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Year : 2019  |  Volume : 30  |  Issue : 3  |  Page : 375-380
Fluoride concentration of bottled water and public water in Lebanon

Department of Dental Public Health, School of Dentistry, Lebanese University, Beirut, Lebanon

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Date of Web Publication9-Aug-2019


Background and Aims: People in Lebanon turned to bottle water consumption because of its poor public water quality. In general, fluoride is known as dental caries preventive. A study in 1986 and two other national surveys in 1994 and 2004 showed that the concentration of fluoride in public Lebanese water was insignificant for the prevention of dental caries (less than 0.3 mg/L). The aim of the study was to measure the fluoride concentration in the highest selling and known commercial brands for bottled water in Lebanon, as well as to assess their effectiveness regarding prevention of dental caries. Result: Fluoride has a notable therapeutic effect but in small doses that fluoride can be found in drinking water. Analysis using an absorptiometry of 625nm and another technique using an Orion electrode of 9609 BN have shown the low content of fluoride in the Lebanese waters (less than 0.3 mg/l). Strategies have recently been evolved based on fluroide supplementation (if the results turn negative) to reduce the index of caries in LEBANON.

Keywords: Adequate fluoride dosage, collection of samples, fluoride content in lebanese water, optimal concentration of fluoride

How to cite this article:
Doumit M, Aad LA, Machmouchi M. Fluoride concentration of bottled water and public water in Lebanon. Indian J Dent Res 2019;30:375-80

How to cite this URL:
Doumit M, Aad LA, Machmouchi M. Fluoride concentration of bottled water and public water in Lebanon. Indian J Dent Res [serial online] 2019 [cited 2023 Oct 3];30:375-80. Available from:

   Introduction Top

Fluoride is a mineral found in water in varying amounts in nature. It is present in certain foods [1] also. In the early 20th century, lower levels of tooth decay were found to be associated with certain fluoride levels in drinking water.[1] Water fluoridation is accomplished by adding sodiumfluoride (NaF), fluorosilisic acid (H2SiF6), or sodium fluorosilicate (Na2SiF6) to drinking water.[2] More than 125 “National and International Organizations” in the United States of America recognized the Public Health Benefits of Community Water Fluoridation for Preventing Dental Decay.[3] In November 2012, the estimated number of people consuming artificially fluoridated water worldwide was 377,655,000 in 25 countries.[2] WHO mainly monitors the effects of fluoride at different doses.

In 2011, the US Department of Health and Human Services and the US Environmental Protection Agency (EPA) recommended fixing fluoride level in a liter of water at 0.7 mg as opposed to the current range of 0.7-1.2 mg.[4]

While over 74% of people living in the US receive fluoridated water [Centers for Disease Control and Prevention (CDC), 2014), challenges to community water fluoridation are observed internationally. In many areas of the world, there is a need to de-fluoridate the water supply owing to an overabundance of fluoride at a non-therapeutic level. There is some global opposition to the practice of adjusting fluoride in water supplies to a therapeutic level despite the results of recent and large reviews about the safety and efficiency of fluoridation of water, [Table 1][1],[2],[3],[4],[5] and the proclamation of The CDC that considers water fluoridation as one of 10 great public health achievements of the 20th century.[6] This opposition results from concerns about possible side effects to health that drinking fluoridated water may cause.[2] The possible health effects of fluoridated water have been studied and reviewed over the last 50 years and show that fluoride consumption at the levels recommended for community water fluoridation (0.7 ppm) do not present a health risk to the population.
Table 1: Effects of Fluoride at different concentration

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Health monitoring report for England 2014 and National Health and Medical research council for Australia 2007 concluded that there was no evidence of a difference between fluoridated and non-fluoridated areas in the rate of occurrence of hip fractures, cancers including osteosarcoma, and that of Down's syndrome.[1],[2],[3],[4],[5],[6],[7] However, the evidence in the rate of kidney stones, deaths with recorded causes, and bladder cancer was lower in fluoridated areas than non-fluoridated areas.[1] Systemic reviews conducted by the Cochrane Health Group Editors found insufficient information about the effects of stopping water fluoridation.[8] This implies that fluoride is safe and effective at the recommended concentration. Fluoride below the therapeutic level was not effective in preventing dental caries whereas excessive amounts of fluoride led to side health effects. The present study will evaluate the content of fluoride in the most common commercial Lebanese brands of bottled water in completion with 3 studies done before.[9],[10]

