Skeletal fluorosis secondary to methoxyflurane use for chronic pain

Skeletal fluorosis is rare and occurs secondary to chronic high amounts of fluoride consumption, manifesting as diffuse osteosclerosis, skeletal pain, connective tissue calcification, and increased fracture risk. Methoxyflurane is a volatile, fluorinated hydrocarbon-inhaled analgesic, and the maximum recommended dose is 15 mL (99.9 % w/w) per wk. A rodent study found increased skeletal fluoride after methoxyflurane exposure. However, skeletal fluorosis secondary to methoxyflurane use in humans has rarely been reported. We present the case of a 47-yr-old female with diffuse osteosclerosis secondary to fluorosis from methoxyflurane use for chronic pain, presenting with 3 yr of generalized bony pain and multiple fragility fractures. Lumbar spine BMD was elevated. CT and radiographs demonstrated new-onset marked diffuse osteosclerosis, with calcification of interosseous membranes and ligaments, and a bone scan demonstrated a grossly increased uptake throughout the skeleton. Biochemistry revealed an elevated alkaline phosphatase and bone turnover markers, mild secondary hyperparathyroidism with vitamin D deficiency, and mild renal impairment. Zoledronic acid, prescribed for presumed Paget's disease, severely exacerbated bony pain. Urinary fluoride was elevated (7.3 mg/L; reference range < 3.0 mg/L) and the patient revealed using methoxyflurane 9 mL per wk for 8 yr for chronic pain. A decalcified bone biopsy revealed haphazardly arranged cement lines and osteocytes lacunae and canaliculi, which was consistent with an osteosclerotic process. Focal subtle basophilic stippling around osteocyte lacunae was suggestive of fluorosis. Although fluorosis is not a histological diagnosis, the presence of compatible histology features was supportive of the diagnosis in this case with clinical-radiological-pathological correlation. Skeletal fluorosis should be considered as a cause of acquired diffuse osteosclerosis. Methoxyflurane should not be recommended for chronic pain. The risk of repeated low-dose exposure to fluoride from methoxyflurane use as analgesia may be greater than expected, and the maximum recommended dose for methoxyflurane may require re-evaluation to minimize skeletal complications.

Abbreviated abstract

Skeletal fluorosis is rare and occurs secondary to chronic high amounts of fluoride consumption, manifesting as diffuse osteosclerosis, skeletal pain, connective tissue calcification, and increased fracture risk. We present the case of a 47-yr-old female with skeletal fluorosis secondary to long-term methoxyflurane for chronic pain. The risk of repeated low-dose exposure to fluoride from methoxyflurane use for analgesia may be greater than expected, and the maximum recommended dose for methoxyflurane may require re-evaluation to minimize skeletal complications.

A skeleton in a huff: insights in etiologies of osteosclerosis

A 30-yr-old man developed right lower leg pain and a palpable solid mass. Radiographic imaging revealed a periosteal reaction with an exostotic mass arising from the right distal fibula. Generalized skeletal osteosclerosis with periosteal reaction was discovered on a radiographic skeletal survey. A biopsy of the right fibular mass revealed reactive woven bone. The patient was referred to a metabolic bone disease clinic, where laboratory values were consistent with secondary hyperparathyroidism and increased bone turnover. A DXA bone density scan revealed high bone density, with an L1-4 spine Z-score of +9.3, a left femoral neck Z-score of +8.5, and a total hip Z-score of +6.5. A dental exam revealed generalized gingival inflammation, teeth mobility, generalized horizontal alveolar bone loss and widening of the periodontal ligament space, increased bone density around the teeth, and thickening of the radicular lamina dura. An extensive evaluation was performed, with the result of a single test revealing the diagnosis. The differential diagnoses of osteosclerosis affecting the skeleton, teeth, and oral cavity are discussed.

