Textbook Water Fluoridation Principles Practices American Water Works Association Ebook All Chapter PDF
Textbook Water Fluoridation Principles Practices American Water Works Association Ebook All Chapter PDF
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M4
Water Fluoridation
Principles & Practices
Sixth Edition
Copyright © 1977, 1987, 1988, 1995, 2004, 2016 American Water Works Association
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopy, recording, or any information or retrieval system,
except in the form of brief excerpts or quotations for review purposes, without the written permission of
the publisher.
Disclaimer
The authors, contributors, editors, and publisher do not assume responsibility for the validity of the
document or any consequences of its use. In no event will AWWA be liable for direct, indirect, special,
incidental, or consequential damages arising out of the use of information presented in this book. In
particular, AWWA will not be responsible for any costs, including, but not limited to, those incurred as a
result of lost revenue. In no event shall AWWA’s liability exceed the amount paid for the purchase of this
book.
If you find errors in this manual, please email [email protected]. Possible errata will be posted at
www.awwa.org/resources-tools/resource.development.groups/manuals-program.aspx.
ISBN-13 978-1-62576-170-5
eISBN-13 978-1-61300-383-1
List of Figures, v
List of Tables, vii
Preface, ix
Acknowledgments, xi
Chapter 1 Water Fluoridation ................................................................................................... 1
Introduction, 1
Occurence, 2
History of Use (Growth of Community Water Fluoridation), 2
Regulatory, 5
References, 8
Chapter 2 Health and the Human Body ................................................................................. 9
Fluoride in the Human Body, 9
Discovery of the Benefits of Fluoride, 10
Fluoride Delivery, 15
References, 15
Chapter 3 Fluoride Products ................................................................................................... 17
Chemical Characteristics, 17
Chapter 4 System Planning .................................................................................................... 25
Deciding Whether to Fluoridate, 25
Fluoride Application Point, 27
Project Permitting and Planning, 28
Process of Implementing Fluoridation, 29
Chapter 5 Design, Equipment, and Installation ................................................................ 37
Saturators, 37
Dry Feeders, 39
Solution Dissolving Tanks, 41
Fluorosilicic Acid Feed Systems, 42
Metering Pumps, 42
Flow Meters, 43
Scales, 43
Storage of Bulk Fluoride Products, 44
Day Tanks, 44
Bag Loaders, 45
Backflow Prevention Devices, 45
Piping and Valves, 45
Corrosion Control, 46
Continuous Analyzers, 46
Injection Location, 47
Calibration Cylinders, 47
Wastewater Connections, 47
Facility Construction and Startup, 48
References, 50
Index, 127
AWWA Manuals, 131
AWWA Manual M4
3-1 Density of fluorosilicic acid vs. percentage based on data provided by The Mosaic
Company, 21
7-1 Activated alumina with pH adjustment fluoride removal water treatment plant, 71
AWWA Manual M4 v
6-1 Analytical methods currently approved for use for SDWA monitoring programs, 55
6-2 Interferences for ISE measurements, 56
6-3 Measured relative error for ISE method compared to SPADNS method, 59
6-4 Recommended overfeed actions, 63
The American Water Works Association has been an active partner in water fluoridation from
the original pioneering studies on its implementation and effectiveness from 1945 through 1951,
and has supported community water fluoridation since 1951.
In addition, from the 1940s to the 1960s, the US Public Health Service provided national
leadership in water fluoridation practice and issued periodic technical advisories on water fluo-
ridation. The US Environmental Protection Agency (USEPA) provided support and guidance on
technical practice from 1972 to 1978 until the Centers for Disease Control and Prevention (CDC)
assumed responsibility for providing support to state water fluoridation programs in 1978.
These organizations’ wealth of knowledge gained through the experiences and manage-
ment of several thousands of fluoridation process installations can improve future installations
and enhance successful continued operations to provide improved health for our communities.
This manual is a resource to assist decision makers planning to use fluoridation treatment,
engineers designing and installing these facilities, and water utility personnel managing water
operations. The manual presents guidelines and is not intended to take the place of expert
advice. Anyone planning or using fluoridation should carefully consider fluoride research,
regulations, and methods. State or provincial regulatory requirements should always be the
first point of reference for water fluoridation design and practices to improve the health of the
citizens.
