Fluoride and caries prevention: a scoping review of public health policies.

Background: Dental caries is the most common infectious disease, affecting approximately 60 to 90% of the world population, especially young children, and disadvantaged communities. Due to the extremely high prevalence and the significant negative impact on general health, well-being, and quality of life it is considered a global public health problem. Despite the improvement of policies to promote oral health care in the past decades, dental caries is still a healthcare challenge, characterized by increasing disparities among different social groups between and within countries. Fluoride-based prevention of dental caries is a cost-effective approach, that has been implemented since 1940's. It includes systemic and topical administrations, through community-based or individual programs. Preventive interventions should be tailored to individual and community caries risk assessment and estimate of cumulative fluoride intake, in order to maximize the preventive effect and avoid the risk of potential adverse effects associated with excessive fluoride exposure. Regulation of public health policies plays a major role in this context. Study design: Scoping review. Methods: The aim of this scoping review was to report an overview of current guidelines regarding fluoride-based preventive strategies for dental caries and relevant policies on the matter, as well as to address current issues related to public health aspects of dental caries prevention. We searched for the relevant literature on the matter, focusing on policy documents, such as recommendations, position papers and guidelines, issued from the major scientific and regulatory institutions involved in oral health promotion and on publications concerning relevant aspects of public health law. Results: Prevention of dental caries through fluoride can rely on topical fluorides for home-use (toothpastes and mouthrinses), professionally applied topical fluorides (gels, varnishes, silver diamine fluoride, fluoride-releasing restorative materials and sealants), fluoride supplements (tablets and drops), and community-based strategies (community water fluoridation, fluoridated salt and milk). Current relevant guidelines for all these preventive aids are outlined in the paper. A significantly greater preventive effect of topical fluorides has been widely established in the recent past, as compared to systemic effects. Furthermore, increasing concerns have emerged on potential adverse effects on general health associated with early and excessive systemic exposure to fluoride, especially for children, supported by recent meta-analyses. Also, community water fluoridation has raised significant aspects of relevance for health law and policies. In a public health perspective, healthcare policymakers should tackle social iniquities by promoting information and oral health literacy, through community and school-based programs, ensuring access to early dental visits and basic dental care and improving availability and affordability of fluoride topical products. Conclusions. Fluoride-based prevention can provide a simple and cost-effective approach to reduce the incidence of dental caries and the associated social burden. Among fluoride-based preventive strategies, systemic community-based administration of fluoride should be considered with great caution, due to the unfavorable risk-benefit ratio currently established. Topical fluoridated pro-ducts are generally preferred, given the optimal risk-benefit ratio. Further efforts must be made to identify and tackle the barriers to dental caries prevention and related social iniquities from a public health perspective. Policies and laws on oral health should promote access to caries prevention with targeted comprehensive strategies.

Variability of groundwater fluoride and its proportionate risk quantification via Monte Carlo simulation in rural and urban areas of Agra district, India.

This study quantifies the groundwater fluoride contamination and assesses associated health risks in fluoride-prone areas of the city of Taj Mahal, Agra, India. The United States Environmental Protection Agency (USEPA) risk model and Monte Carlo Simulations were employed for the assessment. Result revealed that, among various rural and urban areas Pachgain Kheda exhibited the highest average fluoride concentration (5.20 mg/L), while Bagda showed the lowest (0.33 mg/L). Similarly, K.K. Nagar recorded 4.38 mg/L, and Dayalbagh had 1.35 mg/L. Both urban and rural areas exceeded the WHO-recommended limit of 1.5 mg/L, signifying significant public health implications. Health risk assessment indicated a notably elevated probability of non-carcinogenic risk from oral groundwater fluoride exposure in the rural Baroli Ahir block. Risk simulations highlighted that children faced the highest health risks, followed by teenagers and adults. Further, Monte Carlo simulation addressed uncertainties, emphasizing escalated risks for for children and teenagers. The Hazard Quotient (HQ) values for the 5th and 95th percentile in rural areas ranged from was 0.28-5.58 for children, 0.15-2.58 for teenager, and 0.05-0.58 for adults. In urban areas, from the range was 0.53 to 5.26 for children, 0.27 to 2.41 for teenagers, and 0.1 to 0.53 for adults. Physiological and exposure variations rendered children and teenagers more susceptible. According to the mathematical model, calculations for the non-cancerous risk of drinking water (HQ-ing), the most significant parameters in all the targeted groups of rural areas were concentration (CW) and Ingestion rate (IR). These findings hold relevance for policymakers and regulatory boards in understanding the actual impact and setting pre-remediation goals.

