FLUORIDE IN DRINKING WATER CONSUMED SOCIETY, AREA ENDEMIC DENTAL CARIES, DISTRICT SOUTH MINAHASA, IN 2010

Jose A. Sjarkawi1), Suwarja2), I Ketut Harapan3) 1,)3),Jurusan Kesehatan Lingkungan Poltekkes Kemenkes , Jl. Manguni 20 Malendeng 2),Jurusan Keperawatan Poltekkes Kemenkes Manado, Jl. R. W. Mongisidi Malalayang II Manado

Abstract : Based on the results Riskesdas 2007( Riset Kesehatan Dasar = Basic Health Research), has the prevalence of dental caries is high enough and some of them into regional areas of endemic dental caries, Such as in province and specially in the South Minahasa district amounted to 44.99%, caries is still active as an endemic area of dental caries and allegedly the caused by the lack of Fluoride content in drinking water is consumed. The purpose of this study was to find out how Fluoride content in drinking water consumed by people in the South Minahasa district, in 2010. The design of this study will from use of cross-sectional study with a population of drinking water consumed by the people in regency of South Minahasa, and stores a sample of 24 Villages, selected through purposive sampling. The results obtained are analyzed in Statistics, t test, correlation and linear regression test. The results obtained Fluoride concentration in drinking water consumed ranged from 0.01 - 0.80 mgr / L. (P <0.05), the which is Lower Than the required quality standards, the which was statistically influenced by the concentration of Mg in the form of MgCO3. It is suggested this data could be used as basic information on dental caries prevention effort. Needs further research to determine the concentration of Fluoride other areas in order to dental caries prevention in Indonesia.

Keywords : Fluoride, drinking water, dental caries

Based on the results Riskesdas 2007, the including in rural areas (88.0%). And from the prevalence of caries in Indonesia was found at age group, the largest active caries prevalence 43.4%, with caries experience of 67.2%, was in age group 12-14 years (58.2%). whereas according to the provincial level, And has the second highest prevalence in the highest prevalence of active caries the northern province in terms of numbers (more than 50%) were found in Sulawesi edentulous (loss of all teeth) Jambi (56,1%), West Kalimantan and North that is equal to 1.33. In South Minahasa, Sulawesi (52.7%). From the order of ten the dental caries active form of 44.99%. provinces, the highest prevalence of caries (Riskesdas, 2007). Dental Caries disease, an experience, third-ranked North Sulawesi, illness that is chronic, and illness lasts a long namely Bangka Belitung (86.8%), South time, can be for months even years. Kalimantan (84.7%), North Sulawesi (82.8%). Figures Dental Caries prevalence in The mean number of damaged teeth the province of North Sulawesi, especially in per person in North Sulawesi at 6.2 and South Minahasa District, an indication that the the highest average in the South Dental Caries has become endemic in the Minahasa (Index DMT = 7.9). Data public public. Therefore the focus of research sites behavior, in the district of South Minahasa aimed at the South Minahasa district and concerned with oral and dental health is to regency. have a good habit of brushing their teeth every Dental Caries disease caused by day in the morning and or evening (76.4%), various diseases such as agent, the activity of

