Scientific Opinion on Dietary Reference Values for fluoride

Association between fluoride intake from drinking water and severity of dental fluorosis in Northern and Western Mexico: systematic review and meta-analysis

BACKGROUND

Dental fluorosis (DF) is caused by excessive exposure to fluoride during odontogenesis and leads to various changes in the development of tooth enamel. Some regions in Mexico are considered endemic fluorosis zones due to the high fluoride content in drinking water. The objective of this study was to perform a systematic review and meta-analysis to identify the association between the concentration of fluoride in drinking water and the severity of dental fluorosis in northern and western Mexico.

METHODS

This protocol was registered in the PROSPERO database (ID: CRD42023401519). The search for information was carried out in the PubMed/Medline, Scopus, SpringerLink, and Google Scholar databases between January 2015 and October 2023. The overall relative risk was calculated using the inverse of variance approach with the random effects method. The RoB 2.0 tool was used to construct risk plots.

RESULTS

Eleven articles were analyzed qualitatively, and most of the included studies presented at least one level of DF severity; six articles were analyzed quantitatively, dividing them into two regions. In North region it was observed a higher prevalence of severe TF cases, corresponding to ≥ TF 5 category (4.78) [3.55, 6.42]. In the West region, most of the included studies presented a higher prevalence of less severe cases, corresponding to ≤ TF 4, in comparison with the North region (0.01) [0.00, 0.52], interpreted as a protective effect.

CONCLUSION

The concentrations of fluorides in drinking water are reportedly high in these regions and are directly related to the severity of dental fluorosis experienced by the inhabitants. In the Northern region exists a major concentration of fluoride in drinking water compared with the Western region as well as a prevalence of higher severity cases of dental fluorosis.

Investigation of fluoride concentrations, water quality, and non-carcinogenic health risks of borehole water in bongo district, northern Ghana

Access to potable water is a significant concern due to the increasing global threat posed by fluoride contamination in groundwater sources. This study investigated the concentrations of fluoride (F-), the suitability of groundwater for human consumption, the physicochemical characteristics affecting the water quality, and non-carcinogenic adverse health risks to both children and adults in the Bongo district in Northern Ghana. The findings revealed that the groundwater had a mean pH, salinity, TDS, conductivity, and turbidity below the WHO guideline values with a mean fluoride concentration of 1.76 mg/L above the guideline limit of 1.5 mg/L. The study also found that there was no strong relationship between fluoride and the measured water parameters, which may be attributed to poor control of distribution, transport mechanisms, and sources. The WQI scores ranged from 42.62% to 70.72%, indicating that all borehole water samples were of good and excellent quality. The average chronic daily intake showed that children are often more exposed to the harmful impact of fluoride than adults. The average HQ > 1 indicates the probability of dental and skeletal fluorosis after continuous exposure over time in adults and children. The study recommends taking immediate action to mitigate high groundwater fluoride concentrations, implementing appropriate water management strategies, and raising public awareness of the health risks. These measures can guide future groundwater management practices and help policymakers address contamination and protect local communities.

Fluoride - a scoping review for Nordic Nutrition Recommendations 2023

Fluoride has a well-documented role in the prevention and treatment of dental caries, but the mechanism is attributed to local effects on the tooth enamel surface rather than systemic effects. Fluoride is not considered essential for humans, no deficiencies are known, and no optimal range, which will not result in moderate fluorosis in some individuals, can be set. Recently, research studies have shown evidence for a relationship between fluoride intake and cognitive outcomes and interaction with iodine nutrition, but the evidence is weak so more data are warranted. For performing longitudinal cohort studies in the Nordic and Baltic region, data on fluoride in food and beverages need to be implemented in food composition tables. As the preventive effects of fluoride are mainly from topical treatment, monitoring of fluoride intake and establishing reference values for fluoride in urine and plasma are warranted to establish safe intake values.

Fluoride Exposure and Skeletal Fluorosis: a Systematic Review and Dose-response Meta-analysis

PURPOSE OF REVIEW

We performed a systematic review and meta-analysis on the relation between fluoride exposure and skeletal fluorosis (SF) using a novel statistical methodology for dose-response modeling.

RECENT FINDINGS

Skeletal fluorosis, a major health issue that is endemic in some regions, affects millions of people worldwide. However, data regarding the dose-response relation between fluoride exposure and SF are limited and outdated. We included twenty-three studies in the meta-analysis. When comparing the highest versus the lowest fluoride category, the summary risk ratio (RR) for SF prevalence was 2.05 (95% CI 1.60; 2.64), with a value of 2.73 (95% CI 1.92; 3.90) for drinking water and 1.40 (95% CI 0.90; 2.17) for urinary fluoride. The RR by the risk of bias (RoB) was 2.37 (95% CI 1.56; 3.58) and 1.78 (95% CI 1.34; 2.36) for moderate and high RoB studies, respectively. The dose-response curve based on a one-stage cubic spline regression model showed an almost linear positive relation between exposure and SF occurrence starting from relatively low concentrations up to 5 mg/L and 2.5 mg/L, respectively, for water and urinary fluoride, with no substantial increase above this threshold. The RR for developing moderate-severe forms increases at 5.00 mg/L and 2.5 mg/L of water and urinary fluoride, respectively. Better-quality studies are needed to confirm these results, but greater attention should be given to water fluoride levels to prevent SF, in addition to the other potential adverse effects of fluoride exposure.

Human health risks associated with the consumption of groundwater in the Gaza Strip

Groundwater of the Gaza Strip, the main source of drinking water for the Gazans, is highly contaminated by several chemicals of natural and anthropogenic origins. The results of this study confirm the findings of several studies conducted over the past two decades. Over those two decades, the population of Gaza has doubled, resulting in heavy demand for the limited reserves of groundwater. After 20 years since the first comprehensive study, it was found that groundwater salinity increased by 30 %, due to seawater intrusion. On the other hand, nitrate (NO3) decreased by 30 %, due to expansion of the sewer network and decrease in the number and distribution of septic tanks. Salinity, chloride (Cl), NO3 and fluoride (F) distribution maps for the year 2022 are very similar to those of the year 2002. This indicates that sources and loads of such contaminants are still the same. Metals and metalloids are still within the permissible limits set by the World Health Organization (WHO). Strontium (Sr) only showed concentrations of 12 mg/L across the Gaza Strip, which calls for further investigations. Maximum concentrations of the NO3 and F were 365 and 2.6 mg/L, respectively. The results of probabilistic risk assessment using Monte Carlo simulation showed that NO3 and F consumption through drinking water were above the reference dose for 35 % and 5 % of the trials performed, respectively. Consequently, the hazard quotient (HQ) is larger than 1 for 35 % and 5 % of the exposure scenarios simulated for these ions. For all metals and metalloids analyzed, HQ were below one (HQ1) indicating no risk; however, Sr presented an HQ 95th percentile equal to 0.19. Exposure routes such as dietary intake and soil ingestion, among others, should be further investigated to ensure that cumulative exposure does not surpass the safety limit. Recent advances in desalination technology should put an end to this truly regrettable situation.

