Journal of Water Resource and Protection, 2015, 7, 860-870
Published Online July 2015 in SciRes.
How to cite this paper: Guissouma, W. and Tarhouni, J. (2015) Fluoride in Tunisian Drinking Tap Water. Journal of Water
Resource and Protection, 7, 860-870.
Fluoride in Tunisian Drinking Tap Water
Wiem Guissouma*, Jamila Tarhouni
Department of Rural Engineering, National School of Agronomy of Tunis, University of Carthage, Tunis , Tunisia
Email: *wiem.guissouma@g,
Received 18 May 2015; accept ed 19 July 2015; published 22 July 2015
Copyright © 2015 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
This paper presents a fluoride health risk characterization approach to identify the hyper-se nsi -
tive population of adverse effect like tooth decay, dental fluorosis and skeletal fluorosis. In this
context, a sampling campaign has been done over 100 Tunisian water consumption points (tap).
Laboratory analysis results show that the quality of drinking water is affected by high fluoride
concentration level exceeding 2 mgL1. Over these samples, 7% of them present non-compliant
with the Tunisian national standard (NT09.14) and the international guidelines (World Health
Organization recommendations, WHO). The overtake cases are located essentially in southern Tu-
nisian areas, i.e. Medenine, Gabes, Gafsa and Tataouine. One can highlight that groundwater, in
these southern Tunisian areas, are naturally rich of fluoride. This is because of the aquifers geo-
logical and fossil nature. However, commonly northern and central Tunisian areas are characte-
rized by low fluoride concentration level below 0.1 mgL1. These undertaken cases don’t meet the
water quality requirement defined by WHO.
Fluoride, Drinking Water, Health Risk Assessment, Adverse Effects, Hyper-Sensitive Population
1. Introduction
The Tunisian Ministry of Health is devoted to controlling and monitoring the quality of drinking water su pplied
by the Tunisian National Water Distribution Utility (SONEDE). A good bacteriological drinking waterquality
has been translated by decreasing (from 5.8% in 1988 to 2.88% in 2006) diarrheal diseases. However, previous
national authority’s work has not supported the drinking water chemical hazards, i.e. fluoride, for the health
risks assessment. Many epidemiological studies of possible adverse effects of the long-term ingestion of fluoride
via drinking-water have been carried out. These studies clearly estab lish that fluoride primarily produces effects
on skeletal tissues (bones and teeth). Low concentrations provide protection against dental caries, especially in
children. Moreover, Tunisian National Water Distribution Utility (SONEDE) has not adapted an efficient cor-
Corresponding author.
W. Guissouma, J. Tarhouni
rective action to meet the Tunisia dr inking water quality requir ements of fluoride. To prevent adverse effects re-
lated to high daily intake level of fluoride, good water quality manage ment is crucial. This work presents a sam-
pling campaign over 100 Tunisian water consumption points (tap) in order to assess the conformity of the Tuni-
sian drinking water quality with respect to fluoride levels. Section 2 of this paper shows the sampling analysis
results. Conformity assessment is presented in Section 3 by referring to the Tunisian national standard (NT09.14
2013) and the international guidelines [1]. Finally, Section 4 presents a risk characterization approach by adopt-
ing a four-basic-step risk assessment process in order to identify the hyper-sensitive population of adverse effect
like toot h de c ay, dental and skeletal fluorosis.
2. Materials and Methods
2.1. Sampling Process
In this work, a sampling campaign has been done over 100 Tunisian water consumption points (tap). The sam-
ples plan is defined by second degree survey with reasoned choice (mass of population served by networks wa-
ter SONEDE). Laboratory analysis is used to quantitatively describe the fluoride levels in drinking tap water.
2.2. Conformity Assessment
This overview aims to assess conformity of drinking water quality based on a comparative approach between
laboratory analysis results and standards of drinking-water quality presented in Table 1. By referring the Tuni-
sian nati ona l standa rd [2] and the international guidelin es [1] mentioned in Table 1.
2.3. Risk Assessment of Fluoride Content in Drinking Water in Tunisia
As mentioned in the 2007 report edition of the French Institute for Public Health Surveillance [3], risk assess-
ment process is typically structured in four basic steps:
1) Hazard identification ,
2) Selection of toxicological reference values (TRV),
3) Exposure estimation,
4) Risk characterization.
This section explains in detail this fo ur steps risk assessment.
