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Background:

Although randomized controlled trials (RCTs) have demonstrated that high fluoride increases bone mineral density (BMD) and skeletal fragility, observational studies of low-dose chronic exposure through drinking water ($<1.5\mathrm{mg}/\mathrm{L}$, the maximum recommended by the World Health Organization) have been inconclusive.

Objective:

We assessed associations of fluoride in urine, and intake via diet and drinking water, with BMD and fracture incidence in postmenopausal women exposed to drinking water fluoride $\le 1\mathrm{mg}/\mathrm{L}$.

Methods:

Data were from participants in the Swedish Mammography Cohort–Clinical, a population-based prospective cohort study. At baseline (2004–2009), fluoride exposure was assessed based on urine concentrations ($n=\mathrm{4,306}$) and estimated dietary intake (including drinking water) ($n=\mathrm{4,072}$), and BMD was measured using dual energy X-ray absorptiometry. Incident fractures were ascertained via register-linkage through 2017. Residential history was collected to identify women with long-term consistent drinking water exposures prior to baseline.

Results:

At baseline, mean urine fluoride was $1.2\mathrm{mg}/\mathrm{g}$ creatinine ($\pm 1.9$) and mean dietary intake was $2.2\mathrm{mg}/\mathrm{d}$ ($\pm 0.9$), respectively. During follow-up, 850, 529, and 187 cases of any fractures, osteoporotic fractures, and hip fractures, respectively, were ascertained. Baseline BMD was slightly higher among women in the highest vs. lowest tertiles of exposure. Fluoride exposures were positively associated with incident hip fractures, with multivariable-adjusted hazard ratios of 1.50 (95% CI: 1.04, 2.17) and 1.59 (95% CI: 1.10, 2.30), for the highest vs. lowest tertiles of urine fluoride and dietary fluoride, respectively. Associations with other fractures were less pronounced for urine fluoride, and null for dietary fluoride. Restricting the analyses to women with consistent long-term drinking water exposures prior to baseline strengthened associations between fractures and urinary fluoride.

Discussion:

In this cohort of postmenopausal women, the risk of fractures was increased in association with two separate indicators of fluoride exposure. Our findings are consistent with RCTs and suggest that high consumption of drinking water with a fluoride concentration of $\sim 1\mathrm{mg}/\mathrm{L}$ may increase both BMD and skeletal fragility in older women. https://doi.org/10.1289/EHP7404