Toothpaste ingestion-evaluating the problem and ensuring safety: systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the ingestion of toothpaste and its sequelae. The study adhered to the PRISMA guidelines and was registered in the PROSPERO database. A comprehensive search strategy was conducted across multiple databases, resulting in the inclusion of 18 relevant publications. Eligible studies encompassed various designs and included both children and adults as the study population. Data extraction was carried out systematically, and relevant information on study characteristics, interventions, and outcomes were collected. The assessment of bias was performed using the Joanna Briggs Institute's Critical Appraisal Tools showing variations of bias among the included studies. The overall risk of systemic toxicity was found to be low, and no severe or life-threatening events were reported in the included studies. Furthermore, some toothpaste formulations containing higher concentrations of fluoride were associated with an increased risk of dental fluorosis. These findings have several implications for practice and policy. Healthcare providers and dental professionals should emphasize the importance of promoting safe toothpaste use, especially in vulnerable populations such as young children who are more prone to accidental ingestion. Public health campaigns and educational initiatives should aim to raise awareness about appropriate toothpaste usage and the potential risks. In addition, toothpaste manufacturers and regulatory bodies should consider revising guidelines and regulations to ensure the safety of oral care products, including the appropriate concentration of active ingredients. Future research should focus on investigating the long-term effects of toothpaste ingestion, exploring potential interactions between different active ingredients, and evaluating the efficacy of current preventive measures.

Fluoride and Aluminium in Tea (Camellia sinensis L.)-Tea Quality Indicators and Risk Factors for Consumers

In recent years, the quality and sourcing of tea have gained importance in Europe, but information remains scarce. The aim of this study was to determine the concentrations of fluoride (F-) and total aluminium (Al) species in infusions of commercially available teas in Slovenia, and thus in Europe, and to relate them to tea quality and their impact on consumer safety. F- concentrations were determined using a fluoride-ion-selective electrode and Al concentrations using inductively coupled plasma optical emission spectroscopy. A comparison of the results obtained for four selected tea samples using the calibration curve and a standard addition technique showed good agreement, with no interferences caused by the sample matrix. The concentrations of 35 commercial teas ranged from 0.34 to 4.79 and 0.51 to 8.90 mg/L for F- and Al, respectively. The average concentrations of the two elements followed the same descending order: black filter > green filter > black leaves ≈ green leaves. Single and multivariate statistical methods supported the categorisation of teas by packaging but not by type, with tea in filter bags being more expensive than loose tea. The linear relationship between F- and Al concentrations in infusions (C(Al) = 1.2134 · C(F-)) allows for the determination of one element and estimation of the other, leading to a significant reduction in laboratory effort and cost. This research advances tea assessment by proposing Al concentration alongside F- as a quality indicator and provides the basis for tea-monitoring protocols. Finally, the daily consumption of larger quantities of tea (≈1 L) with elevated F- and Al concentrations could potentially pose a health risk.

Effects of calcium supplements on oral bioavailability of fluoride in soil based on In Vivo and In Vitro methods

Dietary calcium (Ca) intake can alleviate fluoride (F) induced fluorosis to maintain bone health. However, it is unclear whether calcium supplements can reduce the oral bioavailability of F present in contaminated soils. Here we evaluated the effects of Ca supplements on F bioavailability in three soils using an in vitro method (Physiologically Based Extraction Test) and an in vivo mouse model. Seven Ca salts, commonly used in calcium supplements, significantly reduced the F bioaccessibility in the gastric and small intestinal phases. Particularly for Ca phosphate at 150 mg Ca supplementation, F bioaccessibility in the small intestinal phase was reduced from 35.1-38.8% to 0.7-1.9% where soluble F concentrations were less than 1 mg/L. Overall, the eight Ca tablets tested in this study showed greater efficiency at decreasing F solubility. The in vitro bioaccessibility after Ca supplementation was consistent with the relative bioavailability of F. As supported by X-ray photoelectron spectroscopy, a possible mechanism is that freed F can be bound by Ca to form insoluble CaF2 and exchanged with OH groups from Al/Fe hydroxide to strongly adsorb F. These findings provide evidence of Ca supplementation in reducing health risks associated soil F exposure.

Association of Dental Fluorosis and Urinary Fluoride with Intelligence among Schoolchildren

Fluoride is present naturally in water and has been used worldwide for the prevention of caries. Several studies conducted in high water fluoride or endemic fluorosis areas reported that fluoride adversely affected children's cognitive function, but some studies had negative findings. This study aimed to assess the relationship between urinary fluoride, dental fluorosis, and intelligence among schoolchildren living in communities with non-fluoridated drinking water. This cross-sectional study was conducted on 562 children aged 6-12 years in Taichung, Taiwan. Each child's urinary fluoride level was determined by a fluoride-ion-selective electrode, and the dental fluorosis condition was evaluated according to the criteria of Dean's Index. The Raven's Colored Progressive Matrices-Parallel and Standard Progressive Matrices-Parallel were used to assess children's intelligence. The results showed that the mean (±standard deviation) urinary fluoride concentrations were 0.40 ± 0.27 mg/L (0.43 ± 0.23 mg/g creatinine) among participants. The prevalence of dental fluorosis was 23.67%. After extensive evaluation of potential confounders, dental fluorosis and urinary fluoride were not associated with intelligence quotient (IQ) scores or grades in the regression models. In conclusion, dental fluorosis and urinary fluoride levels were not significantly related to the IQ of schoolchildren living in areas with low drinking water fluoride.

A case study of neurodevelopmental risks from combined exposures to lead, methyl-mercury, inorganic arsenic, polychlorinated biphenyls, polybrominated diphenyl ethers and fluoride

We performed a mixture risk assessment (MRA) case study of dietary exposure to the food contaminants lead, methylmercury, inorganic arsenic (iAs), fluoride, non-dioxin-like polychlorinated biphenyls (NDL-PCBs) and polybrominated diphenyl ethers (PBDEs), all substances associated with declines in cognitive abilities measured as IQ loss. Most of these chemicals are frequently measured in human biomonitoring studies. A component-based, personalised modified reference point index (mRPI) approach, in which we expressed the exposures and potencies of our chosen substances as lead equivalent values, was applied to perform a MRA for dietary exposures. We conducted the assessment for four different age groups (toddlers, children, adolescents, and women aged 18-45 years) in nine European countries. Populations in all countries considered exceeded combined tolerable levels at median exposure levels. NDL-PCBs in fish, other seafood and dairy, lead in grains and fruits, methylmercury in fish and other seafoods, and fluoride in water contributed most to the combined exposure. We identified uncertainties for the likelihood of co-exposure, assessment group membership, endpoint-specific reference values (ESRVs) based on epidemiological (lead, methylmercury, iAs, fluoride and NDL-PCBs) and animal data (PBDE), and exposure data. Those uncertainties lead to a complex pattern of under- and overestimations, which would require probabilistic modelling based on expert knowledge elicitation for integration of the identified uncertainties into an overall uncertainty estimate. In addition, the identified uncertainties could be used to refine future MRA for cognitive decline.