2.3.1. Hazard Identification
Excessive or deficient exposure to fluoride can have adverse effects on human health [4]:
Tooth decay (caries) or enamel demineralization is caused by deficient exposure during tooth formation [5].
Dental fluorosis is caused by over fluoride exposure occurring during tooth mineralization, starting from
third m ont h of in utero life (temporary teeth) ends at 12 years (permanent teeth) [6] [7].
Skeletal fluorosis can also lead In addition, long-term exposure to high fluoride levels [8] [9].
2.3.2. Toxicity Reference Value (TRV)
A toxicity reference value (TRV) presented in Table 2 is used to qualify or/and quantify a human health risk.
Many toxicity reference values (TRV), specific to fluo ride, are used to assess fluoride risk; depending on expo-
sure duration (acute, sub-chronic or chronic) and exposure route (oral, inhalation, etc.). The TRV used in this
work are selected with resp ect to nation al and interna tional organizatio n s and institu tions like U S Environmental
Protection Agency (US EPA), The Agency for Toxic Substances and Disease Registry (ATSDR), The French
High Council for Public Health (FHCPH) and The French Agency for Food, Environmental and Occupational
Health & Safety [10]. The TRV selected for adverse effects threshold by fluoride ingestion are summarized as
Table 1. Guideline for fluoride concentration in drinking water.
NT 14.09
(2013) OMS
(4éme éditi on , 2011) Directive Européenne
98/83/CE Recommandation
Canadienne Normes
Québécoise Nor me
mg/L 1.5 1.5 1.5 1.5 1.5 4
W. Guissouma, J. Tarhouni
Levels fluoride higher than 0.5 mgL1 is recomme nde d f or de ntal deca y pr e ve ntion [11],
A daily fluoride intake of 122 mg L1 bwd1, can occur dental fluorosis [12] [13],
Fluoride intakes exceeding 200 mgL1 bwd1, may arise the skeletal fluorosis [12],
A daily fluoride intake lower or equal to fluoride safety limit does not produce any harmful effect as estab-
lished by CSHPF [14].
2.3.3. Exposure Assessment
The fluoride daily exposure in drinking water (Ew) is expressed by means of fluoride quantity in water in milli-
grams (mg) over person body weight in kilograms (kg1 b.w.) over exposure period in days (day1). It is ex-
pressed as:
EC CBw= ×
where Cfis the fluoride concentration in drinking water (mgL1), “Cis the daily water consumption (Ld1)
and Bwis the average body weight (kg). The reference values used by the World Health Organization (W HO)
for the daily water consumption and the corresponding average body weight are summarized in the Table 3.
2.3.4. Risk Character ization
Risk characterization combines the information from the daily fluoride exposure by water and the adverse ef-
fects on human health observed at higher exposure level than the TRV [15].
The most population exposed at risk is defined by comparing daily fluoride exposure levels in water for dif-
ferent age groups (adult, child and infant).
The comparative approach of the daily fluoride exposure level with the TRV, allows us to estimate some r isk
indicators illuminating the health dimension of the situ ation inv estigated, such as the hazard quotient (QD). This
is the ratio between the level of exposure and the toxicological reference value.
Adverse effects may occur when the TRV exceeds the unitary value [3]. So, the calculation of this ratio is a
tool for identifying areas affected by higher fluoride levels.
2.4. Comparison of Fluoride Daily Exposure and Safety Limit
A comparative approach is adopted between the daily fluoride exposure and the safety limit established by the
CSHPF in the aim to define the exceeding cases of safety limit in drinking water as it is presented in Figure 1.
This appr oa c h is base d on:
a) safety limit established by the CSHPF: 4 mgday1 for adults, 0.7 mgday1 for children and 0.4 mgday1
for infants.
Table 2. Toxicity reference values (TRV) used for fluoride adverse effects.
Reference Work TRV Reference Value Population Adverse Effects
Health Canada 1996 122 µg/kg bw/day 22 to 26 month Dental fluorosis
US EPA (IRIS 2001) 1950 RfD 60 µg/kg bw/day children Dental fluorosis
1994 MRL 60 µg/kg bw/day
non-vertebral fractures
Health Canada LCPE 1993 200 µg/kg bw/day (12 mg/day) Adults Skeletal fluorosis
Report recommended
dietary allowance 2001 Safety limit 0.4 to 4 mg/day Infants to adults
WHO IPCS 2002 6 mg/day Adults Skeletal fluorosis
Table 3. Daily water consumption and corresponding average body weight (adopted from [11]).