Skeletal Fluorosis in a Patient With Computer Cleaner Inhalant Abuse

Skeletal fluorosis is a metabolic bone disease caused by excessive consumption of fluoride from fluoride-contaminated water or foods. Such a condition often takes place in developing countries without proper handling of drinking water or food. However, in recent years, multiple cases of skeletal fluorosis have been observed in the United States due to the increasing frequency of recreational substance abuse. In this case report, a 26-year-old male with a history of polysubstance use disorder presented to the emergency department after being assaulted by store employees when attempting to steal computer cleaner inhalants. On evaluation for acute traumatic injury, he was incidentally found to have diffuse sclerosis of all visualized bones on knee, femur, and hip X-rays. Labs were significant for elevated serum alkaline phosphatase levels, secondary hyperparathyroidism, and hypovitaminosis D. Given the patient's history of computer cleaner inhalant misuse and imaging findings, serum and urine fluoride levels were obtained and supported the diagnosis of skeletal fluorosis. Skeletal pain and diffuse sclerosis on imaging should prompt clinicians to include skeletal fluorosis in the differential diagnosis. Cessation of substance use is the primary treatment of fluorosis in the setting of computer cleaner inhalant abuse. However, clinical symptoms and laboratory and imaging abnormalities may take decades to resolve due to the prolonged half-life of fluoride in bone. Proper hydration is crucial, as nephrolithiasis and hypercalciuria have been described during the skeletal unloading of fluoride.

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.

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.

Skeletal fluorosis secondary to harmful inhalant use

INTRODUCTION

Inhalants are common household items that may be abused for the desired effect of euphoria. Skeletal fluorosis is an uncommon and debilitating bone disorder caused by excess fluoride deposition. We report a case of skeletal fluorosis from chronic inhalation of an electronic duster product containing 1,1-difluoroethane.

CASE

A 33-year-old male with inhalant use disorder presented to the emergency department with prominent bilateral hand swelling and long bone deformities. The patient reported five years of inhaling "surf onn.© electronic duster" (1,1-Difluoroethane). Diagnostic testing demonstrated urine fluoride 64.5 mg/L (ref <3) and serum fluoride 1.8 mg/L (ref <0.13). Radiographs demonstrated diffuse periosteal new bone formation and sclerosis consistent with skeletal fluorosis.

CONCLUSION

Skeletal fluorosis is an uncommon complication of inhalant use disorder with products containing fluoride.

Association between Bone Morphogenetic Protein 2 Gene Polymorphisms and Skeletal Fluorosis of The Brick-tea Type Fluorosis in Tibetans and Kazakhs, China

To investigate the potential association between BMP2 single nucleotide polymorphisms (SNPs) and brick-tea-type skeletal fluorosis risk in cross-sectional case-control study conducted in Sinkiang and Qinghai, China, a total of 598 individuals, including 308 Tibetans and 290 Kazakhs, were enrolled. Using the standard WS/192-2008 (China), 221 skeletal fluorosis cases were diagnosed, including 123 Tibetans and 98 Kazakhs. Logistic regressions 2 analysis did not find the association between SNPs (Rs235764, Rs235739 and Rs996544) and skeletal fluorosis. Genetic models, linkage disequilibrium (LD) and haplotype analysis were not found to be associated with risk of skeletal fluorosis after adjustment by age and sex (P>0.05).Our data suggested that Rs 235764, Rs 235739 and Rs 996544 were not linked susceptibility for skeletal fluorosis in our cross-sectional case-control study.

Skeletal Fluorosis: A Case of Inhalant Abuse Leading to a Diagnosis of Colon Cancer

Skeletal fluorosis is a long-term bone disease that develops when prolonged fluoride toxicity leads to osteosclerosis and bone deformities that result in crippling pain and debility. The disease is endemic to many countries due to environmental or industrial exposures. However, rare cases in the United States have been reported from various causes including heavy toothpaste ingestion, excessive tea consumption, voriconazole use, and inhalant abuse. Here, we present a case of a 41-year-old man who presented for weight loss and severe joint pains due to bony sclerotic lesions found on X-rays. Social history revealed that he had been recreationally inhaling compressed air dusters used for cleaning electronics. Owing to concern for malignancy, he underwent an extensive work-up which led to a diagnosis of colon cancer, but positron emission tomography/computed tomography (PET/CT) and bone biopsy were unexpectedly negative for metastatic bone disease. Further characterization of his lesions by skeletal survey led to a diagnosis of skeletal fluorosis secondary to inhalant abuse. As in this patient, the disease can be difficult for clinicians to recognize as it can be mistaken for various boney diseases such as metastatic cancer. However, once there is clinical suspicion for skeletal fluorosis, various tests to help confirm the diagnosis can include serum and urine fluoride levels, skeletal survey, and bone ash fluoride concentration. Treatment of skeletal fluorosis primarily involves cessation of fluoride exposure, and recovery can take years. Ultimately, further study is required to develop recommendations and guidelines for diagnosis, management, and prognosis of the disease in the United States.

