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84 Fluoride Vol. 36 No. 2 84-94 2003 Research Report———————————————
a
For Correspondence: Dr Xiang Quanyong, Department of Occupational Health, Schoolof Public Health, Fudan University (Formerly Shanghai Medical University), Shanghai,200032, China. E-mail: quanyongxiang@yahoo.com.cn or yxliang@shmu.edu.cn.
b
Cen-ter for Disease Control and Prevention, Jiangsu Province, China.
c
Center for DiseaseControl and Prevention, Sihong County, Jiangsu Province, China.
EFFECT OF FLUORIDE IN DRINKING WATERON CHILDREN’S INTELLIGENCE
Q Xiang,
a
Y Liang,
a
L Chen,
b
C Wang,
b
B Chen,
a
X Chen,
b
M Zhou
c
Shanghai, P.R. China
SUMMARY: The Intelligence Quotient (IQ) was measured in 512 children,aged 8–13 years, living in two villages in Sihong County, Jiangsu Province,China, differing in the level of fluoride in their drinking water. In the high-fluoride village of Wamiao (water fluoride: 2.47±0.79 mg/L; range: 0.57–4.50mg/L), the mean IQ of 222 children was significantly lower (92.02±13.00;range: 54–126) than in the low-fluoride village of Xinhuai (water fluoride:0.36±0.15 mg/L; range: 0.18–0.76 mg/L), where the mean IQ of 290 childrenwas higher (100.41±13.21; range: 60–128). The children’s IQs were not relatedto urinary iodine, family income, or parent’s education level. Higher drinkingwater fluoride levels were significantly associated with higher rates of mentalretardation (IQ <70) and borderline intelligence (IQ 70–79). The BenchmarkConcentration (BMC) for the concentration-response relationship between IQ<80 and the drinking water fluoride level was 2.32 mg/L, and the lower-boundconfidence limit (BMCL) of the BMC was 1.85 mg/L. Taking dental fluorosisand other sources of dietary fluoride into account, the reference value con-centration (RfC) for fluoride was calculated to be 0.925 mg/L, which is veryclose to the current national Chinese standard of <1.0 mg/L. In endemic fluo-rosis areas, drinking water fluoride levels greater than 1.0 mg/L may adverselyaffect the development of children’s intelligence.
Keywords: Children’s intelligence; China; Fluoride in village water; Intelligence Quotient.
INTRODUCTION
In 1937, Kaj Roholm published his classic study on 68 cryolite workerschronically exposed to fluoride, 84% of whom had skeletal fluorosis with22% of them having neurological symptoms involving excessive tiredness,sleepiness, indisposition, headache, and giddiness.
1
In that same year, Shortt
et al
reported 10 cases of fluorosis complicated by central nervous systemdamage with symptoms of pressure on the spinal cord including tinglingsensations, loss of pain, temperature, touch, vibration sensation in the lowerlimbs, altered reflexes, impotence, and loss of sphincter control but withunimpaired mental powers.
2
In 1961, Singh and Jolly reported that 10% of patients with skeletal fluorosis had nervous system damage.
3
Animal studiesshow that brain fluoride levels increase with increasing exposure to fluo-ride,
4-5
and further studies on humans, particularly in China, have been pub-lished.
6-14
Investigations by Zhao
et al
13
and by Lu
et al,
14
conducted in dif-ferent regions of China, indicated an association between higher levels of drinking water fluoride and a lower IQ in children, whereas a study by Hu
et 
 