Daily water consumption (L/day) Average body weight (kg b.w.)
Infant 0.75 5
Children 1 10
Adults 2 60
W. Guissouma, J. Tarhouni
Figure 1. Exceeding fluoride safety limit cases for infant (a), children (b) and adult (c).
W. Guissouma, J. Tarhouni
b) water consumption defined by the WHO: 2 Lday1 for adults, 1 Lday1 for children and 0.75 Lday1 for
3. Results and Discussion
3.1. Analysis Results Description
In this subsection, analysis results will be explained.
3.1.1. Fluoride in the Drinking Tap Water and Related Geographical Variation
Figure 2 shows that In Tunisia, fluoride levels in drinking tap water are highly changing from north area to
south area. Laboratory analysis results shows that fluoride levels less than 0.1 mgL1 are recorded in some
northern areas; i.e. Beja and Jandouba but these levels are exceeding 2 mgL1 in southern areas, i.e. Medenine,
Gabes, Gafsa and Tataouine. In f act, drinking water supply in northern Tunisian areas is provided from surface
water that has generally low contents of fluoride (less than 0.5 mgL1). As drinking water supply, in southern
Tunisia areas, is provided from groundwater, this can explain the high changing fluoride levels. Indeed,
groundwater is naturally rich of fluoride by the fact that it is in contact with the rock aquifer and can react with it
causing wa t e r e nri chme nt by flu oride [16].
3.1.2. Intra-Regional Variation of Fluoride Levels in the Drinking Tap Water
Figure 3 shows significant intra-regional variability in Gabes area, where fluoride levels fluctuate between
minimum value of 0.29 mgL1) in ElHamma and maximum value of 1.94 mg/L in Mareth. The various water
supply systems can be the major cause of this intra-regional variability: from groundwater wells and water desa-
lination plant [17].
Figure 2. Maximum fluoride level in drinking water in Tunis ia areas.
W. Guissouma, J. Tarhouni
Figure 3. Intra-regional variability of fluoride level in tap water.
3.2. Conformity Assessment Results
Over 7% of samples are non-compliantas it is shown in Table 4. Moreover, Figure 4 shows that the southern
areas, i.e. Medenine, Gabes, Gafsa and Tataouine are considered to be the most areas affected by exceeding flu-
oride standards in drinking water.
3.3. Risk Assessment Results
3.3.1. Identification of the Sensitive Population
Fluoride exposure levels in different Tunisian areas and for different age groups (adult, child and infant) are
calculated by using the WHO reference values for the average body weight and daily water consumption men-
tioned in Table 3. Figure 5 shows a clear difference between the calculated daily exposure to fluoride in drink-
ing water (Ew) for three different age groups; i.e., adult, child and infant. Figure 5 highlights that Infants and
children have higher fluoride exposure levels than adults. Hence, infants and young children are the hy-
per-sensitive age group to fluoride risk. The infant and children hyper-sensitivity is explained by the fact that the
growth skeletal and the mineralization of tooth bud start up during this period. Moreover, a Canadian study [14]
[18] considers that the highest deposition in calcified tissues (bone, teeth) was observed for children case.
W. Guissouma, J. Tarhouni
Table 4. Fluoride analysis results.
Total number of
samples analyzed
Percentage of noncompliance Sampling points Noncompliance cases
based on
NT09.14 based on
l’WHO Number of
noncompliance Levels of
fluoride (mg / L )
100 7% 7%
Monastir 1 1.55
Gafsa (Metlaoui) 1 2.22
Gabes (Mareth) 1 1.94
Mednine (Mednine south) 1 2.4
Mednine (Bengarden) 1 2.22
Mednine (Zarzis city) 1 1.53
Tataouine 1 2.08
Mon asti r
Silia na
Ben Arous
Ga b es
Sidi bouzide
Ga fsa
Sfa x
Figure 4. Ratio of non-compliance fluoride levels in tap water.
W. Guissouma, J. Tarhouni
Figure 5. Age depending fluoride levels exposure.