Progress of Signaling Pathways, Stress Pathways and Epigenetics in the Pathogenesis of Skeletal Fluorosis

Fluorine is widely dispersed in nature and has multiple physiological functions. Although it is usually regarded as an essential trace element for humans, this view is not held universally. Moreover, chronic fluorosis, mainly characterized by skeletal fluorosis, can be induced by long-term excessive fluoride consumption. High concentrations of fluoride in the environment and drinking water are major causes, and patients with skeletal fluorosis mainly present with symptoms of osteosclerosis, osteochondrosis, osteoporosis, and degenerative changes in joint cartilage. Etiologies for skeletal fluorosis have been established, but the specific pathogenesis is inconclusive. Currently, active osteogenesis and accelerated bone turnover are considered critical processes in the progression of skeletal fluorosis. In recent years, researchers have conducted extensive studies in fields of signaling pathways (Wnt/β-catenin, Notch, PI3K/Akt/mTOR, Hedgehog, parathyroid hormone, and insulin signaling pathways), stress pathways (oxidative stress and endoplasmic reticulum stress pathways), epigenetics (DNA methylation and non-coding RNAs), and their inter-regulation involved in the pathogenesis of skeletal fluorosis. In this review, we summarised and analyzed relevant findings to provide a basis for comprehensive understandings of the pathogenesis of skeletal fluorosis and hopefully propose more effective prevention and therapeutic strategies.

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.

Let-7c-5p Regulates CyclinD1 in Fluoride-Mediated Osteoblast Proliferation and Activation

Endemic fluorosis is caused by the intake of high environmental fluoride, which causes dental and skeletal fluorosis. Osteoblast proliferation and activation is closely related to skeletal fluorosis and is tightly regulated by the cell cycle. Several biological processes, including bone metabolism and osteoblast proliferation and activation, are regulated by a type of noncoding RNA called microRNAs (miRNAs). However, the understanding of miRNA functions in skeletal fluorosis is limited. Based on our previous miRNA sequencing results and bioinformatics analysis, we investigated the function of the miRNA let-7c-5p to regulate CyclinD1 in fluoride-induced osteoblast proliferation and activation. We designed population experiments as well as in vitro studies using 5-Ethynyl-2'-deoxyuridine (EdU), flow cytometry, immunofluorescence, dual-luciferase reporters, and chromatin immunoprecipitation. The population-based analysis showed a decrease in let-7c-5p expression as fluoride exposure increased. In addition, let-7c-5p levels were negatively correlated with CyclinD1 and Wnt9a (another let-7c-5p target). We verified in vitro that let-7c-5p participates in the fluoride-induced proliferation and activation of human osteoblasts by directly targeting CyclinD1. Furthermore, we demonstrated that let-7c-5p regulates CyclinD1 expression via the Wnt/β-catenin signaling pathway. This study demonstrated the participation of let-7c-5p in fluoride-induced proliferation and activation of human osteoblasts by regulation of CyclinD1 expression at the post-transcriptional and transcriptional levels.

Association between ALOX15 gene polymorphism and brick-tea type skeletal fluorosis in Tibetans, Kazaks and Han, China

To evaluate the association between ALOX15 gene polymorphism and skeletal fluorosis (SF), a case-control study was conducted. A total of 1023 individuals, including 308 Tibetans, 290 Kazaks and 425 Han, were enrolled in this study, in which cases and controls were 278 and 745, respectively. SF was diagnosed by X-ray absorptiometry. SNPs were genotyped using the Sequenom Mass ARRAY system. The genotypes of ALOX15 rs7220870, rs2664593 and rs1107852 were not associated with the risk of SF. After reconstructing the haplotype of rs7220870 and rs11078528, the risk effect of haplotype CA was found in Han participants aged ≤45 years or with moderate fluoride intake. Diplotype of CC/CC had a protective effect on SF risk in Han participants; whereas, CA/CC diplotype showed a risk effect on SF risk in participants aged ≥65; Our results provide the first evidence of an association between ALOX15 gene polymorphism and SF risk in Han participants.Abbreviation: SF: Skeletal fluorosis; SNP: Single Nucleotide polymorphism.

Expounding on the concerns of indian politicians regarding fluorosis: A qualitative analysis of parliamentary questions on fluorosis over two decades

Fluorosis is a major public health problem in India affecting nearly 20 states. Despite more than three decades of fluorosis prevention efforts, fluorosis continues to be a widely prevalent disease in India. The debilitating effects of skeletal fluorosis are well documented and pose a serious health risk to people who consume excess fluoride. In order to understand whether fluorosis was being given importance as a public health problem by elected politicians, we analyzed parliamentary questions posed in both the houses of the Indian parliament during the question hour. Thematic analysis revealed three major themes, namely health hazards, fluorosis control, and magnitude of fluorosis. The analysis revealed that politicians have posed questions regarding all the aspects that are necessary for fluorosis control in India. However, we have identified the certain key issues which have to be improved and certain obligations that the Government of India has to fulfill for successful fluorosis mitigation in India.

