Page 4: Guidelines for Canadian Drinking Water Quality: Guideline Technical Document – Fluoride

12.0 Rationale

Moderate dental fluorosis has been chosen as the endpoint of concern for fluoride. It is not considered to be a toxicological end-point because it is not a health concern, but it is significant because it correlates with cosmetic problems. Dental fluorosis is the effect occurring at the lowest level of exposure in the population, and is the most widely and frequently studied of all adverse effects of fluoride. However, very mild and mild dental fluorosis are not considered to be adverse effects, either from a health or from a cosmetic perspective. Health Canada has calculated a health-based value of 0.9 mg/L for fluoride in drinking water, which is deemed protective against any potential adverse health effect from fluoride.

Based on the health-based value, the Federal-Provincial-Territorial Committee on Drinking Water has chosen to risk manage this value to a MAC of 1.5 mg/L for fluoride in drinking water, incorporating the following considerations:

  • The current MAC of 1.5 mg/L for fluoride is still considered unlikely to cause moderate dental fluorosis in the Canadian population. The recent CHMS data have shown that the prevalence of Canadian children with moderate dental fluorosis is too low to be reported.
  • The current MAC of 1.5 mg/L is also considered to be protective against all potential adverse health effects, including cancer, bone fracture, immunotoxicity, reproductive/developmental toxicity, genotoxicity, and/or neurotoxicity. Mild to moderate dental fluorosis is not considered to be an adverse health effect.
  • The maximum acceptable concentration is established to ensure levels of fluoride do not exceed this value in treated drinking water. Naturally-occurring levels of fluoride above this value could be expected to be found in groundwater, which generally affects well owners and would require residential scale treatment.
  • Where natural levels of fluoride in drinking water are exceeding the health-based value, the increased water treatment costs that would have to be incurred by those communities and private wells would be excessive.
  • At current exposure levels, Canada is not a country cited in the international literature as having wide areas with elevated fluoride concentrations. Based on data provided by provinces and territories, fewer than 2% of the population would receive community water at levels over 1.0 mg/L. The situation in Canada is such that only a tiny minority of supplies is likely affected by excess fluoride and there appear to be few or no very high fluoride sources.

However, the Committee encouraged efforts to control fluoride intake from sources such as toothpaste ingestion and efforts to obtain other up-to-date estimates of daily fluoride intake in Canada.

13.0 References

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Appendix A: List of acronyms

AA
activated alumina
AChE
acetylcholinesterase
BMD
bone mineral density
bw
body weight
CEPA
Canadian Environmental Protection Act
CI
confidence interval
DMFS
decayed, missing, or filled surfaces of permanent teeth
DMFT
decayed, missing, or filled permanent teeth
DNA
deoxyribonucleic acid
ED
electrodialysis
EDR
electrodialysis reversal
EPA
Environmental Protection Agency (United States)
GD
gestation day
GSH
glutathione
HBV
health-based value
IQ
intelligence quotient
LD 50
median lethal dose
LOAEL
lowest-observed-adverse-effect level
MAC
maximum acceptable concentration
MDL
method detection limit
nAChR
nicotinic acetylcholine receptor
NCI
National Cancer Institute (United States)
NOAEL
no-observed-adverse-effect level
NTP
National Toxicology Program (United States)
OR
odds ratio
PBPK
physiologically based pharmacokinetic
PQL
practical quantitation limit
RNA
ribonucleic acid
RR
relative risk
SCE
sister chromatid exchange
SD
standard deviation
SEER
Surveillance, Epidemiology and End Results
SIDS
sudden infant death syndrome
TDI
tolerable daily intake
TDS
total diet study

Appendix B: Tables

Table B-1: Provincial/territorial estimates for community water fluoridation coverage Footnote 1
Province Total population Population with fluoridated water Population without fluoridated water Percentage with fluoridated water
(%)
Percentage without fluoridated water
(%)

Footnotes

Footnote 1

This information was collected from Provincial or Territorial Environment Ministries and then verified by the Dental Directors of each province and territory. The Ministries of Environment provided detailed data on the community fluoridated, or the water plants well as population numbers (Health Canada, 2009).

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British Columbia 4 113 000 152 241 3 960 759 3.7 96.3
Alberta 3 290 350 2 457 406 832 944 74.7 25.3
Saskatchewan 968 157 356 096 612 061 36.8 63.2
Manitoba 1 148 401 803 116 345 285 69.9 30.1
Ontario 12 160 282 9 229 015 2 931 267 75.9 24.1
Quebec 7 546 131 489 420 7 067 711 6.4 93.7
New Brunswick 729 498 188 607 540 891 25.9 74.2
Nova Scotia 913 462 519 031 394 431 56.8 43.2
Prince Edward Island 135 851 32 174 103 677 23.7 76.3
Newfoundland and Labrador 505 469 7 572 497 897 1.5 98.5
Nunavut 29 474 0 29 474 0.0 100.0
Northwest Territories 41 464 23 400 18 034 56.4 43.6
Yukon 30 372 0 30 372 0.0 100.0
National totals 31 611 911 14 258 078 17 364 803 45.1 54.9
Table B-2: Estimated dietary intake of fluoride by children over 1 year of age and adults in Canadian communities with fluoride levels of about 1 mg/L and 0 mg/L in their food processing water and beverages Footnote 1
Diet Dietary intake (µg/kg bw/day)
1-4 years
M+F
5-11 years
M+F
12-19 years
M
20-39 years
M
40-64 years
M
65+ years
M
12-19 years
F
20-39 years
F
40-64 years
F
65+ years
F
All ages
M+F

Footnotes

Footnote 1

Adapted from Dabeka et al. (2007a). Does not include fluoride intake from straight tap water consumption.