Drinking water fluoride and children’s intelligence 85
Fluoride 
36 (2) 2003
al,
did not.
15,16
The relationships between drinking water fluoride, urinaryfluoride, and IQ are examined further in the present study.
MATERIALS AND METHODS
Two villages, Wamiao and Xinhuai, located 64 km apart in SihongCounty, Jiangsu Province, that are near Lake Hongze, which is about 215km inland from the east coast of the People’s Republic of China and about730 km southeast of Beijing, were selected for study. Wamiao in northeastSihong County, about 32 km northeast of Sihong (
ca.
33° 28’ N and 118°12’ E), lies in a severe endemic fluorosis area. Xinhuai in the southwest partof Sihong County, about 32 km southwest of Sihong, is in a nonendemicfluorosis area. Neither village has fluoride pollution from burning coal orother industrial sources. None of the residents reported drinking brick tea.The study was conducted between September and December 2002 and in-cluded all eligible children in each village. A questionnaire, completed withthe assistance of parents, was used to collect information on personal char-acteristics, medical history including illnesses affecting the nervous systemand head trauma, educational level of the children and parents, family socio-economic status, and lifestyle. Children who had been absent from eithervillage for two years or longer, or who had a history of brain disease or headinjury, were excluded. In Wamiao, 93% of the children (222 out of 238)were included for the study, while in Xinhuai, 95% were included (290 outof 305). The children in Wamiao were divided into five subgroups accordingto the level of fluoride in their drinking water: <1.0 mg/L (group A), 1.0–1.9mg/L (group B), 2.0–2.9 mg/L (group C), 3.0–3.9 mg/L (group D), >3.9mg/L (group E), while those in Xinhuai (0.18–0.76 mg F/L in the drinkingwater) were considered as a single group (group F).The Intelligence Quotient (IQ) of each child was measured with the Com-bined Raven’s Test for Rural China (CRT-RC), published by HuadongNormal University in 1989.
17
The test was administered to the children in aschool class, working independently, in a double-blind manner, under thesupervision of an examiner and two assistants, according to the directions of the CRT-RC manual for the test administration conditions, instructions to begiven, and the test environment.
17
The scores for IQ in the CRT-RC wereranked as: mental retardation (IQ <70), borderline (IQ 70–79), dull normal(IQ 80–89), normal (IQ 90–109), bright normal (IQ 110–119), superior(IQ120–129), and very superior (IQ >129).
Fl
uoride in the drinking water and urine was measured with a fluoride ionselective electrode.
18-19
Iodine in urine was measured with the Test Kitmanufactured by the Center for Disease Control and Prevention, HubeiProvince.
20
Urine samples were collected in the early morning, and thedrinking water was collected from the wells in clean plastic bottles. Children
 
86 Xiang, Liang, Chen, Wang, Chen, Chen, Zhou
Fluoride 
36 (2) 2003
for urine testing were chosen by random sampling: in Wamiao, 155 for fluo-ride and 46 for iodine; in Xinhuai, 135 for fluoride and 40 for iodine.Data were analyzed using SAS and Benchmark Concentration software(BMCS).
RESULTS
F
luoride levels in the drinking water and urine, and iodine levels in theurine are shown in Tables 1–5. The results indicate that significant differ-ences were present between the villages in the levels of fluoride in thedrinking water and urine, but not in the urinary iodine levels.
Table 1.
Fluoride drinking water levels in Wamiao and Xinhuai
VillageNo. samplesFluoride in drinking water (mg/L)t
p 
Mean±SDRangeWamiao2222.47±0.790.57–4.5044.97<0.001Xinhuai2900.36±0.150.18
 
 –0.76
Table 2.
Urinary fluoride in children in Wamiao and Xinhuai
VillageNo. samplesUrinary fluoride (mg/L)t
p 
Mean ±SDRangeWamiao1553.47±1.950.90–12.5013.82<0.001Xinhuai1351.11±0.390.37–2.50
Table 3.
Ratio of urinary fluoride to creatinine in children in Wamiao and Xinhuai
VillageNo. samplesUrinary fluoride/Cre(mg F/mmol Cre)t
p 
Mean ±SDRangeWamiao1550.82±0.750.13–4.698.96<0.001Xinhuai1350.24±0.100.09–0.71
Table 4.
Urinary iodine in children in Wamiao and Xinhuai
VillageNo. samplesUrinary iodine (
µ
g/L)t
p 
Mean ±SDRangeWamiao46280.70±87.16131.31–497.051.04>0.3Xinhuai40300.96±92.88148.46–460.89
of 00

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