Gastrodin alleviates bone damage by modulating protein expression and tissue redox state

Fluorosis is a common disease characterized by disruptions in bone metabolism and enamel development. The production of reactive oxygen species is thought to play an important role in fluorosis. Gastrodin (4‐hydroxybenzylalcohol4‐O‐beta‐d‐glucopyranoside) has been reported to have antioxidative activity, and so here we examined whether gastrodin has protective effects against oxidative stress and bone tissue toxicity in rats with fluorosis. Wistar rats were given different doses of gastrodin 1 month after fluoride administration, and samples of blood, bone and teeth were collected after 2, 3 and 4 months; glutathione peroxidase glu, CAT and SOD levels in the fluorosis group were lower than those in the control group. Gastrodin treatment in rats ameliorated oxidative stress and fluoride accumulation that were induced by fluoride; treatment with 400 mg·kg⁻¹ gastrodin protected trabecular bone structure and reduced femur and alveolar bone injury in rats with fluorosis. Enhanced expression of cysteinyl aspartate‐specific proteinase (caspase) 3, caspase‐9 and Bax and decreased expression of Bcl‐2 induced by fluoride were also reversed by gastrodin. In summary, the present data suggest that gastrodin, and in particular a dose of 400 mg·kg⁻¹, can improve the antioxidative capacity of rats, reduce concentration of fluoride in tissues, alleviate bone damage and modulate expression of Bcl‐2, Bax, caspase‐3 and caspase‐9.

A review on the potential sources and health implications of fluoride in groundwater of Sub-Saharan Africa

Groundwater is a major source of drinking water for millions of people around the world. Over 400 million people in Africa depend solely on it as their main source of water supply. Fluoride is a common contaminant in groundwater. In low concentration (0.5-1.0 mg/L), fluoride is needed by humans for healthy development of bones and teeth, however, a concentration >1.5 mg/L has been linked with several fluorosis and non-fluorosis diseases. Dental and skeletal fluorosis are the major fluorosis diseases commonly reported with the consumption of fluoride-rich water. Although fluoride intake through other pathways such as the drinking of tea and eating of vegetables have been reported, the drinking of fluoride-rich water remains the major pathway of fluoride into humans. Cases of high fluoride levels in groundwater have been reported in almost all the sub-Saharan Africa region but it is more prevalent in East African countries, Sudan and South Africa. Although fluoride is present in surface water mostly in the East African Rift Valley across different countries in East Africa, its significant or high levels are usually associated with groundwater. Geogenic sources such as fluorite, apatite, biotite, amphibole, micas, topaz, cryolite, muscovite and fluorspar have been identified as the major sources of fluoride in groundwater. High fluoride levels have been reported across sub Saharan Africa, with generally higher levels in East Africa resulting from the volcanic activities in the rift system. Dental fluorosis has been reported in many sub-Saharan African countries including South Africa, Tanzania, Uganda, Ethiopia, Kenya, Sudan, Niger, Nigeria, Benin, Ghana and Malawi. Geothermal temperature has been regarded as one of the driving forces for high fluoride levels recorded in groundwater from deep aquifers and geothermal springs. The most affected people with the consumption of fluoride-rich water are the poor with low socioeconomic status who live in rural areas. Some of the proposed alternative sources include rainwater and fog water harvesting and blending of water from various sources. Low-cost and sustainable deflouridation technique remains one of the best ways to treat fluoride contaminated water either at communal level or at the point-of-use.

