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.

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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). Return to footnote 1 referrer
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)
Diet	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. Return to footnote 1 referrer 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. Return to footnote 2 referrer Footnote 3 The concentration of fluoride in coffee from the Toronto composite was used in place of the concentration of fluoride in tea. Return to footnote 3 referrer
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
TDS^{Footnote 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 tea^{Footnote 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}
Diet^{Footnote 2}	Fluoride in water status	Dietary intake (µg/kg bw/day)
Diet^{Footnote 2}	Fluoride in water status	0-1 months	2-3 months	4-6 months	7-9 months	10-12 months
Footnotes Footnote 1 Adapted from Dabeka et al. (2007a). Return to footnote 1 referrer 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). Return to footnote 2 referrer 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). Return to footnote 3 referrer 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). Return to footnote 4 referrer 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 water^{Footnote 3}	33	37	21	26	24
All formulas	No fluoride in water^{Footnote 4}	14	16	12	14	13
TDS estimate, Toronto^{Footnote 5}		18	21	12	15	13
Ready-to-use milk-based formula	Fluoride in water	26	28	28	27	30
Ready-to-use milk-based formula	No fluoride in water	21	23	22	22	21
Powdered milk-based formula	Fluoride in water	119	120	115	97	85
Powdered milk-based formula	No fluoride in water	19	21	20	20	20
Ready-to-use soy-based formula	Fluoride in water	69	70	68	60	55
Ready-to-use soy-based formula	No fluoride in water	64	65	63	54	46
Powdered soy-based formula	Fluoride in water	102	111	102	92	81
Powdered soy-based formula	No fluoride in water	15	17	17	18	18
Breast milk	Fluoride in water	12	14	15	17	21
Breast milk	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)
Fluoride concentration in drinking water (mg/L)	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)
Fluoride concen-tration in drinking water (mg/L)	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)	N^{Footnote 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. Return to footnote 2 referrer
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

Footnote 1

Unless otherwise specified, concentrations of fluoride refer to inorganic fluoride.

Return to footnote 1 referrer

Return to footnote1 referrer

Footnote 2

Target concentration of fluoride in drinking water, according to climate. This level can vary from 0.7 to 1.2 mg fluoride/L, assuming that the drinking water consumption rate varies in different areas of the United States. The target level of fluoride in drinking water is considered to be 0.7 mg/L for locations in warmer climates (higher ingestion rate) and 1.2 mg/L for locations in colder climates (lower ingestion rate) (Bassin et al., 2006).

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Return to footnote2 referrer

Footnote 3

The dmft/DMFT Index is an indicator of dental disease that is obtained by calculating the number of decayed, missing, and filled teeth. The dmft/DMFT Index relates to whole primary teeth (dmft) or permanent teeth (DMFT).It is made up of the number of teeth with active untreated decay. It allows comparisons to be made of the number of children who have experienced caries or have active cases.

Return to footnote 3 referrer

Return to footnote3 referrer

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

12.0 Rationale

13.0 References

Appendix A: List of acronyms

Appendix B: Tables

Footnotes

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