Skeletal fluorosis: don’t miss the diagnosis!

  • Meriem SellamiEmail author
  • Hend Riahi
  • Kaouther Maatallah
  • Hanen Ferjani
  • Mouna Chelli Bouaziz
  • Mohamed Fethi Ladeb
Review Article


Skeletal fluorosis is a rare toxic osteopathy characterized by massive bone fixation of fluoride. The disease occurs as an endemic problem in some parts of the world and is the result of prolonged ingestion or rarely by inhalation of high amounts of fluoride. Radiographic presentation is mainly characterized by bone changes with osteocondensation and later ossification of many ligaments and interosseous membranes. Skeletal fluorosis is not clinically obvious and can be confused with other rheumatologic disorders. Its severity lies in the development of skeletal deformities and neurological complications. Management of fluorosis generally focuses on symptom treatment.


Bone condensation Imaging Ossification Skeletal fluorosis 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Datta P, Datta PP. Prevalence, etiology and clinical features of skeletal fluorosis: a critical review. Innovare J Med Sci. 2013;1:5–6.Google Scholar
  2. 2.
    Tamer MN, KaleKoroglu B, Arslan C, et al. Osteosclerosis due to endemic fluorosis. Sci Total Environ. 2007;373:43–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Chen J, Liu G, Kang Y, et al. Coal utilization in China: environmental impacts and human health. Environ Geochem Health. 2014;36:735–53.CrossRefPubMedGoogle Scholar
  4. 4.
    Majumdar KK. Health impact of supplying safe drinking water containing fluoride below permissible level on flourosis patients in a fluoride-endemic rural area of West Bengal. Indian J Public Health. 2011;55:303–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Kurdi MS. Chronic fluorosis: the disease and its anaesthetic implications. Indian J Anaesth. 2016;60:157–62.CrossRefPubMedGoogle Scholar
  6. 6.
    Gupta N, Gupta N, Chhabra P. Image diagnosis: dental and skeletal fluorosis. Perm J. 2016;20:105–6.Google Scholar
  7. 7.
    Laatar A, Mrabet D, Zakraoui L. Fluorosis in sub-Saharan Africa. Rev Rhum. 2003;70:178–82.CrossRefGoogle Scholar
  8. 8.
    Guissouma W, Hakamic O, Rajab AJ, Tarhounia J. Risk assessment of fluoride exposure in drinking water of Tunisia. Chemosphere. 2017;177:102–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Reber JD, McKenzie GA, Broski SM. Voriconazole -induced periostitis: beyond post-transplant patients. Skelet Radiol. 2016;45:839–42.CrossRefGoogle Scholar
  10. 10.
    Arlappa N, Aatif IQ, Srinivas R. Fluorosis in India: an overview. Int J Res Dev Health. 2013;1:97–102.Google Scholar
  11. 11.
    Liu Q, Liu H, Yu X, et al. Analysis of the role of insulin signaling in bone turnover induced by fluoride. Biol Trace Elem Res. 2016;171:380–90.CrossRefPubMedGoogle Scholar
  12. 12.
    Pei J, Li B, Gao Y, et al. Fluoride decreased osteoclastic bone resorption through the inhibition of NFATc1 gene expression. Environ Toxicol. 2014;29:588–95.CrossRefPubMedGoogle Scholar
  13. 13.
    Teotia SP, Teotia M, Singh KP (2004) Highlights of forty years of research on endemic skeletal fluorosis in India. 4th International Workshop on Fluorosis Prevention and Defluoridation of Water. Colombo, Sri Lanka; March 2–6.Google Scholar
  14. 14.
    Pramanik S, Saha D. The genetic influence in fluorosis. Environ Toxicol Pharmacol. 2017;56:157–62.CrossRefPubMedGoogle Scholar
  15. 15.
    del Carmen Aguilar-Diaz F, Federico Morales-Corona F, Cintra-Viveiro AC, Fuente-Hernández J. Prevalence of dental fluorosis in Mexico 2005-2015: a literature review. Salud Publica Mex. 2017;59:306–13.CrossRefGoogle Scholar
