste, air, and so on, 2–8 mg daily is easily within people’s intakes even if they live in areas that do not have fluoridated drinking water.
In recent years, four additional studies have demonstrated an increased incidence of hip fractures among elderly people living in fluoridated areas. Jacobsen (USA), Cooper (UK) and Colquhoun (New Zealand) all state that increased fracture of the hip has occurred since the advent of fluoridation.14 Colquhoun said: ‘I find it astonishing therefore that, at a time when women’s hip fractures in New Zealand are reaching epidemic proportions, health boards are still claiming that fluoridated water is perfectly safe.’ Dr C. Danielson and colleagues conclude: ‘Fluoridation of water supplies was initiated prior to long-term studies of its effects on bone density. Recent studies suggest that fluoride accumulates with age and may reach toxic bone levels in a person’s lifetime (at a water content of 0.97 ppm).’15
According to Dr Lee there have been ‘seven studies showing a positive correlation of fluoridation with increased hip fracture incidence and not one acceptable study showing the contrary’.16
Conclusion
Skeletal fluorosis has been studied extensively in India and other countries for more than forty years, whereas almost no research has been done in the USA, Britain, Ireland or other artificially fluoridating countries. Don’t be misled by the BFS statement that ‘in temperate climates, such as the UK, USA and Canada, there is no evidence that skeletal fluorosis occurs’. Absence of evidence is not the same as evidence of absence. Many symptoms of skeletal fluorosis – osteoporosis, spondylosis, and other bone conditions – are there to be found. Are they caused by fluoride? I suspect they are, as levels of fluoride intake in Britain and Ireland are not so very different from those in India, where skeletal fluorosis is documented. But we will never know for sure until the situation is taken seriously.
1.Susheela AK. Letter to Rotary International, Oakmont, PA, 24 February 1996.
2.Editorial. Why so many fractured hips? Lancet 1989; i: 57.
3.Suri YP. The bran wagon. Lancet 1987; ii: 42–3.
4.Reynolds JJ. Boneturnover, vitamin D and plasma calcium homeostasis. In Talmage RV, Owen M, Parsons JA (eds) Calcium Regulating Hormones. Excerpta Medica, Amsterdam, 1975.
5.Mertz W, ed. Trace elements in human and animal nutrition, 5th edn. US Department of Agriculture, Agricultural Research Service, Beltsville Human Nutrition Research Center, Beltsville, MD, 1987: 368.
6.Hileman B. Fluoridation of water. Special report. Chem Eng News 1 August 1988: 35–6.
7.Waldbott GL, in collaboration with Burgstahler A, McKinney HL. Fluoridation: The great dilemma. Lawrence, KS: Coronado Press, 1978: 81–4.
8.Albright JA. The effect of fluoride on the mechanical properties of bone. Trans Ann Meet Orthopedics Res Soc 1978; 240 (15): 1630–1.
9.Robin JC, Schepart B, Calkins H et al. Studies on osteoporosis III. Effect of estrogens and fluoride. J Med 1980; 11 (1): 1–14.
10.Danielson C, Lyon JL, Egger M, Goodenough GK. Hip fractures and fluoridation in Utah’s elderly population. J Am Med Assoc 1992; 268: 746–8.
11.Lee JR. Fluoridation and osteoporosis: The facts. Health Freedom News January 1994: 26.
12.Review of fluoride: Benefits and risks. US Department of Health and Human Services, February 1991: 45.
13.WHO. Fluorides and human health. Geneva: World Health Organization, 1970: 239.
14.Jacobsen, S, Goldberg J et al. Regional variation in the incidence of hip fracture: US white women aged 65 years and older. J Am Med Assoc 1990; 264: 500–2. Cooper C, Whickham C et al. Water fluoride concentration and fracture of the proximal femur. J Epidemioc Community Health 1990; 44: 17–19, and Water fluoridation and hip fracture. J Am Med Assoc 1991; 266: 513– 4. Colquhoun J. Water fluoride and fractures. NZ med J 1991; 104: 343.
15.Danielson C, Lyon JL, Egger M, Goodenough GK. Hip fractures and fluoridation in Utah’s elderly population. J Am Med Assoc 1992; 268: 746–8.
16.Lee JR. Fluoridation and hip fracture according to the National Research Council report: ‘Health effects of ingested fluoride’. Fluoride 1993; 26: 274–7.