Outline of control practice of endemic fluorosis in China

In Silico Analysis of Ferroptosis-Related Genes and Its Implication in Drug Prediction against Fluorosis

Fluorosis is a serious global public health problem. Interestingly, so far, there is no specific drug treatment for the treatment of fluorosis. In this paper, the potential mechanisms of 35 ferroptosis-related genes in U87 glial cells exposed to fluoride were explored by bioinformatics methods. Significantly, these genes are involved in oxidative stress, ferroptosis, and decanoate CoA ligase activity. Ten pivotal genes were found by the Maximal Clique Centrality (MCC) algorithm. Furthermore, according to the Connectivity Map (CMap) and the Comparative Toxicogenomics Database (CTD), 10 possible drugs for fluorosis were predicted and screened, and a drug target ferroptosis-related gene network was constructed. Molecular docking was used to study the interaction between small molecule compounds and target proteins. Molecular dynamics (MD) simulation results show that the structure of the Celestrol-HMOX1 composite is stable and the docking effect is the best. In general, Celastrol and LDN-193189 may target ferroptosis-related genes to alleviate the symptoms of fluorosis, which may be effective candidate drugs for the treatment of fluorosis.

Serum Levels of CXCR4, SDF-1, MCP-1, NF-κB and ERK1/2 in Patients with Skeletal Fluorosis

C-X-C motif chemokine receptor 4 (CXCR4), stromal cell-derived factor-1 (SDF-1), monocyte chemoattractant protein-1 (MCP-1), extracellular signal-regulated kinase 1/2 (ERK1/2) and nuclear factor-κB (NF-κB) affect bone cells and play an important role in bone and joint diseases, but the data on CXCR4, SDF-1, MCP-1, ERK1/2 and NF-κB in the serum of skeletal fluorosis (SF) patients are inconclusive. Thus, according to the "Diagnostic Criteria for Endemic Skeletal Fluorosis" (WS 192-2008), we enrolled patients with SF (n = 60) as the SF group and those without SF as the controls (n = 60). Serum levels of CXCR4, SDF-1, MCP-1, ERK1/2 and NF-κB were detected by enzyme-linked immunosorbent assays (ELISAs). Serum SDF-1, CXCR4, MCP-1 and NF-κB levels were significantly higher in the SF group than in the control group. Within the serum of SF patients, CXCR4 and SDF-1 levels were positively correlated with NF-κB levels. There was no correlation between MCP-1 levels and those of ERK1/2 or NF-κB. SDF-1 and CXCR4 may activate the NF-κB pathway, and MCP-1 affects the occurrence and development of SF by regulating osteocytes through other pathways. The SDF-1/CXCR4 axis and MCP-1 signalling pathway provide a new theoretical basis for the occurrence and development of SF.

Distribution, co-existing metals, and potential health risk of fluorine in farmland soil in different anthropogenic activity dominated districts in a county-level city in Sichuan province, Southwest China, in 2015

Continuous fluorine (F) accumulation in soil by anthropogenic activities leads to variously global environmental and health issues. Herein, 300 farmland soil samples were collected from different anthropogenic activity dominated districts for studying the distribution and related health risk of F in soils. Co-existing metal concentrations in soil samples were also analysed to evaluate the relationship between the distribution of F and metals in soil. The median value of the total F concentration of 488 mg kg^-1 in the present samples was higher than the median background F concentration in topsoil in Sichuan province of China (261 mg kg^-1). Concentration of water-soluble F (1.33-26.2 mg kg^-1) was two or three orders of magnitude less than that of total F in soil. Levels of total and water-soluble F in soils collected from the district with longer contamination history were higher than that from other districts with shorter contamination period, indicating a historical contribution of anthropogenic activities to F accumulation in soil. Notable positive correlation between the total F and vanadium (V) concentration in soil can be partly linked to the usually negative charged form or a common source of F and V in soil (e.g. coal combustion). Compared with inhalation and dermal contact, present human exposure of F in soil was mainly caused by oral ingestion, and the health risks posed by F in soil for both children and adults were acceptable. However, considering the higher potential risk for children than adults, the accumulation of F in soil induced by anthropogenic activities should not be neglect.

miR-486-3p regulates CyclinD1 and promotes fluoride-induced osteoblast proliferation and activation

Fluoride is a persistent environmental pollutant, and its excessive intake contributes to skeletal and dental fluorosis. The mechanisms underlying fluoride-induced abnormal osteoblast proliferation and activation, which are related to skeletal fluorosis, have not yet been fully clarified. As important epigenetic regulators, microRNAs (miRNAs) participate in bone metabolism. On the basis of our previous miRNA-seq results and bioinformatics analysis, this study investigated the role and specific molecular mechanism of miR-486-3p in fluoride-induced osteoblast proliferation and activation via CyclinD1. Herein, in the fluoride-challenged population, we observed that miR-486-3p expression decreased while CyclinD1 and transforming growth factor (TGF)-β1 increased, and miR-486-3p level correlated negatively with the expression of CyclinD1 and TGF-β1 genes. Further, we verified that sodium fluoride (NaF) decreases miR-486-3p expression in human osteoblasts and overexpression of miR-486-3p reduces fluoride-induced osteoblast proliferation and activation. Meanwhile, we demonstrated that miR-486-3p regulates NaF-induced upregulation of CyclinD1 by directly targeting its 3'-untranslated region (3'-UTR). In addition, we observed that NaF activates the TGF-β1/Smad2/3/CyclinD1 axis and miR-486-3p mediates transcriptional regulation of CyclinD1 by TGF-β1/Smad2/3 signaling pathway via targeting TGF-β1 3'-UTR in vitro. This study, thus, contributes significantly in revealing the mechanism of miR-486-3p-mediated CyclinD1 upregulation in skeletal fluorosis and sheds new light on endemic fluorosis treatment.