Fluoride exposure and cognitive neurodevelopment: Systematic review and dose-response meta-analysis

Many uncertainties still surround the possible harmful effect of fluoride exposure on cognitive neurodevelopment in children. The aim of this systematic review and meta-analysis was to characterize this relation through a dose-response approach, by comparing the intelligence quotient (IQ) scores in the highest versus the lowest fluoride exposure category with a random-effects model, within a one-stage dose-response meta-analysis based on a cubic spline random-effects model. Out of 1996 potentially relevant literature records, 33 studies were eligible for this review, 30 of which were also suitable for meta-analysis. The summary mean difference of IQ score, comparing highest versus lowest fluoride categories and considering all types of exposure, was -4.68 (95% confidence interval-CI -6.45; -2.92), with a value of -5.60 (95% CI -7.76; -3.44) for drinking water fluoride and -3.84 (95% CI -7.93; 0.24) for urinary fluoride. Dose-response analysis showed a substantially linear IQ decrease for increasing water fluoride above 1 mg/L, with -3.05 (95% CI -4.06; -2.04) IQ points per 1 mg/L up to 2 mg/L, becoming steeper above such level. A weaker and substantially linear decrease of -2.15 (95% CI -4.48; 0.18) IQ points with increasing urinary fluoride emerged above 0.28 mg/L (approximately reflecting a water fluoride content of 0.7 mg/L). The inverse association between fluoride exposure and IQ was particularly strong in the studies at high risk of bias, while no adverse effect emerged in the only study judged at low risk of bias. Overall, most studies suggested an adverse effect of fluoride exposure on children's IQ, starting at low levels of exposure. However, a major role of residual confounding could not be ruled out, thus indicating the need of additional prospective studies at low risk of bias to conclusively assess the relation between fluoride exposure and cognitive neurodevelopment.

Fluoride Levels in Supply Water from the Canary Islands Region

The Canary Islands, located in the Atlantic Ocean, are an archipelago of volcanic origin which, for decades, has been affected by natural fluoride contamination in the water supply of some of its islands, mainly the island of Tenerife. In addition, recent volcanic eruptions in the archipelago and the increased demand for water supply have led to an increase in the fluoride content in other areas which, historically, were not affected. Fluoride content was determined in 274 water supply samples from the most populated islands of the Canary Islands (Tenerife and Gran Canaria) collected during the months of June 2021 to May 2022. The samples were analysed by fluoride ion selective potentiometry. The highest concentrations in Tenerife were found in the municipalities of Sauzal (7.00 mg/L) and Tegueste (5.39 mg/L), both water samples are over the parametric value of 1.5 mg/L set in the supply water legislation. In the Gran Canaria Island, the highest fluoride levels were found in Valsequillo and Mogán with 1.44 mg/L in both locations, but under the parametric fluoride value abovementioned. Consumption of just 1 L of water per day in the El Sauzal area would result in a contribution rate of 77% for adults and children over 15 years of age (Upper Level value of 7 mg/day) and 108% for children 9-14 years of age (UL value of 5 mg/day). The contribution rates increase considerably, reaching or exceeding 100% of the reference value (UL) with increasing consumption of 1 to 2 L of water per day. Therefore, it is considered that there is a health risk of overexposure to fluoride on the island of Tenerife. In the case of the island of Gran Canaria, it has been shown that even the consumption of 2 litres of water per day does not confer contribution rates that pose a health risk.

An Analytical Protocol for the Differentiation and the Potentiometric Determination of Fluorine-Containing Fractions in Bovine Milk

Free fluoride ions are effective in combating caries in children, and their supplementation in milk has been widely used worldwide for this purpose. Furthermore, it is known that ionic fluoride added to milk is distributed among its components, but little is known about their quantitative relationships. This is likely due to the absence of an analytical protocol aimed at differentiating and quantifying the most important forms of fluorine present in milk. For the first time, a comprehensive protocol made up of six potentiometric methods devoted to quantifying the most important fractions of fluorine in milk (i.e., the free inorganic fluoride, the inorganic bonded fluorine, the caseins-bonded fluorine, the whey-bonded fluorine, the lipid-bonded fluorine, and the total fluorine) has been developed and tested on real samples. Four of the six methods of the procedure are original, and all have been validated in terms of limit of detection and quantification, precision, and trueness. The data obtained show that 9% of all fluorine was in ionic form, while 66.3% of total fluorine was bound to proteins and lipids, therefore unavailable for human absorption. Beyond applications in dental research, this protocol could be extended also to other foods, or used in environmental monitoring.

Analysis of the geological control on the spatial distribution of potentially toxic concentrations of As and F- in groundwater on a Pan-European scale

The distribution of the high concentrations of arsenic (As) and fluoride (F^-) in groundwater on a Pan-European scale could be explained by the geological European context (lithology and structural faults). To test this hypothesis, seventeen countries and eighteen geological survey organizations (GSOs) have participated in the dataset. The methodology has used the HydroGeoToxicity (HGT) and the Baseline Concentration (BLC) index. The results prove that most of the waters considered in this study are in good conditions for drinking water consumption, in terms of As and/or F^- content. A low proportion of the analysed samples present HGT≥ 1 levels (4% and 7% for As and F^-, respectively). The spatial distribution of the highest As and/or F^- concentrations (via BLC values) has been analysed using GIS tools. The highest values are identified associated with fissured hard rock outcrops (crystalline rocks) or Cenozoic sedimentary zones, where basement fractures seems to have an obvious control on the distribution of maximum concentrations of these elements in groundwaters.

Association of maternal urinary fluoride concentrations during pregnancy with size at birth and the potential mediation effect by maternal thyroid hormones: The Swedish NICE birth cohort

BACKGROUND

Observational studies have indicated that elevated maternal fluoride exposure during pregnancy may impair child neurodevelopment but a potential impact on birth outcomes is understudied.

OBJECTIVES

To evaluate the impact of gestational fluoride exposure on birth outcomes (birth size and gestational age at birth) and to assess the potential mediating role of maternal thyroid hormones.

METHODS

We studied 583 mother-child dyads in the NICE cohort in northern Sweden. Maternal fluoride exposure was assessed by measuring urinary concentrations at late pregnancy (median: 29th gestational week) using an ion selective electrode. Plasma levels of free and total thyroxine (fT4, tT4) and triiodothyronine (fT3, tT3), and thyroid stimulating hormone (TSH) were measured with electrochemiluminescence immunoassays. The infant's weight, length, head circumference, and gestational age at birth were extracted from hospital records.

