mg/kg/day for adults to 0.634 mg/kg/day for children. The corresponding intake range at 2 mg/L is 0.154 to 0.334 mg/kg/day for adults and children, respectively.

Dental Effects

Enamel fluorosis is a dose-related mottling of enamel that can range from mild discoloration of the tooth surface to severe staining and pitting. The condition is permanent after it develops in children during tooth formation, a period ranging from birth until about the age of 8. Whether to consider enamel fluorosis, particularly the moderate to severe forms, to be an adverse health effect or a cosmetic effect has been the subject of debate for decades. In previous assessments, all forms of enamel fluorosis, including the severest form, have been judged to be aesthetically displeasing but not adverse to health. This view has been based largely on the absence of direct evidence that severe enamel fluorosis results in tooth loss; loss of tooth function; or psychological, behavioral, or social problems.

Severe enamel fluorosis is characterized by dark yellow to brown staining and discrete and confluent pitting, which constitutes enamel loss. The committee finds the rationale for considering severe enamel fluorosis only a cosmetic effect to be much weaker for discrete and confluent pitting than for staining. One of the functions of tooth enamel is to protect the dentin and, ultimately, the pulp from decay and infection. Severe enamel fluorosis compromises that health-protective function by causing structural damage to the tooth. The damage to teeth caused by severe enamel fluorosis is a toxic effect that is consistent with prevailing risk assessment definitions of adverse health effects. This view is supported by the clinical practice of filling enamel pits in patients with severe enamel fluorosis and restoring the affected teeth. Moreover, the plausible hypothesis concerning elevated frequency of caries in persons with severe enamel fluorosis has been accepted by some authorities, and the available evidence is mixed but generally supportive.

Severe enamel fluorosis occurs at an appreciable frequency, approximately 10% on average, among children in U.S. communities with water fluoride concentrations at or near the current MCLG of 4 mg/L. Thus, the MCLG is not adequately protective against this condition.

Two of the 12 members of the committee did not agree that severe enamel fluorosis should now be considered an adverse health effect. They agreed that it is an adverse dental effect but found that no new evidence has emerged to suggest a link between severe enamel fluorosis, as experienced in the United States, and a person’s ability to function. They judged that demonstration of enamel defects alone from fluorosis is not sufficient to change the prevailing opinion that severe enamel fluorosis is an adverse cosmetic effect. Despite their disagreement on characterization of the condition, these



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