Health Risk Assessment in Mexican Children Exposed to Fluoride from Sweetened Beverages.

The primary source of fluoride exposure is groundwater, but evidence suggests that beverages and food are additional fluoride sources. Intake of these products at an early age affects the optimal functioning of soft organs. An increase in sweetened beverage consumption by the pediatric population has been reported, suggesting an increase in fluoride exposure. The objectives of this study were to determine the fluoride concentrations in beverages and analyze the risk to human health from fluoride exposure to sweetened beverages consumed by children. Eighty-two sugar-sweetened beverages produced in different Mexican states were analyzed. The fluoride determination was carried out with an ion-selective electrode. The highest fluoride concentration was 1.92 mg/L; 73.2% of beverages showed fluoride values above permitted limits. Low-cost beverages had the highest fluoride values, suggesting that the water used for their production does not comply with fluorine regulations. According to the risk assessment in children from 3 to 6 years, the daily consumption of juices and sodas with concentrations that exceeded the normative of 0.7 mg/L could represent a risk to dental fluorosis development. It is crucial to control fluoride and regulate its concentrations in beverages for children to ensure food safety, especially in areas of endemic hydrofluorosis.

Fluoride Exposure through Different Drinking Water Sources in a Contaminated Basin in Guanajuato, Mexico: A Deterministic Human Health Risk Assessment.

Water fluoride levels above the World Health Organization's guideline (1.5 mg/L), common in overexploited aquifers, represent a health hazard. Our objective was to assess the health risks posed by exposure to fluoride in different drinking water sources in a contaminated basin in Mexico. Fluoride was measured in mutual drinking water sources and in the urine of 39 children and women. Risks were estimated through hazard quotient (HQ) by drinking water source. Dental fluorosis was assessed in the children. Mean fluoride water concentrations (mg/L) were: well, 4.2; waterhole, 2.7; bottled, 2.1; rainwater, 0.4. The mean urinary fluoride concentrations (specific gravity adjusted) were 2.1 mg/L and 3.2 mg/L in children and women, respectively. Our multiple linear regression model showed children's urinary fluoride concentrations increased 0.96 mg/L for every 1 mg/L increase in water fluoride (p < 0.001). Dental fluorosis was diagnosed in 82% of the children, and their HQ according to drinking water source was: well, 1.5; waterhole, 1.1; bottled, 0.8; harvested rainwater, 0.3. The pervasive dental fluorosis indicates a toxic past fluoride exposure; urinary fluoride levels and HQs indicate high exposure and current health risks for most children. Drinking harvested rainwater will likely prevent most of the local fluoride exposure.

Biomarkers for the Assessment of Exposure to Fluoride in Adults.

To monitor deficient or excessive intakes of biologically available fluoride (F), various biological samples have been tested for use as biomarkers of human exposure to F. Most such studies have concerned children and often have only involved measurement of F in 1 or 2 types of sample. The present study investigated the relationships of F concentrations in biomarkers of F exposure; including plasma, saliva, hair, finger- and toenails, and daily urinary F excretion (UFE) with the total daily F intake (TDFI) of adults. TDFI was assessed in 60 healthy adults, aged ≥20 years; 31 lived in a low-F water area (LFA, 0.04 mg F/L) and 29 in a high-F water area (HFA, 3.05 mg F/L) of Nigeria. All volunteers provided at least 1 biomarker sample from the above list and completed a questionnaire to evaluate F intake from the diet and toothpaste ingestion. TDFI, UFE and F concentrations of biomarkers were statistically significantly higher in the HFA than in the LFA. There were strong statistically significant positive correlations between TDFI and UFE (ρ = 0.730, p < 0.001); plasma F (ρ = 0.729, p < 0.001); fasting whole saliva F (ρ = 0.653, p < 0.001) and hair F (ρ = 0.603, p < 0.001). The statistically significant positive correlations between TDFI and fingernail F (ρ = 0.502, p < 0.001) and between TDFI and toenail F (ρ = 0.556, p < 0.001) were moderate. In conclusion, this study has indicated the usefulness of 24-h UFE as well as F concentration in plasma, fasting whole saliva and hair as biomarkers of contemporary or sub-chronic F exposure in groups of adults. However, they do not appear to have the necessary sensitivity to predict F exposure in individuals.