RESULTS

Median urinary fluoride concentration was 0.71 mg/L (5th-95th percentile 0.31-1.9 mg/L; specific gravity adjusted). In multivariable-adjusted regression models, every 1 mg/L increase of maternal urinary fluoride was associated with a mean increase in birth weight by 84 g (95%CI: 30, 138), length by 0.41 cm (95%CI: 0.18, 0.65), head circumference by 0.3 cm (95%CI: 0.1, 0.4), and with increased odds of being born large for gestational age (OR = 1.39, 95%CI: 1.03, 1.89). Every 1 mg/L increase of maternal urinary fluoride was also associated with a mean increase of the plasma fT3:fT4 ratio (B = 0.007, 95%CI: 0.000, 0.014), but not with the hormones or TSH. In mediation analyses, the maternal fT3:fT4 ratio did not explain the urinary fluoride-birth size relationships.

DISCUSSION

Gestational urinary fluoride concentrations were associated with increased size at birth and even with increased odds of being born large for gestational age. The fluoride-related associations with increased size at birth were not explained by changes in maternal thyroid hormone levels.

Essential metals in health and disease

In total, twenty elements appear to be essential for the correct functioning of the human body, half of which are metals and half are non-metals. Among those metals that are currently considered to be essential for normal biological functioning are four main group elements, sodium (Na), potassium (K), magnesium (Mg), and calcium (Ca), and six d-block transition metal elements, manganese (Mn), iron (Fe), cobalt (Co), copper (Cu), zinc (Zn) and molybdenum (Mo). Cells have developed various metallo-regulatory mechanisms for maintaining a necessary homeostasis of metal-ions for diverse cellular processes, most importantly in the central nervous system. Since redox active transition metals (for example Fe and Cu) may participate in electron transfer reactions, their homeostasis must be carefully controlled. The catalytic behaviour of redox metals which have escaped control, e.g. via the Fenton reaction, results in the formation of reactive hydroxyl radicals, which may cause damage to DNA, proteins and membranes. Transition metals are integral parts of the active centers of numerous enzymes (e.g. Cu,Zn-SOD, Mn-SOD, Catalase) which catalyze chemical reactions at physiologically compatible rates. Either a deficiency, or an excess of essential metals may result in various disease states arising in an organism. Some typical ailments that are characterized by a disturbed homeostasis of redox active metals include neurological disorders (Alzheimer's, Parkinson's and Huntington's disorders), mental health problems, cardiovascular diseases, cancer, and diabetes. To comprehend more deeply the mechanisms by which essential metals, acting either alone or in combination, and/or through their interaction with non-essential metals (e.g. chromium) function in biological systems will require the application of a broader, more interdisciplinary approach than has mainly been used so far. It is clear that a stronger cooperation between bioinorganic chemists and biophysicists - who have already achieved great success in understanding the structure and role of metalloenzymes in living systems - with biologists, will access new avenues of research in the systems biology of metal ions. With this in mind, the present paper reviews selected chemical and biological aspects of metal ions and their possible interactions in living systems under normal and pathological conditions.

Fluoride Exposure from Soybean Beverage Consumption: A Toxic Risk Assessment

The consumption of vegetable milk as a substitute for cow's milk has increased in recent years. Of all the vegetable beverages on the market, soy is the most widely consumed. Soy is exposed to contamination by different chemical elements during harvesting. In this study, the concentration of fluoride in soy beverages was analyzed. Fluoride is an element that in high concentrations can be toxic, causing dental and bone fluorosis. The aims of the study were (i) to analyze the fluoride concentration in 30 samples in the most popular brands (A-Brand, B-Brand, C-Brand) of soybean beverages by a fluoride ion selective potentiometer and (ii) to evaluate the toxicological risk derived from its consumption. The fluoride concentrations were 15.5 mg/L (A-Brand), 11.3 mg/L (B-Brand) and 8.5 mg/L (C-Brand). A consumption of 1 to 3 servings/day was established. One serving (200 mL) of soybean beverage offered a contribution percentage over the ADI (acceptable daily intake) for infants and children. Teenagers and adults did not exceed the ADI (10 mg/day). The consumption of soy beverages contributes significantly to the daily intake of fluoride, which could exceed the ADI with a consequent health risk. It is recommended to control the fluoride levels in the raw material and in the final product to assure the safety of these products.

Toxicological assessment compilation of selected examples of raw materials for homeopathic and anthroposophic medicinal products - Part 2

The present successor article comprises more than 180 substances representing a continuative compilation of toxicologically evaluated starting materials prompted by the wide use and high number of homeopathic and anthroposophic medicinal products (HMP) on the market together with the broad spectrum of active substances of botanical, mineral, chemical or animal origin contained therein, and by the equally important requirement of applying adequate safety principles as with conventional human medicinal products in line with the European regulatory framework. The February 2019 issue of the Regulatory Toxicology and Pharmacology journal includes the antecedent article bearing the same title and entailing safety evaluations of more than 170 raw materials processed in HMP. This part 2 article highlights scientific evaluation following recognized methods used in toxicology with a view to drug-regulatory authority's assessment principles and practice in the context of HMP, and offers useful systematic, scientifically substantiated and simultaneously pragmatic approaches in differentiated HMP risk assessment. As a unique feature, both articles provide the most extensive publicly available systematic compilation of a considerable number of substances processed in HMP as a transparent resource for applicants, pharmaceutical manufacturers, the scientific community and healthcare authorities to actively support regulatory decision making in practice.

Fluoride levels in river water from the volcanic regions of Cauca (Colombia)

Fluoride concentrations of 0.5 mg/L in drinking water are considered useful for dental caries prevention. However, fluoride concentrations higher than 1.2 mg/L in water can pose a risk of dental fluorosis due to high exposure to fluoride. The objective is to determine the fluoride concentration in water from aqueducts of different Colombian municipalities of Cauca (Popayán, Coconuco, and Puracé) to assess the fluoride dietary intake from the consumption of this water. A total of 66 water samples have been taken from Popayán, Coconuco, and Puracé. Fluoride content was determined by fluoride ion-selective electrode (ISE) potentiometry. The fluoride concentrations recorded in Coconuco and Puracé water were ≤ 0.002 mg/L. The mean fluoride content recorded in the Popayán water was 0.42 mg/L, with its highest concentration in Cauca River water (0.83 mg/L). Considering the admissible intake values, the water from Popayán confers remarkable fluoride intakes, especially in children with high percentages of contribution to the admissible daily intake (46.7% to 7- to 12-month children and 41.5% to 1- to 3-year children). The fluoride content in the water of Coconuco and Puracé does not reach an optimal value (< 0.5 mg/L) for the protective effect against dental caries, while the water of the main Cauca River basin does reach the optimal value. Likewise, the intake of fluoride from the consumption of the analyzed water does not confer any health risk. However, the implementation of monitoring systems for fluoride levels is recommended in order to safeguard the consumer's health.

