CASE REPORT A 45-year-old man presented to the Department of Medicine at our institution with 1 year of noninflammatory pain in multiple joints. The pain had begun in both knee joints, followed by low-back ache and neck, wrist, and foot pain. There was no associated fever or swelling of any joint. The patient did not report any history of addiction or illness but did report using fluoridated toothpaste. The patient also lived in a region of India where the problem of fluorosis is endemic. On examination, we found his teeth had brown strains and rough, pitted enamel (Figure 1). There was diffuse tenderness at the cervical spine, the lumbosacral spine, and elbow, wrist, knee, and ankle joints. There was no swelling or restriction of movement in any of these areas. There were no neurologic deficits, and the rest of the physical examination was normal. X-ray scans showed osteosclerosis of the knee (Figure 2), ankle, wrist, pelvis, and vertebral column, and calcification of the sacrotuberous ligament (Figure 3) and the posterior longitudinal ligament (Figure 4). Twenty-four-hour urinary fluoride levels were elevated (18 ppm). The patient was advised to avoid fluoridated water, fluoridated toothpaste, and foods containing fluoride. He was kept under close follow-up and was educated about the potential development of neurologic symptoms and signs.