The association between the prevalence of dental fluorosis and the socio-economic status and area of residence of 12-year-old students in Uruguay.

Objective: This study investigates the association between the prevalence and severity of dental fluorosis, the socio-economic status (SES) and area of residence among 12-year-old schoolchildren in Uruguay.Material and methods: The study was descriptive, cross-sectional, explanatory and observational. Subjects considered eligible were born in 1999 and had their parents' or guardian's prior consent. A questionnaire was used to identify SES according to Centro de Investigaciones Económicas Institute on four levels. Dental fluorosis was determined using the Thylstrup-Fejerskov (TF) index.Results: Of the 1544 students examined, 45.0% showed dental fluorosis. A TF index 1-2 was recorded in 29.3% of the subjects, TF 3 in 20.9%, TF 4 in 6.7% and TF 5-9 in 2.1%. In area 1 (the capital Montevideo city), 84.8% of the subjects had dental fluorosis, a value that was significantly higher than in the inland region (area 2, 24.4%) and border departments (area 3, 22.5%) (x2 = 27.92, p < .0001). Students from families with a low socio-economic level showed less prevalence of dental fluorosis than those with a high level (x2 = 14.58, p = .002).Conclusion: Significant differences exist in the prevalence of dental fluorosis in relation to place of residence and socio-economic level.

Human health risk assessment: Study of a population exposed to fluoride through groundwater of Agra city, India.

Fluoride (F-), a harmful compound if present in high concentration, is typically found in groundwater. It is important to investigate the F- concentrations in groundwaters of areas where individuals use groundwater for drinking purposes. The objectives of this study were: (a) to estimate the F- exposure, and (b) to assess the non-carcinogenic risk through consumption of groundwater among urban population (different age groups) of Agra city. A total of 28 groundwater samples were collected from Agra city in May 2016, which comprised 22 samples from hand pump and 6 samples from tube wells from shallow aquifers at different sites. The F- concentrations varied from 0.90 to 4.12 mg/L with an average value of 1.88 mg/L. The results obtained reveal that about 64% of the samples exceeded the F- permissible limit of 1.5 mg/L. Nevertheless, 32% of the samples were well within the WHO drinking water guidelines and 3.5% of the samples from the groundwater were below the 1.0 mg/L threshold. The maximum estimated exposure doses were 0.69, 0.31 and 0.12 mg/kg/day for infants, children and adults, respectively. A dental fluorosis becomes evident when the results obtained are compared with an oral reference dose of 0.06 mg/kg/day. The hazard quotient (HQ) was found to be more than 1 for infants and children in all the studied areas which indicates that young consumers are more vulnerable to non-carcinogenic risk due to exposure of F-. On the other hand, the adults at about 71% of the sampled sites may be victims of non-carcinogenic risk. From the results obtained in this study, it is recommended that there be implementation of the appropriate remediation for defluoridation of water to circumvent the population from the probable health risks of F-.

Probabilistic risk assessment of exposure to fluoride in most consumed brands of tea in the Middle East.

The aim of this study was to evaluate the fluoride concentration in seven most consumed brands of tea in the Middle East which was imported to Iran through Zabol County. In the present study, the health risk of exposure to fluoride was estimated using a probabilistic approach. Monte Carlo simulation and sensitivity analysis were applied to quantify uncertainties in risk estimation. The highest mean and 95th percentile of chronic daily intake (CDI) was observed for children group. Iranian tea and Kenya tea had maximum CDI and target hazard quotient (THQ) values among studied brands of tea which followed by Green tea, Taksetare tea, Ceylan tea, Red tea, and White tea. These result indicated that there were significant risks of exposure to fluoride in most of studied brands of tea for children (THQ>1). Sensitivity analysis showed that fluoride concentration and daily intake were the most influential variables in three exposed populations. In conclusion, the fluoride concentration in some studied brands of tea is high and it put children at risk risks of exposure to fluoride.

Geochemical sources, hydrogeochemical behavior, and health risk assessment of fluoride in an endemic fluorosis area, central Iran.

