information (if any) given on the labels or provided by the manufacturer. Private water sources (e.g., wells and cisterns) probably are even more variable in fluoride content, with some regions of the country being especially high and others very low. A number of authors have pointed out the difficulty doctors and dentists face in ascertaining individual fluoride intakes, just from drinking water (from all sources), for the purpose of prescribing appropriate fluoride supplementation (Nowak and Nowak 1989; Chan et al. 1990; Stannard et al. 1990; Levy and Shavlick 1991; Weinberger 1991; Dillenberg et al. 1992; Jones and Berg 1992; Levy and Muchow 1992; Toumba et al. 1994; Duperon et al. 1995; Van Winkle et al. 1995; Heller et al. 1999; Bartels et al. 2000; Lalumandier and Ayers 2000; Johnson and DeBiase 2003; Zohouri et al. 2003).
EPA, in its report to Congress on sensitive subpopulations (EPA 2000b), defines sensitive subpopulations in terms of either their response (more severe response or a response to a lower dose) or their exposure (greater exposure than the general population). Hence, it is appropriate to consider those population subgroups whose water intake is likely to be substantially above the national average for the corresponding sex and age group. These subgroups include people with high activity levels (e.g., athletes, workers with physically demanding duties, military personnel); people living in very hot or dry climates, especially outdoor workers; pregnant or lactating women; and people with health conditions that affect water intake. Such health conditions include diabetes mellitus, especially if untreated or poorly controlled; disorders of water and sodium metabolism, such as diabetes insipidus; renal problems resulting in reduced clearance of fluoride; and short-term conditions requiring rapid rehydration, such as gastrointestinal upsets or food poisoning (EPA 2000a). (While the population sample described in Appendix B [Water Ingestion and Fluoride Intakes] included some of these individuals, the study did not attempt to estimate means or distributions of intake for these specific subgroups.)
As shown in Appendix B (Tables B-4 to B-9), some members of the U.S. population could have intakes from community water sources of as much as 4.5-5 L/day (as high as 80 mL/kg/day for adults). Some infants have intakes of community water exceeding 200 mL/kg/day. Heller et al. (1999), using the same data set as EPA (2000a), reported that 21 of 14,640 people (of all ages) had water intakes over 6 standard deviations from the mean (greater than 249 mL/kg/day). Whyte et al. (2005) describe an adult woman who consistently consumed 1-2 gallons (3.8-7.6 L) of fluid per day (instant tea made with well water); no specific reason for her high fluid consumption is given.