Hip Fractures

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Fluoridation and Hip Fractures

by John R. Lee, M.D.

The costs and health effects of osteoporotic fractures in the US are enormous. The total cost of fracture care is now about $9 billion/year. It is estimated that about 350,000 hip fractures occur per year and the incidence is rising.

A study by the University of Iowa’s Department of Preventive Medicine and Environmental Health, calculated that the lifetime risk of a fracture of the hip, spine or distal forearm is almost 40% in white women and 13% in men from age 50 years onward. Hip fractures account for 87-100% of fracture-related nursing home placements and 87-96% of short-term fracture costs.

In an effort to treat osteoporosis and prevent hip fracture, some doctors administer “therapeutic” doses of fluoride. Four US studies have examined the effect of these “therapeutic” doses and all of them found that, even though bone density appeared to increase, hip fracture rates increased within three years of treatment. In addition, all reported significant periarticular joint pain and gastrointestinal side effects in the treated subjects.

Dr. L. V. Avioli, Shoenberg Professor of Medicine at the Washington University School of Medicine, concluded that “sodium fluoride is accompanied by so many medical complications and side effects that it is hardly worth exploring in depth as a therapeutic mode for post-menopausal osteoporosis.” Dr. Saul Genuth, chairman of the FDA advisory committee that analyzed the fluoride/fracture findings, was quoted in the Medical World News as saying the FDA “should quietly forget about fluoride.”

More recently, attention has shifted to lower dosages of fluoride, such as found in fluoridated water. There are now at least eight studies that showed an increase of hip fracture incidence in fluoridated communities. They are summarized here:

In 1986, M.R. Sowers et al, in a retrospective study, found an increased fracture rate in both pre- and postmenopausal women relative to their water fluoride exposure.

In 1991, M.R. Sowers et al completed a prospective study again showing that water fluoride was correlated with more than double the unfluoridated fracture rates.

In 1991, Jacobsen et al showed a very strong positive correlation of hip fracture to fluoridation.

In 1991, C. Cooper et al showed a statistically significant increase of hip fracture incidence in England relative to fluoride content of drinking water ranging from 0 to 1 mg/L [ppm].

Also in 1991, C. Keller compared hip fracture rates in 216 US counties with natural fluoride concentrations in drinking water and found significantly higher fracture rates in counties with fluoride levels of >1.2 ppm.

D.S. May and M.G. Wilson reported finding that, as the percentage of persons exposed to fluoride in water increased, the hip fracture rate generally increased.

In 1992, C. Danielson et al reported that the risk of hip fracture was approximately 30% higher for women and 40% higher for men in fluoridated communities. Among women at age 75, the risk was about twice as high in fluoridated communities.

In 1995, H. Jaqmin-Gedda et al, scientists from the University of Bordeaux, France, studied hip fracture rates in 75 civil parishes in southwestern France and found (after adjustment for multiple alternative variables) an increased risk [odds ratio] for hip fracture of 1.86, i.e., 86% more likely, in parishes with water fluoride levels higher than 0.11 ppm.

In addition, a number of studies suggest fluoride induces pathologically mineralized bone and a deterioration in the overall strength of bone. A 1994 report by P. Fratzl et al in the Journal of Bone & Mineral Research described abnormal bone mineralization after fluoride treatments. In that same year, C.H. Sogaard et al reported a marked decrease in trabecular bone quality after just five years of sodium fluoride therapy. Pediatric orthopedists are finding that, here in the US, sports injuries to the young are rising sharply – ranging from stress fractures of the lower spine in young gymnasts to tendonitis in swimmers.
In 1992, orthopedic surgeon Carl L. Stanitski observed: “We are seeing more and more stress fractures in children and more and more injuries caused by repetitive use.” Some might argue that overuse and too much training are the cause, but others are concerned that something is causing defective bone and connective tissue of US kids, and that something might well be fluoridation.

