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CW and YG contributed
equally to this work.
Received 27 May 2012
Accepted 21 August 2012
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ABSTRACT
Objective: To assess the effects of provided fluoridesafe drinking-water for the prevention and control of
endemic fluorosis in China.
Design: A national cross-sectional study in China.
Setting: In 1985, randomly selected villages in 27
provinces (or cities and municipalities) in 5 geographic
areas all over China.
Participants: Involved 81 786 children aged from 8 to
12 and 594 698 adults aged over 16.
Main outcome measure: The prevalence of dental
fluorosis and clinical skeletal fluorosis, the fluoride
concentrations in the drinking-water in study villages
and in the urine of subjects.
Results: The study showed that in the villages where
the drinking-water fluoride concentrations were higher
than the government standard of 1.2 mg/l, but no
fluoride-safe drinking-water supply scheme was
provided (FNB areas), the prevalence rate and index of
dental fluorosis in children, and prevalence rate of
clinical skeletal fluorosis in adults were all significantly
higher than those in the historical endemic fluorosis
villages after the fluoride-safe drinking-water were
provided (FSB areas). Additionally, the prevalence rate
of dental fluorosis as well as clinical skeletal fluorosis,
and the concentration of fluoride in urine were found
increased with the increase of fluoride concentration in
drinking-water, with significant positive correlations in
the FNB areas. While, the prevalence rate of dental
fluorosis and clinical skeletal fluorosis in different age
groups and their degrees of prevalence were
significantly lower in the FSB areas than those in the
FNB areas.
Conclusions: The provision of fluoride-safe drinkingwater supply schemes had significant effects on the
prevention and control of dental fluorosis and skeletal
fluorosis. The study also indicated that the dental and
skeletal fluorosis is still prevailing in the high-fluoride
drinking-water areas in China.
ARTICLE SUMMARY
Article focus
In 20082009, through accessing the prevalence
of endemic fluorosis in China, the effects of providing fluoride-safe drinking water supply on the
prevention and control of fluorosis were
evaluated.
Key messages
The subjects involved 81 786 children and
594 698 adults in 1985 randomly selected villages in 27 provinces (or cities and municipalities) in 5 geographic areas all over China.
The prevalence rate of dental fluorosis as well as
clinical skeletal fluorosis, and the concentration
of fluoride in urine were found increased with
the increase of fluoride concentration in drinking
water.
The provision of fluoride-safe water supply had
significant effects on controlling the occurrence
and progress of dental fluorosis and skeletal
fluorosis.
INTRODUCTION
Fluoride is one of the very few chemicals that
have been shown to cause signicant health
effects in people through drinking water.
Correspondence to
Prof Dianjun Sun;
hrbmusdj@163.com
randomly selected to test the urine uoride concentration, and the total number of identied children in
each village would be 30. If the total numbers of children in each village are less than 30 or there were less
than 6 children in each age group, all childrens urine
uoride concentrations in this village were to be tested.
For the test of urine uoride level in adults, 20 adults
were randomly selected among adult age group over 20
with the male-to-female ratio at 1 : 1. The urine uoride
in adults was tested only in 2009 instead of 2008. The
prevalence of clinical skeletal uorosis was investigated
in all subjects over 16 years old (denoted as adults). The
study protocol was approved by the Ethical Committee
of the Harbin Medical University.
Assessment of fluorosis endemic areas
Endemic uorosis areas were assessed in the following
areas in this study.
The areas where water uoride concentration is
higher than 1.2 mg/l, are identied as the endemic
uorosis areas, and divided into three levels according
to the prevalence of uorosis: (1) mild endemic uorosis areas: areas where the prevalence rate of dental
uorosis is moderate, and the severe patients in the
native-born residents of 8-year-old to 12 -year-old children is equal to, or less than 20%, or there are mild skeletal uorosis patients but no moderate skeletal uorosis
patients; (2) moderate endemic uorosis areas: areas
where the prevalence rate of dental uorosis is
moderate, and the severe patients in the native-born residents of 8-year-old to 12-year-old children is in the range
of 2040%, or there are skeletal uorosis patients in
moderate and severe degrees, but the prevalence of
severe skeletal uorosis is equal to, or less than 2% and
(3) severe endemic areas: areas where the prevalence
rate of dental uorosis is moderate, and the severe
patients in the native-born residents of 8-year-old to
12-year-old children is higher than 40%, or the prevalence rate of severe skeletal uorosis is more than 2%.