3.3.2. Tunisian Areas Affected by High Fluoride Levels in Drinking Water
Levels of daily exposure to fluoride depend mainly on the geographical area. The long time exposure to recom-
mended fluoride level does not produce any harmful effects to human. However, upper limit o f fluoride in water
causes adverse effects. These effects can be classified as acute and chronic toxicity.
3.3.3. Acute Toxicity by Fluoride in Drinking Water in Tuni sia
After calculating the fluoride exposure via drinking water, the highest exposition value is observed in Medenine
area (0.08 mgkg1 bwd1). So that; there are no region exhibits a level of water exposure that exceeds the ref-
erence value of acute intoxication set by the WHO (1 mgkg1 bwd1), thus we can estimate that the consumer is
not exposed to fluoride acu te tox ic ity v ia drinking tap water.
3.3.4. Chronic Toxicity by Fluoride in Drinking Water in Tunisia
The chronic toxicity is caused due to long-term ingestion of inadequate amounts of fluor i de in drinki ng water.
a) Tooth decay risk in Tunisia
A total of 18 from 24 Tunisian governorates (75% of regions) have fluoride concentrations below the mini-
mum recommended concentration by WHO (0.5 mgL1) for tooth decay prevention. These regions are located
mainly in the northern Tunisia and especially in Beja and Jendouba. Hence, the fluoride supplementation in
drinking water is required, can be done by the kitchen salt fluorinated whose real contributions are not known or
in the form fluorinated drugs. In Gabes area two water types are observed: water fluoride levels of 0.29 mgL1
in ElHamma area and water fluoride levels of 1.94 mgL1 in Mareth area. So the mixture of these two water
types of could be the solution to bring up the beneficial effect of fluoride and to prevent these adverse effects.
b) Dental fluorosis risk in Tunisia
W. Guissouma, J. Tarhouni
A total number of 6 from 24 Tunisia governorates (25% of regions) have fluoride exposure levels for children
exceeding the TRV established by Health Canada (122 mg kg1 bwd1) of occurrence dental fluorosis. As well
drinking tap water contributes at 100% of TRV. So the excess of TRV can appear in another areas if we asso-
ciate to water exposure, the food exposure and that provided by the drink (tea) and toothpastes. This step of risk
characterization, allows estimating some risk indicators. Such as the hazard quotient (HQ), this is the ratio be-
tween the exposure level and the TRV. When the QD exceeds unitary value an adverse effects may occur [18].
Figure 6 shows that 5 areas have HQ higher than the unity, in these areas the tap water consumer can be af-
fected by dental fluorosis: e.g. in Medenine area the children have an exposure level is 2 times greater than
c) Skeletal fluorosis risk in Tunisia
A total number of 5 from 24 Tunisia governorates (20% of regions) have fluoride exposure levels for infants
exceeding the TRV established by Health Canada (200 mg∙kg1 bw∙d1) of occurrence skeletal fluorosis [12].
Figure 7 shows that these areas are located in southern Tunisia (Medenine, Gab e s , Gafsa, Tataouine and Zidi-
Bouzid) where the HQ is higher than the unity.
3.4. Exceeding Cases of the Safety Limit in Tunisia
The percentages of exceeding cases of the safety limit are:
33% for infants;
20% for children;
3% for adults.
This analysis pinpoints that infants and children are the most population exposed to fluoride risk.
4. Conclusions
This study was the starting point for locating ar ea s with high s anitary risk attributed to drinking water.
75% of Tunisian areas present dental decay risk through tap water consumption,
25% of Tunisian areas present dental fluorosis risk through tap water consumption,
20% of Tunisian areas present skeletal fluorosis risk through tap water consumption.
Figure 6. Evolution of hazard quotient in Tunisian areas.
W. Guissouma, J. Tarhouni
Ben arous
Sidi Bouzid
Sfa x
Figure 7. Fluoridated areas with skeletal fluorosis risks.
In Gabes ar ea two w ater types are ob serv ed: wa ter fluoride levels of 0.29 mgL1 in ElHamma ar ea and water
fluoride levels of 1.94 mgL1 in Mareth area. So the mixture of these two water types could be the solution to
bring up the beneficial effect of fluoride and to prevent these adverse effects.
As well, this study concludes that young children and infants are considered as the hyper sensitive age group
and they are the most population exposed to risk associated with excess and deficiency fluoride levels in water.
Authors thank the National Agency of Sanitary and Environmental Control Products (ANCSEP) for further dis-
cussions and useful information.
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