The present study is the first attempt to put forward the possible source(s) and health risk assessment of fluoride in Bahabad, central Iran. Fluoride concentrations ranged from 0.22 to 2.35 mg/L and 292-355 mg/kg in the groundwater and soil samples, respectively. Geochemical provenance techniques using major and rare earth elements in soils revealed that local shale is the most probable source rock of fluoride in the area. A two-step chemical fractionation method applied on soil samples demonstrated that residual and water-soluble fractions were the most probable modes of fluoride in soil, whereas exchangeable fraction had a minor role. The coefficient of aqueous migration showed that fluoride in the studied soils behaved as a mobile element. Moreover, the relative mobility indicated that soils played a more important role than rocks in releasing fluoride into groundwater. In groundwater medium, chemical weathering, evaporation, and ion exchange acted as the main geochemical controlling factors of fluoride enrichment. Findings of this study signify that the role of NaCl and NaSO4-type waters should be considered more to recognize susceptible areas to fluoride contamination in groundwater. People in the study area are exposed to high levels of fluoride intake through drinking water, thus making dental fluorosis a major public health concern in the area. Scanning electron microscopy of the dentin's enamel showed morphological modifications (e.g., cracks and fissures) in residents' enamel structures. The results of this study may lead to suitable management strategies to mitigate the endemic fluorosis problem.

Black Tea Source, Production, and Consumption: Assessment of Health Risks of Fluoride Intake in New Zealand.

In countries with fluoridation of public water, it is imperative to determine other dietary sources of fluoride intake to reduce the public health risk of chronic exposure. New Zealand has one of the highest per capita consumption rates of black tea internationally and is one of the few countries to artificially fluoridate public water; yet no information is available to consumers on the fluoride levels in tea products. In this study, we determined the contribution of black tea as a source of dietary fluoride intake by measuring the fluoride content in 18 brands of commercially available products in New Zealand. Fluoride concentrations were measured by potentiometric method with a fluoride ion-selective electrode and the contribution of black tea to Adequate Intake (AI) and Tolerable Upper Intake Level (UL) was calculated for a range of consumption scenarios. We examined factors that influence the fluoride content in manufactured tea and tea infusions, as well as temporal changes in fluoride exposure from black tea. We review the international evidence regarding chronic fluoride intake and its association with chronic pain, arthritic disease, and musculoskeletal disorders and provide insights into possible association between fluoride intake and the high prevalence of these disorders in New Zealand.

Risk assessment of fluoride exposure in drinking water of Tunisia.

The presence of fluoride in drinking water is known to reduce dental cavities among consumers, but an excessive intake of this anion might leads to dental and skeletal fluorosis. This study reports a complete survey of the fluoridated tap water taken from 100 water consumption points in Tunisia. The fluoride concentrations in tap water were between 0 and 2.4 mg L-1. Risk assessment of Fluoride exposure was assessed depending on the age of consumers using a four-step method: hazard identification, toxicity reference values selection (TRVs), daily exposure assessment, and risk characterization. Our findings suggest that approximately 75% of the Tunisian population is at risk for dental decay, 25% have a potential dental fluorosis risk, and 20% might have a skeletal fluorosis risk according to the limits of fluoride in drinking water recommended by WHO. More investigations are recommended to assess the exposure risk of fluoride in other sources of drinking water such as bottled water.

Probabilistic risk assessment of Chinese residents' exposure to fluoride in improved drinking water in endemic fluorosis areas.

Studies have yet to evaluate the effects of water improvement on fluoride concentrations in drinking water and the corresponding health risks to Chinese residents in endemic fluorosis areas (EFAs) at a national level. This paper summarized available data in the published literature (2008-2016) on water fluoride from the EFAs in China before and after water quality was improved. Based on these obtained data, health risk assessment of Chinese residents' exposure to fluoride in improved drinking water was performed by means of a probabilistic approach. The uncertainties in the risk estimates were quantified using Monte Carlo simulation and sensitivity analysis. Our results showed that in general, the average fluoride levels (0.10-2.24 mg/L) in the improved drinking water in the EFAs of China were lower than the pre-intervention levels (0.30-15.24 mg/L). The highest fluoride levels were detected in North and Southwest China. The mean non-carcinogenic risks associated with consumption of the improved drinking water for Chinese residents were mostly accepted (hazard quotient < 1), but the non-carcinogenic risk of children in most of the EFAs at the 95th percentile exceeded the safe level of 1, indicating the potential non-cancer-causing health effects on this fluoride-exposed population. Sensitivity analyses indicated that fluoride concentration in drinking water, ingestion rate of water, and the exposure time in the shower were the most relevant variables in the model, therefore, efforts should focus mainly on the definition of their probability distributions for a more accurate risk assessment.