Fluoride Geochemistry and Exposure Risk Through Groundwater Sources in Northeastern Parts of Rajasthan, India

Exposure to fluoride concentrations above a threshold of 1.5 mg/L can cause joint pains, restricted mobility, skeletal and dental fluorosis. This study aims to determine the hydrochemical evolution of the fluoride-rich groundwater and estimate the risk of fluoride exposure to the residents of semi-arid northeastern part of Rajasthan, India. The methodology involves measurement of fluoride and other ionic concentrations in groundwater using ion chromatography, followed by an estimation of the cumulative density function and fluorosis risk. The fluoride concentration in water samples varied from 0.04 to 8.2 mg/L with 85% samples falling above the permissible limit. The empirical cumulative density function was used to estimate the percentage and degree of health risks associated with the consumption of F^- contaminated water. It is found that 55% of the samples indicate risk of dental fluorosis, 42% indicate risk of deformities to knee and hip bones, and 18% indicate risk of crippling fluorosis. In addition, instances of high nitrate concentrations above the permissible limit of 45 mg/L are also found in 13% of samples. The fluoride rich groundwater is mainly associated with the Na-HCO₃-Cl type water facies while low fluoride groundwater shows varied chemical facies. The saturation index values indicate a high probability of a further increase in F^- concentration in groundwater of this region. The calculated fluoride exposure risk for the general public in the study area is 3-6 times higher than the allowed limit of 0.05 mg/kg/day. Based on the results of this study, a fluorosis index map was prepared for the study area. The northern and northeastern parts are less prone to fluorosis, whereas the south-central and southwestern parts are highly vulnerable to fluorosis. The inferences from this study help to prioritize the regions that need immediate attention for remediation.

Probabilistic human health risk assessment associated with fluoride and arsenic co-occurrence in drinking water from the metropolitan area of San Luis Potosí, Mexico

A major public health concern in Mexico is the natural contamination of groundwater with fluoride and arsenic. Therefore, this work aimed to evaluate the magnitude of human health risk after determining fluoride and arsenic concentrations in groundwater samples (n = 50) from the Metropolitan area of the city of San Luis Potosi, Mexico. Fluoride levels in water were determined via a potentiometric method using an ion-selective electrode. Arsenic concentrations in water samples were determined with an Atomic Absorption technique. Subsequently, a probabilistic health risk assessment was developed (Monte Carlo Analysis). Fluoride levels in water ranged from 0.20 to 3.50 mg/L. For arsenic, the mean level found in the assessed water samples was 15.5 ± 5.50 μg/L (range: 2.50-30.0 μg/L). In addition, when the probabilistic health risk assessment was completed, a mean HI (cumulative hazardous index) of higher than 1 was detected, indicating a high NCR (non-carcinogenic risk) for children and adults. According to the results found in this study, exposure protection campaigns are imperative in the Metropolitan area of the city of San Luis Potosí, Mexico, to successfully diminish exposure to arsenic and fluoride and, as a consequence, decrease the NCR in the population living in that region of Mexico.

Fluorine in the environment in an endemic fluorosis area in Southwest, China

Soils in large areas of China are enriched in fluorine (F). The present study analyzed F concentrations in cultivated soil, water, chemical fertilizer, and human hair, and metal concentrations in soils from an endemic fluorosis area in Southwest, China. In order to reveal the effects of industry on F concentration in the environment, 3 towns mainly with agriculture production and another 3 towns with developed phosphorus chemical industry in a same city were selected for sample collection. The total F concentrations of the 277 surface agricultural soil samples were 378.79-1576.13 μg g^-1, and F concentrations of nearly 95% of the soil samples were higher than the Chinese average topsoil F concentration (480 μg g^-1). Only a small fraction (0.75%) of total F was water soluble. The average total F, water soluble F, Ca, Cr, Fe, K, Mn, Rb, and Sr concentrations in soil samples from towns with intensive industry were higher than those from towns mainly with agriculture. Significant correlations were found between soil pH with total F (p < 0.01) and with water soluble F concentration (p < 0.1). Low F concentrations (<0.5 mg L^-1) were found in irrigation water, well water and tap water in a town where the industry is dense. The phosphorus fertilizer and compound fertilizer had hundreds of times of contribution to soil F increment than the nitrogen fertilizer and potassium fertilizer. Nearly half percent of F in the human hair samples was of exogenic origin. Based on soil ingestion pathway, the health risk for adults exposure to F in soils was acceptable, however, F may pose possible health risks to children in high F concentration areas.

Aberrant DNA methylation of Cyclind-CDK4-p21 is associated with chronic fluoride poisoning

Endemic fluorosis is a serious problem in public health, affecting thousands of people. Abnormal proliferation and activation of osteoblasts in skeletal fluorosis lesions play a leading role and osteoblast proliferation is finely regulated by the cell cycle. There are a few reports on fluoride-induced DNA methylation. However, the role of DNA methylation of the cyclin/cyclin-dependent kinase (CDK)/cyclin-dependent kinase inhibitor (CKI) regulatory network in skeletal fluorosis has not been investigated. We used a population study and in vitro experiment to explore the relationship between the pathogenesis of skeletal fluorosis and methylation of Cyclin d1/CDK4/p21. The results showed a positive relationship between fluoride exposure and expression of Cyclin d1/CDK4, and a negative relationship between fluoride exposure and expression of P21. Hypermethylation of p21 was found in the fluoride-exposed population, and low expression of p21 attributed to promoter hypermethylation was confirmed in vitro. However, no changes in methylation levels of Cyclin d1 and CDK4 genes were observed in the population exposed to fluoride and NaF-treated osteoblasts. These results show that methylation of p21 gene has a significant impact on the proliferation of osteoblasts during the development of skeletal fluorosis. The present study was a first attempt to link the methylation of the Cyclin d1/CDK4/p21 regulatory network with osteoblast proliferation in skeletal fluorosis.

