Five papers described enamel fluorosis in association with diabetes insipidus or polydipsia (Table 2-3). Two of the papers described cases of enamel fluorosis in the United States resulting from fluoride concentrations of 1, 1.7, or 2.6 mg/L in drinking water (Juncos and Donadio 1972; Greenberg et al. 1974). The two individuals drinking water with fluoride at 1.7 and 2.6 mg/L also had roentgenographic bone changes consistent with “systemic fluorosis”⁸ (Juncos and Donadio 1972). These patients and four other renal patients in the U.S. “in whom fluoride may have been the cause of detectable clinical and roentgenographic effects” were also reported by Johnson et al. (1979); most of the patients had urine volumes exceeding 3 L/day and drinking water with fluoride concentrations around 1.7-3 mg/L.

Moderate and severe enamel fluorosis have been reported in diabetes insipidus patients in other countries with drinking water containing fluoride at 0.5 mg/L (Klein 1975) or 1 mg/L (Seow and Thomsett 1994), and severe enamel fluorosis with skeletal fluorosis has been reported with fluoride at 3.4 mg/L (Mehta et al. 1998). Greenberg et al. (1974) recommended that children with any disorder that gives rise to polydipsia and polyuria⁹ be supplied a portion of their water from a nonfluoridated source.

Table 2-4 provides examples of fluoride intake by members of several population subgroups characterized by above-average water consumption (athletes and workers, patients with diabetes mellitus or diabetes insipidus). It should be recognized that, for some groups of people with high water intakes (e.g., those with a disease condition or those playing indoor sports such as basketball or hockey), there probably will be little correlation of water intake with outdoor temperature—such individuals in northern states would consume approximately the same amounts of water as their counterparts in southern states. However, fluoridation still varies from state to state (Appendix B), so that some individuals could consume up to 1.7 times as much as others for the same water intake (1.2 versus 0.7 mg/L).

Measured fluoride in samples of human breast milk is very low. Dabeka et al. (1986) found detectable concentrations in only 92 of 210 samples (44%) obtained in Canada, with fluoride ranging from <0.004 to 0.097 mg/L. The mean concentration in milk from mothers in fluoridated

Front matter (R1-R22)

Summary (1-12)

1 Introduction (13-22)

2 Measures of Exposure to Fluoride in the United States (23-88)

3 Pharmacokinetics of Fluoride (89-102)

4 Effects of Fluoride on Teeth (103-130)

5 Musculoskeletal Effects (131-180)

6 Reproductive and Developmental Effects of Fluoride (181-204)

7 Neurotoxicity and Neurobehavioral Effects (205-223)

8 Effects on the Endocrine System (224-267)

9 Effects on the Gastrointestinal, Renal, Hepatic, and Immune Systems (268-303)

10 Genotoxicity and Carcinogenicity (304-339)

11 Drinking Water Standards for Fluoride (340-353)

References (354-410)

Appendix A Biographical Information on the Committee on Fluoride in Drinking Water (411-415)

Appendix B Measures of Exposure to Fluoride in the United States: Supplementary Information (416-438)

Appendix C Ecologic and Partially Ecologic Studies in Epidemiology (439-441)

Appendix D Comparative Pharmacokinetics of Rats and Humans (442-446)

Appendix E Detailed Information on Endocrine Studies of Fluoride (447-508)