Quality Assessment of Fluoridation of Public Water Supply in 88
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ARTICLE https://doi.org/10.22239/2317-269x.00926 Quality Assessment of fluoridation of public water supply in 88 municipalities in the Northeast region of the state of São Paulo (Brazil) Avaliação da qualidade da fluoretação de águas de abastecimento público em 88 municípios da região Nordeste do estado de São Paulo (Brasil) ABSTRACT Sergio Dovidauskas* Introduction: During 1 year, the Núcleo de Ciências Químicas e Bromatológicas do Centro Isaura Akemi Okada de Laboratório Regional do Instituto Adolfo Lutz de Ribeirão Preto (SP, Brasil) has increased the number of public water supply samples analyzed for fluoride concentration in relation Maria Helena Iha to what is usually requested by 88 Municipal Sanitary Surveillance of Northeast State of Álvaro Gennari Cavallini São Paulo (Brazil). Objective: To verify if fluoridation indicators values will vary when increasing the number of samples analyzed and to assess the quality of fluoridation in the Marina Miyuki Okada region. Method: Fluoride was determined by ion chromatography in samples collected Rita de Cássia Briganti by Sanitary Surveillances. Results: Indicators values of fluoridation obtained in the two sampling (Sanitary Surveillances and expanded) were similar for most cases. The mapping indicated a greater number of municipalities with values greater than 80% in Regional Departments of Health of Barretos and Franca, while in Araraquara and Ribeirão Preto prevail indicator values lower than 40%. Conclusions: Investment and technical assistance are insufficient to increase the values above 80% in municipalities with small populations. For the cases in which the values are smaller than 40% an approach based on the similarity between municipalities is suggested to increase these values. KEYWORDS: Fluoride; Public Water Supply; Quality of Fluoridation; Sanitary Surveillance RESUMO Introdução: Durante um ano, o Núcleo de Ciências Químicas e Bromatológicas do Centro de Laboratório Regional do Instituto Adolfo Lutz de Ribeirão Preto (SP, Brasil) aumentou o número de amostras de águas de abastecimento público analisadas para concentração de fluoreto em relação ao que é normalmente solicitado por 88 Vigilâncias Sanitárias Municipais do Nordeste do estado de São Paulo (Brasil). Objetivo: Verificar se os valores dos Indicadores de Fluoretação variam quando se aumenta o número de amostras analisadas e avaliar a qualidade da fluoretação na região. Método: Fluoreto foi determinado por cromatografia de íons em amostras coletadas pelas Vigilâncias Sanitárias. Resultados: Os valores dos Indicadores de Fluoretação obtidos nas duas amostragens (das Vigilâncias e as ampliadas) foram similares para a maioria dos casos. O mapeamento indicou um maior número de municípios com indicadores maiores que 80% nos Departamentos Regionais de Saúde de Barretos e Franca, enquanto nos de Araraquara e Ribeirão Preto I Centro de Laboratório Regional, Instituto Adolfo Lutz de Ribeirão Preto prevalecem indicadores menores que 40%. Conclusões: Investimento e assessoria técnica VI (CLR/IAL), São Paulo, SP, Brazil são insuficientes para elevar os indicadores a valores acima de 80% em municípios com populações pequenas. Para os casos em que os valores são menores que 40% sugere-se uma abordagem baseada na similaridade entre municípios para se aumentar esses valores. * E-mail: [email protected] PALAVRAS-CHAVE: Fluoreto; Água de Abastecimento Público; Qualidade da Fluoretação; Received: Feb 02, 2017 Vigilância Sanitária Approved: Jun 26, 2017 http://www.visaemdebate.incqs.fiocruz.br/ Vigil. sanit. debate 2017;5(3):1-10 | 1 Dovidauskas S et al. Water fluoridation in the Northeast of São Paulo INTRODUCTION In chemical terms, fluorine (F2) is a highly reactive halogen that minimum and maximum concentrations should be 0.8 and 1.3 is not found in the environment. Instead, what we find is its ion, mgL-1, respectively. The fluoride concentration of 1.0 mgL-1 is whether combined with other elements forming minerals, or in considered optimal. In particular, in the state of São Paulo, Bra- the simple ionic form called fluoride (F-) which is predominant zil, the current legislation5 establishes that the concentration of in aqueous media: seawater contains approximately 1 mg L-1 of the fluoride ion should be in the range of 0.6 to 0.8 mg L-1, and fluoride, while the water of rivers and lakes has concentrations 0.7 mg L-1 is considered the ideal content. lower than 0.5 mg L-1. Low or high concentrations may occur in groundwater depending on the nature of the soil and the pres- The previous paragraph implies that a given sample of water supply ence of fluoride-containing minerals in its composition1. can be classified into two categories, based on the classification of fluoride concentration and human consumption: (i) adequate In terms of Public Health, excessive intake of fluoride may lead to (concentration within the range of the minimum and maximum dental fluorosis (characterized by the occurrence of yellowish or concentrations and (ii) inadequate (concentration outside the orange striations or spots on the enamel) and, in more severe cases, range between minimum and maximum concentrations). To this bone fluorosis (osteofluorosis), which presents various degrees of dichotomous classification, in 2011 the Collaborating Center of severity and occurs in several places, especially in India, China the Ministry of Health in Oral Health Surveillance (CECOL) pro- and Africa. Prolonged exposure to high levels of fluoride may lead posed a new classification relating the concentration of fluoride individuals to conditions of disabling bone deformation. Bone flu- to the preventive benefit of dental caries and, simultaneously, orosis is mainly attributed to the consumption of water containing the risk of dental fluorosis6. This new classification is indicated in high levels of fluoride, but exposure to other sources such as air Table 1, in which we can notice that is also considered. (in China, certain provinces burn fluoride-rich coal for cooking and máx curing food). Some foods (the brick tea in Asia, for example) are If non-fluoridation (or its discontinuation) eliminates the benefit also important. In the case of water with high levels of fluoride, of caries prevention, the insufficient addition of fluoride makes there are several defluoridation processes, such as those involving the procedure innocuous, and the addition of excessive amounts the use of activated alumina or bone charcoal, but the first option may cause dental fluorosis, thus constant monitoring of fluoride to mitigate the fluoride contamination of an affected community is levels in public water supply is key to promote the quality of oral 1 to provide an alternative source of supply . health without deleterious effects. In this sense, it is up to the municipality to determine the basic characteristics of this mon- On the other hand, the beneficial action of fluoride in controlling itoring in accordance with the “National Guideline of the Sam- the progression of dental caries2 is recognized by the World pling Plan for the Environmental Surveillance Related to Water Health Organization, mainly through its topical use in toothpaste and its systemic use in water intended for human consumption (fluoridation) – in which case the concentration of the ion in Table 1. Water classification of CECOL according to fluoride content and the water should be maintained within a certain range, gener- benefit-to-risk commitment6. -1 ally between 0.5 and 1.0 mg L . Caries is a condition caused by Fluoride Benefit Risk enzymes released by certain bacteria that ferment sugar resi- Tmax(°C) concentration in (preventing (causing -1 dues present in the mouth causing acids that demineralize the water (mg L ) caries) dental fluorosis) tooth enamel, forming cavities - fluoride increases the resistance 0.00 to 0.44 Insignificant Insignificant of the tooth enamel, additionally leading to the remineralization 0.45 to 0.54 Minimum Low of the areas that suffered the action of acids. In Brazil, caries 0.55 to 0.64 Moderate Low Below 0.65 to 0.94 Maximum Low is a serious problem in oral health, affecting a large share of 26.3 the population. To face this problem, the National Health Foun- 0.95 to 1.24 Maximum Moderate dation (Funasa) admits that “access to treated and fluoridated 1.25 to 1.44 Questionable High water is fundamental for the health conditions of the popula- Higher than 1.45 Harm Very high tion. Enabling public policies that ensure the implementation of 0.00 to 0.44 Insignificant Insignificant water fluoridation is the most comprehensive and socially fair 0.45 to 0.54 Minimum Low Between 3 0.55 to 0.84 Maximum Low way of having access to fluoride.” 26.3 and 32.5 0.85 to 1.14 Maximum Moderate For the beneficial action of fluoride with regard to oral health, 1.15 to 1.44 Questionable High there is an optimal amount of ingestion: above this amount there Higher than 1.45 Harm Very high is the risk of fluorosis, and below there would be loss of efficiency 0.00 to 0.34 Insignificant Insignificant in the reduction of dental caries. In this sense, the Ministry of 0.35 to 0.44 Minimum Low 4 Health through Decree n. 635/Bsb of December 26, 1975 , which Above 0.45 to 0.74 Maximum Low sets out norms and standards on water fluoridation, recommends 32.5 0.75 to 0.84 Maximum Moderate thresholds for fluoride concentration as a function of average 0.85 to 1.44 Questionable High daily maximum air temperatures ( máx) - e.g. in locations where Higher than 1.45 Harm Very high máx are between 14.7 and 17.7° C, it is recommended that the Source: CECOL/USP, 2011. http://www.visaemdebate.incqs.fiocruz.br/ Vigil. sanit. debate 2017;5(3):1-10 | 2 Dovidauskas S et al. Water fluoridation in the Northeast of São Paulo Quality for Human Consumption”7 which establishes not only was municipal and with a population below 30,000 inhabitants, for the number of samples (n) to be collected for analysis, but also which IFLU values were only 9.2%.