Skeletal Fluorosis: An Unusual Manifestation of Computer Cleaner Inhalant Abuse

Skeletal fluorosis is a metabolic bone disease caused by accumulation of fluoride and is generally associated with chronic exposure to fluoride-contaminated groundwater, a phenomenon endemic to developing countries. Whereas elevated water fluoride concentrations do not constitute a public health issue in the United States, emergence of skeletal fluorosis as a sequela of chronic recreational exposures has been described. In this case report, our 33-year-old male patient with a history of major depressive disorder and substance abuse was hospitalized for hyperkalemia and acute kidney injury discovered on routine bloodwork due to concomitant nonsteroidal anti-inflammatory drugs (NSAID) and antihypertensive use. Upon hospital admission, he was found to be anemic with a significantly elevated alkaline phosphatase. Given a history of low back pain in the setting of these laboratory abnormalities, lower spine and pelvic imaging revealed diffusely increased bone density and sclerosis. Hematologic evaluation ensued to include a peripheral smear and bone marrow biopsy. Given the patient’s history of computer cleaner inhalant abuse, serum and urinary fluoride levels were obtained. Serum fluoride returned within normal limits though urinary fluoride was increased. Bone marrow histopathology revealed prominent diffuse sclerosis which in conjunction with urinary fluoride levels and computer cleaner inhalant abuse history supported the diagnosis of skeletal fluorosis. Skeletal fluorosis in the United States is rare and presents with non-specific findings requiring a high index of suspicion based on a detailed patient history for expedient diagnosis.

[Relationship between fluoride exposure, orthopedic injuries and bone formation markers in patients with coal-burning fluorosis]

Chronic exposure to fluoride is a public health problem worldwide. We explored the relationship between fluoride exposure, orthopedic injuries and bone formation markers alkaline phosphatase (ALP), bone Gla protein (BGP) in participants with coal-burning fluorosis in Hehua Village (coal-burning fluorosis endemic area) in Zhijin County of Guizhou Province and Zhangguan Village (non-fluoride contaminated area) in Anshun City of Guizhou Province. Environmental samples were collected and fluoride contents were examined using a fluoride ion-selective electrode. Dental fluorosis and skeletal fluorosis of 295 participants from Hehua Village and 85 participants from Zhangguan Village were diagnosed with informed consent. Urinary samples and peripheral blood samples were collected from the participants to determine urinary fluoride (UF), ALP acti-vity, and BGP content. The results showed that fluoride contents in rice, pepper, corn, drinking water, clay, vegetable-grown soil, coal and indoor and outdoor air were significantly higher than those in the control area, but lower than the previously reported values. With the increases of UF concentration, the ALP activity and BGP content significantly increased, the severity of skeletal fluorosis was greater, but with no significant changes in dental fluorosis. There was positive correlation between the severity of skeletal fluorosis and ALP activity, BGP content. These results indicated that low fluoride exposure could cause orthopedic injuries. ALP and BGP could be used to eva-luate the bone turnover in patients with skeletal fluorosis, which would be useful in the auxiliary diagnosis and therapeutic evaluation of skeletal fluorosis.

Aberrant methylation-induced dysfunction of p16 is associated with osteoblast activation caused by fluoride

Chronic exposure to fluoride continues to be a public health problem worldwide, affecting thousands of people. Fluoride can cause abnormal proliferation and activation of osteoblast and osteoclast, leading to skeletal fluorosis that can cause pain and harm to joints and bones and even lead to permanent disability. Nevertheless, there is no recognized mechanism to explain the bone lesions of fluorosis. In this work, we performed a population study and in vitro experiments to investigate the pathogenic mechanism of skeletal fluorosis in relation to methylation of the promoter of p16. The protein coded by the p16 gene inhibits cdk (cyclin-dependent kinase) 4/cdk6-mediated phosphorylation4 of retinoblastoma gene product and induces cell cycle arrest. The results showed that hypermethylation of p16 and reduced gene expression was evident in peripheral blood mononuclear cells of patients with fluorosis and correlated with the level of fluoride exposure. Studies with cell cultures of osteoblasts revealed in response to sodium fluoride (NaF) treatment, there was an induction of p16 hypermethylation and decreased expression, leading to increased cell proliferation, a longer S-phase of the cell cycle, and development of skeletal fluorosis. Further, the methylation inhibitor, 5-aza-2-deoxycytidine, reversed the p16 hypermethylation and expression in response to NaF. These results reveal a regulatory role of p16 gene methylation on osteoblasts activation during the development of skeletal fluorosis.

Delayed epidural pseudoaneurysm following cervical laminectomy and instrumentation in a patient with canal stenosis secondary to skeletal fluorosis: A case report

RATIONALE

The typical intraoperative presentation of vertebral artery injury (VAI) usually involves profuse bleeding and requires immediate treatment. However, an occult VAI may occur intraoperatively and result in delayed life-threatening epidural pseudoaneurysm several days postoperatively.

PATIENT CONCERNS

A 21-year-old man with compressive cervical myelopathy resulting from canal stenosis of skeletal fluorosis underwent decompression of C1 to C7 and instrumentation from C2 to C7. No impressive bleeding event occurred during the operation. On postoperative day 40, progressive quadriplegia developed.

DIAGNOSES

Pseudoaneurysm of the VA was established by angiography.