Dietary fluoride intake during pregnancy and neurodevelopment in toddlers: A prospective study in the progress cohort

Foods and beverages provide a source of fluoride exposure in Mexico. While high fluoride concentrations are neurotoxic, recent research suggests that exposures within the optimal range may also pose a risk to the developing brain. This prospective study examined whether dietary fluoride intake during pregnancy is associated with toddlers' neurodevelopment in 103 mother-child pairs from the PROGRESS cohort in Mexico City. Food and beverage fluoride intake was assessed in trimesters 2 and 3 using a food frequency questionnaire and Mexican tables of fluoride content. We used the Bayley-III to evaluate cognitive, motor, and language outcomes at 12 and 24 months of age. Adjusted linear regression models were generated for each neurodevelopment assessment time point (12 and 24 months). Mixed-effects models were used to consider a repeated measurement approach. Interactions between maternal fluoride intake and child sex on neurodevelopmental outcomes were tested. Median (IQR) dietary fluoride intake during pregnancy was 1.01 mg/d (0.73, 1.32). Maternal fluoride intake was not associated with cognitive, language, or motor outcomes collapsing across boys and girls. However, child sex modified the association between maternal fluoride intake and cognitive outcome (p interaction term = 0.06). A 0.5 mg/day increase in overall dietary fluoride intake was associated with a 3.50-point lower cognitive outcome in 24-month old boys (95 % CI: -6.58, -0.42); there was no statistical association with girls (β = 0.07, 95 % CI: -2.37, 2.51), nor on the cognitive outcome at 12-months of age. Averaging across the 12- and 24-month cognitive outcomes using mixed-effects models revealed a similar association: a 0.5 mg/day increase in overall dietary fluoride intake was associated with a 3.46-point lower cognitive outcome in boys (95 % CI: -6.23, -0.70). These findings suggest that the development of nonverbal abilities in males may be more vulnerable to prenatal fluoride exposure than language or motor abilities, even at levels within the recommended intake range.

Contribution to the ongoing discussion on fluoride toxicity

Since the addition of fluoride to drinking water in the 1940s, there have been frequent and sometimes heated discussions regarding its benefits and risks. In a recently published review, we addressed the question if current exposure levels in Europe represent a risk to human health. This review was discussed in an editorial asking why we did not calculate benchmark doses (BMD) of fluoride neurotoxicity for humans. Here, we address the question, why it is problematic to calculate BMDs based on the currently available data. Briefly, the conclusions of the available studies are not homogeneous, reporting negative as well as positive results; moreover, the positive studies lack control of confounding factors such as the influence of well-known neurotoxicants. We also discuss the limitations of several further epidemiological studies that did not meet the inclusion criteria of our review. Finally, it is important to not only focus on epidemiological studies. Rather, risk analysis should consider all available data, including epidemiological, animal, as well as in vitro studies. Despite remaining uncertainties, the totality of evidence does not support the notion that fluoride should be considered a human developmental neurotoxicant at current exposure levels in European countries.

Fluoride contamination of selected food crops, domestic water, and milk consumed by communities around mount Meru in Northern Tanzania

This study assessed fluoride levels in domestic water, commonly consumed food crops, cow's, and human milk. Samples of vegetables were collected from farmer's home gardens, green banana from local markets, maize flour, and domestic water from households, while cow's and human (breast) milk were obtained from cows and lactating mothers. Fluoride levels were determined by using a fluoride ion-selective electrode. Fluoride levels were 0.03 ± 0.02 mg/kg in maize, In leafy vegetables the highest levels were found in nightshade 0.081 ± 0.008 mg/kg, while for banana varieties the highest levels were found in in East African highland 0.025 ± 0.004 mg/kg. Levels in cows and human breast milk were 0.34 ± 0.2 mg/L and 0.077 ± 0.06 mg/L, respectively. Levels in domestic and public tap water were 4.57 ± 0.4 mg/L and 4.74 ± 0.8 mg/L, respectively. Study provided useful knowledge of fluoride levels in several crops, milk, and domestic water.

Chemical Aspects of Human and Environmental Overload with Fluorine

Over the last 100-120 years, due to the ever-increasing importance of fluorine-containing compounds in modern technology and daily life, the explosive development of the fluorochemical industry led to an enormous increase of emission of fluoride ions into the biosphere. This made it more and more important to understand the biological activities, metabolism, degradation, and possible environmental hazards of such substances. This comprehensive and critical review focuses on the effects of fluoride ions and organofluorine compounds (mainly pharmaceuticals and agrochemicals) on human health and the environment. To give a better overview, various connected topics are also discussed: reasons and trends of the advance of fluorine-containing pharmaceuticals and agrochemicals, metabolism of fluorinated drugs, withdrawn fluorinated drugs, natural sources of organic and inorganic fluorine compounds in the environment (including the biosphere), sources of fluoride intake, and finally biomarkers of fluoride exposure.

Fluoride in Drinking Water, Diet, and Urine in Relation to Bone Mineral Density and Fracture Incidence in Postmenopausal Women

BACKGROUND

Although randomized controlled trials (RCTs) have demonstrated that high fluoride increases bone mineral density (BMD) and skeletal fragility, observational studies of low-dose chronic exposure through drinking water (<1.5mg/L, the maximum recommended by the World Health Organization) have been inconclusive.

OBJECTIVE

We assessed associations of fluoride in urine, and intake via diet and drinking water, with BMD and fracture incidence in postmenopausal women exposed to drinking water fluoride ≤1mg/L.

METHODS

Data were from participants in the Swedish Mammography Cohort-Clinical, a population-based prospective cohort study. At baseline (2004-2009), fluoride exposure was assessed based on urine concentrations (n=4,306) and estimated dietary intake (including drinking water) (n=4,072), and BMD was measured using dual energy X-ray absorptiometry. Incident fractures were ascertained via register-linkage through 2017. Residential history was collected to identify women with long-term consistent drinking water exposures prior to baseline.

RESULTS

At baseline, mean urine fluoride was 1.2mg/g creatinine (±1.9) and mean dietary intake was 2.2mg/d (±0.9), respectively. During follow-up, 850, 529, and 187 cases of any fractures, osteoporotic fractures, and hip fractures, respectively, were ascertained. Baseline BMD was slightly higher among women in the highest vs. lowest tertiles of exposure. Fluoride exposures were positively associated with incident hip fractures, with multivariable-adjusted hazard ratios of 1.50 (95% CI: 1.04, 2.17) and 1.59 (95% CI: 1.10, 2.30), for the highest vs. lowest tertiles of urine fluoride and dietary fluoride, respectively. Associations with other fractures were less pronounced for urine fluoride, and null for dietary fluoride. Restricting the analyses to women with consistent long-term drinking water exposures prior to baseline strengthened associations between fractures and urinary fluoride.