Fate of over 480 million inhabitants living in arsenic and fluoride endemic Indian districts: Magnitude, health, socio-economic effects and mitigation approaches.

During our last 27 years of field survey in India, we have studied the magnitude of groundwater arsenic and fluoride contamination and its resulting health effects from numerous states. India is the worst groundwater fluoride and arsenic affected country in the world. Fluoride results the most prevalent groundwater related diseases in India. Out of a total 29 states in India, groundwater of 20 states is fluoride affected. Total population of fluoride endemic 201 districts of India is 411 million (40% of Indian population) and more than 66 million people are estimated to be suffering from fluorosis including 6 million children below 14 years of age. Fluoride may cause a crippling disease. In 6 states of the Ganga-Brahmaputra Plain (GB-Plain), 70.4 million people are potentially at risk from groundwater arsenic toxicity. Three additional states in the non GB-Plain are mildly arsenic affected. For arsenic with substantial cumulative exposure can aggravate the risk of cancers along with various other diseases. Clinical effects of fluoride includes abnormal tooth enamel in children; adults had joint pain and deformity of the limbs, spine etc. The affected population chronically exposed to arsenic and fluoride from groundwater is in danger and there is no available medicine for those suffering from the toxicity. Arsenic and fluoride safe water and nutritious food are suggested to prevent further aggravation of toxicity. The World Health Organization (WHO) points out that social problems arising from arsenic and fluoride toxicity eventually create pressure on the economy of the affected areas. In arsenic and fluoride affected areas in India, crisis is not always having too little safe water to satisfy our need, it is the crisis of managing the water.

Risk Assessment of Fluoride Intake from Tea in the Republic of Ireland and its Implications for Public Health and Water Fluoridation.

The Republic of Ireland (RoI) is the only European Country with a mandatory national legislation requiring artificial fluoridation of drinking water and has the highest per capita consumption of black tea in the world. Tea is a hyperaccumulator of fluoride and chronic fluoride intake is associated with multiple negative health outcomes. In this study, fifty four brands of the commercially available black tea bag products were purchased and the fluoride level in tea infusions tested by an ion-selective electrode method. The fluoride content in all brands tested ranged from 1.6 to 6.1 mg/L, with a mean value of 3.3 mg/L. According to our risk assessment it is evident that the general population in the RoI is at a high risk of chronic fluoride exposure and associated adverse health effects based on established reference values. We conclude that the culture of habitual tea drinking in the RoI indicates that the total cumulative dietary fluoride intake in the general population could readily exceed the levels known to cause chronic fluoride intoxication. Evidence suggests that excessive fluoride intake may be contributing to a wide range of adverse health effects. Therefore from a public health perspective, it would seem prudent and sensible that risk reduction measures be implemented to reduce the total body burden of fluoride in the population.

[TOXIC RISK ASSESSMENT OF FLUORIDE PRESENCE IN BOTTLED WATER CONSUMPTION IN THE CANARY ISLANDS]. / EVALUACIÓN DEL RIESGO TÓXICO POR LA PRESENCIA DE FLUORURO EN AGUAS DE BEBIDA ENVASADA CONSUMIDAS EN CANARIAS.

INTRODUCTION: fluorine, as an hormetin, is necessary in the organism to avoid caries; but large amounts can produce toxic side effects such as dental fluorosis or skeletal fluorosis. Thus, it is important not to exceed chronically the RDIs (Recommended Daily Intakes) per each age and sex range. It is assumed that the main fluoride source is water. OBJECTIVES: to establish fluoride concentrations at certain bottled water brands being consumed in the Canary Islands for renovating the outdated data, and to evaluate the subsequent toxic risk. METHOD: 25 samples have been used from 7 different registered and commercialized brands, being analyzed by a potentiometer with a fluoride ion selective electrode. RESULTS: all analyzed water brands satisfied quality criteria according to the Spanish law, no one could be considered "fluorinated water" and all of them could be used to prepare baby food. Moreover, according to the recommended daily water intake by the EFSA per each age range, no water analyzed brand could exceed the RDI for no one over 4 years old. CONCLUSIONS: the bottled waters that are produced in the Canary Islands have similar fluoride concentrations than those that are produced in the Peninsula (all of them have a data range between 0.24 and 0.62 mg/L). The individuals who have more water restrictions are those under 1 year old; but in any case, while the child is growing up, the levels of fluoride consumption can be higher (until 19 years old) and therefore the water brands variety that can be drunk, without exceeding the RDI, is also higher. In some places in the Canary Islands, it would be advisable to consume bottled water in place of tap water.

