Fluorosis

What is fluorosis?

Fluorosis is a condition that happens because of fluoride overexposure. Fluoride is a naturally occurring mineral. In small quantities, it helps prevent tooth decay. In large quantities, it’s harmful to your health. When it comes to how much fluoride you need, it’s all about balance.

Almost all water contains some fluoride. Depending on where you are in the world, your water source might contain too little or too much. The U.S. Department of Health and Human Services recommends a level of 0.7 milligrams per liter (mg/L) of fluoride in your drinking water. The goal is to get enough to reduce your risk of tooth decay, but not so much that you develop health problems.

Types of fluorosis

There are different types of fluorosis:

• Dental fluorosis affects your teeth. It happens when you have fluoride overexposure during the first eight years of your life. Dental fluorosis can be mild or severe, but it’s not painful. It’s a cosmetic concern that usually doesn’t affect your health or tooth function.
• Skeletal (bone) fluorosis affects your bones and joints. It can have a negative impact on your overall health, resulting in osteoporosis, arthritis and chronic joint pain. It happens when you have chronic fluoride overexposure for many years.
• Non-skeletal fluorosis is early-stage skeletal fluorosis. It affects your gastrointestinal tract and may cause symptoms like abdominal pain, constipation, diarrhea, bloating or loss of appetite.

How common is fluorosis?

Dental fluorosis is a common condition affecting people worldwide. In the U.S., it affects about 23% of the population.

Skeletal fluorosis is rare in the U.S., but it’s endemic (regularly occurring) in many parts of Asia and Africa. Most cases occur in India and China. It’s difficult to know exactly how many people have skeletal fluorosis in the world right now. But one study done in an area with high fluoride concentrations found that 94 out of 445 people had the condition.

In the United States, many areas have water with fluoride levels below 0.7 mg/L. That’s why so many local governments add it to the drinking water. But in other regions of the world, like parts of Asia and Africa, natural groundwater contains excessive amounts of fluoride. In India, the average concentration in drinking water is around 2.37 mg/L, and the highest recorded level is 9.22 mg/L. People living in these areas are far more likely to develop fluorosis compared to people living in the U.S.

What are the symptoms of fluorosis?

Symptoms vary depending on the type of fluorosis you have. In general, the more exposure to fluoride you’ve had, the more severe your symptoms.

Dental fluorosis symptoms

Tooth discoloration is the only symptom of dental fluorosis. Discoloration varies depending on severity. Dentists use the following terms to categorize fluorosis:

• Questionable: A few very light white flecks and white spots.
• Very mild: Light white areas covering less than 25% of your tooth surfaces.
• Mild: Light white areas covering less than 50% of your tooth surfaces.
• Moderate: White or light brown areas covering more than 50% of your tooth surfaces.
• Severe: White, light brown or dark brown spots affecting all surfaces. Your teeth may also have pitting (small depressions in your tooth enamel).

Skeletal and non-skeletal fluorosis symptoms

Early symptoms related to non-skeletal fluorosis include:

• Abdominal pain.
• Bloating.
• Constipation.
• Diarrhea.
• Joint pain and stiffness.
• Lower back pain.
• Muscle wasting.
• Nausea and vomiting.

As the condition worsens and skeletal fluorosis symptoms begin, you might develop:

• Bone fractures.
• Bone and spinal deformities.
• Mild cognitive impairment.
• Myelopathy (pain from spinal cord compression).
• Osteosclerosis (abnormal bone hardening).
• Radiculopathy (pain from a pinched nerve in your spinal column).
• Skin rash.
• Sleep disorders.

What causes fluorosis?

Fluorosis occurs due to fluoride overexposure. That means you ingest (swallow) excess amounts of fluoride over a long period of time. The way it happens depends on the type of fluorosis.

Dental fluorosis happens when a child consistently ingests too much fluoride while their permanent teeth are still forming under their gums. This includes drinking heavily fluoridated water or formula or swallowing large amounts of fluoride toothpaste.

Skeletal and non-skeletal fluorosis happens when a person (of any age) ingests large amounts of fluoride over the course of several years. This includes drinking heavily fluoridated water, or brewed beverages made from heavily fluoridated water.

Risk factors

A risk factor is something that increases your chances of developing a certain condition. Fluorosis risk factors are:

• Living in a region where groundwater has too much fluoride.
• Routinely drinking water that contains more than 0.7 mg/L of fluoride.
• Regularly swallowing a lot of fluoride toothpaste. (Tiny amounts are fine. But consuming extreme amounts over long periods of time can cause fluorosis.)
• Mixing fluoridated infant formulas with fluoridated water over long periods of time. (If you use fluoridated formula, mix it with non-fluoridated water. If you use fluoridated water, find a non-fluoridated baby formula.)