1 2 JIK Volume 7 No. 1 Oktober 2012 Sjarkawi, J,A, dkk. Fluoride In Drinking bacteria, i.e. Streptococcus mutants, Fluorine or Fluoride (fluoride), is one Lactobacillus casei, and Actinomises viscosis. of the chemical elements Halogen group, There are some other factors involved in the which is found in the environment, both in the occurrence of dental caries is the risk of caries air (as emissions in the atmosphere), as well is in addition to the activities of as land and in water, or as a by product of microorganisms are also caused by the result industrial activities. Its presence in the form of of anatomical structures teeth, especially complex mineral and negative charged F ions. email and cemented; the formation of plaque Natural sources of fluoride in soil and flora as breeding grounds for bacteria, water, often associated with activity of fermentation of carbohydrates, and time volcanoes, i.e. water hot springs especially, duration of the process of caries occur. those who have water acidity (pH) is high. (O'Mullane D; 1995) These bacteria Other fluoride sources input to human body in metabolize carbohydrates to which is attached everyday situations many also come from to the tooth surface causing the pH in the food beverages consumed daily. Plaque (bio-film) and the potential occurrence In physiologic, Fluoride function of caries, because of changes the composition reduces demineralization process, if the of the plaque matrix. Among the elements of concentration of Fluoride in the oral carbohydrates, most are sucrose as caries environment can be maintained. Fluoride factors, when compared with Glucose, and although not directly affect the etiology of the Fructose. Each time, the sugar would disease, but to prevent reduce the occurrence penetrate into the layer of bio-film and of the process and strengthen demineralization changes into acid by the bacterial metabolism. and re-mineralization process, as it works to Solution in the bio-film will become saturated help saliva to control the caries process, which will affect the solubility properties by reducing dental caries lesions. Provision of of tooth enamel; and occurs demineralization Fluoride in drinking water as a basis for process. At the mouth of the low maintaining Fluoride concentration in saliva acidity environment that is at a pH below is higher than if it is not fluoridated, 5.5 will result in Hydroxyl-apatite (HA) or when continuously providing optimum Ca10 (PO4) 6 (OH) will reach the layers F luoride , then the blood will serve as a bio-films which will cause the minerals will "watertight compartments" that are dissolve enamel. responsible for distributing Fluoride into all Circumstances that cause tooth enamel tissues including the salivary be constant. soluble in acid, is a hydrogen ion would shift If Fluoride intake at any time experience the hydroxyl ions from water molecules interruptions, the concentration in the blood (Dawes C, 2003) and after a while if the sugar will be disturbed, thus Fluoride concentrations had disappeared, the solubility of the email in saliva may also be disrupted. And this will be reduced and will be back to normal situation will be at risk for the occurrence physiologic If the pH is increased then it will of caries. (Cury, JA and Tenuta, LMA,) super-saturated conditions occur again, and Various sources of fluoride intake for some minerals are lost can be recovered the human-body, can be derived from food by email, and this process is called and beverages, including drinking water re-mineralization. consumed daily by the community. Some Some factors that can prevent or treat research indicates that dental caries is often dental caries, among others, is to increase the associated with lack of intake of fluoride in pH of saliva, re-mineralization with Fluoride drinking water, and some developed countries administration and good oral hygiene. have been promoting the provision of fluoride

3 JIK Volume 7 No. 1 Oktober 2012 Sjarkawi, J,A, dkk. Fluoride In Drinking in drinking water consumption / Fluoridation; fluoride) that there is drinking water, and it turns out this program is proven to consumed by people in area endemic Dental reduce the prevalence of dental caries in the Caries, South Minahasa; by means of: community. Alleged temporary occurrence measuring the concentration of fluoride in dental caries in the people here probably public drinking water, measure pH and caused by a deficiency of fluoride in drinking temperature of drinking water source, water is consumed. hardness (in MgCO3) drinking water and to WHO, and Ministry of Health assess the relationship of pH, and Mg on the Indonesia (PERMENKES 2002), determine concentration of fluoride in drinking water. the minimum content of fluoride in drinking water at 1 - 1.5 mgr / L for daily consumption METHOD AND RESULT and addition of it depends also on the amount of water consumed, duration of exposure and METHOD other Fluoride intake foods that contain fluoride, age at risk, and including also the Design & research methodology climate / weather is local. Deficiency Fluoride This study is a cross sectional study is expressed when its concentration is less (cross sectional study); the subject population than 1 mgr / L fluoride content in water is was all drinking water in the district South much influenced by various factors such as, Minahasa. In accordance with staff time and the presence of Ca, Mg and pH of the water. funds available then the sample was taken, Lack of fluoride intake in drinking water can using a purposive sampling method samples. cause dental caries. Giving is the The amount will initially be taken as many as demineralization of fluoride tooth enamel, 10 (ten) villages as a sample, but with existing making it very effective as a prevention and conditions be replaced by as many as control and the provision of fluoride in 26 (twenty six) village located side highway ” drinking water (Water Supply Fluoridation), South Line Amurang-”. it also serves to inhibit the growth of bacteria Chemicals will be checked for water "cario-genic" (which cause dental caries) study is variable Fluoride, MgCO3, CaCO3 because it can reduce the quantity of and pH contained in drinking water consumed acidity mouth caused by bacterial activity. by the public, with the frequency of taking as (Dawes C, 2003). When the concentration in much as 3 times to reduce error and bias drinking water exceeds 1.5 ppm can factor. cause chronic fluorosis which will affect The number of samples the bones, reproductive system and IQ, and examined = 26 villages x 3 times = 78 water the process of development of the child. samples. Sample examination conducted by (Wang S, et al , 2005). the Health Laboratory Manado Health Publications about the content of Laboratory, and Institute for Environmental fluoride in Indonesia or areas not yet widely Health Technology Manado. Comparative known or publicized, and in 2005 there is examination results with standard fluoride, a study conducted by Heinsly in 2005, pH, and Mg in drinking water set by found that fluoride content in well PERMENKES 2010.; By using t test (t-test), water consumed by people in Asembagus then the results of pH and Mg correlated with (Central Java ) is 0.1 - 4.2 mgr / L or ppm. fluoride by using regression or correlation. (Fawell J, Chilton J et al, 2006). The purpose of this study was to determine the content or the concentration of