The first edition of the American Water Works Association M4 Water Fluoridation Principles
& Practices was prepared from material supplied and previously published by the USEPA. The
second edition was updated and revised using additional technical collaboration with the US
Centers for Disease Control and Prevention. The third, fourth, and fifth editions were updated
and revised incrementally by section. This sixth edition represents a substantial updating and
revising of the manual’s content to remain consistent with industry practices and to reflect
changes in regulatory and public health guidance and the experience of contributing authors.
AWWA Manual M4 ix
This manual was revised by the AWWA Treatment Plant Operations and Maintenance
Committee.
The following committee members served as the editorial review board in the preparation
of this edition of the manual:
Molly Beach, former Manuals Specialist, Mindy Burke, current Manuals Specialist, and
Steven J. Posavec, Standard Methods Manager, provided AWWA staff support.
The editorial review committee would like to acknowledge the contribution of Kip Duchon,
National Fluoridation Engineer for the Centers for Disease Control and Prevention, for his
assistance during the editing process.
AWWA Manual M4 xi
M4
Chapter 1
Water Fluoridation
INTRODUCTION
The goal of this manual is to assist with the planning and operation of fluoridation sys-
tems by decision makers, design engineers, and water utility personnel. This chapter
discusses fluoride occurrence, growth of community water fluoridation, and legal issues
surrounding fluoridation. The regulatory requirements of community water fluoridation
are also addressed, including both federal regulations and the varying approaches states
have used to implement fluoridation programs. Additionally, fluoridation outside of the
United States is discussed.
Fluoridation in this manual refers to the addition of fluoride to drinking water to
maintain a recommended level to improve oral health. Fluoridation was named as one of
the Ten Great Public Health Achievements in the 20th Century by the Centers for Disease
Control and Prevention (CDC) along with the use of chlorine for disinfection of public
water supplies (CDC Morbidity and Mortality Weekly Report, April 2, 1999). Control of
infectious diseases has resulted from clean water and improved sanitation. Infections
such as typhoid and cholera transmitted by contaminated water, a major cause of illness
and death early in the 20th century, have been reduced dramatically by improved sanita-
tion. Water fluoridation was first implemented in 1945, and in 1951, the National Research
Council (NRC) of the National Academy of Sciences (NAS), the US Surgeon General, and
professional organizations including the American Water Works Association (AWWA)
and the American Dental Association (ADA) recommended that communities implement
water fluoridation. The US Public Health Service (USPHS) recommended a range of 0.7
to 1.2 mg/L (based on annual average ambient temperature) as part of the 1962 Drinking
Water Standards. In 2011, the US Department of Health and Human Services (USHHS)
proposed changing the recommended fluoride level in drinking water to a single value of
0.7 mg/L. According to national health surveillance statistics reported by the USPHS and
the CDC, the number of people with access to fluoridated water continues to increase and
in 2012, 210.6 million people in the United States had access to fluoridated water.*
* 2012 Water Fluoridation Statistics from the US Centers for Disease Control (CDC).
OCCURRENCE
Fluorine, a gaseous halogen, is the 13th most abundant element in the earth’s crust.
Fluorine is also the most electronegative element, so it is not found in its free elemental
form in nature. Instead, it exists as a mineral such as fluorosilicates in granites, calcium
fluorides in some ores, along with other mineral forms, or as a dissolved reduced ionic
form in solution. Fluoride ion solubility varies, but the sodium and potassium salts of
fluoride are highly water soluble.
There are both natural and anthropogenic sources of fluoride. Natural sources of
fluoride include volcanic and geothermal activity emissions, weathering of certain types
of rocks, wind-blown erosion of soils, and marine origin. Commercial ore deposits of flu-
orspar, fluorapatite, and cryolite are the source for most fluoride products. Anthropogenic
releases of fluoride occur predominantly because of the burning of coal for power pro-
duction and are also caused by manufacturing, steel and aluminum production, and oil
refining.