Introducción: el flúor, como hormetina, es necesario en el organismo para evitar las caries, pero en cantidades excesivas puede llevar a efectos tóxicos adversos como la fluorosis dental o la fluorosis invalidante. Así, será importante no sobrepasar de forma crónica las IDR (Ingestas Diarias Recomendadas) para cada rango de edad y sexo. Se asume que la principal fuente de aporte de fluoruros es el agua. Objetivos: establecer las concentraciones de fluoruro en determinadas marcas de agua envasada que se consumen en Canarias, para renovar los datos ya desactualizados, y hacer la correspondiente evaluación del riesgo tóxico. Método: se han utilizado 25 muestras de siete marcas registradas y comercializadas diferentes, siendo analizadas mediante determinación potenciométrica con electrodo ion selectivo de fluoruro. Resultados: todas las marcas de agua analizadas cumplen con los criterios de calidad según la legislación actual española, ninguna puede considerarse "agua fluorada" y todas se pueden usar en la preparación de alimentos infantiles. Además, según las ingestas diarias de agua recomendadas por la EFSA para cada rango de edad, no se supera la IDR para ningún individuo mayor de cuatro años ni para ninguna de las marcas de agua analizadas. Conclusiones: las aguas envasadas producidas en Canarias tienen niveles de fluoruro similares a las producidas en la península (todas en un rango de 0,24 a 0,62 mg/L). Los individuos sobre los que recaen las restricciones más amplias de consumo de agua son los menores de un año, pero en cualquier caso, a medida que el individuo crece va aumentando la permisibilidad del aporte de fluoruros (aumenta hasta los 19 años) y, por tanto, aumenta la variedad de aguas envasadas que se pueden consumir sin superar la IDR. En ciertos lugares de la Comunidad Autónoma Canaria sería recomendable consumir agua envasada respecto al agua de abastecimiento público.

[Tap water as a dietary source of exposure to fluoride in Tenerife; risk assessment]. / El agua de consumo como fuente de exposición crónica a fluoruro en Tenerife; evaluación del riesgo.

INTRODUCTION: drinking water is the main source of fluoride exposure for the population. According to the Spanish Law RD 140/2003, the fluoride content in drinking water should not exceed the parametric value of 1.5 mg/L. Historically, certain drinking waters in the island of Tenerife have exceeded this value due to the geological/volcanic characteristics of the Canary Islands. Fluoride (F) plays an important role in the prevention of dental caries (tooth decay). However, long exposure to concentrations above 1.5 mg/L in drinking water can cause disorders such as dental fluorosis. OBJECTIVES: To determine the amount of fluoride in the tap waters of the 11 municipalities in the north of the island of Tenerife that, at the time of the study, exceeded the parametric value for fluoride set by the Spanish legislation and to toxicologically estimate and evaluate the fluoride daily intakes from water considering the RDI (Recommended Daily Intake) established in Spain for different population groups. METHOD: 44 samples of tap water collected in the 11 municipalities in the study were analyzed using the fluoride potentiometric determination with an ion selective electrode. RESULTS: 9 of the 11 municipalities presented mean fluoride concentrations in their tap water that exceeded the parametric value set by the Spanish legislation (1.5 mg/L). Considering an average daily water consumption of 2 L, the recommended daily intake (RDI) for women (3mg F/day) is exceeded in 9 of the 11 municipalities and the RDI for men (4 mg F/day) is exceeded in 5 of the 11 municipalities. Considering a daily water consumption of 1.5 L, the RDI for children of 2-3 years (0.7 mg/day) is clearly exceeded in all municipalities. CONCLUSIONS: The results show the existing public health problem on the island of Tenerife and justify the tap water consumption restrictions put in force by the Public Health Authorities of the Canary Islands at the time of the study. Children are the most exposed population group to the risks of fluoride because its RDI is lower.

