dated”1 water in 2000 (CDC 2002a). This represents an increase from 144 million (62.1%) in 1992. The total number of people served by public water systems in the United States is estimated to be 246 million; an estimated 35 million people obtain water from other sources such as private wells (CDC 2002a,b). The U.S. Environmental Protection Agency (EPA) limits the fluoride that can be present in public drinking-water supplies to 4 mg/L (maximum contaminant level, or MCL) to protect against crippling skeletal fluorosis, with a secondary maximum contaminant level (SMCL) of 2 mg/L to protect against objectionable enamel fluorosis (40CFR 141.62(b)[2001], 40CFR 143.3[2001]).

Of the 144 million people with fluoridated public water supplies in 1992, approximately 10 million (7%) received naturally fluoridated water, the rest had artificially fluoridated water (CDC 2002c). Of the population with artificially fluoridated water in 1992, more than two-thirds had a water fluoride concentration of 1.0 mg/L, with almost one-quarter having lower concentrations and about 5% having concentrations up to 1.2 mg/L (CDC 1993; see Appendix B).

Of the approximately 10 million people with naturally fluoridated public water supplies in 1992, approximately 67% had fluoride concentrations ≤ 1.2 mg/L (CDC 1993; see Appendix B). Approximately 14% had fluoride concentrations between 1.3 and 1.9 mg/L and another 14% had between 2.0 and 3.9 mg/L; 2% (just over 200,000 persons) had natural fluoride concentrations equal to or exceeding 4.0 mg/L.2 Water supplies that exceeded 4.0 mg/L ranged as high as 11.2 mg/L in Colorado, 12.0 mg/L in Oklahoma, 13.0 mg/L in New Mexico, and 15.9 mg/L in Idaho (see Appendix B, Table B-3).3 States with the largest populations receiving water supplies with fluoride at ≥ 4.0 mg/L included Virginia (18,726 persons, up to 6.3 mg/L), Oklahoma (18,895 persons, up to 12.0 mg/L), Texas (36,863 persons, up to 8.8 mg/L), and South Carolina (105,618 persons, up to 5.9 mg/L).

Little information is available on the fluoride content of private water sources, but the variability can reasonably be expected to be high and to


The term optimally fluoridated water means a fluoride level of 0.7-1.2 mg/L; water fluoride levels are based on the average maximum daily air temperature of the area (see Appendix B).


More recently (2000), CDC has estimated that 850,000 people are served by public water supplies containing fluoride in excess of 2 mg/L; of these, 152,000 people receive water containing fluoride in excess of 4 mg/L (unpublished data from CDC as reported in EPA 2003a). Based on analytical data from 16 states, EPA (2003a) estimates that 1.5-3.3 million people nationally are served by public water supplies with fluoride concentrations exceeding 2 mg/L; of these 118,000-301,000 people receive water with fluoride concentrations greater than 4 mg/L.


High-fluoride municipal waters are generally found in regions that have high fluoride concentrations in the groundwater or in surface waters. ATSDR (2003) has reviewed fluoride concentrations in environmental media, including groundwater and surface water. Fleischer (1962) and Fleischer et al. (1974) reported fluoride concentrations in groundwater by county for the coterminous United States.

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