Fluoride is ubiquitous in the environment and therefore likely to be present to some
extent in all water sources. Seawater contains approximately 1.2 to 1.5 mg/L of fluoride.
The concentration present in source water is often equal to the fluoride in rainfall, which
is typically 0.1 to 0.2 mg/L. However, natural levels in proximity to volcanic sources can
be significantly higher because volcanic emissions are recognized as a significant envi-
ronmental source. The naturally occurring concentrations in surface waters are gener-
ally lower than those needed to promote good dental health. Fluoride concentrations in
groundwater can be more variable than in surface water, with the concentration depen-
dent on the geological setting. In the United States, groundwater levels typically range
from nondetectable levels to greater than 4 mg/L. However, elevated levels of naturally
occurring fluoride are not common. Based on reported natural fluoride levels in commu-
nity public water systems, the CDC estimates that less than 0.5% of the US population
served by public water systems has natural fluoride levels exceeding 2 mg/L, and less than
0.1% of the population served by public water supplies has naturally occurring fluoride in
excess of 4 mg/L. The US Geological Survey (USGS), in a survey of private groundwater
wells, estimated that up to 4% of private wells exceed 2 mg/L and up to 1.2% exceed 4
mg/L (Quality of Water from Domestic Wells in the United States, Leslie DeSimone et al.
November 2009). Private wells can have a higher incidence of elevated fluoride as many
homeowners do not test their wells for contaminants, while public water supplies are
required to report on contaminants levels and have worked to identify alternate sources
when possible.
AWWA Manual M4
city implemented community water fluoridation, while at least one other city acted as the
control. The cities had parallel characteristics except for the fluoride content of the water
supply. Several of these studies, implemented between 1945 and 1947, are listed here (nat-
urally occurring fluoride levels are given in parentheses):
1. Grand Rapids, Mich. (0.15 mg/L): Adjusted to 1.0 mg/L as part of this study. This
city was compared with the control cities of Muskegon, Mich. (0.15 mg/L) and
Aurora, Ill. (naturally 1.2 mg/L).
2. Newburgh, N.Y. (0.1 mg/L): Adjusted to 1.1 mg/L as part of this study. The control
city for this trial was Kingston, N.Y. (0.1 mg/L).
3. Evanston, Ill.: Adjusted to approximately 1 mg/L as part of this study. This city
was compared with the control city of Oak Park, Ill. (negligible amounts of natural
fluoride).
4. Brantford, Ont. (0.1 mg/L): Adjusted to 1.0 mg/L as part of the study. This city was
compared with the control cities of Sarnia, Ont. (0.1 mg/L), and Stratford, Ont.
(naturally 1.2 mg/L).
On Jan. 25, 1945, Grand Rapids, Mich., became the first city to add fluoride to its
water supply. In this study, the oral health in Grand Rapids was compared with that of
Muskegon, a nearby community consuming water from the same source without fluoride
addition. Six years after the study began, surveys indicated that tooth decay levels in six-
year-old children (i.e., those born since fluoridation commenced) in Grand Rapids was
approximately half that of Muskegon.
At the time of these early community trials, poor oral health and widespread dental
decay was common, so favorable results were met with great interest. The analysis of the
first results from these community trials was published by the National Research Council
(NRC) of the National Academy of Sciences (NAS) in November 1951 and summarized
in the January 1952 issue of Journal AWWA (Vol. 44, no. 1, 1–8) with the recommenda-
tion that all cities with a child population of sufficient size should fluoridate the water
supply. Preliminary reports from the NRC in 1951 prompted the US Surgeon General to
recommend that cities should fluoridate their water supplies. In July 1951, city officials
in Muskegon decided to withdraw from the study and fluoridate the city’s water sup-
ply. Similar results were observed in the other trials referenced, i.e., significant reduction
in dental decay rates was observed in the cities that were fluoridating, with little or no
change in the controls. Since that time, the US population receiving optimally fluoridated
drinking water has continued to increase (Figure 1-1).