Distribution, formation and human-induced evolution of geogenic contaminated groundwater in China: A review

The sustainability of groundwater usage faces quality problem caused by anthropogenic activity as well as geogenic contamination. With varied climate zones, geomorphology and geological background, China faces a variety of geogenic contaminated groundwater (GCG) reported known as high TDS, Fe, Mn, As, F, I, NH₄⁺, U, Cr and low I, Se, etc., may still exist some others not fully known yet. The problem of GCG is more significant in northern China due to extensive groundwater usage, arid climate and widespread Holocene strata. High salinity groundwater is mainly distributed in semi-arid/arid northwestern inland basins and coastal areas. Elevated Fe and Mn are frequently concomitant and controlled by redox potential, prevailing in the Sanjiang Plain, Yellow River Basin, and middle and lower reaches of the Yangtze River Basin. High As groundwater occurs in reducing aquifer is mainly distributed in the Yellow River, Yangtze River and Huai River Basins as well as the Songnen Plain and Xinjiang. Fluoride is characterized by its areal distribution in northern China in comparison with scatter occurrence in the south. The dissolution of F-bearing minerals as well as evaporation effect both contribute to elevated F. High iodine groundwater mainly distributed in the Yellow-Huai-Hai River Basin and low iodine prevailing in piedmont areas both pose health issues. Iodine is related to decomposition of organic matter (OC) as well as marine origin. Contributed by OC mineralization naturally-occurring NH₄⁺ was found in reducing aquifers. The GCG triggers endemic disease in addition to reduce groundwater resource. The co-occurrence like high TDS and F, As and F are frequently observed posing major challenges for mitigation. Anthropogenic influence like abstraction and pollutant infiltration would alter groundwater flow and the redox condition causing the further evolution of GCG. Identification of GCG should be made in rural areas where private wells prevail to ensure resident's health.

Managing Early Childhood Caries for Young Children in China

The latest national survey found that 70% of 5-year-old children in China had dental caries. The prevalence of early childhood caries (ECC) may not only be attributed to poor oral hygiene and unhealthy diet, but also to limited access to and availability of dental care. The prevailing preventive measures adopted by industrialised countries for ECC management are neither practical nor affordable in China. Hence, an alternative approach to ECC management is necessary. Atraumatic restorative treatment (ART) has been advocated because the simple and short operative time renders ART affordable. However, the success rate of ART in restoring anterior primary teeth is unfavourable. Although there is no water fluoridation in China, topical fluorides may be used to manage ECC. Tooth brushing with fluoride toothpaste is effective for caries control, but not all toothpastes in China are fluoridated. Professionally applied fluorides such as sodium fluoride varnish can be a cost-effective treatment for managing the high prevalence of ECC in China. Silver diamine fluoride (SDF) at 38% is suggested to be effective in arresting ECC in China. It can be a simple, non-invasive and low-cost treatment. However, it stains caries black. Children and their parents must be well informed before SDF treatment.

Probabilistic risk assessment of Chinese residents' exposure to fluoride in improved drinking water in endemic fluorosis areas

Studies have yet to evaluate the effects of water improvement on fluoride concentrations in drinking water and the corresponding health risks to Chinese residents in endemic fluorosis areas (EFAs) at a national level. This paper summarized available data in the published literature (2008-2016) on water fluoride from the EFAs in China before and after water quality was improved. Based on these obtained data, health risk assessment of Chinese residents' exposure to fluoride in improved drinking water was performed by means of a probabilistic approach. The uncertainties in the risk estimates were quantified using Monte Carlo simulation and sensitivity analysis. Our results showed that in general, the average fluoride levels (0.10-2.24 mg/L) in the improved drinking water in the EFAs of China were lower than the pre-intervention levels (0.30-15.24 mg/L). The highest fluoride levels were detected in North and Southwest China. The mean non-carcinogenic risks associated with consumption of the improved drinking water for Chinese residents were mostly accepted (hazard quotient < 1), but the non-carcinogenic risk of children in most of the EFAs at the 95th percentile exceeded the safe level of 1, indicating the potential non-cancer-causing health effects on this fluoride-exposed population. Sensitivity analyses indicated that fluoride concentration in drinking water, ingestion rate of water, and the exposure time in the shower were the most relevant variables in the model, therefore, efforts should focus mainly on the definition of their probability distributions for a more accurate risk assessment.

Fluorosis and its hematological effects

Although it has been reported that fluoride ingestion has no influence on various indices of hematopoiesis, some research has been published that excessive fluoride developed anemia and eosinophilia of leukocytes. Isparta is situated on the lake region of Turkey where fluorosis is endemic. Our aim was to explore the hematological effects in rats induced by fluoride. In this study, Wistar-Albino rats were used, divided into two groups as control and fluorized. While the control group was administered commercial water (including 0.07 ppm fluoride), the fluorized group was administered 100 ppm fluoride in commercial drinking water for four months. At the end of four months, hematological indices (Hb, Hct, MCV, MCH, RDW, RBC, WBC, and platelet counts) were measured. In addition, bone marrow samples were investigated. Mean leukocyte counts (WBC) in the control group and fluorized group were 7.07 (2.62-12.25) and 2.76 (3.13-5.24)-/103/mm3, respectively. We observed displastic changes on granulocytes in the bone marrow samples of the fluorized group. Although there were significant statistical changes in WBC, we did not determine red blood cell and platelet changes in the fluorized group.