   Materials and Methods Top

In total, 13 commercial brands of locally produced bottled water were collected by the authors from big supermarkets in Lebanon. The chosen brands were the most common consumed and approved by the Ministry of Health. Each bottle contained 0.5 liter of water. All the samples were stored in their original containers until the fluoride analysis was performed and were then sent to analytical testing laboratories. The fluoride concentrations of the 13 samples were determined by using the SPADNS Spectrophotometric Method. This method involved the reaction of fluoride with a red zirconium-dye solution. The fluoride combined with a part of the zirconium to form a colorless complex bleaching the red color with an amount proportional to the fluoride concentration. The EPA accepted this method for National Pollutant Discharge Elimination System and National Primary Drinking Water Regulation reporting purposes when the samples had been distilled. Seawater and wastewater samples required distillation to eliminate most interferences such as alkalinity (CaCo3), Aluminium, Chloride, Chlorine, Iron ferric, Phosphate ortho, Sodium hexametaphosphate, and sulfate. Because this test was sensitive to small amounts of contamination, glassware must be very clean (acid rinse before each use). The test was repeated with the same glassware to make sure that the results were accurate. The wavelength measurement should be 580 nm for spectrophotometers or 610 nm for colorimeters.

   Results Top

The concentration of fluoride in commercial bottled water in Lebanon is illustrated in [Table 2].
Table 2: Fluoride concentration in commercial bottled water in Lebanon

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[Table 2] shows that the concentration of fluoride in compercially boddled water in Lebanon is below the recommended fluoride level for tooth decay prevention. However, the concentration of fluoride is at its highest level at 0.23 mg/L.

Background on Water fluoridation in Lebanon

In 1986, a study on fluoride water concentration in Lebanon was performed by Doumit M. There was no data from previous studies concerning the fluoride concentration in Lebanon. Overall, 32 samples from different locations of water resources in Lebanon and bottled water in the market were collected between 21-07-86 and 31-08-86. The collected samples are represented in [Figure 1] “map of Lebanon.”
Figure 1: Locations of water resources in Lebanon

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By using an absorptiometry of 625 nm technique, the results are illustrated in [Table 3] and [Table 4].
Table 3: Illustration of geographical locations of water resources in Lebanon, and amount of fluoride in it

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Table 4: Concentration of fluoride from different water resources in Lebanon (1986)

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[Table 4] shows that the concentration of fluoride in different location of water resources in Lebanon is below the recommended fluoride level for tooth decay prevention. However, the concentration of fluoride is at its highest level at 0.25 mg/L.

[Table 3] shows that the concentration of fluoride in different location of water resources in Lebanon is below the recommended fluoride level for tooth decay prevention. However, the concentration of fluoride is at its highest level at 0.25 mg/L.

In 2004, under the collaboration of an Oral Health program in Lebanon and the assistance of the Lebanese University (School of Dentistry) and the University of Texas Health Science Center at San Antonio, USA, samples of 263 water sources were collected covering all Lebanon. Using an Orion electrode technique of 9609BN similar to that of the first study in 1986, a poor concentration of fluoride was detected. *The procedures of water sample collection for the determination of fluoride:

  1. Water samples: These are used to identify and locate water sources and are required for obvious reasons
  2. Sequential number: This information is of vital importance for a follow-up or verification of the sample if needed
  3. Source name: Equally indispensable to identify the origin of the water sample, then track and/or collect additional water samples in case of discrepancies
  4. Location: It is significant to obtain the name of the district, city, and community to specify the location of the water source origin
  5. Zone: Needed to find out if it is urban, peri-urban, or rural
  6. Coverage: It is important to record coverage to determine the approximate number of inhabitants that benefit from this source. Some sources supply water to various communities.
  7. Soil: The type of soil where the source is located can influence the amount of fluoride in the water; whether the soil is rocky, clay, sandy, volcanic, etc. should be identified

  • Techniques for the collection of water samples that were considered:

    • Plastic bottles of 125 ml or plastic cylinders of 50 ml
    • Wash the recipient 3 or 4 times with the same water that is to be collected
    • Leave the water running up to the brim of the recipient
    • After taking the sample, close the bottle tightly
    • Immediately identify the bottle with a pre-made label. The label should have the necessary information regarding its origin, number, name of the source, geographical location, date and name of responsible party
    • The samples should be placed in a suitable container for transportation to the analysis site.