Determination of fluoride in drinking water and urine and
the diagnosis of dental fluorosis and skeletal fluorosis
The water uoride concentrations in two different areas
were tested: (1) in areas where uoride-safe water supply
schemes had been built (FSB villages) and (2) in areas
where uoride-safe water supply scheme had not been
built (FNB villages). In the FNB villages, ve water
samples were randomly collected in the wells located in
the east, west, south, north and centre of each village,
that represent the water quality of the whole village. The
concentrations of uoride in water samples were tested,
and the mean value was calculated. In the FSB villages,
three water samples from the pipeline of each uoridesafe water supply scheme were randomly collected and
the uoride concentrations were tested, and the mean
value was calculated. The urina sanguinis of the study
subjects were collected in the morning for testing. The
concentrations of uoride in drinking water samples
and inspection on assessment conducted in project villages, and if some problems were found/detected, corrections should be made in due course for further
project implementation. At the end of the project, the
consistency of project implementation, the rationality of
sample collections and sampling methods, as well as the
accuracy of the analysis technologies and disease diagnostic were all needed to be assessed.
Statistical analysis
Statistical analysis was carried out in all FSB and FNB villages, respectively. In FSB areas, the prevalence of uorosis was compared in three stages, based on the length
of time when the uoride-safe water supply schemes
were provided, equal to or less than 5 years, between 5
and 10 years and more than 10 years. In FNB areas (the
FSB villages where uoride concentration in water
supply schemes is higher than 1.2 mg/l were considered
as uoride-safe water supply non-provided areas), the
prevalence of uorosis was compared according to the
uoride concentrations in drinking water, that is,
between 1.22, 24 and higher than 4 mg/l. Statistical
analysis was carried out using SPSS. Data were presented
as meanSD or M-estimators by Andrew with IQR as
appropriate. Data that were not normally distributed, as
determined with the Kolmogorov-Smirnov test, were
logarithmically transformed to obtain near normality
before analysis. 2 Test was used to compare categorical
variables. Bivariate correlations with spearman were used
to analyse the correlation between variables. All p values
are two-tailed and p value <0.05 were considered as signicant for all statistical analyses in this study.
RESULTS
In the FSB and FNB areas, 1404 and 581 villages were
selected, respectively. A total of 676 484 study subjects
were investigated including 81 786 children and 5 94 698
adults. The prevalence of dental uorosis was investigated
in 1876 villages covering 1318 FNB villages and 558 FSB
villages. The prevalence of clinical skeletal uorosis was
investigated in 1622 villages consisting of 1152 FNB villages and 470 FSB villages, respectively (in some villages,
only dental uorosis and/or clinical skeletal uorosis
were surveyed) as presented in tables 1 and 2.
The prevalence of dental uorosis and clinical skeletal
uorosis was compared between FSB and FNB areas.
The photographs taken in the surveyed villages represented the patients suffering from dental uorosis and
skeletal uorosis (gure 2).
Prevalence of dental and skeletal fluorosis in five
geographic areas of China
Prevalence rates of dental uorosis and clinical skeletal
uorosis in FNB areas were signicantly higher than
that in FSB areas in ve geographic parts in China as
presented in table 1.
4.82
2.13
27
Northwest
Central
Southwest
South
Total
Northeast: Heilongjiang, Jilin and Liaoning; Northwest: Inner Mongolia, Xinjiang, Qinghai, Ningxia, Gansu and Shaanxi; Central: Beijing, Tianjin, Hebei, Shanxi, Shandong, Henan, Jiangsu and
Anhui; Southwest: Sichuan, Chongqing and Yunnan; South: Hubei, Zhejiang, Hunan, Jiangxi, Fujian, Guangxi and Guangdong.
*All p values in the comparison of dental fluorosis or clinical skeletal fluorosis between FNB and FSB areas were <0.001.
9082
613
28749
188400
121
6.70
19.02
2985
200
558
119
128
581
10.81
10.75
293
43940
406298
2726
16
1152
50.44
36.62
319
27669
54855
871
19
1318
1404
19
26931
5121
470
2.44
3.99
4309
96
3928
107998
17
29.50
26.11
785
205
182
12
17
190
9.00
17.50
970
28155
312922
5544
15
743
52.36
78.43
1080
20069
38326
1377
16
838
838
16
9982
2945
183
5.60
10.26
3064
1000
17858
29867
90
13.25
59
14.34
320
1451
2231
10948
186
59
59
187
18.79
11.56
2356
12166
64732
20374
94
284
44.64
38.70
1137
5064
11343
2938
108
337
421
110
3
Northeast
Prevalence
rate (%)*
(n)
Patients
Subjects
(n)
(n)
rate (%)*
(n)
Areas
(n)
(n)
(n)
(n)
(n)
rate (%)
(n)
(n)
(n)
rate (%)
(n)
(n)
(n)
Prevalence
Patients
Subjects
Prevalence
Patients
Subjects
Prevalence
Patients
Subjects
Villages
Villages
Provinces
Dental fluorosis
FNB areas
Village
Villages
Villages
Dental fluorosis
FSB areas
Villages
FNB areas
FSB areas
p Values
1318/1404
54855
10.071.44
25395(46.52)
27669(50.44)
1.09
2.31(1.41, 3.82)
2.17(1.66, 2.94)
558/581
26931
10.081.44
12610(46.82)
5121(19.02)
0.40
0.90(0.54, 1.51)
0.54(0.29, 0.77)
<0.001
<0.001
1152/1404
406298
42.3616.79
196526(48.37)
43940(10.81)
2.38(1.50, 4.07)
2.17(1.62, 3.05)
470/581
188400
42.9116.67
92711(49.21)
9082(4.82)
1.05(0.69, 1.75)
0.53(0.35, 0.75)
<0.001
<0.001
<0.001
<0.001
<0.001
0.32
0.42
<0.001
FSB and FNB areas: fluoride-safe water supply project had been built and not been built in these areas.
