Social and Nutritional Factors in Adolescent Osteochondritis of the Spine

Introduction The association of endemic dental fluorosis with skeletal changes in the native inhabitants of certain villages in the Madras Presidency was first reported by Shortt and others (1937). Similar bone lesions due to an excess of fluorine in drinking water have been recorded in natives in South Africa (Ockerse, 1941) and in aboriginal tribes in China (Lyth, 1946). The evidence that these changes are caused by fluorine is conclusive, for the radiological appear ances are identical with those found in industrial workers with fluorine (M0ller and Gudjonsson, 1932; Wilkie, 1940) and in the skeletal changes produced experimentally by feeding fluorine to animals (Roholm, 1937). In some cases the clinical features of endemic skeletal fluorosis resemble those seen in the type of ankylosing spondylitis (Marie Strumpell) known in this country as " bamboo spine," which occurs chiefly in young men. Further more, fluorosis tends to affect the spine at a later age and it is common to both sexes. The radiological appearances are totally different (Kemp, 1946). The level of fluorine, about 3 to 4 parts per million (p.p.m.), in the drinking waters associated with bone lesions seen in India and among indigen ous populations in other parts of the world, is often no greater than the amount present in certain English waters, for example at Maldon in Essex, but in this country the social environment is never so unfavourable, and severe skeletal deformity is not seen. As a trace-element, the concentration at which fluorine is effective suggests a catalytic effect and/pr an inhibitor action on certain enzyme systems. Epidemiological studies in the United States combined with standardized grading of dental fluorosis showed less dental caries and more teeth of good structure among people who had used drinking water containing fluorine 0-5 to 1 0 p.p.m. for at least the first eight years of life, that is to say before calcification of the dental enamel is complete (vide Murray and Wilson, 1946). Observations on fluorosis and nutrition in Morocco have made it likely that the effect of fluorine on the development and structure of the dental enamel depends very much on the state of general nutrition (Murray and Wilson, 1948). In certain Oxfordshire villages where severe dental fluorosis is seen amongst the inhabitants, no evidence of developed skeletal fluorosis was found (Kemp and others, 1942), but there was a remarkable incidence of changes in the spines of children of the type described by Scheuremann (1921 and 1936) as kyphosis dorsalis juvenilis! In one school at least a third of the children were affected. The worst cases were seen in the lower social classes, among the younger members of large families, or in children with a history of defective nutrition in the early years. A group of poor Oxford city children examined at this time?the incidence of dental fluorosis in Oxford city as a whole is negligible? showed no such changes. In general the children showing the radiological changes of juvenile . osteochondritis had no complaints, yet many were deformed. The induced changes can, however, give rise to pain under conditions of strain or stress in later life. We have traced the progress of some of these cases and found that further changes have ensued in early adult life. Later we advanced further evidence to show that the occurrence of the disease was related to sustained malnutrition, and that benefit can result from improvements in the diet (Kemp and Wilson, 1947). The changes are not entirely confined to children of the poorer classes, but they certainly occur less frequently in the children of the " well-to-do." Whenever we have seen a case from the higher-income groups, there has been a history of long-continued ill-health or of feeding difficulties (Kemp and Wilson, 1948). Other contributory factors are postural disturbances and the rate at which growth occurs. The original radiographs illustrating the disease have been published elsewhere (vide Kemp and Wilson, 1947). The accompanying line drawings taken from a severe case, and from a normal spine for comparison, illustrate the changes observed in this condition.