People who huff (inhale) fluorocarbons also have a higher risk of skeletal and non-skeletal fluorosis. Certain household products — like sealants, lubricants and air dust cleaners — contain fluorocarbons. Inhalant use disorder can lead to seizures, arrhythmias and sudden death.

If you huff substances to get high and want to stop, call SAMHSA’S National Helpline at 1-800-662-HELP (4357). They can give you the resources you need.

How is fluorosis diagnosed?

A dentist can diagnose dental fluorosis on your teeth during a routine exam. They may take dental X-rays to rule out other conditions.

It’s more difficult to diagnose skeletal and non-skeletal fluorosis because many of the symptoms overlap with other conditions. Healthcare providers usually need to run several tests, which may include:

• Imaging tests to check your bones, including X-rays, CT scans (computed tomography scans) and bone density tests (DXA).
• Blood tests to check the fluoride levels in your blood’s serum.
• Urinalysis to check the fluoride levels in your pee.

How is fluorosis treated?

Fluorosis treatment depends on the type of fluorosis you have. Healthcare providers can correct dental fluorosis with cosmetic dentistry.

Treating skeletal fluorosis is more complicated and depends on several factors. Specifically, it depends on the severity of symptoms and which part(s) of your body they affect.

Dental fluorosis treatment

If you have dental fluorosis, your dentist might recommend one of these cosmetic treatments:

• Teeth whitening. Your dentist applies bleaching gel to your teeth for a set amount of time. The gel lightens your tooth enamel, so it blends in with areas of fluorosis. Teeth whitening is a common option for mild fluorosis.
• Dental bonding. During this procedure, your dentist uses tooth-colored composite resin to cover up fluorosis stains. Then, they shape and polish your teeth.
• Dental veneers. Made from resin or porcelain, veneers are thin shells that cover the front surfaces of your teeth. Veneers are custom-made, so you’ll need dental impressions to get the correct fit and size.
• Dental crowns. This custom dental restoration fits over your entire tooth. Your dentist will need to remove some of your natural enamel so the crown fits properly.
• Enamel microabrasion. Your dentist removes a small layer of enamel from your teeth. This helps eliminate many fluorosis stains. Often, your dentist will follow enamel microabrasion with teeth whitening to make the color of your teeth even more uniform.

Skeletal and non-skeletal fluorosis treatment

The main goal is to remove the source of the problem. To do that, you’ll need to remove fluoride from your drinking water. You can filter your water using reverse osmosis, distillation or activated carbon filters. (Boiling water won’t work. While it removes impurities, fluoride is too strong to break down under heat.)

In addition, healthcare providers may recommend treatments like:

• Anabolic steroids. These medications can reduce symptoms of osteoporosis.
• Calcium and vitamin D. Together, calcium and vitamin D can reduce bone hardening. They may also change how your gut absorbs fluoride.
• NSAIDs (nonsteroidal anti-inflammatory drugs). These medications help control pain and inflammation related to skeletal fluorosis.

This isn’t an exhaustive list. Your healthcare provider will tailor your treatment plan to meet your unique needs.

Can fluorosis be prevented?

The only way to prevent fluorosis is to control the amount of fluoride you ingest. Here are some tips:

• Ask your local water company about fluoridation laws in your area.
• Test your well water or municipal water source for fluoride levels.
• Learn more about fluoridation concentrations in your area.

To reduce your child’s risk for fluorosis, be aware of how much fluoride they’re exposed to. While you don’t want them to get too much fluoride, you also want them to get enough while their teeth are developing. Appropriate levels are important for your child’s health.

What can I expect with fluorosis?

The outlook for dental fluorosis is good because it’s not harmful. You can correct it with in-office dental treatments.

The outlook for skeletal fluorosis depends on how early you detect it. The sooner you stop fluoride intake, the better your chances for long-term recovery.

How long fluorosis lasts

In general, fluorosis isn’t reversible. Once you have it, it doesn’t go away. Some studies show that treatment can improve symptoms of skeletal fluorosis. But it depends on how severe your symptoms are to begin with.

How do I take care of myself?

If you have fluorosis or live in an area where it’s common, the best thing you can do is stay aware. Be sure you know how much fluoride is in your drinking water. Once you know the levels, you can make informed decisions about your health.

When should I see my healthcare provider?

If you think you have dental fluorosis, schedule a visit with your dentist to discuss treatment options.

You should also tell your healthcare provider if you develop sudden symptoms of skeletal fluorosis, including nausea, joint pain or frequent broken bones. They can run tests to determine the cause.