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{{Infobox medical condition (new)
| name = Skeletal fluorosis
| image = Fluorosis in Chhattisgarh.jpg
| caption = Fluorosis patient in the industrial city of [[Raigarh]], India
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'''Skeletal fluorosis''' is a [[bone]] disease caused by excessive accumulation of [[fluoride]] leading to weakened bones.<ref>{{cite journal |author=Whitford GM |title=Intake and Metabolism of Fluoride |journal=Advances in Dental Research |volume=8 |issue=1 |pages=5–14 |year=1994 |pmid=7993560 |doi=10.1177/08959374940080011001 |s2cid=21763028 }}</ref> In advanced cases, skeletal fluorosis causes painful damage to bones and [[joints]].

==Symptoms==
Symptoms are mainly promoted in the bone structure. Due to a high fluoride concentration in the body, the bone is [[hardness|hardened]] and thus less [[Elasticity (physics)|elastic]], resulting in an increased frequency of [[bone fracture|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]].<ref>Kalia LV, Lee L, Kalia SK, Pirouzmand F, Rapoport MJ, Aviv RI, Mozeg D, Symons SP. Thoracic myelopathy from coincident fluorosis and epidural lipomatosis. [[Canadian Journal of Neurological Sciences]]. 2010 March; 37(2):276–278.</ref> Most patients with skeletal fluorosis show side effects from the high fluoride dose such as [[gastrointestinal perforation|ruptures of the stomach lining]] and [[nausea]].<ref>{{cite web |author=Gönnewicht, Daniela |title=Untersuchung eines Zusammenhanges von Fluoridkonzentrationen in privaten Trinkwasserversorgungsanlagen und Kariesentwicklung im Raum Ascheberg (Südliches Münsterland/Westfalen) |year=2005 |work= Dissertation |publisher=Universität Münster, Fachbereich Medizinische Fakultät |url= http://miami.uni-muenster.de/servlets/DerivateServlet/Derivate-2190/diss_goennewicht.pdf }}</ref>
Fluoride can also damage the [[parathyroid gland]]s, leading to [[hyperparathyroidism]], the uncontrolled secretion of [[parathyroid hormone]]s. 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 [[Hypercalcemia|higher calcium concentration in the blood]]. As a result, bone flexibility decreases making the bone more susceptible to fractures.<ref>{{cite journal |vauthors=Teotia SP, Teotia M |title=Secondary hyperparathyroidism in patients with endemic skeletal fluorosis |journal=Br Med J |volume=1 |issue=5854 |pages=637–40 |date=March 1973 |pmid=4692708 |pmc=1588649 |doi=10.1136/bmj.1.5854.637}}</ref>

==Causes==
Common causes of fluorosis include inhalation of fluoride dusts or fumes by workers in industry and consumption of fluoride from drinking water (levels of fluoride in excess of levels that are considered safe.<ref>{{cite web|url=https://www.cdc.gov/fluoridation/safety/nrc_report.htm |title=CDC – National Research Council (NRC) Report – Safety – Community Water Fluoridation – Oral Health |publisher=Cdc.gov |access-date=2013-09-04}}</ref>)

In [[India]], especially the [[Nalgonda]] region ([[Telangana]]), a common cause of fluorosis is fluoride-rich drinking water that is sourced from [[water well|deep-bore wells]]. Over half of groundwater sources in India have fluoride above recommended levels.<ref name=Reddy>{{cite journal |author=Reddy DR |title=Neurology of endemic skeletal fluorosis |journal=Neurol India |volume=57 |issue=1 |pages=7–12 |year=2009 |pmid=19305069 |doi=10.4103/0028-3886.48793 |url=http://www.bioline.org.br/abstract?id=ni09004 }}</ref>

Fluorosis can also occur as a result of volcanic activity. The 1783 eruption of the [[Laki]] volcano in Iceland is estimated to have [[Mist Hardships|killed about 22% of the Icelandic population, and 60% of livestock]], as a result of fluorosis and sulfur dioxide gases.<ref>{{cite journal |doi=10.1029/2001JD002042|title=Atmospheric and environmental effects of the 1783–1784 Laki eruption: A review and reassessment|year=2003|last1=Thordarson|first1=Thorvaldur|last2=Self|first2=Stephen|journal=Journal of Geophysical Research|volume=108|issue=D1|page=4011|bibcode=2003JGRD..108.4011T|url=https://www.pure.ed.ac.uk/ws/files/11783768/Atmospheric.pdf|doi-access=free}}</ref> The 1693 eruption of [[Hekla]] also led to fatalities of livestock under similar conditions.<ref>[http://volcano.oregonstate.edu/vwdocs/volc_images/europe_west_asia/eruption_history.html Eruption History]</ref>