INTERVENTIONS

After occlusion of the right VA, the patient underwent hematoma clearing.

OUTCOMES

Fortunately, the patient experienced significant recovery of neurologic function after the second surgery.

LESSONS

From this case, we realize even in the absence of obvious signs of VAI during a cervical operation, postoperative evaluation should be mandatory for suspected bleeding events occurring at VAI-prone sites during surgery. Moreover, the bone morphological abnormality of skeletal fluorosis was determined to be the most important risk contributing to VAI in this case. The safety limits of bone removal should be determined preoperatively to avoid the effects of bone morphological abnormalities.

Comparative Evaluation of Dental and Skeletal Fluorosis in an Endemic Fluorosed District, Salem, Tamil Nadu

Background:

High levels of fluoride in the drinking water, especially ground water, results in skeletal fluorosis which involves the bone and major joints. This study was conducted to assess the prevalence of skeletal fluorosis to compare with dental fluorosis in an endemically fluorosed population in the District of Salem, Tamil Nadu.

Materials and Methods:

Institutional ethical clearance was obtained. A total of 206 patients who reported to the Department of Hematology for blood investigations were the participants in this study. Age, sex, place, weight, height, dental fluorosis, and skeletal complaints were noted down. Body mass index was calculated, and statistical analysis was performed.

Results:

Dental fluorosis was present in 63.1% and absent in 36.9% of the samples reported. Skeletal fluorosis was present in 24.8% and was absent in 75.2%. A large number of the patients had knee pain and difficulty in bending. Chi-square test was used for statistical analysis. Skeletal fluorosis and age were compared and P value was 0.00 and was significant. Dental fluorosis and skeletal fluorosis were compared and P value was found to be 0.000 and significant.

Discussion and Conclusion:

There is a need to take measures to prevent dental and skeletal fluorosis among the residents of Salem district. Calcium balance should be maintained, and fluoride intake should be minimized to reduce the symptoms. The government should provide water with low fluoride level for drinking and cooking. Once the symptoms develop, treatment largely remains symptomatic, using analgesics and physiotherapy.

Association of dental and skeletal fluorosis with calcium intake and serum vitamin D concentration in adolescents from a region endemic for fluorosis

CONTEXT

Fluorosis is controlled by the duration of fluoride exposure and calcium and Vitamin D nutrition status.

AIM

To examine (a) prevalence of dental and skeletal fluorosis in adolescents from upper, middle, and lower socioeconomic strata (SES) and (b) association of fluorosis with calcium intake and Vitamin D status.

SETTINGS AND DESIGN

A cross-sectional study conducted in 10-13.9 years apparently healthy adolescents (n = 90), from different SES of Patan (Gujarat, India).

MATERIALS AND METHODS

Dental fluorosis was graded as mild, moderate, and severe. Radiographs of the right hand and wrist were examined and graded. Serum 25 hydroxyvitamin D3 (25OHD) and parathyroid hormone concentrations were measured. Diet was recorded (24 h recall) and calcium intake was computed (C-diet V-2.1, 2013, Xenios Technologies Pvt. Ltd).

STATISTICAL ANALYSIS

Generalized linear model was used to analyze relationships between fluorosis, SES, serum 25OHD concentration, and calcium intake.

RESULTS

Fluorosis was predominant in lower SES (17% had both dental and radiological features whereas 73% had dental fluorosis); no skeletal deformities were observed. Mean 25OHD concentrations and dietary calcium were 26.3 ± 4.9, 23.4 ± 4.7, and 18.6 ± 4 ng/ml and 441.2 ± 227.6, 484.3 ± 160.9, and 749.2 ± 245.4 mg/day, respectively, for lower, middle, and upper SES (P < 0.05). Fluorosis and SES showed a significant association (exponential β = 2.5, P = 0.01) as compared to upper SES, middle SES adolescents were at 1.3 times while lower SES adolescents were at 2.5 times higher risk. Serum 25OHD concentrations (P = 0.937) and dietary calcium intake (P = 0.825) did not show a significant association with fluorosis.

CONCLUSION

Fluorosis was more common in lower SES adolescents, probably due to the lack of access to bottled water. Relatively adequate calcium intake and serum 25OHD concentrations may have increased the efficiency of dietary calcium absorption, thus preventing severe fluorosis.