Conclusion: All studies of fracture rates relative to long-term fluoridation exposure indicate a significant increase in fracture risk from fluoridation. The increased fracture risk due to fluoridation appears to range from 40-100%, depending on the age of the subjects studied. For women in their seventh decade who have been exposed to life-long fluoridation, the risk of hip fracture is approximately doubled. The risk increases with fluoride concentration at all levels over 0.11 ppm. Increased bone and connective tissue injuries of US youngsters should alert us to the probability that our high fluoride environment is adversely affecting our youngsters as well as our elderly.

John R Lee, MD, is the former director of the Marin Medical Society in California and the author of Optimal Health Guidelines, Optimal Fluoridation and Gilbert’s Disease and Fluoride Toxicity. The full text of this article was published in the research journal, Fluoride (Vol. 26 No. 4, pages 274-277, 1993).

JAMA on Fluoride and Hip Fractures

“‘Hip Fractures and Fluoridation in Utah’s Elderly Population,’ a study by C. Danielson et al [Journal of the American Medical Association, August 12, 1992, 268:746-8], compared the incidence of femoral neck fractures in a community with long-standing water fluoridation (to 1 ppm) with the incidence in two communities without water fluoridation (less than 0.3 ppm). The findings of this report support other epidemiologic studies suggesting that fluoride increases the risk of hip fracture.”
– Journal of the American Medical Association

“A review of recent scientific literature reveals a consistent pattern of evidence – hip fractures, skeletal fluorosis, the effect of fluoride on bone structure, fluoride levels in bones and osteosarcomas – pointing to the existence of causal mechanisms by which fluoride damages bones…. [Fluoridation] proponents must come to grips with a serious ethical question: is it right to put fluoride in drinking water and to mislead the community that fluoride must be ingested, when any small benefit is due to the topical action of fluoride on teeth.”
– Australian and New Zealand Journal of Public Health, 1997

Case studies from Fluoride Action Network

Due to its ability to increase vertebral bone mass, fluoride has been used as an experimental treatment for osteoporosis (doses > 20 mg/day). Fluoride treatment, however, proved far more harmful than beneficial. Not only was fluoride therapy shown to increase fracture rates among the treated patients, it was also found to cause spontaneous hip fracture. The clinical studies that found increased rates of spontaneous fractures are excerpted in section 1 below.

Fluoride’s ability to cause spontaneous fracture is believed to be the result of a mineralization defect that fluoride produces in bone which renders it more susceptible to stress fractures (“microfractures”). Clinical studies that linked fluoride to stress fracture are excerpted in section 2 below.

Due to the harm that fluoride caused to bone in the clinical trials, the FDA has rejected fluoride therapy as a safe of effective way of treating osteoporosis.

Fluoride & Spontaneous Bone Fracture:

“We report 11 fluoride-treated postmenopausal patients who developed spontaneous fractures of the femoral necks… [W]e believe that the available evidence strongly favors an association between spontaneous femoral fractures (stress and surgical) and NaF (sodium fluoride) plus Ca treatment under certain circumstances.”
SOURCE: Gutteridge DH, et al. (1990). Spontaneous hip fractures in fluoride-treated patients: potential causative factors. Journal of Bone and Mineral Research 5 Suppl 1:S205-15.

“Bone fragility during fluoride therapy for osteoporosis was observed in 24 (37.5%) of 64 patients treated with sodium fluoride, calcium, and vitamin D for 2.5 years who developed episodes of lower-limb pain during treatment. Eighteen (28%) of these patients had clinical and roentgenographic features of 41 stress fractures and 12 new spinal fractures. There were 26 periarticular, six femoral neck, three pubic rami, three tibia and fibula, one greater trochanter, and two subtrochanteric fractures. Vertebral fractures appeared first, then periarticular, then femoral neck, and lastly long-bone shaft fractures. All fractures were spontaneous in onset. The peripheral fracture rate during treatment was three times that in untreated osteoporosis.”
SOURCE: Schnitzler CM, et al. (1990). Bone fragility of the peripheral skeleton during fluoride therapy for osteoporosis. Clinical Orthopedics (261):268-75.

“In four of the six hip fractures in this study, the history strongly suggested that the fracture occurred before the patient fell. The spontaneous character of the fracture in our patients, and in other reports, suggest that fluoride treatment probably increases the risk of stress fractures.”
SOURCE: Hedlund LR, Gallagher JC. (1989). Increased incidence of hip fracture in osteoporotic women treated with sodium fluoride. Journal of Bone and Mineral Research 4:223-5.