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Footnote 2

TDS stands for "Total Diet Study." Fluoride levels in Toronto drinking water were 0.54 mg/L, and water used to process food had fluoride concentrations of 0.28 mg/L.

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Footnote 3

The concentration of fluoride in coffee from the Toronto composite was used in place of the concentration of fluoride in tea.

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Fluoride in water at 1 mg/L, with tea 26 21 20 38 47 41 19 42 48 43 32
No fluoride in water, with tea 16 14 13 24 31 29 13 27 33 31 21
TDSFootnote 2 estimate, Toronto, with tea 17 14 12 21 24 20 11 21 23 21 17
Fluoride in water at 1 mg/L, no tea 22 16 12 17 15 12 10 15 14 11 12
No fluoride in water, no tea 13 10 7 7 6 5 6 6 6 5 6
TDS estimate, Toronto, no teaFootnote 3 15 12 9 11 10 7 7 8 8 6 8
Table B-3: Estimated dietary intake of fluoride by infants as a function of fluoride level in their community drinking water and the type of infant formula fed to them Footnote 1
DietFootnote 2 Fluoride in water status Dietary intake (µg/kg bw/day)
0-1
months
2-3
months
4-6
months
7-9
months
10-12
months

Footnotes

Footnote 1

Adapted from Dabeka et al. (2007a).

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Footnote 2

Except for the "All formulas" and for the "TDS estimate," all dietary intake estimates were calculated assuming that the only milk or formula type fed to the infant was that described in the table. For the powdered formula, a dilution of 8.5 g (water) ± 1.5 g (powder) was used to estimate the concentration of fluoride in the formula as fed, assuming water contains fluoride at 1 mg/L or 0 mg/L. The fluoride concentrations used for human milk were 0.013 mg/L and 0.009 mg/L, geometric means obtained previously in Canada for mothers living in communities with fluoridated and non-fluoridated water, respectively (Dabeka et al., 1986).

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Footnote 3

For foods and beverages with important water components (such as canned soups, pasta, rice, frozen juices, coffee, tea, infant formula, and cereals), the water used was fluoridated (0.99 mg fluoride/L).

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Footnote 4

For foods and beverages with important water components (such as canned soups, pasta, rice, frozen juices, coffee, tea, infant formula, and cereals), the water used was fluoride-free (0 mg fluoride/L).

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Footnote 5

TDS stands for "Total Diet Study." Fluoride levels in Toronto drinking water were 0.54 mg/L, and water used to process food had fluoride concentrations of 0.28 mg/L.

Return to footnote 5 referrer

All formulas Fluoride in waterFootnote 3 33 37 21 26 24
No fluoride in waterFootnote 4 14 16 12 14 13
TDS estimate, TorontoFootnote 5   18 21 12 15 13
Ready-to-use milk-based formula Fluoride in water 26 28 28 27 30
No fluoride in water 21 23 22 22 21
Powdered milk-based formula Fluoride in water 119 120 115 97 85
No fluoride in water 19 21 20 20 20
Ready-to-use soy-based formula Fluoride in water 69 70 68 60 55
No fluoride in water 64 65 63 54 46
Powdered soy-based formula Fluoride in water 102 111 102 92 81
No fluoride in water 15 17 17 18 18
Breast milk Fluoride in water 12 14 15 17 21
No fluoride in water 6 8 9 11 12
Table B-4: Estimated dietary intakes of infants living in the 1940s in communities with differing concentrations of fluoride in drinking water Footnote 1
Fluoride concentration in drinking water
(mg/L)
Average dietary intakes (µg/kg bw/day)
0-1 months
M+F
2-3 months
M+F
4-6 months
M+F
7-9 months
M+F
9-12 months
M+F
All ages
0-12 months
M+F

Footnotes

Footnote 1

Adapted from Dabeka et al. (2007b).

Return to footnote 1 referrer

0 9 11 11 12 12 11
1 57 52 33 31 25 36
1.5 81 72 45 40 32 48
Table B-5: Estimated dietary intakes of children 1 year of age and older and adults living in the 1940s in communities with differing concentrations of fluoride in drinking water Footnote 1
Fluoride concen-tration in drinking water
(mg/L)
Average dietary intakes (µg/kg bw/day)
1-4 years
M+F
5-11 years
M+F
12-19 years
M
20-39 years
M
40-64 years
M
65+ years
M
12-19 years
F
20-39 years
F
40-64 years
F
65+ years
F
All ages
>1 year old
M+F

Footnotes

Footnote 1

Adapted from Dabeka et al. (2007b).

Return to footnote 1 referrer

0 14 11 10 16 20 18 9 18 21 19 16
1 23 19 17 30 35 30 15 31 35 31 26
1.5 27 22 20 37 42 36 18 38 42 36 32
Table B-6: Estimated dose of fluoride ingested from fluoridated dentifrice per day in children aged 6 to 144 months old Footnote 1
Age
(months)
NFootnote 2 Average ingested dose
µg/kg bw/day

Footnotes

Footnote 1

Adapted from Levy et al. 2006.

Return to footnote 1 referrer

Footnote 2

N = number of subjects. Only subjects brushing with fluoridated toothpaste are included in the table.

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6 13 30
12 214 20
24 558 30
36 577 30
48 582 40
60 603 40
72 587 40
84 531 40
96 514 30
102 474 30
108 434 30
120 504 30
132 342 30
144 137 20

Footnotes

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