Dietary Fluoride Intake and Associated Skeletal and Dental Fluorosis in School Age Children in Rural Ethiopian Rift Valley

An observational study was conducted to determine dietary fluoride intake, diet, and prevalence of dental and skeletal fluorosis of school age children in three fluorosis endemic districts of the Ethiopian Rift Valley having similar concentrations of fluoride (F) in drinking water (~5 mg F/L). The duplicate plate method was used to collect foods consumed by children over 24 h from 20 households in each community (n = 60) and the foods, along with water and beverages, were analyzed for fluoride (F) content. Prevalence of dental and skeletal fluorosis was determined using presence of clinical symptoms in children (n = 220). Daily dietary fluoride intake was at or above tolerable upper intake level (UL) of 10 mg F/day and the dietary sources (water, prepared food and beverages) all contributed to the daily fluoride burden. Urinary fluoride in children from Fentale and Adamitulu was almost twice (>5 mg/L) the concentration found in urine from children from Alaba, where rain water harvesting was most common. Severe and moderate dental fluorosis was found in Alaba and Adamitulu, the highest severity and prevalence being in the latter district where staple foods were lowest in calcium. Children in all three areas showed evidence of both skeletal and non-skeletal fluorosis. Our data support the hypothesis that intake of calcium rich foods in addition to using rain water for household consumption and preparation of food, may help in reducing risk of fluorosis in Ethiopia, but prospective studies are needed.

Risk Assessment of Fluoride Intake from Tea in the Republic of Ireland and its Implications for Public Health and Water Fluoridation

The Republic of Ireland (RoI) is the only European Country with a mandatory national legislation requiring artificial fluoridation of drinking water and has the highest per capita consumption of black tea in the world. Tea is a hyperaccumulator of fluoride and chronic fluoride intake is associated with multiple negative health outcomes. In this study, fifty four brands of the commercially available black tea bag products were purchased and the fluoride level in tea infusions tested by an ion-selective electrode method. The fluoride content in all brands tested ranged from 1.6 to 6.1 mg/L, with a mean value of 3.3 mg/L. According to our risk assessment it is evident that the general population in the RoI is at a high risk of chronic fluoride exposure and associated adverse health effects based on established reference values. We conclude that the culture of habitual tea drinking in the RoI indicates that the total cumulative dietary fluoride intake in the general population could readily exceed the levels known to cause chronic fluoride intoxication. Evidence suggests that excessive fluoride intake may be contributing to a wide range of adverse health effects. Therefore from a public health perspective, it would seem prudent and sensible that risk reduction measures be implemented to reduce the total body burden of fluoride in the population.

Fluoride decreased osteoclastic bone resorption through the inhibition of NFATc1 gene expression

Over the past two decades, fluoride effects on osteoclasts have been evaluated; however, its molecular mechanisms remain unclear. In this study, we investigated the effect of fluoride on osteoclast formation, function, and regulation using osteoclasts formed from mice bone marrow macrophages treated with the receptor activator of NF-κB ligand and macrophage colony-stimulating factor. Our data showed that fluoride levels ≤ 8 mg/L had no effect on osteoclast formation; however, it significantly reduced osteoclast resorption at 0.5 mg/L. Fluoride activity on bone resorption occurred through the inhibition of nuclear factor of active T cells (NFAT) c1 expression. Furthermore, the expression of its downstream genes, including the dendritic cell-specific transmembrane protein, c-Src, the d2 isoform of vacuolar (H+) ATPase v0 domain, matrix metalloproteinase 9, and cathepsin K were decreased, leading to impaired osteoclast acidification, reduced secretion of proteolytic enzymes, and decreased bone resorption. In summary, our results suggested that fluoride has different roles in osteoclast formation and function. Fluoride ≤ 8 mg/L did not impact osteoclast formation; however, it significantly decreased the resorption activity of newly formed osteoclasts. The molecular mechanism of fluoride action may involve inhibition of NFATc1 and its downstream genes.

Assessment of Skeletal and Non-skeletal Fluorosis in Endemic Fluoridated Areas of Vidharbha Region, India: A Survey

OBJECTIVES

To evaluate skeletal and non-skeletal fluorosis in patients living at endemic fluoridated areas and also the morphological changes in red blood cells (R.B.C.'s).

MATERIALS AND METHODS

The cross-sectional study was conducted at Vidharbha region of Maharashtra, India. An ethical clearance was obtained from the concerned authorities. Fifty families were screened and 204 subjects who had dental/skeletal fluorosis were included in the study. The aims and objectives were explained to the study subjects of the village and biochemical, hematological and radiological assessment was done. The main source of drinking water in this area was tube well. The concentrations of fluoride in two different areas of same village were 4 and 4.5 ppm.

