sKlotho is associated with the severity of brick tea-type skeletal fluorosis in China

Association between ESR1 and COL1A1 gene polymorphisms and skeletal fluorosis in Tibetan, Kazakh, Mongolian and Russian populations, China

BACKGROUND

Skeletal fluorosis is a chronic metabolic bone disease caused by excessive accumulation of fluoride in the bones. Previous studies have found that when the intake of tea fluoride is similar, the prevalence of skeletal fluorosis varies greatly among different ethnic groups, which may be related to different genetic backgrounds. Single nucleotide polymorphisms (SNPs) of estrogen receptor 1 (ESR1) and collagen type 1 α1 (COL1A1) were strongly associated with bone metabolism as well as bone growth and development, but their association with the risk of skeletal fluorosis has not been reported.

PURPOSE

To explore the incidence of skeletal fluorosis in different nationalities in the endemic fluorosis area of brick-tea type. To study the relationship between 4 SNPS of ESR1 and COL1A1 gene and skeletal fluorosis.

METHODS

A cross-sectional study was conducted in Inner Mongolia, Qinghai and Xinjiang. By including exclusion criteria, a total of 989 people were included in the study, demographic data were collected, and physical examinations and laboratory biochemical tests were performed. The X-ray of the participants were diagnosed according to the diagnostic criteria of Chinese endemic skeletal fluorosis (WS192-2008). Fluoride levels in tea or urine were measured using fluoride ion electrodes. SNP was evaluated using Sequenom-MassARRAY system.

RESULT

The prevalence of skeletal fluorosis varies among different nationalities. Binary logistic regression found that carried the ESR1 Rs9340799 G allele played a protective role in brick-tea-type fluorosis (OR = 0.673[95% CI, 0.495,0.914]). Russians carried the COL1A1 Rs1800012 T allele had a significantly higher risk of developing skeletal fluorosis (OR = 6.370 [95% CI, 1.413,28.715]). When stratified by sex, carriage of the T allele in COL1A1 Rs1800012 significantly increased the risk of developing skeletal fluorosis in Russian men. At the same time, changes in tea fluoride intake and older age can affect the effect of genetic background differences on the risk of skeletal fluorosis.

CONCLUSION

Our data suggested that there may be a genetic component to the risk of skeletal fluorosis in participants of different ethnicities and that this difference could modified by tea fluoride intake, sex or age.

Sirtuin 3-activated superoxide dismutase 2 mediates fluoride-induced osteoblastic differentiation in vitro and in vivo by down-regulating reactive oxygen species

Skeletal fluorosis is a chronic metabolic bone disease caused by long-term excessive fluoride intake. Abnormal differentiation of osteoblasts plays an important role in disease progression. Research on the mechanism of fluoride-mediated bone differentiation is necessary for the prevention and treatment of skeletal fluorosis. In the present study, a rat model of fluorosis was established by exposing it to drinking water containing 50 mg/L F-. We found that fluoride promoted Runt-related transcription factor 2 (RUNX2) as well as superoxide dismutase 2 (SOD2) and sirtuin 3 (SIRT3) expression in osteoblasts of rat bone tissue. In vitro, we also found that 4 mg/L sodium fluoride promoted osteogenesis-related indicators as well as SOD2 and SIRT3 expression in MG-63 and Saos-2 cells. In addition, we unexpectedly discovered that fluoride suppressed the levels of reactive oxygen species (ROS) and mitochondrial reactive oxygen species (mtROS) in osteoblasts. When SOD2 or SIRT3 was inhibited in MG-63 cells, fluoride-decreased ROS and mtROS were alleviated, which in turn inhibited fluoride-promoted osteogenic differentiation. In conclusion, our results suggest that SIRT3/SOD2 mediates fluoride-promoted osteoblastic differentiation by down-regulating reactive oxygen species.

Fluoride impairs vascular smooth muscle A7R5 cell lines via disrupting amino acids metabolism