=== Skeletal fluorosis phases ===
{| class="wikitable"
|-
! Osteosclerotic phase
! Ash concentration (mgF/kg)
! Symptoms and signs
|-
| Normal Bone
| 500 to 1,000
| Normal
|-
| Preclinical Phase
| 3,500 to 5,500
| Asymptomatic; slight [[radiography|radiographically]]-detectable increases in [[bone mass]]
|-
| Clinical Phase I
| 6,000 to 7,000
| Sporadic [[pain]]; stiffness of [[joint]]s; [[osteosclerosis]] of [[human pelvis|pelvis]] and [[vertebral column]]
|-
| Clinical Phase II
| 7,500 to 9,000
| Chronic joint pain; [[arthritis|arthritic]] symptoms; slight [[calcification]] of [[ligaments]]' increased osteosclerosis and [[cancellous bones]]; with/without [[osteoporosis]] of long bones
|-
|Clinical Phase III
| 8,400
| Limitation of joint movement; calcification of ligaments of neck vertebral column; crippling deformities of the spine and major joints; [[muscle wasting]]; neurological defects/compression of spinal cord
|}

==Treatment==
As of now, there are no established treatments for skeletal fluorosis patients.<ref>{{cite journal |vauthors=Whyte MP, Essmyer K, Gannon FH, Reinus WR |title=Skeletal fluorosis and instant tea |journal=Am. J. Med. |volume=118 |issue=1 |pages=78–82 |date=January 2005 |pmid=15639213 |doi=10.1016/j.amjmed.2004.07.046 }}</ref> 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.<ref>{{cite journal |vauthors=Grandjean P, Thomsen G |title=Reversibility of skeletal fluorosis |journal=Br J Ind Med |volume=40 |issue=4 |pages=456–61 |date=November 1983 |pmid=6626475 |pmc=1009220 |doi=10.1136/oem.40.4.456}}</ref> 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.<ref name="sankannavar">{{cite journal |last1=Sankannavar |first1=Ravi |last2=Chaudhari |first2=Sanjeev |date=2019 |title=An imperative approach for fluorosis mitigation: Amending aqueous calcium to suppress hydroxyapatite dissolution in defluoridation |journal=Journal of Environmental Management |volume=245 |pages=230–237 |doi=10.1016/j.jenvman.2019.05.088|pmid=31154169 |s2cid=173993086 }}</ref> 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.<ref name="sankannavar" />

==Epidemiology==
In some areas, skeletal fluorosis is endemic. While fluorosis is most severe and widespread in the world's two most populous 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."<ref>{{cite web |url=http://www.unicef.org/wes/index_wes_related.html |title=UNICEF – Water, environment and sanitation – Common water and sanitation-related diseases |access-date=2007-09-17 }}</ref>

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.<ref name=Reddy/>

==Effects on animals==

[[File:Fluworôze egzostozes1-800h.jpg|thumb|100 px|right|alt=knobby hoofed leg|Moroccan cow with fluorosis]]

The histological changes which are induced through fluorine on rats resemble those of humans.<ref>{{cite journal |vauthors=Franke J, Runge H, Fengler F, Wanka C |title=[Experimental bone fluorosis] |language=de |journal=Int Arch Arbeitsmed |volume=30 |issue=1 |pages=31–48 |year=1972 |pmid=5084923 |doi=10.1007/bf00539123|s2cid=75961170 }}</ref>

==See also==
* [[Dental fluorosis]]
* [[Fluoride poisoning]]
* [[Kaj Roholm]]

==References==
{{reflist}}

==Further reading==
* Fluorosis from drinking very large amounts of tea: {{cite journal | date=2013-03-21 | author = Naveen Kakumanu, M.D. | author2 = Sudhaker D. Rao, M.B., B.S. | name-list-style = amp | title = Skeletal Fluorosis Due to Excessive Tea Drinking | journal = New England Journal of Medicine | volume = 368 | issue = 12 | pages = 1140 | doi=10.1056/NEJMicm1200995| pmid = 23514291 }}

== External links ==
{{Medical resources
| ICD10 = {{ICD10|M|85|1|m|80}}
| ICD9 = {{ICD9|733.9}}
}}
{{Osteochondropathy}}

{{DEFAULTSORT:Skeletal Fluorosis}}
[[Category:Osteopathies]]
[[Category:Fluorine]]
[[Category:Health disasters in India]]

Skeletal fluorosis - Revision history

Ajay Kumar: Created a new article