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RESULTS The correlation between the third stage of sampling is the result of its acquisition of pH Location research correlated significantly (p <0.05), and the Location of study subjects were housed in results of test t. (One Sample Test) also South with profiles of obtained the results of pH, both of the districts as follows: Capital District was three phases, the average was not significantly Amurang; and serves as the administrative different (p <0.05). From this analysis it can center of government. Total Population be deduced that the pH of drinking water 1.591.65 people. South Minahasa District who consumed by people in the district South represents the area endemic Dental Caries Minahasa, about 7.06, with spreads ranges as selected as sample (purposive sampling) the lowest 5.91 and the highest pH 8.09. study that began in 24 villages of northern regions (lowlands) to the southern region Elevation and pH correlation (plateau, and hilly / mountainous) namely Altitude relationship with pH is quite village located along the south lane highway significant p <0.05 = 0.28, although the Amurang to Modayag-Kotamobagu. correlation Pearson’s shows the value of Sampling was done 3 times with 0.432. And it turns out there is the influence intervals of time each week making less than of altitude on the pH value, as evidenced by ever, because the expected fluctuation the Linear Regression tests obtained Fluoride concentrations are influenced by significant results (12.28, at p = 0.05). local conditions such as rainfall. Samples sent From this regression test can be concluded directly to the next day to the laboratory for that any change in altitude will affect the examination. According to WHO, drinking concentration of pH. Any height of 1 meter, water samples for examination in the field the pH is equal to: 7405-0001 x altitude in Fluoride does not require special treatment or meters. (Y = 7405-0.001x) preservation, simply stored at room temperature and sample storage period Fluoride concentration in drinking water permitted up to 28 days. (Fawel, 2006) samples From the data obtained by sampling the Altitude concentration of Fluoride in drinking water Measurement altitude of sampling sites community with the lowest score under ranged from 7 meters to 1079 meters above 0.01 mgr / L and the highest concentration of sea level.The temperature of drinking water 0.28 mgr / L with an average of 0.09 mgr / L. samples range from 26 ° C lowest lying areas With this result, the hypothesis about the and 22 ° C mountain area. This temperature concentration of Fluoride in drinking water in computes directly at the site of sampling. local communities Endemic Caries Dentis, in South Minahasa regency, accepted pH (in accordance with Null Hypothesis). The During the 3 times / stages of drinking water obtained correlation test indicated that the samples were obtained the results of pH concentration of Fluoride in drinking water is measurements of water with a pH range as not correlated between each measurement of low as 5.91 and the highest pH 8.09. And if the first phase with the second and third computed mean his every step is 6.96 in stages; vice versa. (p> 0.05), and Fluoride phase / first sample and 7.31 and 6.91, when compared with the value that has been on taking second and third stages. Of the three examined by other researchers in 2006 in pH results was obtained also averages 7.06. Sub-district (Kecamatan) of Tenga, South