  16. 16.
    Neurath C, Limeback H, Osmunson B, Connett M, Kanter V, Wells CR. Dental fluorosis trends in US oral health surveys: 1986 to 2012. JDR Clinical and translational Research; 2019.
  17. 17.
    Pendrys DG. The differential diagnosis of fluorosis. J Public Health Dent. 1999;59:235–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Liu J, Fu Z, WU L, Ding H, Wang D-l, YU B-l. The Imaging Value of Bone Turnover of Skeletal Fluorosis. Foreign medical sciences (section of medgeography). 2004;25(2):95–98.Google Scholar
  19. 19.
    Roholm K. Fluorine intoxication: a clinical hygienic study. London: Lewis; 1937.Google Scholar
  20. 20.
    Izuora K, Twombly JG, Whitford GM, Demertzis J, Pacifici R, Whyte MP. Skeletal fluorosis from brewed tea. J Clin Endocrinol Metab. 2011;96:2318–24.CrossRefPubMedGoogle Scholar
  21. 21.
    Bisseret D, Kaci R, Lafage-Proust MH, Alison M, Parlier-Cuau C, Laredo JD, et al. Periosteum: characteristic imaging findings with emphasis on radiologic-pathologic comparisons. Skelet Radiol. 2015;44:321–38.Google Scholar
  22. 22.
    Ramakrishna K, Sasikiran NO. Fluorosis-an update. Int J Res Pharmaceut. Biomed Sci. 2013;4:1084–8.Google Scholar
  23. 23.
    Subbarao K. Musculoskeletal fluorosis-imaging spectrum. J Med Sci Res. 2013;1:117–23.CrossRefGoogle Scholar
  24. 24.
    Yildiz M, Akdoğan M, Tamer N, Oral B. Bone mineral density of the spine and femur in early postmenopausal Turkish women with endemic skeletal fluorosis. Calcif Tissue Int. 2003;72:689–93.CrossRefPubMedGoogle Scholar
  25. 25.
    Numan Tamer M, Kale Köroğlu B, Arslan C, Akdoğan M, Köroğlu M, Çam H, et al. Osteosclerosis due to endemic fluorosis. Sci Total Environ. 2007;373:43–8.Google Scholar
  26. 26.
    Winn N, Lalam R, Cassar-Pullicino V. Imaging of Paget's disease of bone. Wien Med Wochenschr. 2017;167:9–17.CrossRefPubMedGoogle Scholar
  27. 27.
    John DR, Suthar PP. Radiological features of long-standing hypoparathyroidism. Pol J Radiol. 2016;81:42–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Jimenez-Garcia R, del Barrio J, Hernandez-Barrera V, Miguel-Díez J, Jimenez-Trujillo I, Martinez-Huedo M. Is there an association between diabetes and neck pain and lower back pain? Results of a population-based study. J Pain Res. 2018;11:1005–15.CrossRefPubMedGoogle Scholar
  29. 29.
    Kumar H, Boban M, Tiwari M. Skeletal fluorosis causing high cervical myelopathy. J Clin Neurosci. 2009;16:828–30.CrossRefPubMedGoogle Scholar
  30. 30.
    Wang W, Kong L, Zhao H, et al. Thoracic ossification of ligamentum flavum caused by skeletal fluorosis. Eur Spine J. 2007;16:1119–28.CrossRefPubMedGoogle Scholar
  31. 31.
    Di Giovanni T, Eliades T, Papageorgiou SN. Interventions for dental fluorosis: a systematic review. J Esthet Restor Dent. 2018;30:502–8.Google Scholar
  32. 32.
    Khairnar MR, Dodamani AS, Jadhav HC, Naik RG, Deshmukh MA. Mitigation of fluorosis—a review. J Clin Diagn Res. 2015;9:ZE05–9.PubMedGoogle Scholar

Copyright information

© ISS 2019

Authors and Affiliations

  • Meriem Sellami
    • 1
    Email author
  • Hend Riahi
    • 1
  • Kaouther Maatallah
    • 2
  • Hanen Ferjani
    • 2
  • Mouna Chelli Bouaziz
    • 1
  • Mohamed Fethi Ladeb
    • 1
  1. 1.Radiology Department, Orthopaedic Institute M T KassabUniversity of Tunis El Manar- Faculty of Medicine of TunisManoubaTunisia
  2. 2.Rheumatology Department, Orthopaedic Institute M T KassabUniversity of Tunis El Manar- Faculty of Medicine of TunisManoubaTunisia

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