Given the insidious and high-fatality nature of cardiovascular diseases (CVDs), the emergence of fluoride as a newly identified risk factor demands serious consideration alongside traditional risk factors. While vascular smooth muscle cells (VSMCs) play a pivotal role in the progression of CVDs, the toxicological impact of fluoride on VSMCs remains largely uncharted. In this study, we constructed fluorosis model in SD rats and A7R5 aortic smooth muscle cell lines to confirm fluoride impaired VSMCs. Fluoride aggravated the pathological damage of rat aorta in vivo. Then A7R5 were exposed to fluoride with concentration ranging from 0 to 1200 μmol/L over a 24-h period, revealing a dose-dependent inhibition of cell proliferation and migration. The further metabolomic analysis showed alterations in metabolite profiles induced by fluoride exposure, notably decreasing organic acids and lipid molecules level. Additionally, gene network analysis underscored the frequency of fluoride's interference with amino acids metabolism, potentially impacting the tricarboxylic acid (TCA) cycle. Our results also highlighted the ATP-binding cassette (ABC) transporters pathway as a central element in VSMC impairment. Moreover, we observed a dose-dependent increase in osteopontin (OPN) and α-smooth muscle actin (α-SMA) mRNA level and a dose-dependent decrease in ABC subfamily C member 1 (ABCC1) and bestrophin 1 (BEST1) mRNA level. These findings advance our understanding of fluoride as a CVD risk factor and its influence on VSMCs and metabolic pathways, warranting further investigation into this emerging risk factor.

LDL receptor-related protein 5 rs648438 polymorphism is associated with the risk of skeletal fluorosis

To investigate the potential association between LRP5 rs648438 polymorphism and the risk of skeletal fluorosis (SF) was evaluated in a cross-sectional case-control study conducted in Shanxi, China, in 2019. A total of 973 individuals were enrolled in this study, in which cases and controls were 346 and 627, respectively. SF was diagnosed according to the standard WS/192-2008 (China). The LRP5 rs648438 was detected by the multiple PCR and sequencing. LRP5 rs648438 was found to follow a dominant genetic model using a web-based SNP-STATS software. Logistic regression analysis found that the TC/CC genotype of LRP5 rs648438 might be a protective factor for SF. When stratified by gender, this protective effect of TC/CC genotype in rs648438 was pronounced in males. There was an interaction between gender and rs648438 on risk of SF. Our study suggested that TC/CC genotype of rs648438 might be a protective factor for water-drinking-type skeletal fluorosis, especially in male participants.

The fluorosis conundrum: bridging the gap between science and public health

Fluorosis, a chronic condition brought on by excessive fluoride ingestion which, has drawn much scientific attention and public health concern. It is a complex and multifaceted issue that affects millions of people worldwide. Despite decades of scientific research elucidating the causes, mechanisms, and prevention strategies for fluorosis, there remains a significant gap between scientific understanding and public health implementation. While the scientific community has made significant strides in understanding the etiology and prevention of fluorosis, effectively translating this knowledge into public health policies and practices remains challenging. This review explores the gap between scientific research on fluorosis and its practical implementation in public health initiatives. It suggests developing evidence-based guidelines for fluoride exposure and recommends comprehensive educational campaigns targeting the public and healthcare providers. Furthermore, it emphasizes the need for further research to fill the existing knowledge gaps and promote evidence-based decision-making. By fostering collaboration, communication, and evidence-based practices, policymakers, healthcare professionals, and the public can work together to implement preventive measures and mitigate the burden of fluorosis on affected communities. This review highlighted several vital strategies to bridge the gap between science and public health in the context of fluorosis. It emphasizes the importance of translating scientific evidence into actionable guidelines, raising public awareness about fluoride consumption, and promoting preventive measures at individual and community levels.

Fluoride Exposure and Skeletal Fluorosis: a Systematic Review and Dose-response Meta-analysis

PURPOSE OF REVIEW

We performed a systematic review and meta-analysis on the relation between fluoride exposure and skeletal fluorosis (SF) using a novel statistical methodology for dose-response modeling.

RECENT FINDINGS

Skeletal fluorosis, a major health issue that is endemic in some regions, affects millions of people worldwide. However, data regarding the dose-response relation between fluoride exposure and SF are limited and outdated. We included twenty-three studies in the meta-analysis. When comparing the highest versus the lowest fluoride category, the summary risk ratio (RR) for SF prevalence was 2.05 (95% CI 1.60; 2.64), with a value of 2.73 (95% CI 1.92; 3.90) for drinking water and 1.40 (95% CI 0.90; 2.17) for urinary fluoride. The RR by the risk of bias (RoB) was 2.37 (95% CI 1.56; 3.58) and 1.78 (95% CI 1.34; 2.36) for moderate and high RoB studies, respectively. The dose-response curve based on a one-stage cubic spline regression model showed an almost linear positive relation between exposure and SF occurrence starting from relatively low concentrations up to 5 mg/L and 2.5 mg/L, respectively, for water and urinary fluoride, with no substantial increase above this threshold. The RR for developing moderate-severe forms increases at 5.00 mg/L and 2.5 mg/L of water and urinary fluoride, respectively. Better-quality studies are needed to confirm these results, but greater attention should be given to water fluoride levels to prevent SF, in addition to the other potential adverse effects of fluoride exposure.