“Thirteen cases of spontaneous fissure or fracture of the lower limbs observed in 8 patients under treatment with sodium fluoride are reported; 7 of these patients were being treated for osteoporosis… Fluor seems to be responsible for the fissures which cannot be avoided by calcium and/or vitamin D intake… When such fissures occur, fluoride therapy must be discontinued and the limb put at rest…”
SOURCE: Orcel P, et al. (1987). [Spontaneous fissures and fractures of the legs in patients with osteoporosis treated with sodium fluoride]. Presse Med 16:571-5.

“Two patients with moderate renal failure sustained spontaneous bilateral hip fractures during treatment with fluoride, calcium, and vitamin D for osteoporosis….As bilateral femoral neck fractures are very rare these data suggest a causal link between fractures and fluoride in patients with renal failure.”
SOURCE: Gerster JC, et al. (1983). Bilateral fractures of femoral neck in patients with moderate renal failure receiving fluoride for spinal osteoporosis. British Medical Journal (Clin Res Ed). 287(6394):723-5.

“Three or four of the fractures in the fluoride group appeared to be spontaneous hip fractures… We believe that the fluoride treatment here was probably partly responsible for the fractures in our cases.”
SOURCE: Inkovaara J, et al. (1975). Phophylactic fluoride treatment and aged bones. British Medical Journal 3: 73-74.

“Spontaneous fractures are fairly frequent.”
SOURCE: Roholm K. (1937). Fluoride intoxication: a clinical-hygienic study with a review of the literature and some experimental investigations. London: H.K. Lewis Ltd.

Stress Fracture: A likely Cause of fluoride-induced spontaneous Hip Fracture

“Stress fractures are part of a spectrum of structural inadequacy, spanning from a few asymptomatic microscopic fractures of trabeculae, which also occur in untreated individuals, to undisplaced stress fractures to displaced spontaneous fractures of the hip and long-bone shafts.”
SOURCE: Schnitzler CM, et al. (1990). Bone fragility of the peripheral skeleton during fluoride therapy for osteoporosis. Clinical Orthopaedics (261):268-75.

“Orcel et al (1988) from France described 18 patients with spontaneous lower limb fractures, including 10 with hip fractures, of which three became complete and required surgery… The femoral neck was the most common site of stress fracture.”
SOURCE: Gutteridge DH, et al. (1990). Spontaneous hip fractures in fluoride-treated patients: potential causative factors. Journal of Bone and Mineral Research 5(Suppl 1):S205-15.

“In four of the six hip fractures in this study, the history strongly suggested that the fracture occurred before the patient fell. The spontaneous character of the fracture in our patients, and in other reports, suggest that fluoride treatment probably increases the risk of stress fractures.”
SOURCE: Hedlund LR, Gallagher JC. (1989). Increased incidence of hip fracture in osteoporotic women treated with sodium fluoride. Journal of Bone and Mineral Research 4:223-5.

2) Fluoride & Stress Fracture:

“Some histomorphometric studies have confirmed that accumulation of fluoride in certain bone sites worsens microfractures… It is now widely recognized that the lower limb pain syndrome (in fluoride-treated patients) is related to the presence of bone fissures.”
SOURCE: Haguenauer D, et al. (2000). Fluoride for the treatment of postmenopausal osteoporotic fractures: a meta-analysis. Osteoporosis International 11(9):727-38.

“We report here stress fractures of the lower limbs occurring in patients undergoing fluoride therapy for osteoporosis. Similar features have been reported by several authors. These stress fractures could not be prevented by calcium supplementation in most of our patients.”
SOURCE: Orcel P, et al. (1990). Stress fractures of the lower limbs in osteoporotic patients treated with fluoride. Journal of Bone and Mineral Research 5(Suppl 1): S191-4.