DISCUSSION

In this cohort of postmenopausal women, the risk of fractures was increased in association with two separate indicators of fluoride exposure. Our findings are consistent with RCTs and suggest that high consumption of drinking water with a fluoride concentration of ∼1mg/L may increase both BMD and skeletal fragility in older women. https://doi.org/10.1289/EHP7404.

Review of the existing maximum residue levels for sulfuryl fluoride according to Article 12 of Regulation (EC) No 396/2005

According to Article 12 of Regulation (EC) No 396/2005, EFSA has reviewed the maximum residue levels (MRLs) currently established at European level for the pesticide active substance sulfuryl fluoride. To assess the occurrence of sulfuryl fluoride and fluoride ion residues in plants, processed commodities and livestock, EFSA considered the conclusions derived in the framework of Directive 91/414/EEC, the MRLs established by the Codex Alimentarius Commission as well as the European authorisations reported by Member States (including the supporting residues data). Based on the assessment of the available data, MRLs were calculated, but a consumer risk assessment could be carried out for sulfuryl fluoride only. Although no apparent risk to consumers was identified for sulfuryl fluoride, a standard consumer risk assessment to fluoride ion could not be performed, lacking information on the toxicological reference values for fluoride. Hence, an 'overall' consumer risk assessment could not be performed, only tentative MRLs proposal could be derived and measures for reduction of the consumer exposure should also be considered. Nevertheless, considering that fluoride ion is naturally occurring in food of plant and animal origin, EFSA performed an indicative calculation of the consumer exposure to estimate whether the uses currently authorised will contribute significantly to the overall consumer exposure to fluoride.

Human exposure to fluoride from tea (Camellia sinensis) in a volcanic region-Canary Islands, Spain

Fluoride is highly present in the environment, especially in water and its derivatives. Excessive fluoride contribution to diet poses a health risk. Tea leaves accumulate fluoride and the consumption of tea (Camellia sinensis) could pose a risk to human by the excessive fluoride intake. Ninety tea samples were analyzed by potentiometry using a selective fluoride ion electrode. Mixed tea samples (2.82 ± 1.11 mg/L) and black tea samples (2.28 ± 0.79 mg/L) recorded the highest fluoride levels. The contribution of drinking water is important for increasing fluoride levels in teas. The daily consumption of two cups (250 mL per cup) of mixed and black teas prepared with La Laguna tap water does pose a health risk for children (4-8 years old) because of the high contribution percentages (74.4% and 63.6%, respectively) of the Tolerable Upper Intake Level set in 2.5 mg/day by the EFSA (European Food Safety Authority). A minor consumption in children (4-8 years old) and adults during pregnancy is advisable.

Toxicity of fluoride: critical evaluation of evidence for human developmental neurotoxicity in epidemiological studies, animal experiments and in vitro analyses

Recently, epidemiological studies have suggested that fluoride is a human developmental neurotoxicant that reduces measures of intelligence in children, placing it into the same category as toxic metals (lead, methylmercury, arsenic) and polychlorinated biphenyls. If true, this assessment would be highly relevant considering the widespread fluoridation of drinking water and the worldwide use of fluoride in oral hygiene products such as toothpaste. To gain a deeper understanding of these assertions, we reviewed the levels of human exposure, as well as results from animal experiments, particularly focusing on developmental toxicity, and the molecular mechanisms by which fluoride can cause adverse effects. Moreover, in vitro studies investigating fluoride in neuronal cells and precursor/stem cells were analyzed, and 23 epidemiological studies published since 2012 were considered. The results show that the margin of exposure (MoE) between no observed adverse effect levels (NOAELs) in animal studies and the current adequate intake (AI) of fluoride (50 µg/kg b.w./day) in humans ranges between 50 and 210, depending on the specific animal experiment used as reference. Even for unusually high fluoride exposure levels, an MoE of at least ten was obtained. Furthermore, concentrations of fluoride in human plasma are much lower than fluoride concentrations, causing effects in cell cultures. In contrast, 21 of 23 recent epidemiological studies report an association between high fluoride exposure and reduced intelligence. The discrepancy between experimental and epidemiological evidence may be reconciled with deficiencies inherent in most of these epidemiological studies on a putative association between fluoride and intelligence, especially with respect to adequate consideration of potential confounding factors, e.g., socioeconomic status, residence, breast feeding, low birth weight, maternal intelligence, and exposure to other neurotoxic chemicals. In conclusion, based on the totality of currently available scientific evidence, the present review does not support the presumption that fluoride should be assessed as a human developmental neurotoxicant at the current exposure levels in Europe.

Fluoride levels in supply water from a volcanic area in the Macaronesia region

Fluoride is a widely distributed ion in the environment and, consequently, in water as well. High levels of fluoride in waters can be found in the Canary Islands because of their volcanic origin. Due to the risk and detrimental effects associated with a high fluoride intake, the content of this ion has been potentiometrically determined in 256 supply water samples from the islands of Tenerife, El Hierro, and La Palma, using a fluoride selective ion electrode. Fluoride mean concentration found on Tenerife is 4.22 mg/L, exceeding the parametric value of 1.5 mg/L set out in Spanish legislation. The consumption of 2 L of water from the studied municipalities of Tenerife would mean there is an excessive fluoride intake. The consumption of this water poses a serious risk to health. It is necessary to take action aimed at reducing the level of fluoride in the north of the island of Tenerife.

Fluoride network and circular economy as potential model for sustainable development-A review

Fluorine is the most reactive elements among the halogen group and commonly and ubiquitously occurs as fluoride in nature. The industrial processes produce fluoride by-products causing the increase of unwanted environmental levels and consequently posing risk on human and environmental health worldwide. This review gives a fundamental understanding of fluoride networks in the industrial processes, in the geological and hydrological transport, and in the biological sphere. Numerous biological pathways of fluoride also increase the risk of exposure. Literature shows that various environmental levels of fluoride due to its chemical characteristics cause bioaccumulation resulting in health deterioration among organisms. These problems are aggravated by emitted fluoride in the air and wastewater streams. Moreover, the current waste disposal dependent on incineration and landfilling superpose to the problem. In our analysis, the fluoride material flow model still follows a linear economy and reuse economy to some extent. This flow model spoils resources with high economic potential and worsens environmental problems. Thus, we intend a shift from the conventional linear economy to a circular economy with the revival of three-dimensional objectives of sustainable development. Linkages between key dimensions of the circular economy to stimulate momentum for perpetual sustainable development are proposed to gain economic, environmental and social benefits.

Current Guidance for Fluoride Intake: Is It Appropriate?