In 1951, major organizations such as the USPHS, NRC, US Surgeon General, and
AWWA all endorsed community water fluoridation. In 1962, the USPHS recommended
that fluoride in drinking water should be 0.7 to 1.2 mg/L based on ambient annual tem-
perature to reflect the different consumption of water between warmer climates and cooler
climates. In 2011, the Department of Health and Human Services proposed changing this
range to a single recommended value of 0.7 mg/L to reflect modern exposures and water
consumption; this is discussed in further detail in chapter 2.
The AWWA policy statement on fluoridation was adopted by the organization’s
board of directors on Jan. 25, 1976, reaffirmed on Jan. 31, 1982, and revised on Jan. 20, 2002,
Jan. 21, 2007, and Jan. 22, 2012. The official text is as follows:
AWWA Manual M4
350
Total US population
Total community water system population
300
Total fluoridated water population
Population receiving adjusted fluoridated water
250 Population receiving naturally fluoridated water
Population (millions)
200
150
100
50
0
1940 1946 1948 1950 1952 1954 1956 1958 1960 1962 1964 1969 1975 1985 1989 1992 2002 2006
Year
In 1945, Brantford, Ont., became the first Canadian city to add fluoride to its water
as part of the community trials referenced previously. Approximately 45 percent of the
Canadian population using public water supplies receives fluoridated water.
As the use of drinking water fluoridation increased in the United States and Canada,
countries in Europe, South America, Africa, and Asia also began implementing water
fluoridation. By the year 2004, water fluoridation was being practiced in more than 60
countries for almost 405 million people. In addition, another 50 million people have
water supplies that are considered naturally fluoridated at levels sufficient for good oral
health. Fluoridation is practiced extensively in Australia, Brazil, Canada, Chile, Columbia,
Ireland, Israel, Malaysia, New Zealand, People’s Republic of China, Hong Kong, Singapore,
and the United Kingdom. In addition to US organizations such as the American Medical
Association (AMA), American Dental Association (ADA), and the CDC, international
organizations such as the World Health Organization (WHO) support water fluoridation.
More detailed information about fluoridation in the international community can be
found in the American Dental Association’s Fluoridation Facts document.
AWWA Manual M4
Legal Issues
Fluoridation of public water supplies has not been without controversy. Opponents of
community water fluoridation have challenged its safety and effectiveness. The legality of
fluoridation has been tested in the courts numerous times. Beginning in 1952, injunctions
were sought in some communities to prevent the initiation or continuance of fluoridation.
These cases were generally based on the following types of arguments:
REGULATORY
Federal
Fluoridation of public water supplies is not mandated by the US Environmental Protection
Agency (USEPA) or any other federal agency in the United States. The 1974 Safe Drinking
Water Act (SDWA) specified that no national primary drinking water regulation can
require the addition of any substance for preventive health benefits not related to drinking
water contamination. This prohibition inherently established fluoridation as a decision to
be made by each individual state or local municipality.
The SDWA further required that the USEPA determine the level of contaminants in
drinking water at which no adverse health effects are likely to occur, and to apply limits
based on possible health risks assuming a lifetime of exposure. These limits (which are
nonenforceable) are maximum contaminant levels goals (MCLGs). The enforceable limits
AWWA Manual M4
are maximum contaminant levels (MCLs). Though MCLs are set as close as possible to
MCLGs, the enforceable MCLs must also consider cost, the ability to provide a meaningful
impact on human health, and the ability of utilities to detect and remove contaminants.
MCLs are never lower than MCLGs, but may be higher.
The Interim Regulation for Fluoride was promulgated in 1975 as a National Interim
criteria with the MCL varying from 1.4 to 2.4 mg/L based on annual ambient temperature
that was double the level recommended by the USPHS. This Interim Standard was chal-
lenged in 1981 by South Carolina with a request to delete the MCL but instead implement a
Secondary Maximum Contaminant Level (SMCL) for dental fluorosis. In 1986, the USEPA
established the current regulatory basis for fluoride in drinking water with a MCL of 4
mg/L and a SMCL of 2 mg/L. The MCLG and MCL for fluoride are both 4 mg/L. This con-
centration is the level below which a lifetime of exposure is not expected to cause health
problems associated with skeletal fluorosis, a crippling disease, and is an enforceable max-
imum allowable concentration under the SDWA. As of the publication of this manual,
USEPA was in the process of reviewing its criteria for fluoride.