Introducción: el agua de consumo humano es la principal fuente de exposición al fluoruro para la población. De acuerdo con el Real Decreto 140/2003, el contenido en fluoruro en el agua de consumo humano no debe superar el valor paramétrico de 1,5 mg/L. Históricamente, ciertas aguas de consumo en Tenerife han superado este valor debido a sus características geológicas/volcánicas. El flúor juega un papel importante en la prevención de la caries dental. Sin embargo, la exposición crónica a concentraciones superiores a 1,5 mg/L en el agua de bebida puede provocar trastornos como la fluorosis dental. Objetivos: determinar la cantidad de fluoruro en el agua de consumo humano de 11 municipios del norte de la isla de Tenerife que en el momento del estudio superaba el valor paramétrico de fluoruro y estimar y evaluar toxicológicamente las ingestas diarias a partir del consumo de agua considerando las IDR (Ingestas Diarias Recomendadas) establecidas en España para distintos grupos poblacionales. Método: 44 muestras de aguas de abastecimiento público recogidas en los 11 municipios objeto del estudio fueron analizadas usando la determinación potenciométrica de fluoruro mediante el uso de un electrodo de ión selectivo. Resultados: 9 de los 11 municipios las aguas de abasto presentaron concentraciones de fluoruro medias que superaron el valor paramétrico fijado por la legislación española. Considerando un consumo medio diario de agua de 2 L, la ingesta diaria recomendada (IDR) para mujeres (3 mg/día) es superada en 9 de los 11 municipios y la IDR para hombres (4 mg/día) es superada en 5 de los 11 municipios. Considerando un consumo medio diario de agua de 1,5 L, la IDR establecida para los niños de 2 a 3 años (0,7 mg/día) es superada ampliamente en todos los municipios. Conclusiones: los resultados obtenidos evidencian el problema de salud pública existente en la isla de Tenerife y justifican las restricciones de consumo establecidas por la Dirección General de Salud Pública del Servicio Canario de Salud, vigentes en el momento del estudio. Los niños son el grupo poblacional más expuesto a los riesgos del fluoruro debido a que su IDR es menor.

Assessment of relationship on excess fluoride intake from drinking water and carotid atherosclerosis development in adults in fluoride endemic areas, China.

Cross-sectional analysis was conducted to access the relationships between developing carotid artery atherosclerosis through consuming high fluoride in drinking water and its possible mechanism, using the baseline data collected from 585 study subjects. In the cross sectional analysis, subjects were divided into four groups based on the concentrations of fluoride in their drinking water. The range of fluoride concentrations was: normal group (less than 1.20 mg/L), mild group (1.21-2.00 mg/L), moderate group (2.01-3.00 mg/L), and high concentration group (more than 3.01 mg/L). The prevalence rate of carotid artery atherosclerosis in the subjects in each group was found to be 16.13%, 27.22%, 27.10%, and 29.69%, respectively. Significant difference between the prevalence of carotid artery atherosclerosis in the mild, moderate and high fluoride exposure group and in the normal group was observed (P<0.05). In addition, it was found that elevated intercellular cell adhesion molecule-1 (ICAM-1) and reduced glutathione peroxidases (GPx) was associated with carotid artery atherosclerosis in fluoride endemic areas. The findings of the research study revealed a significant positive relationship between excess fluoride exposure from drinking water and prevalence of carotid artery atherosclerosis in adults living in fluoride endemic areas. The possible mechanism was the excess fluoride induced the decreasing level of GPx causing the systemic inflammation and endothelial activation by oxidative stress.

Impact of socio-demographic, socioeconomic, and water variables on dental fluorosis in adolescents growing up during the implementation of a fluoridated domestic salt program.

The objective of this study is to determine the impact of socio-demographic, socioeconomic, and other risk indicators on dental fluorosis (DF) among Mexican adolescents. A cross-sectional study was carried out in 1,538 adolescents 12 and 15 years of age in semi-rural communities located at high altitude (>2,000 m) and with high concentration of fluoride in water (1.38-3.07 ppm) in Hidalgo, Mexico. DF was determined by means of Dean's Index and all teeth were examined. Remaining variables were collected using a questionnaire. The adjusted final model was performed using ordered logistic regression. After adjusting for sex, the variables associated with DF were (p < 0.05): being 12 years old (OR = 1.10) versus 15 years old; having lived the first 6 years of life in El Llano (3.07 F ppm) (OR = 3.19) or San Marcos (1.38 F ppm) (OR = 1.63) versus Tula (1.42 F ppm); having public (OR = 1.35) or private health insurance (OR = 1.36) versus those without insurance; belonging to the lower quartiles of socioeconomic position (SEP) [1st quartile (OR = 2.48), 2nd quartile (OR = 1.81), 3rd quartile (OR = 1.49)] versus the highest quartile; having drunk tap water (OR = 1.83) or from a well or spring (OR = 2.30) versus those who drank water purchased in large containers or bottles. Demographic and socioeconomic variables were associated with DF. While better SEP appeared to play an important role in DF, a pattern of water intake associated with water purchased in large containers or bottles (which have different connotations to the use of bottled water in industrialized Western countries) did reduce DF risk in these high fluoride content, high altitude communities.