The purpose of this report is to examine critically the appropriateness of the current guidance for fluoride intake in the population (0.05-0.07 mg F/kg bodyweight/d), consider whether changes to the current guidance are desirable, and suggest further research that will strengthen the evidence base for future decisions on guidance/advice in this area. The benefits and the risks of using fluoride particularly concern preschool children because it is at this age that excessive fluoride intake may result in dental fluorosis. Data from mostly cross-sectional studies show a wide variation in exposure and a considerable variation in the amount of fluoride ingested. Fluorosis, mostly mild, is commonly observed. For considering changes in current guidance, there is a need for more knowledge on the relationship between exposure to fluoride at an early age and the development of fluorosis. For that, prospective epidemiological studies with sufficiently large and representative samples of children are required. It is also important to study children in communities both with and without water fluoridation and to include populations where salt or milk fluoridation is used. There is also a need for professional agreement on acceptable levels of mild and moderate/severe fluorosis and a more comprehensive knowledge on the appreciation of mild fluorosis among the public.

Chronic Fluoride Exposure and the Risk of Autism Spectrum Disorder

The continuous rise of autism spectrum disorder (ASD) prevalent in the past few decades is causing an increase in public health and socioeconomic concern. A consensus suggests the involvement of both genetic and environmental factors in the ASD etiopathogenesis. Fluoride (F) is rarely recognized among the environmental risk factors of ASD, since the neurotoxic effects of F are not generally accepted. Our review aims to provide evidence of F neurotoxicity. We assess the risk of chronic F exposure in the ASD etiopathology and investigate the role of metabolic and mitochondrial dysfunction, oxidative stress and inflammation, immunoexcitotoxicity, and decreased melatonin levels. These symptoms have been observed both after chronic F exposure as well as in ASD. Moreover, we show that F in synergistic interactions with aluminum's free metal cation (Al3+) can reinforce the pathological symptoms of ASD. This reinforcement takes place at concentrations several times lower than when acting alone. A high ASD prevalence has been reported from countries with water fluoridation as well as from endemic fluorosis areas. We suggest focusing the ASD prevention on the reduction of the F and Al3+ burdens from daily life.

Spatial distribution of groundwater fluoride levels and population at risk for dental caries and dental fluorosis in Sri Lanka

OBJECTIVES

To investigate the distribution of groundwater fluoride levels in Sri Lanka in relation to its population distribution to determine the population at risk for dental caries or dental fluorosis.

METHODS

The study used the most upgraded spatial distribution map of groundwater fluoride levels in Sri Lanka, and it was overlaid with a census of population data of the country.

RESULTS

The results indicated that 12% of children aged <12 years were at risk for dental fluorosis, while 81.4% of those who lived in low-fluoride zones were vulnerable for development of dental decay. Overall, 82.4% of the country's population lived in low-fluoride zones and 11.2% were at risk of potential health hazards posed by ingestion of excessive fluoride.

CONCLUSION

The spatial approach provides a useful decision-support tool for developing an oral health strategy of safe fluoride use based on predicted oral health risks in communities.

Safety assessment of the substance, titanium dioxide surface treated with fluoride-modified alumina, for use in food contact materials

This scientific opinion of the EFSA Panel on Food Contact Materials, Enzymes and Processing Aids (CEP Panel) is a safety assessment of the additive titanium dioxide surface treated with fluoride‐modified alumina, a defined mixture of particles of which ■■■■■% in number have a diameter in the range of 1–100 nm. It is intended to be used as filler and colourant up to 25% w/w in potentially all polymer types. Materials and articles containing the additive are intended to be in contact with all food types for any time and temperature conditions. The data provided demonstrate that the additive particles stay embedded even in swollen polar polymers such as polyamide, and do not migrate. Moreover, the additive particles resisted release by abrasion and did not transfer into a simulant for solid/dry foods. Thus, the additive particles do not give rise to exposure via food and to toxicological concern. Migration of solubilised ionic fluoride and aluminium occurs from the surface of the additive particles and particularly from swollen plastic. The Panel concluded that the substance does not raise safety concern for the consumer if used as an additive up to 25% w/w in polymers in contact with all food types for any time and temperature conditions. However, uses in polar polymers swelling in contact with foodstuffs simulated by 3% acetic acid should be limited to conditions simulated by contact up to 4 h at 100°C. This is due to the fact that when used at 25%, and contact was followed by 10 days at 60°C, the migration of aluminium and fluoride largely exceeded the specific migration limit (SML) of 1 and 0.15 mg/kg food, respectively. The Panel emphasises that the existing SMLs for aluminium and fluoride should not be exceeded in any case.

Fluoride Exposure Induces Inhibition of Sodium-and Potassium-Activated Adenosine Triphosphatase (Na+, K+-ATPase) Enzyme Activity: Molecular Mechanisms and Implications for Public Health

In this study, several lines of evidence are provided to show that Na + , K + -ATPase activity exerts vital roles in normal brain development and function and that loss of enzyme activity is implicated in neurodevelopmental, neuropsychiatric and neurodegenerative disorders, as well as increased risk of cancer, metabolic, pulmonary and cardiovascular disease. Evidence is presented to show that fluoride (F) inhibits Na + , K + -ATPase activity by altering biological pathways through modifying the expression of genes and the activity of glycolytic enzymes, metalloenzymes, hormones, proteins, neuropeptides and cytokines, as well as biological interface interactions that rely on the bioavailability of chemical elements magnesium and manganese to modulate ATP and Na + , K + -ATPase enzyme activity. Taken together, the findings of this study provide unprecedented insights into the molecular mechanisms and biological pathways by which F inhibits Na + , K + -ATPase activity and contributes to the etiology and pathophysiology of diseases associated with impairment of this essential enzyme. Moreover, the findings of this study further suggest that there are windows of susceptibility over the life course where chronic F exposure in pregnancy and early infancy may impair Na + , K + -ATPase activity with both short- and long-term implications for disease and inequalities in health. These findings would warrant considerable attention and potential intervention, not to mention additional research on the potential effects of F intake in contributing to chronic disease.

The Contribution of Fluoride to the Pathogenesis of Eye Diseases: Molecular Mechanisms and Implications for Public Health

This study provides diverse lines of evidence demonstrating that fluoride (F) exposure contributes to degenerative eye diseases by stimulating or inhibiting biological pathways associated with the pathogenesis of cataract, age-related macular degeneration and glaucoma. As elucidated in this study, F exerts this effect by inhibiting enolase, τ-crystallin, Hsp40, Na⁺, K⁺-ATPase, Nrf2, γ -GCS, HO-1 Bcl-2, FoxO1, SOD, PON-1 and glutathione activity, and upregulating NF-κB, IL-6, AGEs, HsP27 and Hsp70 expression. Moreover, F exposure leads to enhanced oxidative stress and impaired antioxidant activity. Based on the evidence presented in this study, it can be concluded that F exposure may be added to the list of identifiable risk factors associated with pathogenesis of degenerative eye diseases. The broader impact of these findings suggests that reducing F intake may lead to an overall reduction in the modifiable risk factors associated with degenerative eye diseases. Further studies are required to examine this association and determine differences in prevalence rates amongst fluoridated and non-fluoridated communities, taking into consideration other dietary sources of F such as tea. Finally, the findings of this study elucidate molecular pathways associated with F exposure that may suggest a possible association between F exposure and other inflammatory diseases. Further studies are also warranted to examine these associations.