*Only have dental fluorosis or clinical skeletal fluorosis in some villages; values are meanSD for continuous variables.
The variable was calculated as (questionable number0.5+very mild number1+mild number2+moderate number3+severe number4)/the
total number of subjects.
Log transformed before analysis, and data were expressed as M-estimator by Andrew and IQR (P25P75).
54855
p
Values
26931
<0.001
<0.001
<0.001
<0.001
406298
188400
780 (0.96)
2143 (3.15)
6949 (7.43)
10990 (15.93)
12374 (22.83)
10704 (26.85)
77 (0.22)
225 (0.71)
1192 (2.75)
2003 (5.96)
2714 (10.82)
2871 (14.89)
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
26491 (6.52)
13707 (3.37)
3742 (0.92)
5236 (2.78)
3013 (1.60)
833 (0.44)
<0.001
<0.001
<0.001
Figure 3 (A) Relationships between prevalence rate of dental fluorosis and various fluoride concentrations in the drinking water
in FNB areas, and the period of fluoride-safe drinking water supply schemes built in FSB areas. (B) Relationships between the
index of dental fluorosis and urine fluoride concentrations in children, and the fluoride concentration in drinking water in FNB
areas and the period of fluoride-safe drinking water supply schemes built in FSB areas. * Comparing with that in the areas with
fluoride concentration was 1.22.0 mg/l in drinking water. ** Comparing with that in the areas with fluoride concentration was 2.0
4.0 mg/l in drinking water. Comparing with that of fluoride-safe water supply projects built for 5 years. Comparing with that
of fluoride-safe water supply projects built for 510 years. All p values were <0.001.
uoride-contaminated areas should incorporate calciumrich foods in their routine diet. But such measures
could not fundamentally solve such a problem, and it
could be hard to implement in poverty areas. Therefore,
changing the drinking water sources used for the inhabitants living in uoride contaminated areas would be an
appropriate and reasonable way for prevention and
control of the uorosis. In 1995, a study by Boyle et al19
in Gasp region, Quebec of Canada mentioned the well
drilling should be in different deeps according to the
F-levels in different groundwater layers through studying
the relationships between the prevalence of uorosis
and F-levels in groundwater in different areas. And
Boyle indicated that hydrogeochemists, hydrologists,
health ofcials and environmental regulators should
work closely together in order to efciently eradicate
the risk of skeletal uorosis from drinking water associated with geological environments where such risks
exist. Although some advices were proposed, with the
exception of China,58 there were few relative reports in
Figure 4 Correlation between fluoride concentrations in drinking water and variables including (A) prevalence of dental
fluorosis, (B) dental fluorosis index, (C) fluoride concentration in children urine, (D) prevalence rate of skeletal fluorosis and
(E) fluoride concentration in adult urine (mg/l). All p values were <0.001.
CONCLUSIONS
In summary, the uoride-safe drinking water supply
schemes had been provided in various localities in provinces in China for decades. The study found that providing uoride-safe water supply had signicant effects
on controlling the occurrence and progress of dental
uorosis and skeletal uorosis. The study also indicates
that the dental and skeletal uorosis is still prevailing in
the high-uoride drinking water areas in China. To
control and prevent the continuous spreading of
endemic uorosis, we suggest that governments effort
be given to provide the uoride-safe drinking water
supply schemes with proper operation and maintenance
in all high-uoride drinking water areas in China.
Figure 5 (A) Relationships between prevalence rate of clinical skeletal fluorosis and fluoride concentration in drinking water in
FNB areas, as well as the period of fluoride-safe water supply schemes built in FSB areas; (B) the relationships between fluoride
concentration in urine of adult and fluoride concentration in drinking water in FNB areas, as well as the period of fluoride reducing
schemes carried out in FSB areas. * Comparing with that in the areas with fluoride concentration was 1.22.0 mg/l in drinking
water. ** Comparing with that in the areas with fluoride concentration was 2.04.0 mg/l in drinking water. Comparing with that of
fluoride-safe water supply projects built for 5 years. All p values were <0.001.
2.
3.
4.
5.
6.
Funding This work was supported by the Chinese government for Endemic
Disease Control in 20082009 years.
7.
8.
9.
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doi: 10.1136/bmjopen-2012-001564
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