GO TO Inside CMA
GO TO Advocacy and Communications
GO TO Member Services
GO TO Publications
GO TO Professional Development
GO TO Clinical Resources

GO TO What's New
GO TO Contact CMA
GO TO Web Site Search
GO TO Web Site Map

Canadian Medical Association Journal
April 7'98

Fluoridation and fracture

CMAJ 1998;158:870

The article "Current and projected rates of hip fracture in Canada" (CMAJ 1997;157[10]:1357-63 [full text / résumé]), by Emmanuel A. Papadimitropoulos and colleagues, exhibits the "view through the wrong end of the telescope" that is so often criticized as a deficiency of allopathic medicine. This paper is excellent, in terms of pointing to the seriousness of the problem of proximal femoral fracture (PFF) in the elderly. However, it presents a limited view with regard to the cause. The "grabber" in the first sentence is that "Osteoporosis is an important public health problem, especially in postmenopausal women." The "clincher" in the Discussion refers to "the serious implications for Canadians if incidence rates are not decreased by some form of intervention."

The interventions implied are hormone replacement therapy for postmenopausal women and therapy with calcium, vitamin D, bisphosphonates, calcitonin and fluoride. One important aspect not mentioned is the mounting evidence of a positive relation between excess fluoride intake and PFF, especially as a result of the fluoridation of drinking water. Although the references for this paper include articles by S.J. Jacobsen and C. Cooper, the epidemiological studies of the same authors showing a statistically significant relation between residence in a "fluoridated" community and PFF1,2 are not cited. Also omitted are studies by other researchers showing a positive relation.3­5

The study reported in CMAJ found a lower incidence of PFF among men in BC than in the other 2 provinces studied — of the 3, BC happens to be the one with the least fluoridation. Several researchers have observed higher incidences of PFF in fluoridated than in non-fluoridated communities.3,6,7

The issue of the relation between fluoride and PFF is of concern at the level of government. For example, the Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine (F), published by the Agency for Toxic Substances and Disease Registry, US Public Health Services, includes the following statement:8

The weight of evidence . . . suggests that fluoride added to water can increase the risk of hip fracture in both elderly women and men. . . . If this effect is confirmed, it would mean that hip fracture in the elderly replaces dental fluorosis in children as the most sensitive end point of fluoride exposure.
The discontinuation of fluoridation should be considered — along with diet, exercise and decreased tobacco and alcohol consumption — as a frontline strategy to prevent PFF. The issue of prevention should be addressed before we immerse ourselves in the debate about which treatment is best and which causes the lowest incidence of iatrogenic illness.

Richard G. Foulkes, MD
Abbotsford, BC


  1. Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA. Regional variation in the incidence of hip fracture. US white women aged 65 and older. JAMA 1990;264(4):500-2.
  2. Cooper C, Wickham C, Barker DJR. Water fluoridation and hip fracture [letter]. JAMA 1991;266(4):513-4.
  3. Danielson C, Lyon JL, Egger M, Goodenough GK. Hip fractures and fluoridation in Utah's elderly population. JAMA 1992;268(6):746-8.
  4. Jaqmin-Gadda H, Commenges D, Dartiques JF. Fluorine concentration in drinking water and fractures of the elderly (France) [letter]. JAMA 1995;273(10):775-6.
  5. Sowers MFR, Clark MK, Jannausch ML, Wallace RB. A prospective study of bone mineral content and fracture in communities with differential fluoride exposure. Am J Epidemiol 1991;133:649-60.
  6. Saurez-Almazor ME, Flowerdew G, Saunders LD, Soskolne CL, Russell AS. The fluoridation of drinking water and hip fracture hospitalization rates in two Canadian communities. Am J Public Health 1993;83(5):689-93.
  7. Jacobsen SJ, Goldberg J, Cooper C, Lockwood SA. The association between water fluoridation and hip fracture among white women and men aged 65 years and older. A national ecologic study. Ann Epidemiol 1992;2:617-26.
  8. Agency for Toxic Substances and Disease Registry, US Public Health Services. Toxicological profile for fluoride, hydrogen fluoride, and fluorine (F). Cat no TP-91/17. Washington: US Department of Health and Human Services. 1993. p. 56-7.

Comments Send a letter to the editor
Envoyez une lettre à la rédaction