Toxicological assessment compilation of selected examples of raw materials for homeopathic medicinal products

The considerable number of homeopathic medicinal products (HMP) on the German market and the staggering breadth of active substances of various origin along with the specific legal requirements of adequate safety principles posed the need to compile data on toxicologically evaluated raw materials. In line with the European regulatory framework, HMP applications must consider appropriate safety standards in analogy to conventional human medicinal products. This review presents an option for a systematic and scientifically substantiated approach for regulatory use. Furthermore, this paper provides a multitude of data for selected raw materials processed in HMP with up to now rather scarce knowledge and, thus, aims at filling data gaps on acceptable amounts per day (AAD). The inclusion of raw materials into the compilation was determined considering the frequencies of their occurrence in HMP in Germany along with the availability of appropriate safety assessments. This safety evaluation compilation represents a practical, fairly comprehensive and systematic set of more than 170 raw materials. It is designed to both effectively support regulatory decision making and to be recognized and exploited by applicants, stakeholders and the scientific community.

Understanding Optimum Fluoride Intake from Population-Level Evidence

Policy on fluoride intake involves balancing caries against dental fluorosis in populations. The origin of this balance lies with Dean’s research on fluoride concentration in water supplies, caries, and fluorosis. Dean identified cut points in the Index of Dental Fluorosis of 0.4 and 0.6 as critical. These equate to 1.3 and 1.6 mg fluoride (F)/L. However, 1.0 mg F/L, initially called a permissible level, was adopted for fluoridation programs. McClure, in 1943, derived an “optimum” fluoride intake based on this permissible concentration. It was not until 1944 that Dean referred to this concentration as the “optimal” concentration. These were critical steps that have informed health authorities through to today. Several countries have derived toxicological estimates of an adequate and an upper level of intake of fluoride as an important nutrient. The US Institute of Medicine (IOM) in 1997 estimated an Adequate Intake (AI) of 0.05 mg F/kg bodyweight (bw)/d and a Tolerable Upper Intake Level (UL) of 0.10 mg F/kg bw/d. These have been widely promulgated. However, a conundrum has existed with estimates of actual fluoride intake that exceed the UL without the expected adverse fluorosis effects being observed. Both the AI and UL need review. Fluoride intake at an individual level should be interpreted to inform more nuanced guidelines for individual behavior. An “optimum” intake should be based on community perceptions of caries and fluorosis, while the ultimate test for fluoride intake is monitoring caries and fluorosis in populations.

Determination of Fluoride in Organic and Non-organic Wines

Fluorine is an element of great importance to human health, as it is considered to be an essential element. However, both a deficiency and an excess, it can cause various problems. It is for this reason that values have been established regarding the recommended daily intake (RDI) and acceptable daily intake (ADI). The largest source of incorporation of fluoride is water, but it can be found in other foods and beverages, such as vegetables, tea, and wine. The aim of the study was to establish the fluoride concentration in organic and non-organic wines from different appellations of origin of the Canary Islands and mainland Spain, in order to assess the contribution of fluoride and toxic risk. A total of 53 samples of red, white, and rosé wines, both organic and non-organic, from different appellations of origin were analyzed. They were analyzed by potentiometric determination with ion-selective electrode for fluoride using the method of standard addition. The wines analyzed are within the recommended limits set by the International Organisation of Vine and Wine. RDI is not exceeded for adults, taking into account the data provided by the Spanish Agency for Consumer Affairs, Food Safety and Nutrition on the average consumption of "table wines" in Spain. Fluoride intake from wine poses no risk to the health of adults. The fluoride concentration of organic and non-organic wines is within the range of 0.03 to 0.70 mg/L.

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.

[Fluoride intake through consumption of water from municipal network in the INMA-Gipuzkoa cohort]

OBJECTIVE

To estimate fluoride intake through consumption of water from the municipal network in pregnant women and their children from the INMA-Gipuzkoa cohort and to compare these intakes with recommended levels. In Euskadi (Spain), fluoridation of drinking water is compulsory in water supplies for more than 30,000 inhabitants.

METHOD

575 pregnant women (recruitment, 2006-2008) and 424 4-year-old children (follow-up, 2010-2012) have been included. Fluoride levels in drinking water were obtained from the water consumption information system of the Basque Country (EKUIS). Water consumption habits and socioeconomic variables were obtained by questionnaire.

RESULTS

74.9% and 87.7% of women and children consumed water from the municipal network. Average fluoride levels in fluoridated water were 0.805 (SD: 0.194) mg/L during baseline recruitment and 0.843 (SD: 0.080) mg/L during follow up, at 4 years old of the children. Average and 95th percentile of fluoride intake were 0.015 and 0.026mg/kg per day in women and 0.033 and 0.059mg/kg per day in children. Considering only fluoride provided by drinking water, 8.71% of children living in fluoridated areas exceeded intake level recommended by the European Food Safety Authority, consisting in 0.05mg/kg per day.

CONCLUSION

The results show that ingested levels of fluoride through consumption of municipal water can exceed the recommended levels in children and encourages further studies that will help in fluoridation policies of drinking water in the future.

"Borderline" fluorotic region in Serbia: correlations among fluoride in drinking water, biomarkers of exposure and dental fluorosis in schoolchildren

This study explores relation between dental fluorosis occurrence in schoolchildren, residents of Ritopek, a small local community near Belgrade, and fluoride exposure via drinking water. Additionally, fluoride levels were determined in children's urine and hair samples, and efforts were made to correlate them with dental fluorosis. Dental fluorosis and caries prevalence were examined in a total of 52 schoolchildren aged 7-15 years (29 boys and 23 girls). Fluoride levels in three types of samples were analyzed using composite fluoride ion-selective electrode. Results showed high prevalence of dental fluorosis (34.6 %) and low prevalence of dental caries (23.1 %, mean DMFT 0.96) among children exposed to wide range of water fluoride levels (0.11-4.14 mg/L, n = 27). About 11 % of water samples exceeded 1.5 mg/L, a drinking-water quality guideline value for fluoride given by the World Health Organization (2006). Fluoride levels in urine and hair samples ranged between 0.07-2.59 (n = 48) and 1.07-19.83 mg/L (n = 33), respectively. Severity of dental fluorosis was positively and linearly correlated with fluoride levels in drinking water (r = 0.79). Fluoride levels in urine and hair were strongly and positively correlated with levels in drinking water (r = 0.92 and 0.94, respectively). Fluoride levels in hair samples appeared to be a potentially promising biomarker of fluoride intake via drinking water on one hand, and severity of dental fluorosis on the other hand. Based on community fluorosis index value of 0.58, dental fluorosis revealed in Ritopek can be considered as "borderline" public health issue.

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.