The USEPA has established the secondary drinking water regulations with asso-
ciated SMCLs, which are nonenforceable guidelines. The secondary contaminant list is
based on aesthetic (taste, odor, staining of clothes or materials) or cosmetic effects (skin or
tooth discoloration). Fluoride is the only contaminant other than copper that has both a
primary and secondary standard. The SMCL for fluoride is 2 mg/L and is meant to prevent
discoloration or pitting of teeth in children exposed during their formative years to water
with high naturally occurring levels of fluoride. The SMCL seeks to balance the benefi-
cial effects of fluoridation (protection against dental caries) with the undesirable cosmetic
effects caused by excessive exposure. A state may choose to adopt a secondary standard
(or any level lower than the federal MCL) as its enforceable standard.
The SDWA requires that water utilities notify customers in their annual Consumer
Confidence Report when any regulated contaminant exceeds the regulatory limit in its
treated water, regardless of whether the contaminant is naturally occurring or added as
part of the treatment process. Any public water system that exceeds the primary or sec-
ondary MCL for fluoride should consult with its primary drinking water administrator to
clarify the specific requirements for public notification. In general, an exceedance of the
4 mg/L MCL must meet the Tier 2 public notification requirements. An exceedance of the
2 mg/L SMCL must meet the Tier 3 public notification requirements. Because some states
use the SMCL as the enforceable standard, the public notification requirements may differ
from state to state. Any water utility serving a community considering fluoridation should
have a firm understanding of the notification requirements in its state prior to initiating
fluoridation.
AWWA Manual M4
In addition to the states listed in Table 1-1, Washington, D.C., and Puerto Rico have
fluoridation mandates. The US Army Corps of Engineers Washington Aqueduct (the
wholesale water supplier to the District of Columbia Water and Sewer Authority; Arlington
County, Va.; and the City of Falls Church, Va.) has been adding fluoride since 1952.
Puerto Rico enacted legislation in 1998 requiring water fluoridation as needed to
bring the fluoride concentration to an optimal level. The standards are governed by the
Department of Health and operational compliance is overseen by the Aqueduct and Sewer
Authority. Although Puerto Rico requires community water fluoridation, it is not widely
practiced primarily due to infrastructure issues.
Although only 13 states have a fluoridation mandate, no state prohibits fluoridation.
In most states, the decision is made at a local (regional or municipal) level. The decision at a
local level can arise and be implemented in several ways. As an example, a local municipal
health agency may make the recommendation to a city’s governing body (i.e., mayor, city
council, etc.). The local legislature may put the recommendation to referendum as a ballot
question during a future election. Some municipalities have local ordinances requiring
fluoridation. A local ordinance may be instituted if the legislature grants the recommend-
ing health agency the authority to require fluoridation without a referendum. The issue
can become more complex when a public water supplier serves more than one municipal-
ity, such as in consecutive systems.
In most cases, the water supplier is not the entity that authorizes fluoridation,
although it is tasked with implementation. The mandate to fluoridate can be the result of
a legislative act or a directive from a state or local health agency. Regardless of the mech-
anism by which fluoridation was instituted, the water supplier is responsible for work-
ing with its primary regulatory drinking water administrator to ensure compliance with
relevant permit requirements, such as design and maintenance of the fluoride chemical
feed system, monitoring of fluoride levels in water samples, reporting data, and public
notification.
The obligation a utility may have under fluoridation requirements is likely to be dif-
ferent in different communities. It is imperative that the water utility in any community
considering fluoridation consult with its state drinking water administrator throughout
the process of consideration and implementation of fluoridation.
AWWA Manual M4
REFERENCES
Susan Griffin, K. Jones, and S.L. Tomar. 2001. An Economic Evaluation of Community Water
Fluoridation. Journal of Public Health Dentistry 61(2):7886. http://onlinelibrary.wiley.com
/doi/10.1111/j.1752-7325.2001.tb03370.x/pdf.
DeSimone, L.A. 2009. Quality of Water from Domestic Wells in Principle Aquifers of the United
States. Reston, VA: US Geologic Survey.
