Fluoride in drinking water and risk of hip fracture in the UK: a case-control study

Background Although the benefits of water fluoridation for dental health are widely accepted, concerns remain about possible adverse effects, particularly effects on bone. Several investigators have suggested increased rates of hip fracture in places with high concentrations of fluoride in drinking water, but this finding has not been consistent, possibly because of unrecognised confounding effects. Methods We did a case-control study of men and women aged 50 years and older from the English county of Cleveland, and compared patients with hip fracture with community controls. Current addresses were ascertained for all participants; for those who agreed to an interview and who passed a mental test, more detailed information was obtained about lifetime residential history and exposure to other known and suspected risk factors for hip fracture. Exposures to fluoride in water were estimated from the residential histories and from information provided by water suppliers. Analysis was by logistic regression. Findings 914 cases and 1196 controls were identified, of whom 514 and 527, respectively, were interviewed. Among those interviewed, hip fracture was strongly associated with low body-mass index (p for trend <0.001) and physical inactivity (p for trend <0.001). Estimated average lifetime exposure to fluoride in drinking water ranged from 0.15 to 1.79 ppm. Current residence in Hartlepool was a good indicator for high lifetime exposure to fluoride, After adjustment for potential confounders, the odds ratio associated with an average lifetime exposure to fluoride greater than or equal to 0.9 ppm was 1.0 [95% CI 0.7-1.5]. Interpretation There is a low risk of hip fracture for people ingesting fluoride in drinking water at concentrations of about 1 ppm. This low risk should not be a reason for withholding fluoridation of water supplies.