Effect of Sodium Fluoride on the Proliferation and Gene Differential Expression in Human RPMI8226 Cells

Although fluoride is known to reduce the incidence of caries, chronic excessive fluoride exposure can impair human health, even resulting in fluorosis. Now the underlying mechanisms of fluoride-induced toxicity are not fully understood. So, we conducted this study with the purpose of investigating the effect of sodium fluoride (NaF) in human RPMI8226 cells. In this experiment, human RPMI8226 cells were cultured with varied doses of fluoride (10, 20, 40, 80, 160, 320 μM). After 48 h exposure, the change of cell viability was examined by CCK-8 assay, and also the messenger RNA (mRNA) expression of relevant genes was assessed by QRT-PCR. Compared to the control group, fluoride exposure increased the human RPMI8226 cells viability at relatively lower levels (10-160 μM); however, when the concentration reached to 320 μM, the cell proliferation was significantly inhibited (p < 0.05). In addition, the genes mRNA expression, including ANKRD1, CRSP6, KLF2, SBNO2, ZNF649, FANCM, PDGFA, RNF152, CDK10, and CETN2 changed in a concentration-dependent manner and increased with fluoride exposure concentration. The results suggest that overexposure to fluoride (160-320 μM) can induce cytotoxicity and regulate relevant genes expression. Our findings provide novel insights into the mechanisms of action of fluoride-induced toxicity.

Soil washing of fluorine contaminated soil using various washing solutions

Bench-scale soil washing experiments were conducted to remove fluoride from contaminated soils. Five washing solutions including hydrochloric acid (HCl), nitric acid (HNO3), sodium hydroxide (NaOH), sulfuric acid (H2SO4) and tartaric acid (C4H6O6) were tested. The concentration of the washing solutions used ranged from 0.1 to 3 M with a liquid to solid ratio of 10. The soil washing results showed that the most effective washing solution for the removal of fluoride from contaminated soils was HCl. The highest fluoride removal results of approximately 97 % from the contaminated soil were obtained using 3 M HCl. The fluoride removal efficiency of the washing solution increases in the following order: C4H6O6 < NaOH < H2SO4 < HNO3 < HCl.

Treatment of High Fluorine Water by Zeolite

This paper describes the structural characteristics of zeolite; studies the factors influencing the defluorining capacity of activated zeolite, such as fluorine concentration, pH value, absorption time of the water examples, and further verifies the technical practicability of the application of activated zeolite in defluorining of drinking water. The results indicated at suitable condition of regeneration the adsorption capacity of zeolite was steady, it can be used repeatedly.

Health risk assessment of fluoride in drinking water from Anhui Province in China

This study analyzes the concentrations and health risks of fluoride in 249 drinking water samples collected from different regions of Anhui Province in China. Results indicated that fluoride content in drinking water ranged from 0.12 to 1.94 mg L(-1) (mean = 0.57 mg L(-1)) in the following order: Huaibei plain region > Jianghuai hill region ≈ Dabieshan mountainous region > plain along the Yangtze River region > southern Anhui mountainous region. The fluoride contents were less than 0.50 mg L(-1) in 66.66 % of the drinking water samples, 0.51-1.0 mg L(-1) in 23.29 %, and higher than 1.0 mg L(-1) in 12.04 %. The fluoride levels in some samples were lower than the recommended values for controlling dental caries (0.50-1.0 mg L(-1)). The total fluoride intake from drinking water was between 0.14 and 2.33 mg per day in different regions of the province, supposing an individual consumes 1.2 L of water per day. Therefore, measures should be taken to increase fluoride intake in the Jianghuai hill region, Dabieshan mountainous region, plain along the Yangtze River, and southern Anhui mountainous region to control dental caries. On the other hand, the fluoride levels must be reduced in the Huaibei plain region to decrease endemic fluorosis. The results serve as crucial guidelines for managing fluoride safety in drinking water and controlling endemic fluorosis in different regions of Anhui Province.

Change of urinary fluoride and bone metabolism indicators in the endemic fluorosis areas of southern China after supplying low fluoride public water

Background

Few studies have evaluated health impacts, especially biomarker changes, following implementation of a new environmental policy. This study examined changes in water fluoride, urinary fluoride (UF), and bone metabolism indicators in children after supplying low fluoride public water in endemic fluorosis areas of Southern China. We also assessed the relationship between UF and serum osteocalcin (BGP), calcitonin (CT), alkaline phosphatase (ALP), and bone mineral density to identify the most sensitive bone metabolism indicators related to fluoride exposure.

Methods

Four fluorosis-endemic villages (intervention villages) in Guangdong, China were randomly selected to receive low-fluoride water. One non-endemic fluorosis village with similar socio-economic status, living conditions, and health care access, was selected as the control group. 120 children aged 6-12 years old were randomly chosen from local schools in each village for the study. Water and urinary fluoride content as well as serum BGP, CT, ALP and bone mineral density were measured by the standard methods and compared between the children residing in the intervention villages and the control village. Benchmark dose (BMD) and benchmark dose lower limit (BMDL) were calculated for each bone damage indicator.