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Minahasa regency shows the average values drinking water samples showed different were significantly different, and when results in significant (p> 0.05). compared with other studies in the District. If the average per location, And comparative degree with Fluoride the obtained value of 2.3954. Mg-hardness concentrations at sub-district of Likupang showed a significant correlation values (North coast of North Sulawesi) also different (p <0.05); so that the amount of MgCO3 to. Than of all analysis with t test results with concentration in drinking water can be an average rating of comparator 1 mgr / L inferred by 2.3954. (as a standard reference mgr/ L Fluoride in And with this Fluoride correlation test drinking water), then these values differ was correlated with MgCO3. And therefore significantly. correlated then continued with Linear Regression test and obtained the value The Altitude, pH and concentration of of significance (p = .044) with a constant Fluoride correlation value - 0.66 and MgCO3 function and when Test Results correlation between Elevation of correlated with altitude, it was not proven the pH and concentrations in drinking water existence of a statistically significant Fluoride shown result that the three items relationship. showed no significant correlation (p> 0.05) CaCO3’s concentration Hardness of Drinking Water The second element is CaCO3. Total hardness Drinking water hardness is measured with CaCO3 hardness of the element in drinking total hardness, hardness obtained the lowest water every stage of sampling is, 0.2250, and highest 1.21 and 5.40 respectively. Total 0.2658 and 0.1012. The lowest score and hardness in taking the first stage, second and highest 0.2267, and 12.00, value of measuring third; average each stage are, 2.6546, 2.6681, the concentration of CaCO3, respectively. The and 2.4831 respectively. And as a whole third measurement was not correlated with the obtained a lower hardness value is 1.8265 measurement of all CaC03. Hardness of with a spread of 1.21 and the highest lowest CaCO3 in drinking water in this study does score 3.47. For the total hardness of drinking not correlate, either with altitude, or with pH, water consumed by the public showed its and Fluoride: but the only significantly value related to each other, with a total correlated with total hardness and MgCO3. hardness overall with p <0.05. so that the total (p<0.05). Linear Regression Test of MgCO3 value of Community Drinking water hardness and CaCO3 with a total hardness showed is 1.8265. And if the value of total hardness is a constant value of 0.18 to the functions associated with altitude place, pH and of 0.682 and functions MgCO3 CaCO3 Fluoride concentration did not correlate at 0887. statistically with each other. (p> 0.05). DISCUSSION MgCO3 concentration Constituent element of hardness in drinking Effect of Location of the subject water is MgCO3 and CaCO3. Examination North Sulawesi is a volcanic region, when in results MgCO3 concentration in drinking fact this region should the Fluoride water samples every stage sample obtained concentration are high levels. However, results with the lowest distribution are 1.05 especially in South Minahasa regency in this and the highest 4.40. Correlation of Mg district has not yet appeared / common hardness figures show that the three stages of geothermal activity, such as hot springs,

6 JIK Volume 7 No. 1 Oktober 2012 Sjarkawi, J,A, dkk. Fluoride In Drinking as in other Minahasa region. So this situation papaya for pickles) will affect the is one answer to why the Fluoride environment of critical oral environmental. Concentration in South Minahasa regency pH around 5.5 and if it is lower to 4.5 will ranges 0.01-0.8 mgr / L, with an average of more easy the process of de-mineralization 0.09 mgr / L; and its water have temperature enamel teeth. (Kumar, JV; 2008). In this cool and cold (23 ° C). Another factor also is research, it turns out statistically every meter a rather high rainfall, so need to be researched in altitude will decrease pH of the water. again maybe there is a relationship between Concentration / Concentration Fluoride rainfalls with Fluoride content in drinking From the measurement result was the water. High rainfall, causing the volume concentration or existing Fluoride levels in of water is abundant and slightly drinking water at the lower ranges of society alkaline (pH> 7). Profile of the area south of is under the 12.01 mgr/L and the highest Minahasa District consists of lowlands and concentration of 0.28 with an average of 0.09. highlands, coupled with the height above the PERMENKES 249/2010, provides for location of the sea surface is also different to. a limited Fluoride of 1.5 mgr / L. In this This will impact on some chemical parameters study, on the concentration of Fluoride in that are in the public drinking water, a bit drinking water in local communities Endemic difficult in summing up the results when the Dental Caries in South Minahasa regency, the concentration is based on the average value Null Hypothesis accepted and can be received statistically-rating, because of differences in by the due Fluoride concentrations lower geographic location and were significantly than 1 -1, 5. different. In Indonesia has not officially publicized about how the content or Sources of drinking water concentration of Fluoride in the drinking Sources of drinking water consumed by the water community, at both regional and people of South Minahasa regency, generally national level from recharge springs, and wells dug. At this time there is a tendency of society to consume MgCO3 and CaCO3 concentration bottled water and drinking water that The concentration of Mg in relation to comes from Water Refill. According to the water hardness is measured in the form of research content of Fluoride in tap water MgCO3 in drinking water. each stage samples around 0.04 mgr / L, and refill water from obtained results with the lowest range springs and artesian generally <0.1, therefore and highest 1:05 4:40. When compared Fluoride lost due to sand filtered or absorbed with the optimal concentration MgCO3. Active Carbon . (Lulumandier JA, 2000) MgCO3 concentrations in drinking water was significantly correlated with Fluoride and pH of drinking water Linear Regression to test the value of Provided the distribution of drinking water the constants - 0065 and 0.66 MgCO3 pH range between pH range of pH as low function. When correlated with the altitude as 5.91 and the highest 8:09, with a mean of where it is not proven the existence of 7:06. Distribution of water pH is strongly statistically significant relationships. influenced by natural conditions, especially This proves that the concentration also by rainfall that will cause the pH will CO3 in this study affect the concentration of shift to alkaline conditions. (pH>7). Deals fluoride in drinking water, thus indirectly also with the case of dental caries, patterns of to support the occurrence of dental caries. The eating food that had low pH (such as vinegar’s low levels of calcium in drinking water