Center for Disease Control. 2012. Fluoridation Growth. Atlanta, GA: CDC.
Health Canada. 2010. Fluoride and Human Health. Ottawa, ONT; Health Canada.
AWWA Manual M4
M4
Chapter 2
This chapter focuses on the health effects of fluoride and, in particular, the role of fluoride
in preventing tooth decay.
AWWA Manual M4
Once the agent causing fluorosis had been identified, research into the occurrence
and dose-response relationships could commence. In the 1930s, H. Trendley Dean, the
head of the Dental Hygiene Unit of the US Public Health Service (PHS), and McKay col-
laborated to better understand the adverse health effects of fluoride in drinking water.
As the investigations continued with few adverse effects but increasing evidence of the
benefits, their research continued to determine optimal fluoride concentrations in drink-
ing water to balance the benefits of fluoride with the adverse effects. Dean identified loca-
tions around the United States with naturally occurring levels of fluoride, establishing a
community fluorosis index. This led to further studies that quantified the dose-response
relationship between fluoride, mottling, and the reduction of dental caries. The 21 Cities
study in 1942 by Dean used environmental observations to establish a basis for an optimal
level of fluoride for oral health benefits. From this research stemmed an optimal level of
fluoride that both maximized caries reduction in a community while minimizing adverse
health effects. Three distinct relationships were recognized:
Community water fluoridation studies in the 1940s were initiated to test the hypoth-
esis that dental caries could be prevented by adjusting the fluoride level of community
water supplies from negligible levels up to 1.0 to 1.2 mg/L. Studies were conducted in
four pairs of cities in the United States and Canada, and caries were reduced 50 percent
to 70 percent among children in communities with fluoridated water. These studies estab-
lished fluoridation as a practical and effective public health measure.
In 1962, the USPHS set the recommended range of fluoride in drinking water from
0.7 mg/L (in warmer climates) to 1.2 mg/L (in colder climates). A range was recommended
because average water consumption was believed to vary with average daily air tempera-
ture with an increased consumption of water in warmer locations. In January 2011, the US
Department of Health and Human Services proposed as the recommended level of fluo-
ride for community water systems a single value of 0.7 mg/L, which is the lowest level of
the accepted beneficial range. The basis for setting the recommended value near the lowest
recognized beneficial fluoride level is twofold: (1) Multiple sources of fluoride contribute to
modern exposure levels, and (2) studies conducted since the recommended range was first
introduced indicate that water consumption is not dependent on ambient air temperature
as was once believed.
Dental Health
Dental caries, or tooth decay, is a largely preventable bacterial disease. Nearly everyone
suffers from dental caries, making tooth decay the most prevalent chronic human disease.
Before the widespread use of fluoride, more than 98 out of every 100 Americans experi-
enced tooth decay by the time they reached adulthood. Tooth decay begins in early child-
hood and reaches a peak in adolescence, with the highest incidence of tooth decay being
found in school-aged children. In the United States, tooth decay is experienced by more
than 40 percent in the primary teeth of children ages two to 11 years, more than 60 percent
AWWA Manual M4
AWWA Manual M4
Demineralization
Acid
Calcium
Enamel Crystal = Phosphate
Carbonated Apatite
Carbonate
Partly Dissolved
Enamel Crystal
Calcium
Phosphate
Reformed Fluoride
Enamel Crystal
New
Fluorapatite-Like
Coating on Crystals
considered a cosmetic issue, represent less than 3.5 percent of the cases of fluorosis nation-
ally based on the National Health and Nutrition Examination Survey (Beltran-Aguilar
et al. 2010). Figure 2-2 illustrates that a small percentage of the population is affected by
very mild and mild fluorosis at 1 mg/L fluoride, which corresponds to the concentration
at which the optimal benefit from dental caries reduction is achieved. Recent studies have
shown a slight increase in dental fluorosis in communities with nonfluoridated water. This
may be the result of other sources of fluoride, including toothpastes, dietary supplements,
mouth rinses, professional applications, and foods and beverages processed with fluori-
dated water.