Results

Our study found that after water source change, fluoride concentrations in drinking water in all intervention villages (A-D) were significantly reduced to 0.11 mg/l, similar to that in the control village (E). Except for Village A where water change has only been taken place for 6 years, urinary fluoride concentrations in children of the intervention villages were lower or comparable to those in the control village after 10 years of supplying new public water. The values of almost all bone indicators in children living in Villages B-D and ALP in Village A were either lower or similar to those in the control village after the intervention. CT and BGP are sensitive bone metabolism indicators related to UF. While assessing the temporal trend of different abnormal bone indicators after the intervention, bone mineral density showed the most stable and the lowest abnormal rates over time.

Conclusions

Our results suggest that supplying low fluoride public water in Southern China is successful as measured by the reduction of fluoride in water and urine, and changes in various bone indicators to normal levels. A comparison of four bone indicators showed CT and BGP to be the most sensitive indicators.

Total knee arthroplasty in a patient with skeletal fluorosis

Published reports on patients with skeletal fluorosis undergoing total knee arthroplasty are rare. Skeletal fluorosis is a chronic condition that occurs secondary to the ingestion of food and water that contain high levels of fluoride. Although fluorosis may be described as osteosclerotic and marble-like in appearance, features may also include characteristics of osteomalacia and osteoporosis. This article describes the case of a 67-year-old man with skeletal fluorosis who underwent total knee arthroplasty complicated by fracture. An intramedullary guide was used for the proximal tibia and distal femoral bone cuts intraoperatively. Following the completion of the femoral bone cuts, it was noted that the drill used to open the femoral canal had breached the medial femoral cortex. Multiple fractures were seen in both femoral condyles. A revision femoral stem was chosen to complete the total knee arthroplasty but, after further manipulation of the femur, it appeared that the fracture had displaced. A LISS plate (Synthes, West Chester, Pennsylvania) was used to ensure fracture reduction and implant stability. The remainder of the procedure was completed without complication. One year postoperatively, functional knee range of motion was limited to 70° of flexion. Radiographs showed signs of healing and satisfactory implant position. This case highlights the importance of the preoperative examination and the need to fully appreciate the bone quality of patients prior to undertaking an orthopedic procedure. Variation from the use of intramedullary guides should be considered in patients with questionable bone quality undergoing total knee arthroplasty.

Fluoride content and distribution pattern in groundwater of eastern Yunnan and western Guizhou, China

For study, the fluoride (F) content and distribution pattern in groundwater of eastern Yunnan and western Guizhou fluorosis area in southwestern China, the F content of 93 water samples [groundwater (fissure water, cool spring, and hot springs), rivers water] and 60 rock samples were measured. The result shows the F content of the fissure water and cold spring water is 0.027-0.47 mg/L, and river water is 0.048-0.224 mg/L. The F content of hot spring water is 1.02-6.907 mg/L. The drinking water supplied for local resident is mainly from fissure water, cool spring, and river water. And the F content in all of them is much lower than the Chinese National Standard (1.0 mg/L), which is the safe intake of F in drinking water. The infected people in eastern Yunnan and western Guizhou fluorosis area have very little F intake from the drinking water. The hot spring water in fluorosis area of eastern Yunnan and western Guizhou, southwest China has high F content, which is not suitable for drinking.

Serum copper, zinc, and magnesium levels in patients with chronic fluorosis

Although there are many studies on effect of fluoride on trace elements in experimental animals, few studies exist on serum trace elements levels in patients with endemic fluorosis. We aimed to determine the serum levels of trace elements including serum copper (Cu), zinc (Zn), and serum levels of minerals including calcium (Ca), phosphorus (P), magnesium (Mg), sodium (Na), potassium (K) in patients with endemic fluorosis. The study group consisted of 30 patients with endemic fluorosis (17 females, 13 males, mean age 33.53±9.85 years). An age, gender, and body mass index matched 30 healthy volunteers comprised control group (21 females, ten males with a mean age 33.93±7.39 years). Urine fluoride levels of chronic fluorosis patients were significantly higher than that of control subjects as expected (1.92±0.10 mg/l vs. 0.41±0.09 mg/l, respectively; P<0.001). Serum Cu levels (89.14±16.77 μg/dL vs. 102.69±25.04 μg/dL, respectively, P=0.017), serum Zn levels (77.98±20.58 μg/dL vs. 94.57±35.87μg/dL, respectively, P=0.032), and serum Mg levels (1.92±0.18 mg/dL vs. 2.07±0.31 mg/dL, respectively, p=0.022) was significantly lower in chronic fluorosis patients than in controls. There were no statistically significant differences between the fluorosis group and control group with respect to serum levels of Na, K, Ca, and P. We concluded that chronic fluorosis is associated with reduced serum levels of Cu, Zn, and Mg.

Sodium fluoride induces apoptosis and alters bcl-2 family protein expression in MC3T3-E1 osteoblastic cells

Chronic excessive fluoride intake is known to be toxic and can lead to fluorosis and bone pathologies. However, the cellular mechanisms underlying NaF-induced cytotoxicity in osteoblasts are not well understood. The objectives of this study were to determine the effects of fluoride treatment on MC3T3-E1 osteoblastic cell viability, cell cycle analysis, apoptosis and the expression levels of bcl-2 family members: bcl-2 and bax. MC3T3-E1 cells were treated with 10(-5); 5 × 10(-5); 10(-4); 5 × 10(-4) and 10(-3)M NaF for up to 48 h. NaF was found to reduce cell viability in a temporal and concentration dependent manner and promote apoptosis even at low concentrations (10(-5)M). This increased apoptosis was due to alterations in the expression of both pro-apoptotic bax and anti-apoptotic bcl-2. The net result was a decrease in the bcl-2/bax ratio which was found at both the mRNA and protein levels. Furthermore, we also noted that NaF-induced S-phase arrest during the cell cycle of MC3T3-E1 cells. These data suggest that fluoride-induced osteoblast apoptosis is mediated by direct effects of fluoride on the expression of bcl-2 family members.