7 JIK Volume 7 No. 1 Oktober 2012 Sjarkawi, J,A, dkk. Fluoride In Drinking increases the solubility of Fluoride in water, So Fluoride serves as a control and stimulate the process of tooth enamel measure in addition to prevention, and de-mineralization. cessation of fluoride in public drinking water proved to increase the occurrence of Dental Effect of Fluoride on Dental Caries Cavitations, thereby increasing the prevalence PERMENKES 492/2010, requires that of caries. When granting Fluoride is drinking water quality, by including Fluoride interrupted, either through drinking water or as Mandatory Parameters for Inorganic through other means then the pH environment Chemistry, with the maximum level allowed topical mouth will drop, this condition can is 1.5 mgr / L or ppm. But this rule does not cause caries. specify how many levels there should be The government has not implemented minimal in the drinking water consumed by a policy to implement the program the public. Fluoride in drinking water "Water Fluoridation, but some neighboring requirements specified society is likely countries since 2001, has implemented intended to prevent the occurrence of this program such as Singapore coverage toxicology Fluoride causes fluorosis, not the (100% of the population), Malaysia (70%), goal to prevent the occur-dental caries. Brunei (56%), Philippines (8% ), Vietnam Optimal levels needed to prevent dental caries (6%), and Thailand (4%). is 1 mgr / L. That is not advantageous in granting The low concentration of Fluoride in program Fluoride in drinking water systems drinking water in South Minahasa regency are public, the public generally good many would be a risk factor for the occurrence of who reside in the city and in rural areas far caries, which will increase the from the reach of drinking water installations epidemiological prevalence of dental caries can mengsupplai Fluoride into drinking water. which was already quite high in societies. (Clarkson, Bowen,). Based on this then if Adding Fluoride in drinking water Fluoride administration through drinking was consumed by the public is still water is not possible it is necessary to look for very much needed because this Fluoride other alternatives, such as granting Fluoride Anti-Caries nevertheless the use of various together with salts, such as iodine-salt dietary intake content a variety of materials granting program. containing Fluoride can cause fluorosis. From these results we concluded that, (Catani DB, Hugo FN, et al, 2007). The use the concentration of Fluoride in drinking of fluoride during prenatal Fluoride is needed water consumed by study subjects were lower because it will be joined, and strengthen bones than what has been determined. Similarly, the and teeth will fetus, although the numbers a pH is still within normal limits and the bit due to placental permeability of Fluoride temperature of the source of drinking water a relative rather low. Fluoride concentration in bit cold and cool (23 ° C), hardness (MgCO3) fetal blood approximately ¼ of the mother's in drinking water is still low and there is a blood Fluoride. With the intake of Fluoride weak correlation between pH and altitude from prenatal represents Caries preventive study sites, and the concentration of Mg in the measures earlier. (Schlesinger RE, 1968). form of MgCO3 can affect the concentration Fluoride is as protective against the of fluoride, in public water supply. occurrence of dental caries and prevention or Management of dental caries by dental control of caries that has occurred, and not as health workers are more "drill, fill and bill" a gift Fluoride treatment or medication action rather than prevention. Dental caries including against Dental Caries. chronic infectious diseases and prevention is