  • The determination results of fluoride in community water supplies:

Complete information on each water sample was not available or recorded at the time of collection while the sample origin of region, department, and source with its corresponding identification code were recorded.

The results are illustrated in [Table 4].

[Table 5]: The results found in 2004 of the concentration of fluoride from different water resources in Lebanon are similar to those found in previous studies.
Table 5: Concentration of fluoride from different water resources in Lebanon (2004)

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   Discussion Top

For any prevention policy or individual prevention action, and before implementing or suggesting any plan on oral health promotion, the data on fluoride exposure should be known. One of the main elements that need to be examined is water.

Dental caries remains one of the most prevalent diseases worldwide.[11],[12],[13] The high consumption of sugar and the inadequate exposure to fluoride are the major reasons for this widespread disease (WHO, 2010; 2015). It affects 60% to 90% of school children [12] and continues to older age (Petersen, 2008a; WHO, 2016). Meanwhile, there is an improvement in dental health in westernized high-income countries through public dental health prevention programs, education, and changing lifestyle attitude regarding dental health.[12] In Eastern Europe and Central Asia the prevalence of dental decay is high, and the exposure to fluoride for disease prevention remains low.[12] In Africa, Asia, and Latin America the situation is more complicated because the health system is limited to treatment and emergency care.[12]

Dental caries history in Lebanon from the last national survey in 2004 showed that caries prevalence is critical. Over 50% of children of all ages required prompt dental treatment, and 22% of children in the 6–8 year-old group and approximately, 15% of children in the 12 and 15 year-old required urgent treatment.[9]

Fluoride is often called nature's cavity fighter (American Dental Association), and hence, fluorides have been used in many different forms.

The application of fluoride is divided in 2 groups:

1- Systemic F (F water, milk, or salt, and F supplements as tablets, drops, or lozenges).

2- Topical F (F toothpaste, mouthwashes, varnishes, gels, and sealants).

Regardless of fluoridated water and the different sources of fluoride intake, studies have proved that water fluoridation continues to be effective in reducing dental decay.[14],[15]

In their systemic review, McDonagh et al.(2000) showed that dental decay was significantly decreased in children who were exposed to fluoridated water compared to children who were not.[7] However, children drinking fluoridated water developed mild fluorosis.[3],[7],[12] The last national study (2004) in Lebanon showed an insignificant occurrence of fluorosis [10] and urinary fluoride concentration of children from all regions to be very low-approximately one half of optimal level.[10] In fact, education attained by parents was an influencing factor on children's lifestyle, habits, and oral health status. Unfortunately, no data in the issue were provided to correlate with, but a study was made at the Lebanese University in 2013 to investigate oral health knowledge and practices among undergraduate dental students and their evolution through academic years. The finding showed that the oral health attitudes and behavior of dental students improved with increasing levels of education. Dental students from the last academic years were the highest among all to do regular checkups and use auxiliary oral hygiene aids (toothpaste with fluoride and dental floss).[16] The use of toothpaste and toothbrush among Lebanese citizens were investigated between 2000 and 2014. It showed that the citizens used an average of 2 tubes of toothpaste and 2 toothbrushes per year, which were below the recommendations of WHO.[17] Moreover, the recommended amount of toothpaste is 6 tubes per year and that of toothbrushes are 4 per year.[18]

Pediatricians, however, are the primary care providers and the first health physicians for infants. A study was made in Lebanon about these issues to evaluate the awareness regarding children's oral health. The study showed the majority believed that fluoride was effective in prevention. However, those who were academically affiliated believed that fluoride was safe compared to those practicing in private sectors.[19] The same authors made another study about the behavior of pediatricians in Lebanon regarding children's oral health. It showed that the behavior of children was inefficient,[20] and the pediatricians did not have a relatively high degree of knowledge concerning oral health or explaining their self-reported behavior. There is the need to develop awareness about oral health in pediatricians and to make them consider prescribing fluoride in a systemic form. Owing to many studies, fluoridated water is one of the systemic and most effective prescriptions in reducing dental decay,[14],[15] especially when it is pre- and post-eruptively used.[15]

   Conclusion Top

This study has proved that fluoride concentration of water in Lebanon is poor and insufficient. From the results found, it is obvious that water as it is now cannot play any role in caries prevention.