Fluoride in the environment and its metabolism in humans

The presence of environmental fluoride and its impact on human health is well documented. When consumed in adequate quantity, fluoride prevents dental caries, assists in the formation of dental enamels, and prevents deficiencies in bone mineralization. At excessive exposure levels, ingestion of fluoride causes dental fluorosis skeletal fluorosis, and manifestations such as gastrointestinal, neurological, and urinary problems. The distribution of fluoride in the environment is uneven and largely is believed to derive from geogenic causes. The natural sources of fluoride are fluorite, fluorapatite, and cryolite, whereas anthropogenic sources include coal burning, oil refining, steel production, brick-making industries, and phosphatic fertilizer plants, among others. Among the various sources of fluoride in the environment, those of anthropogenic origin have occasionally been considered to be major ones. The gourndwater is more susceptible to fluoride accumulation and contamination than are other environmental media, primarily because of its contact with geological substrates underneath. The high fluoride concentration in water usually reflects the solubility of fluoride (CaF₂). High concentrations are also often associated with soft, alkaline, and calcium-deficient waters. The fluoride compounds that occur naturally in drinking water are almost totally bioavailable (90%) and are completely absorbed from the gastrointestinal tract. As a result, drinking water is considered to be the potential source of fluoride that causes fluorosis. Because the bioavailability of fluoride is generally reduced in humans when consumed with milk or a calcium-rich diet, it is highly recommended that the inhabitants of fluoride-contaminated areas should incorporate calcium-rich foods in their routine diet. Guidelines for limiting the fluoride intake from drinking water have been postulated by various authorities. Such limits are designed to protect public health and should reflect all fluoride intake sources, including dietary fluoride. The toxicological risks posed by fluoride could be better understood if epidemiological surveillance for dental and skeletal fluorosis would be systematically conducted in fluoride-affected areas. Such input would greatly improve understanding of the human dose-response relationship. Such surveillance of potentially high fluoride areas is also important because it would help to delineate, much earlier, the remedial measures that are appropriate for those areas.

Impact of chronic fluorosis on left ventricular diastolic and global functions

Sixty three patients with endemic fluorosis (36 males/27 females; mean age 33.9+/-8.6years) and 45 age, sex and body mass index (BMI) matched healthy controls (30 males/15 females; mean age 32.7+/-8.8years) were included in this study. Basic echocardiographic measurements, left ventricular diastolic parameters and left ventricular myocardial performance index (MPI) were measured. The left ventricular MPI was calculated as (isovolumic contraction time+isovolumic relaxation time)/aortic ejection time by Doppler. The urine fluoride levels of fluorosis patients were significantly higher than control subjects as expected (1.9+/-0.1mg/l vs 0.4+/-0.1mg/l respectively; P<0.001). Isovolumic relaxation time (IVRT) and deceleration time (DT) were significantly higher in fluorosis patients than in controls (for IVRT 106.9+/-15.6ms vs 96.7+/-12.2ms; P<0.001 and for DT 211.7+/-30.7ms vs 188.0+/-30.0ms; P<0.001, respectively). MPI was significantly higher in fluorosis patients than in controls (0.62+/-0.15ms vs 0.49+/-0.10ms; P<0.001, respectively). We have shown that chronic fluorosis patients had left ventricular diastolic and global dysfunctions.

Child skeletal fluorosis from indoor burning of coal in southwestern China

OBJECTIVES

We assess the prevalence and pathogenic stage of skeletal fluorosis among children and adolescents residing in a severe coal-burning endemic fluorosis area of southwest China.

METHODS

We used a cross-sectional design. A total of 1,616 students aged between 7 and 16 years in Zhijin County, Guizhou, China in late 2004 were selected via a cluster sampling of all 9-year compulsory education schools to complete the study questionnaire. Any student lived in a household that burned coal, used an open-burning stove, or baked foodstuffs over a coal stove was deemed high-risk for skeletal fluorosis. About 23% (370) of students (188 boys, 182 girls) were identified as high-risk and further examined by X-ray.

RESULTS

One-third of the 370 high-risk participants were diagnosed with skeletal fluorosis. Overall prevalence of child skeletal fluorosis due to indoor burning of coal was 7.5%. Children aged 12-16 years were significantly more likely to be diagnosed with skeletal fluorosis than children aged 7-11 years (OR = 1.84, 95% CI: 1.17-2.90; P = .0082). Four types of skeletal fluorosis were identified: constrictive (60.7%), raritas (15.6%), mixed (16.4%), and soft (7.4%). Most diagnosed cases (91%) were mild or moderate in severity. In addition, about 97% of 370 high-risk children were identified with dental fluorosis. Dental fluorosis was highly correlated with skeletal fluorosis in this study.

CONCLUSIONS

Skeletal fluorosis among children may contribute to poor health and reduced productivity when they reach adulthood. Further efforts to reduce fluoride exposure among children in southwestern of China where coal is burned indoors are desperately needed.

