At 2 mg/L, drinking water contributes 57% to 90% for average-water-intake individuals and 86% to 96% for high-water-intake individuals. Thus, it is important that future revisions to the MCLG take into consideration that water is a significant, and sometimes the most significant, source of exposure to fluoride.

FINDINGS AND RECOMMENDATIONS

Maximum-Contaminant-Level Goal

In light of the collective evidence on various health end points and total exposure to fluoride, the committee concludes that EPA’s MCLG of 4 mg/L should be lowered. Lowering the MCLG will prevent children from developing severe enamel fluorosis and will reduce the lifetime accumulation of fluoride into bone that the majority of the committee concluded is likely to put individuals at increased risk of bone fracture and possibly skeletal fluorosis, which are particular concerns for subpopulations that are prone to accumulating fluoride in their bone.

Recommendation: To develop an MCLG that is protective of severe enamel fluorosis, clinical stage II skeletal fluorosis, and bone fractures, EPA should update the risk assessment of fluoride to include new data on health risks and better estimates of total exposure (relative source contribution) in individuals and to use current approaches to quantifying risk, considering susceptible subpopulations, and characterizing uncertainties and variability.

Secondary Maximum Contaminant Level

The prevalence of severe enamel fluorosis is very low (near zero) at fluoride concentrations below 2 mg/L. However, from a cosmetic standpoint, the SMCL does not completely prevent the occurrence of moderate enamel fluorosis. EPA has indicated that the SMCL was intended to reduce the severity and occurrence of the condition to 15% or less of the exposed population. The available data indicates that fewer than 15% of children would experience moderate enamel fluorosis of aesthetic concern (discoloration of the front teeth). However, the degree to which moderate enamel fluorosis might go beyond a cosmetic effect to create an adverse psychological effect or an adverse effect on social functioning is not known.

Recommendations: Additional studies, including longitudinal studies, of the prevalence and severity of enamel fluorosis should be done in U.S. communities with fluoride concentrations greater than



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