A large number of fluorosis and arseniasis cases appeared in a mountainous area in northwest China. The residents relied on local inferior coal ("bone coal") of high fluorine and arsenic content for domestic heating and cooking. For deep-inside information about this rare case of co-endemia of fluorosis and arseniasis in the population in this special exposure scenario, a field investigation in one of the hyperendemic townships was conducted. The resident population registered (n = 27,713) was enrolled in the investigation. All cases were diagnosed and assigned to three symptom severity groups, that is severe, medium, and mild according to Chinese National Standard Criteria GB 16396-96 and to the technical guideline WS/T208-01 or WS/T211-01 issued by the Chinese Ministry of Health. Gender difference was analyzed by standardized incidence ratio. Age trend and severity trend were tested by χ(2) analysis. Fluorosis was diagnosed in 56.7% of the residents. Over 95% of the diagnosed arseniasis cases were simultaneously diagnosed with fluorosis symptoms. Combined fluorosis-arseniasis represented 11.9% of the total fluorosis cases and 6.7% of the local population. No gender-related differences in the prevalence of skeletal, dental, or dermal symptoms inside all severity groups were detected. Symptom severity increased with age. The high frequency of superposition of arseniasis with fluorosis might be due to the fact that the local resident population has been exposed to very high levels of fluorine and arsenic via the same exposure route.