Osteosclerosis due to endemic fluorosis

Endemic water borne fluorosis is a public health problem in Isparta, a city located in southern Turkey. In order to investigate the association between osteosclerosis and fluorosis, we retrospectively screened the results of lumbar spine and femur neck bone mineral density (BMD) of 1500 patients who were examined before, for any reason in between 2001-2003. Sixty nine patients (67 females and 2 males, mean age 52.6+/-10.2) with vertebra T-scores>or=+2 were found only except a patient with osteoid osteoma in the femur neck (femur T-score+6.64). Thirty-four of the patients could be reexamined with lateral vertebra BMD and investigated for fluorosis and the other etiologic causes of osteosclerosis. Of 34 patients, 14 had either mottled tooth enamel or urine fluoride level greater than 1.5 mg/l. Other etiologic causes were hypothyroidism (2), hypoparathyroidism (1), history of lumbar fracture (1), use of retinoids (1), vitamin D (7), oral calcium preparations (9), and bisphosphanates (3). Lateral lumbar vertebral T-score was greater than+2 in 12 patients (35.3%). Femur T-score was greater than+2 in 7 patients (20.6%). Fourteen patients (41.2%) had lateral vertebral or femur T-score>or=+2. Five (35.7%) of these patients had signs of fluorosis, as discussed before. Mean body mass index of individuals with fluorosis was 36.4+/-7.9 and this result was significantly higher than other osteosclerotic subjects (31.6+/-4.4). In conclusion we believe that approximately one third of the osteosclerosis in our region was due to endemic skeletal fluorosis and obesity may enhance this osteosclerotic type bone changes in endemic fluorosis.

Screening high-fluoride and high-arsenic drinking waters and surveying endemic fluorosis and arsenism in Shaanxi province in western China

The objectives of this study were to screen high-fluoride and high-arsenic drinking waters, to evaluate the effectiveness of fluoride-reducing projects and to assess the present condition of endemic fluorosis and arsenism in Shaanxi province in western China. For screening high-fluoride drinking waters, five water samples were collected from each selected village where dental fluorosis patients were detected in 8-12 year-old children. For evaluating the effectiveness of fluoride-reducing projects, four water samples were collected from each project at end-user level. Fluoride concentrations in water samples were measured by fluoride-selective electrode method or spectrophotometry. Dental fluorosis in children aging 8-12 years was examined according to Horowitz's Tooth Surface Index of Fluorosis. Skeletal fluorosis in adults was detected clinically and radiologically according to Chinese Criteria of Clinical Diagnosis of Skeletal Fluorosis. For screening high-arsenic waters, 20 water samples were collected from each village which was selected from areas characterized by the geographic features to induce high-arsenic underground water, i.e., alluvial plains, ore mining or smelting areas, geothermal artesians, and thermal springs. Arsenic concentrations in water samples were determined by spectrophotometry or arsine generation atomic fluorospectrophotometry. Arsenism in adults aging 40-89 years was examined in villages with arsenic concentrations in drinking water above 0.05 mg/l according to Chinese Criteria for Classification of Endemic Arsenism Areas and Clinical Diagnoses of Endemic Arsenism. The results showed that the fluoride level of 7144 water samples was 1.17 +/- 0.93 mg/l. There were 3396 (47.6%) high-fluoride waters (fluoride level was above 1.0 mg/l) distributing in 786 (45.1%) villages, where about 0.8 million (50.0%) people inhabited. Additionally, the 1315 fluoride-reducing projects were studied. The fluoride level of the projects was 2.79 +/- 1.09 and 0.98 +/- 0.47 mg/l before and after building the projects, which remained at relatively lower level (1.03 +/- 0.47 mg/l). But there were still 58.0% of the projects providing drinking waters with fluoride concentrations beyond 1.0mg/l. The rates of dental fluorosis and skeletal fluorosis were 38.2% and 11.8%, respectively. The arsenic level of 1732 water samples was 0.010 +/- 0.082 mg/l. There were 174 (14.9%) high-arsenic waters (arsenic level was above 0.010 mg/l) being detected, distributing in 41 (38.7%) villages. The arsenic level in 53 (4.5%) water samples was beyond 0.025 mg/l. There were 3 villages with arsenic level in drinking water beyond Chinese National Permissible Limits (0.050 mg/l), and the prevalence rate of arsenism reached 37.0% in these three villages, 3.7%, 22.2%, and 11.1% of subjects suffering from mild, moderate, and severe arsenism, respectively. Conclusively, the wide distribution of high-fluoride drinking waters contributes to the prevalence of dental and skeletal fluorosis in Shaanxi province and the quality of fluoride-reducing projects should be further improved. Ore mining and smelting induces high-arsenic drinking waters, resulting in arsenism prevalence in Shang-luo city. Proper measures should be taken to deal with water pollution in the ore mining and smelting areas in order to solve the high-arsenic water problem in Shaanxi province.

The impact of the hyperacid Ijen Crater Lake: risks of excess fluoride to human health

The Asembagus irrigation area (East Java, Indonesia) receives a high input of fluoride (F) via surface water that partially originates from the hyperacid crater lake of the Ijen volcano. Endemic dental fluorosis among local residents has been ascribed to F in water wells. In this study, the total F intake by children and adults was estimated, based on concentrations in well waters and foods throughout the area. These values were compared with the Lowest Observed Adverse Effect Level (LOAEL) for dental fluorosis among children and skeletal fluorosis among adults. Fluorosis hazard maps were prepared, identifying the most hazardous locations in the area. It was concluded that there is not only a high risk of dental fluorosis, but also of skeletal fluorosis. Based on the total daily intake, the lowest F concentration in drinking water that poses a risk of developing fluorosis is approximately 0.5 mg/l for dental fluorosis and 1.1 mg/l for skeletal fluorosis. This is below 1.5 mg/l, which is both the guideline value for drinking water from the World Health Organization (WHO) and the Indonesian drinking water standard. This is the first documented case of human health problems that may be directly associated with natural pollutants originating from a volcano-hosted crater lake.

