ter containing fluoride at 2-4 mg/L. Single high doses of ingested fluoride are known to elicit acute GI symptoms, such as nausea and vomiting, but whether chronic exposure to drinking water with fluoride at 4 mg/L can elicit the same symptoms has not been documented well.

The primary symptoms of GI injury are nausea, vomiting, and abdominal pain (see Table 9-1). Such symptoms have been reported in case studies (Waldbott 1956; Petraborg 1977) and in a clinical study involving double-blind tests on subjects drinking water artificially fluoridated at 1.0 mg/L (Grimbergen 1974). In the clinical study, subjects were selected whose GI symptoms appeared with the consumption of fluoridated water and disappeared when they switched to nonfluoridated water. A pharmacist prepared solutions of sodium fluoride (NaF) and sodium silicofluoride (Na2SiF6) so that the final fluoride ion concentrations were 1.0 mg/L. Eight bottles of water were prepared with either fluoridated water or distilled water. Patients were instructed to use one bottle at a time for 2 weeks. They were asked to record their symptoms throughout the study period. Neither patients nor the physician administering the water knew which water samples were fluoridated until after the experiments were completed. The fluoridation chemicals added to the water at the time of the experiments were likely the best candidates to produce these symptoms. Despite those well-documented case reports, the authors did not estimate what percentage of the population might have GI problems. The authors could have been examining a group of patients whose GI tracts were particularly hypersensitive. The possibility that a small percentage of the population reacts systemically to fluoride, perhaps through changes in the immune system, cannot be ruled out (see section on the immune system later in this chapter).

Perhaps it is safe to say that less than 1% of the population complains of GI symptoms after fluoridation is initiated (Feltman and Kosel 1961). The numerous fluoridation studies in the past failed to rigorously test for changes in GI symptoms and there are no studies on drinking water containing fluoride at 4 mg/L in which GI symptoms were carefully documented. Nevertheless, there are reports of areas in the United States where the drinking water contains fluoride at concentrations greater than 4 mg/L and as much as 8 mg/L (Leone et al. 1955b). Symptoms of GI distress or discomfort were not reported. In the United Kingdom, where tea drinking is more common, people can consume up to 9 mg of fluoride a day (Jenkins 1991). GI symptoms were not reported in the tea drinkers. The absence of symptoms might be related to the hardness of the water, which is high in some areas of the United Kingdom. Jenkins (1991) reported finding unexpectedly high concentrations of fluoride (as high as 14 mg/L) in soft water compared with hard water when boiled. In contrast, in India, where endemic fluorosis is well documented, severe GI symptoms are common (Gupta et al. 1992; Susheela et al. 1993; Dasarathy et al. 1996). One cannot rule out the



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