Young children and dental fluorosis. The principal cause of moderate and severe dental
fluorosis is from children swallowing fluoride toothpaste. For children who use toothpaste,
there is an increased chance of dental fluorosis among those younger than six years, and
especially for those younger than two years, because they are more likely to swallow the
toothpaste than older children as their spitting reflex has not yet developed. To prevent fluo-
rosis, the CDC recommends that health-care professionals provide direct individual advice
on the use of fluoride toothpaste by young children, especially those younger than two
years, depending on individual assessment of diet, availability of dental health care, fluoride
levels in the community water, and other risk factors for dental decay. Universally, dental
health professionals should advise parents to supervise children while brushing teeth and
to use only a smear or pea-size quantity of fluoride-containing toothpaste until age six.
Skeletal fluorosis and bone fractures. Fluoride is readily incorporated into the crystalline
structure of bone and will accumulate over time. A small exposure of fluoride, as asso-
ciated with water fluoridation, is generally considered beneficial for bones, but excessive
exposure at levels above the recommended level for good oral health can result in adverse
effects. Skeletal fluorosis is an adverse health effect caused by an accumulation of exces-
sive fluoride in bone. This is the result of excessive chronic fluoride exposure.
Skeletal fluorosis is extremely rare in the United States with only seven reported
cases by the Centers for Disease Control (CDC). However, fluorosis does occur in countries
with areas of very high levels of naturally occurring fluoride, such as India and China.*
* Other confounding factors, such as inhalation of fluoride fumes from burning coal indoors, are
often also present, thus increasing exposure levels.
AWWA Manual M4
Figure 2-2 Dental caries and dental fluorosis in relation to fluoride in public
water supplies
Source: Water Fluoridation: A Manual for Engineers and Technicians (US Department of Health and Human
Services, Centers for Disease Control and Prevention, September 1986).
The Institute of Medicine (IOM) established recommendations for the tolerable upper
intake level for fluoride to safeguard against skeletal fluorosis. This value is 10 mg/day for
10 or more years. This corresponds to a drinking water fluoride concentration of 5 mg/L,
assuming a 2-L/day rate of water consumption. Fluoride increases bone density but can
increase brittleness in long slender bones. Fluoride has been shown to affect bone calcifica-
tion, and some studies have linked chronic elevated doses to bone fractures.
Cancer
Numerous human epidemiological studies on the potential carcinogenic effects of fluoride
in drinking water have been conducted. The general consensus among the reviews com-
pleted to date is that no evidence exists linking water fluoridation and cancer.
According to a 2006 NRC review of fluoride in drinking water, the studies that had
been completed to date regarding fluoride exposure and osteosarcoma risk were incon-
clusive and tentative. The NRC study went on to state that the multiyear Harvard-based
hospital study that was in progress at the time would be an important assessment of the
potential relationship between osteosarcoma and fluoride. The results from the full study
did not find a significant association between bone fluoride levels and osteosarcoma risk
(Kim et al. 2011).
In 2011, California’s Office of Environmental Health Hazard Assessment published a
report on the carcinogenicity of fluoride and its salts. This report concluded that the cur-
rent body of epidemiological evidence on the carcinogenicity of fluoride is inconclusive,
suggesting that fluoride is not a recognized causative agent for cancer.
AWWA Manual M4
FLUORIDE DELIVERY
REFERENCES
Beltrán-Aguilar E.D., L. Barker, B.A. Dye. 2010. Prevalence and Severity of Dental Fluorosis
in the United States, 1999–2004. NCHS data brief 53. Hyattsville, MD: National Center
for Health Statistics.
Dye, B.A., S. Tan, V. Smith, B.G. Lewis, L.K. Barker, G. Thornton-Evans, et al. 2007. Trends
in Oral Health Status: United States, 1988–1994 and 1999–2004. National Center for
Health Statistics. Vital Health Stat 11(248).
Featherstone, J.D.B. 1999. Prevention and reversal of dental caries: Role of low-level fluo-
ride. Community Dent Oral Epidemiol 27:31–40.
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Characterization of Dental Nociceptive Neruons. Journ. of Dental Research 90(6):
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