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most effective and efficient is through the of MgCO3, can affect the concentration of Water Fluoridation, especially in preventing fluoride in the public water supply. risks to children under five compared with the use of toothpaste or any other topical. Giving RECOMMENDATION Fluoride in water consumption proved effective in reducing dental caries are To prevent dental caries need of Fluoride in cumulative. And this program has been done drinking water, and if the means of supplying by many developing countries, because drinking water hard to reach areas we need of caries affecting the social, economic another alternative of providing fluoride salt .. and health of a person, (Kumar JA, 2008). Please do further research in both the And the need of constant concentration Educational Institution or other related around 0.04 - 0.1 mgr/L in dental plaque. institutions Fluoride in drinking water and its (O'Mullane D; 1995). impact on health. Control and prevention of caries depends entirely on the decision REFERENCES makers, stakeholders, and in large-scale program / community, and to the personal as Anusavice KJ, 2005: Present and Future an act of Personal Hygiene. Approach for the Control of caries; With the review studies that have been J Dent.Educ, vol 69: No5, p. 538-542. expressed above, so we need action Dental Aoba T, Fajerskov O, 2002; Dental Fluorosis Caries prevention and control, especially in Chemistry and Biology, Crit. Rev Oral addition to giving Fluoride either through Biol Med, 13 (2): 155-170. drinking water or by providing salt, topical, Catani DB, Hugo FN, et al, 2007; toothpaste, mouthwash, gargle and mouth and Relationship Between fluoride levels in dental hygiene. the public water supply and dental There are much vulnerability of the Fluorosis, Roy Saúde Publica, 41 (5). researchers, including the methods and in Cox CR, 1969: Operation and Control of analyzing the research findings, and also the Water Treatment Processes, WHO, limited time and funds available and Geneva. materials for reference, so needs a re-study or Cury JA, Tenuta LMA, 2008; How to advanced research for the development of a maintenance a Cariestatic more perfect. concentration Fluoride in the oral environment, ADR, July 2008, vol 20, CONCLUSION No. 1: 13-15. Dawes C, 2003; What is the Critical pH and From these results we concluded that, the Why does a tooth dissolve in acid?, concentration of Fluoride in drinking water Jour.Canadian Dental Association, consumed by study subjects were lower than Dec-2003, vol 69, No.11. what has been determined. pH is still within Degremond, 1985; Water Treatment normal limits and the temperature of the Handbook, p.1128. Holsted Press, source of drinking water a bit cold and John Wiley & Son Inc.. NY. cool (23 °C), hardness (Mg) in drinking water DEPKES, Agency for Health Research and is low and affect the concentration of Fluoride Development, 2008, Reports Results of in drinking water. And there is a weak RISKESDAS 2007 correlation between pH and altitude study sites and the concentration of Mg in the form

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DEPKES, 2010; PERMENKES No. 492 / O'Mullane D, 1995; Can Prevention Eliminate MENKES / PER/IV/2010: About caries ?; Adv Dent Res 9 (2) :106-109, Drinking Water Quality Requirements. July 1995. DEPKES,Agency for Health Research and Peterson PE, Lennon MA, 2004; Development, 2008, Reports 2007 Effectiveness use of Fluoride the Results RISKESDAS 2007 for North prevention of dental caries in 21st Sulawesi Province. Century: The WHO Approach, Fawell J, Clinton J, et al, 2006; Fluoride in Commun. Dent.Oral Epidemic 32: drinking Water, WHO-IWA, London. 319 -21. Jenkins GN, Armstrong PA et al, 1952; Robinson C et al, 2000, The Chemistry Laboratory Investigation on the Enamel caries; Grit Rev Oral Biol. Relation of Fluorine to dental caries; Med 1 (4) :481-495) Proceedings of the Royal Society of Wang S, et al, 2005; Investigation and Fluoride Medicine, Vol. 45, p517-25. Evaluation on Intelligence and Growth Newcastle. of Fluoride Children in Endemic Kumar JV, 2008; Is Water Fluoridation still Fluorosis and Arsenism Area, Fluoride Necessary?, Adv Dent Res 20:8-12, Chinese Journal of Epidemiology 24: July2008. 179-182. Lulumandier JA, 2000; Fluoride and Bacterial Content of Bottled Water vs. Tap Water.; Arch Fam Med, vol. 9, March 2000.