An assessment of the relationship between excess fluoride intake from drinking water and essential hypertension in adults residing in fluoride endemic areas.

In this study, the relationships between high water fluoride exposure and essential hypertension as well as plasma ET-1 levels were investigated. A total of 487 residents aged 40 to 75 were randomly recruited from eight villages in Zhaozhou County from Heilongjiang Province in China and were divided into 4 groups according to the concentrations of fluoride in their water. Consumption levels of drinking water fluoride for normal, mild, moderate, and high exposure groups were 0.84±0.26 mg/L, 1.55±0.22 mg/L, 2.49±0.30 mg/L, and 4.06±1.15 mg/L, respectively. The prevalence of hypertension in each group was 20.16%, 24.54%, 32.30%, and 49.23%, respectively. There were significant differences between all the groups; namely, with the increase in water fluoride concentrations, the risk of essential hypertension in adults grows in a concentration-dependent manner. Significant differences were observed in the plasma ET-1 levels between the different groups (P<0.0001). In the multivariable logistic regression model, high water fluoride concentrations (F(-)≥3.01 mg/L, OR(4/1)=2.84), age (OR(3/1)=2.63), and BMI (OR(2/1)=2.40, OR(3/1)=6.03) were closely associated with essential hypertension. In other words, the study not only confirmed the relationship between excess fluoride intake and essential hypertension in adults, but it also demonstrated that high levels of fluoride exposure in drinking water could increase plasma ET-1 levels in subjects living in fluoride endemic areas.

Fluorosis and dental caries: an assessment of risk factors in Mexican children.

OBJECTIVE: To determine the sources of fluoride exposure and the prevalence and severity of fluorosis and dental caries and sources of fluoride exposure in the permanent dentition of 11-year-old children. MATERIAL AND METHODS: A cross-sectional study of 111 children attending elementary schools in the State of Mexico, where the concentration of fluoride in drinking water is < 0.3 ppm, was performed using a self-administered questionnaire was directed towards the children' mothers. The level of fluorosis was determined using both the Dean's Modified Index (ID) and the Community Fluorosis Index (CFI). The decayed, missing, filled teeth (DMFT) was recorded using methods recommended by the World Health Organization (WHO). Statistical analysis was conducted using bivariate analysis with a chi2 test; odds ratios (OR) and 95% confidence intervals (CI). Logistic regression models were used in the final model. RESULTS: Children had a fluorosis prevalence of 52.73% (95% CI: 48.2-55.4) with CFI = 0.75 +/- 0.91 (95% CI: 0.58-0.92). The caries prevalence was 53.2% (95% CI: 50.1-56.3) with DMFT = 1.27 +/- 1.67 (D = 0.85 and F = 0.42). Children who had no fluorosis showed more caries (p = 0.001). Dental fluorosis was associated with the initial age of brushing (before age four), OR = 0.511 (0.338-0.772); frequency of brushing (three times a day), OR = 0.681 (0.483-0.958), brushing before sleeping (yes), OR = 0.664 (0.473-0.932), and applications of fluoride (yes), OR = 0.756 (0.576-0.994). Dental caries was associated with several variables, such as initial age of brushing, OR = 11.28 (4.6-27.7), frequency of brushing, OR = 0.245 (0.109-0.553), brushing before sleeping, OR = 8.03 (3.295-19.59), and applications of fluoride, OR = 14.2 (4.54-44.53). In the final regression model, the level of caries and fluorosis was significantly associated (p = 0.000) with the amount of fluoride exposure. The multivariate shows this relationship. CONCLUSIONS: Fluorosis prevalence was high for low levels and low for more severe levels. According to the CFI in the studied example, dental fluorosis represents a public health problem in the studied sample. Dental caries was low with a predominance of tooth decay. Exposure to different sources of fluoride, was a risk factor for the development of fluorosis and a benefit with regard to dental caries.