“In 19 of the 20 (fluoride-treated) women wtih the acute lower-extremity pain syndrome, a search was made for incomplete (‘stress’) fractures by roentgenography of the painful area at least two weeks after the onset of the pain. Eleven such fractures were identified by the radiologist… The incomplete fractures resembled the stress fractures reported after a skeletal overload from athletic activities and, like them, occurred almost entirely in weight-bearing bones.”
SOURCE: Riggs BL, et al. (1990). Effect of fluoride treatment on the fracture rates in postmenopausal women with osteoporosis. New England Journal of Medicine 322:802-809.

“The rate of peripheral stress fractures of 25.6% per year in the present study was more than three times the overall fracture rate of 7% per year in untreated, osteoporotic post-menopausal women. The fact that periarticular stress fractures were confined to the lower limbs suggests that the bone had become too weak to withstand weight bearing.”
SOURCE: Schnitzler CM, et al. (1990). Bone fragility of the peripheral skeleton during fluoride therapy for osteoporosis. Clinical Orthopaedics (261):268-75.

“In four of the six hip fractures in this study, the history strongly suggested that the fracture occurred before the patient fell. The spontaneous character of the fracture in our patients, and in other reports, suggest that fluoride treatment probably increases the risk of stress fractures.”
SOURCE: Hedlund LR, Gallagher JC. (1989). Increased incidence of hip fracture in osteoporotic women treated with sodium fluoride. Journal of Bone and Mineral Research 4:223-5.

“It is now believed that the articular pain occuring during fluoride therapy is the result of microfractures.”
SOURCE: Pak CY. (1989). Fluoride and osteoporosis. Proceedings of the Society for Experimental Biology and Medicine 191: 278-86.

“Joint pain and swelling occur in about one third of treated patients. Although these features are generally attributed to rheumatic phenomena, such as synovitis or plantar fasciitis, it has been suggested that they are, in fact, due to juxtaarticular stress fractures. Until now this assertion has been based entirely on radiographic evidence. In the present paper we report the histologic features of one such lesion in a patient receiving fluoride, calcium, and 1a-vitamin D for postmenopausal osteoporosis.”
SOURCE: Schnitzler CM, Solomon L. (1986). Histomorphometric analysis of a calcaneal stress fracture: a possible complication of fluoride therapy for osteoporosis. Bone 7: 193-8.

“How fluoride can produce stress microfractures is unclear. That they are complications of fluoride therapy is clear, as there were no microfractures in the 101 patients in the calcium-treated group.”
SOURCE: O’Duffy JD, et al. (1986). Mechanism of acute lower extremity pain syndrome in fluoride-treated osteoporotic patients. American Journal of Medicine 80: 561-6.

“Periarticular pain and swelling during fluoride have usually been attributed to synovitis and our finding of synovial effusions in two such cases would seem to support this notion. However, in our patients passive movement of the affected joints did not aggravate the pain and examination of the synovial fluid revealed no sign of inflammation. We suggest that this is a sympathetic effusion secondary to juxta-articular stress fractures. Similarly, pain in the sole of the foot, usually ascribed to plantar fascitis, can be accounted for by calcaneal stress fractures. The arguments in favour of this explanation are persuasive: in our (as well as other) series, symptoms have been confined to the lower limbs, suggesting a mechanical rather than a ‘rheumatological’ cause; in each case pain was followed by the appearance of a radiodense band in the juxta-articular bone and in seven out of 17 instances there was a well-marked periosteal reaction. Radiographic signs of a stress fracture are unlikely to be present when the patient first complains of pain and in our cases they appeared 6-8 weeks after the onset of symptoms…”
SOURCE: Schnitzler CM, Solomon L. (1985). Trabecular stress fractures during fluoride therapy for osteoporosis. Skeletal Radioliology 14:276-9.

“An increased number of microfractures was found frequently in fluorotic bone. They were generally located in old bone with a high mineral-to-matrix concentration ratio… More frequent and abrupt variations in this ratio were found in fluorotic bone, and this probably increased the susceptibility of areas with a high ratio to microfractures.”
SOURCE: Baylink DJ, Bernstein DS. (1967). The effects of fluoride therapy on metabolic bone disease. Clinical Orthopaedics and Related Research 55: 51-85.

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