There is a need to implement nationwide public health measures for prevention of dental caries. There is also the need to support any program that focuses on improvement and maintenance of oral hygiene, advising the use of topical fluoride. There is a need to work on creating and implementing a clear, feasible oral health policy.

In summary, we recommend the following:

  • Implementing nationwide public health measures for prevention of dental caries, by adding fluoride in water or in salt
  • Supporting any programs that focus on improvement and maintenance of oral hygiene
  • Advising the use of topical fluoride
  • Fostering collaboration between pediatric dentists and pediatricians is recommended not only through education programs but also by promoting oral examination of the children during their first year of life.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Public Health England: Water Fluoridation Health Monitoring Report for England (PDF, 1.51Mb); 2014.  Back to cited text no. 1
Health Research Board (Ireland): Health Effects of Water Fluoridation (PDF, 1.58Mb). Health Research Board; 2015.  Back to cited text no. 2
ADA, Association of State and Territorial Dental Directors, CDC Honor Fluoridation Efforts of States, Communities; 10 June, 2013.  Back to cited text no. 3
HHS and EPA Announce New Scientific Assessments and Actions on Fluoride. Agencies Working Together to Maintain Benefits of Preventing Tooth Decay While Preventing Excessive Exposure; 07 January, 2011.  Back to cited text no. 4
WHO (2010): Inadequate or excess fluoride: a major public health concern. Geneva: World Health Organization.  Back to cited text no. 5
Centers for Disease Control and Prevention (US): Recommendations on Selected Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers and Sports-Related Craniofacial Injuries (PDF, 69kb) – in 2002.  Back to cited text no. 6
National Health and Medical Research Council (Australian Government): Efficacy and Safety of Fluoridation. Australian: National Health and Medical Research Council; 2007.  Back to cited text no. 7
Cochrane Oral Health Group. Water fluoridation for prevention of dental caries. Cochrane Libr Cochrane Database Syst Rev 2010; DOI: 10.1002/14651858. CD010856.pub2.  Back to cited text no. 8
Doumit M. “The advantage of water fluoridation in Lebanon”, Department of publication at the Lebanese University, Beirut, 1995.  Back to cited text no. 9
Doumit M, Doughan B, Baez R. Program for Dental Public Health, Lebanese University/ WHO/ Lebanese Ministry of Health/ EMRO, 2004.  Back to cited text no. 10
Tewari A. Fluorides and dental caries: A compendium 1st ed. Indore. J Indian Dent Assoc 1986;17:24-9.  Back to cited text no. 11
Petersen PE, Ogawa H. Prevention Dental Caries Through the Use of Fluoride the WHO Approach, Community Dental Health 2016;33:66-8.  Back to cited text no. 12
Petersen PE. World Health Organization global policy for improvement of oral health – World health assembly 2007. Int Dent J 2008;58:115-21.  Back to cited text no. 13
Brunelle JA, Carlos JP. Recent trends in dental caries in U.S. Children and the effect of water fluoridation. J Dent Res 1990;69:723-7.  Back to cited text no. 14
Iheozor-Ejiofor Z, Worthington HV, Walsh T, O'Malley L, Clarkson JE, Macey R, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev 2015;6:CD010856.  Back to cited text no. 15
Daou D, Abi Aad L. Oral health attitudes and practices among dental students in Lebanon. Int J Oral Dent Sci 2015;1:12-8.  Back to cited text no. 16
Sayah F, Nasredinne S. Imported and consumed quantity of toothpaste and toothbrushes by the Lebanese since year 2000 until 2014. Int J Oral Dent Sci 2017;2:21-9.  Back to cited text no. 17
World Health Organization. “Oral Health Promotion”: An essential of a health- Promoting School. Geneva, Switzerland: WHO; 2003.  Back to cited text no. 18
Nassif N, Noueiri B, Bacho R, Kassak K. Awareness of Lebanese pediatricians regarding children's oral health. Int J Clin Pediatr Dent 2017;10:82-8.  Back to cited text no. 19
Noueiri B, Nassif N, Bacho R. Behavior of Lebanese pediatricians regarding children's oral health. Int J Clin Pediatr Dent 2017;10:379-83.  Back to cited text no. 20

Correspondence Address:
Prof. Mounir Doumit
Department of Dental Public Health, School of Dentistry, Lebanese University, Beirut
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_604_18

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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