RESULTS

Prevalence of skeletal fluorosis and non-skeletal fluorosis in male patients was 56.87% (116) and in female patients (88) it was 43.13%. RBC count in male patients was 5.03 ± 0.49 while in female patients it was 4.70 ± 0.47. With significant difference between male and female patients, P value was 0.003. Hb% in male patients was 12.44 ± 1.76 and in female patients it was 11.31± 1.34, showing significant difference between male and female patients P value 0.038. Alkaline phosphate level in male patients was 289.68 ± 149.09 and in female patients it was 276.68 ± 164.97. ESR count in male patients was found 11.41 ± 8.75 and in female patients it was 13.29 ±7.37. Radiological finding of fluorosis patients shows thickening of inner and outer tables of skull bone in 83.92% of patients and only 7.84% of the patients were suffering from barrowing of long bone.

Thoracic ossification of ligamentum flavum caused by skeletal fluorosis

Thoracic ossification of ligamentum flavum (OLF) caused by skeletal fluorosis is rare. Only six patients had been reported in the English literature. This study reports findings from the first clinical series of this disease. This was a retrospective study of patients with thoracic OLF due to skeletal fluorosis who underwent surgical management at the authors' hospital between 1993 and 2003. Diagnosis of skeletal fluorosis was made based on the epidemic history, clinical symptoms, radiographic findings, and urinalysis. En bloc laminectomy decompression of the involved thoracic levels was performed in all cases. Cervical open door decompression or lumbar laminectomy decompression was performed if relevant stenosis was present. Neurological status was evaluated preoperatively, at the third day postoperatively, and at the end point of follow-up using the Japanese Orthopaedic Association (JOA) scoring system of motor function of the lower extremities. A total of 23 cases were enrolled, 16 (69.6%) males and 7 (30.4%) females, age ranging from 42 to 72 years (mean 54.8 years). All patients came from a high-fluoride area, and 22 (95.7%) had dental fluorosis. Medical imaging showed OLF together with ossification of many ligaments and interosseous membranes, including interosseous membranes of the forearm (18/23 patients 78.3%), leg (14/23 patients 60.9%), and ribs (11/23 patients 47.8%). OLF was classified into five types based on MRI findings: localized (4/23 patients 17.4%), continued (12/23 patients 52.2%), skip (3/23 patients 13.0%), combining with anterior pressure (2/23 patients 8.7%), and combining with cervical and/or lumbar stenosis (2/23 patients, 8.7%). Urinalysis showed a markedly high urinary fluoride level in 14 of 23 patients (60.9%). Patients were followed up for an average duration of 4 years, 5 months. Paired t-test showed that the JOA score was slightly but nonsignificantly increased relative to preoperative measurement 3 days after surgery (P = 0.0829) and significantly increased at the end of follow-up (P = 0.0001). In conclusion, Fluorosis can cause ossification of thoracic ligamentum flavum, as well as other ligaments. Comparing with other OLF series, a larger number of spinal segments were involved. The diagnosis of skeletal fluorosis was made by the epidemic history, clinical symptom, imaging study findings, and urinalysis. En bloc laminectomy decompression was an effective method.

Pathological bone changes in the mandibles of wild red deer (Cervus elaphus L.) exposed to high environmental levels of fluoride

A macroscopic, microscopic and scanning electron microscope study was performed on the pathological bone changes of the mandibles of wild red deer (n = 61) exhibiting severe dental fluorosis. The animals originated from a highly fluoride polluted area in Central Europe (Ore mountains and their southern foreland, Czech-German border region) and constituted 11.2 % of the studied red deer sample (n = 545) from this area. Pathologically increased wear and fracture of fluorosed teeth caused a variety of mandibular bone alterations, including periodontal breakdown, periostitis, osteitis and chronic osteomyelitis. As a further consequence of severe dental attrition, opening of the pulp chamber and formation of periapical abscesses were occasionally observed. In case of severe periodontal breakdown, loss of teeth from the mandibles was found. In addition to the inflammatory bone changes, the occurrence of osteofluorotic alterations was also diagnosed in the specimens with the highest bone fluoride concentrations (> 4000 mg F-/kg dry wt). These changes comprised extended apposition of periosteal bone onto the mandibular cortex as well as deformation of the mandibular body, which was attributed to a fluoride-induced osteomalacia. The present study provided circumstantial evidence that, in addition to fluoride induced dental lesions, the occurrence of marked periodontal disease and tooth loss is an important factor responsible for a reduction of life expectancy in severely fluorotic wild red deer.