Fluoride-induced disruption of reproductive hormones in men

Fluoride-induced reproductive effects have been reported in experimental models and in humans. However, these effects were found in heavily exposed scenarios. Therefore, in this work our objective was to study reproductive parameters in a population exposed to fluoride at doses of 3-27 mg/day (high-fluoride-exposed group-HFEG). Urinary fluoride levels, semen parameters, and reproductive hormones in serum (LH, FSH, estradiol, prolactin, inhibin-B, free and total testosterone) were measured. Results were compared with a group of individuals exposed to fluoride at lower doses: 2-13 mg/day (low-fluoride-exposed group-LFEG). A significant increase in FSH (P<0.05) and a reduction of inhibin-B, free testosterone, and prolactin in serum (P<0.05) were noticed in the HFEG. When HFEG was compared to LFEG, a decreased sensitivity was found in the FSH response to inhibin-B (P<0.05). A significant negative partial correlation was observed between urinary fluoride and serum levels of inhibin-B (r=-0.333, P=0.028) in LFEG. Furthermore, a significant partial correlation was observed between a chronic exposure index for fluoride and the serum concentrations of inhibin-B (r=-0.163, P=0.037) in HFEG. No abnormalities were found in the semen parameters studied in the present work, neither in the HFEG, nor in the LFEG. The results obtained indicate that a fluoride exposure of 3-27 mg/day induces a subclinical reproductive effect that can be explained by a fluoride-induced toxic effect in both Sertoli cells and gonadotrophs.

Determination of appropriate exposure to fluoride in non-EME countries in the future

An appropriate exposure to fluoride must be able to interfere with the development of dental caries (benefit) without great concern for dental fluorosis (risks). This condition in relation to individual seems feasible leading to a rational use of fluoride. Nevertheless, dealing with population and particularly non-EME countries (non-Established Market Economies or developing), the most suitable method of fluoride use will depend on each nation. On the other hand, each country should have a public health program to control dental caries as part of its health system. The choice between fluoridated dentifrice or fluoridated drinking water and the option for salt will depend on its applicability in each country. At the same time, it is important that either the appropriate exposure to a community method of fluoride use as well as the association with other methods and preventive measures in relation to risks-benefits are evaluated for each country. The determination of an appropriate exposure to fluoride in non-EME countries in the future will depend on critical analysis of how it has been used at present. Available data have shown that some non-EME countries have even been able to revert the dramatic situation of dental caries in their population, but in others caries experience continues a public health problem. Nevertheless, in other countries the increase in caries prevalence, which was expected, has not occurred but endemic fluorosis has been a concern. The challenges for non-EME countries are huge and identical solutions cannot be used for distinct problems.

Effects of menopause on bone mineral density in women with endemic fluorosis

PURPOSE

The effects of menopause on bone mineral density (BMD) in women with endemic fluorosis were investigated.

MATERIALS AND METHODS

Eighty healthy Turkish women who lived in and around the city of Isparta were selected randomly and enrolled in this study. They were separated into four groups: group 1, 20 premenopausal women with regular menstrual cycles and endemic fluorosis; group 2, 20 postmenopausal women with endemic fluorosis; group 3, 20 premenopausal normal women constituting one control group; and group 4, 20 postmenopausal normal women constituting the other control group. Bone mineral density was measured in the lumbar spine and proximal femur using dual-energy x-ray absorptiometry.

RESULTS

In the premenopausal group, BMD values of vertebrae L2-L4 and Ward's triangle in women with endemic fluorosis were significantly greater than the respective values in women without endemic fluorosis (P = 0.024, P = 0.036). There were no differences between the groups in BMD values of the femoral neck (P = 0.156) and intertrochanteric area (P = 0.076). The BMD values of vertebrae L2-L4, the femoral neck, intertrochanteric area, and Ward's triangle in the postmenopausal women with endemic fluorosis were significantly greater than those of postmenopausal women without endemic fluorosis (P < 0.001, P = 0.015, P = 0.002, and P < 0.001, respectively). The BMD values of vertebrae L2-L4, the femoral neck, intertrochanteric area, and Ward's triangle in the premenopausal women with endemic fluorosis were significantly greater than those of postmenopausal women with endemic fluorosis (P = 0.010, P = 0.002, P = 0.004, and P = 0.010, respectively). The BMD values of the sites noted for the premenopausal controls were significantly greater than those of postmenopausal controls (P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively).

CONCLUSIONS

Postmenopausal BMD values in both endemic fluorosis and controls were significantly less than premenopausal BMD values. Although the differences were less prominent in women with endemic fluorosis, menopause is still the major determinant of BMD in the spine and femur.

Paleopathology of skeletal fluorosis

Skeletal fluorosis is one of a range of conditions causing excessive ossification and joint ankylosis in skeletons. It is rarely considered, however, in differential diagnoses of palaeopathological lesions. This paper considers the identification of skeletal fluorosis in a skeletal sample from the island of Bahrain, Arabian Gulf, dating to ca. 250 BC-AD 250. Approximately 4% of 255 adult skeletons in the sample have hyperostosic lesions resulting in joint ankylosis primarily of the lumbar vertebrae, as well as the major joints. These lesions most frequently occur among males in the 50+ age group. Chemical analysis on a small series of bone and dental samples confirmed the presence of high levels of fluoride, while staining of the teeth is evidence of dental fluorosis. The level of dental fluorosis is comparable with a naturally occurring fluoride level in water of between 1-2 ppm. The prevalence of hyperostosic lesions, however, appears higher than expected, and two possible reasons are suggested: confusion between a diagnosis of diffuse idiopathic skeletal hyperostosis and skeletal fluorosis on partial or less severely affected skeletons; and the presence of predisposing factors for skeletal fluorosis on the island in the past.