The mechanism underlying fluoride-induced low-renin hypertension is related to an imbalance in the circulatory and local renin-angiotensin systems

The renin-angiotensin system (RAS) is an important fluid regulation system in the body, and excessive activation of the circulatory or local RAS can increase blood pressure (BP). Excess fluoride can increase BP, although the underlying mechanism related to activation of the RAS remains unclear. Thus, the aim of this study was to elucidate the role of the RAS in fluoride-induced hypertension. Markers of the circulating and local RASs related to pathological changes to the kidneys, myocardium, and aorta were measured. Fluoride reduced serum levels of renin, angiotensin II (Ang II), and angiotensin (1-7) [Ang (1-7)], and dysregulated plasma levels of aldosterone and potassium levels. Excess fluoride can damage the kidneys, myocardium, and aorta, overactivate the renal angiotensin converting enzyme (ACE)-Ang II-angiotensin type 1 receptor axis, and inhibit activation of the ACE2-Ang (1-7)-Mas axis, leading to dysregulation of alpha epithelial sodium channels and significantly increased expression of Ang II in the myocardium and aorta. Hence, excess fluoride can cause low-renin hypertension via an imbalance between the circulatory and local RASs.

Necessity to Pay Attention to the Effects of Low Fluoride on Human Health: an Overview of Skeletal and Non-skeletal Damages in Epidemiologic Investigations and Laboratory Studies

Due to the implementation of water improvement and fluoride reduction plans supported by central and local governments in recent years, areas with high fluoride exposure are being gradually decreased. Therefore, it is of practical importance to study the effect of low fluoride on human health. Epidemiologic investigations and in vivo and in vitro studies based on low fluoride have also confirmed that fluoride not only causes skeletal damage, such as dental fluorosis, but also causes non-skeletal damage involving the cardiovascular system, nervous system, hepatic and renal function, reproductive system, thyroid function, blood glucose homeostasis, and the immune system. This article summarizes the effects of low fluoride on human and animal skeletal and non-skeletal systems. A preliminary exploration of corresponding mechanisms that will help to fully understand the harm of low fluoride on human health was undertaken to provide the basis for establishing new water fluoride standards and help to implement individual guidance.

Brick tea consumption and its relationship with fluorosis in Tibetan areas

Brick tea-type fluorosis (BTF) due to a high intake of brick tea is possible in Tibetan populations, and dental fluorosis (DF) and skeletal fluorosis (SF) are its primary manifestations. To determine the prevalence of DF and SF and their relationships with brick tea intake in Tibetan populations, a literature review was conducted for studies published between 1994 and 2021. The available evidence revealed that brick tea may be produced from older stems and leaves of the tea plant and that the fluoride content of brick tea exceeds the national standard. The harsh environment of the plateau has led to limited food sources for the local Tibetan people who form the habit of drinking tea leaves as a satiation solution to digest greasy food and replenish vitamins, and regular consumption of brick tea leads to excessive exposure of Tibetan residents to fluoride. Studies in Tibet showed that the prevalence of DF in children was 14.06-75.93% in different districts, and the overall pooled prevalence of DF was 26.08%. The prevalence of SF in adults was 19.90-74.77% in different Tibetan districts, and the overall pooled prevalence of SF was 33.84%. The analysis of risk factors showed that the prevalence of BTF may be related to high-altitude and different working and living conditions, and BTF in children may be associated with fluoride intake during mothers' pregnancy and lactation. With the development of bioinformatics research, gene polymorphisms were suspected to be related to susceptibility to fluorosis in Tibetan populations. The study of BTF in Tibetan people needs to be further investigated and standardized, and additional studies evaluating the pathogenesis and preventive measures of BTF are warranted.

DNA Methylation Profiles of Ovarian Granular Cells from Fluorosis Female Patients Suffering Reproductive Dysfunctions

Fluorosis often causes female reproductive dysfunction. A rapid turnover of DNA methylation is a pathological change in many human diseases, including female reproductive dysfunction. The role of DNA methylation in fluorosis was unknown and investigated in this experiment. Fifty fluorosis women patients were selected as High F group and forty-six healthy women were recruited as Control group were enrolled. In addition, ovarian granulosa cells were obtained from five women in High F group and five women in Control group. All ten women went through in vitro fertilization (IVF) process with DNA methylation sequencing. KGN cells (human granulosa cell line) were cultured with different concentrations of sodium fluoride (0-8 mM NaF) for 24 h for the in vitro study. The level of DNA methylation in blood samples was significantly higher in High F group than that in Control group. The level of serum estradiol (E₂) was significantly lower in women from High F group, while the levels of serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in High F group were significantly higher than that in Control group. The methylation sequences of KGN cells relating to autophagy were significantly changed by NaF treatment dose-dependently. Based on these results, it is concluded that DNA methylation and autophagy may play a significant role in the pathophysiology of reproductive dysfunction caused by fluorosis.

Fluoride exposure induces lysosomal dysfunction unveiled by an integrated transcriptomic and metabolomic study in bone marrow mesenchymal stem cells

Fluoride has received much attention for its predominant bone toxicity in the human body. However, the toxic mechanism of bone injury caused by fluoride exposure remains largely unclear. Bone marrow mesenchymal stem cells (BMSCs) are widely used as model cells for evaluating bone toxicity after environmental toxicant exposure. In this study, BMSCs were exposed to fluoride at 1, 2, and 4 mM for 24 h, and fluoride significantly inhibited cell viability at 2 and 4 mM. A multiomics analysis combining transcriptomics with metabolomics was employed to detect alterations in genes and metabolites in BMSCs treated with 2 mM fluoride. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis of transcriptomics profiles identified "lysosomes" as the top enriched pathway, which was severely damaged by fluoride exposure. Lysosomal damage was indicated by decreases in the expression of lysosomal associated membrane protein 2 (LAMP 2) and cathepsin B (CTSB) as well as an increase in pH. Upregulation of the lysosome-related genes Atp6v0b and Gla was observed, which may be attributed to a compensatory lysosomal biogenesis transcriptional response. Interestingly, inhibition of glutathione metabolism was observed in fluoride-treated BMSCs at the metabolomic level. Moreover, an integrative analysis between altered genes, metabolites and lysosome signaling pathways was conducted. Palmitic acid, prostaglandin C2, and prostaglandin B2 metabolites were positively associated with Atp6v0b, a lysosome-related gene. Overall, our results provide novel insights into the mechanism responsible for fluoride-induced bone toxicity.

Spatial-Temporal Variation and Health Risk Assessment of Fluoride in Surface Water in the Tibetan Plateau

The Tibetan Plateau (TP) is known as the "Asian Water Tower" and provides vital drinking water for residents of China and Southeast Asian countries. However, large-scale regional research on water quality in this climate-sensitive and ecologically-fragile area is still lacking. Considering that drinking from fluoride-contaminated water poses serious health concerns worldwide, especially in Asian counties, it is urgent to clarify the spatial-temporal distribution characteristics, influencing factors, and health risk of fluoride in surface water in the TP. In this study, a total of 2697 surface water samples from major rivers and typical lakes in the TP were systematically analysed. Overall, fluoride concentrations ranged from 0.003 to 6.240 mg L^-1 and varied among water periods, water basins and even water types. Pearson's correlation analysis showed that the distribution of fluoride concentration was closely related to the regional climate and positively correlated with anthropogenic activities. Probabilistic health risk assessment revealed that potential hazards in the Inner Basin were the highest for all age groups (HR > 1), especially for infants and adults (HR > 3), while the risks in most other water basins were acceptable (HR < 1). Our findings can provide scientific support for fluorosis prevention, and guide water resource utilization in the TP and adjacent regions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12403-022-00490-4.

Study of Chitosan Ingestion Remitting the Bone Damage on Fluorosis Mice with Micro-CT

Chronic excessive fluoride exposure may lead to fluorosis, which causes health problems like a decrease in bone mechanical strength. It was speculated that chitosan may combine with fluorine to form in vivo organic fluorine, and may reduce the damage caused by fluorine. Hence, it is necessary to conduct a study to investigate the influence of chitosan on fluorosis mice. To investigate this problem, forty-four 4-week-old male Kunming mice were randomly divided into four groups, the control group, the fluoride group, the fluoride plus chitosan group, and the chitosan group. After 100 days of feeding, the femurs were collected to scan the Micro-CT image. The ultimate load of the femur in the fluoride group was significantly lower than control group. The trabecular separation was increased in the fluoride group compared with the fluoride plus chitosan group and the chitosan group. The level of trabecular thickness was increased in the fluoride plus chitosan group compared with the fluoride group. Our findings suggest that chitosan ingestion can improve the condition of cancellous bone and cortical bone affected by fluorine.