Assessment of groundwater quality with respect to fluoride

Probabilistic modelling is superior to deterministic approaches in the human health risk assessment: an example from a tribal stretch in central India

This case drew national attention in 2018. About 100 people died and more than 300 hospitalized in a span of few years in a village of 1200 people in a tribal stretch in central India. Medical teams visiting the area reported severe renal failure and blamed the local eating and drinking habits as causative factors. This human health assessment based on geochemical investigations finds nitrate (NO3-) and fluoride (F-) pollution as well in village's groundwater. Both deterministic and probabilistic techniques are employed to decipher the contamination pathways and extent of contamination. Source apportionments of NO3- and F- and their relationship with other ions in groundwater are carried out through chemometric modelling. Latent factors controlling the hydrogeochemistry of groundwater too are explored. While hazard quotients ([Formula: see text]) of the chemical parameters ([Formula: see text] and [Formula: see text]) identify ingestion as the prominent pathway, the calculated risk certainty levels (RCL) of the hazard index (HI) values above unity are compared between the deterministic and probabilistic approaches. Deterministic model overestimates the HI values and magnify the contamination problems. Probabilistic model gives realistic results that stand at infants ([Formula: see text] = 34.03%, [Formula: see text] = 24.17%) > children ([Formula: see text] = 23.01%, [Formula: see text] = 10.56%) > teens ([Formula: see text] = 13.17%, [Formula: see text] = 2.00%) > adults ([Formula: see text] = 11.62%, [Formula: see text] = 1.25%). Geochemically, about 90% of the samples are controlled by rock-water interaction with Ca2+-Mg2+-HCO3- (~ 56%) as the dominant hydrochemical facies. Chemometric modelling confirms Ca2+, Mg2+, HCO3-, F-, and SO42- to originate from geogenic sources, Cl- and NO3- from anthropogenic inputs and Na+ and K+ from mixed factors. The area needs treated groundwater for human consumption.

Fluoride in groundwater of industrial town of Sonbhadra district, Uttar Pradesh, India: probable release mechanism and potential health risk assessment

In the selected study region of Sonbhadra district, coal burning and mining activities are dominant. Previous studies reported F contamination in very few groundwater samples of this region. A detailed study is required to estimate the fluoride in groundwater of this area. Hence, a total of 128 groundwater samples were collected during post- and pre-monsoon seasons in the year 2017 to estimate the F-, its geochemistry, and health risk assessment from Renukoot and Anpara industrial clusters of Sonbhadra district, Uttar Pradesh, India. The pH of groundwater samples varied from slightly acidic to alkaline during both seasons. Almost all the major cations (Ca2+, Mg2+, Na+, and K+) and major anions (HCO3-, Cl-, SO42-, and F-) values in groundwater samples of both clusters were found within the permissible limit of World Health Organization (WHO) and Beauro of Indian standards except F- in both seasons. The scatter plots of F- with Ca2+, Na+, HCO3-, and pH are used to explain the release mechanism of fluoride in groundwater. Saturation indices (SI) calcite versus SI fluorite and SI dolomite versus SI fluorite plots of both clusters used to check the involvement of these minerals in fluoride enrichment of aquifers. F- contamination in groundwater due to coal burning in coal mining and thermal power plant dominated region is discussed globally and locally both. The non-carcinogenic health risk due to consumption of fluoride-contaminated water is estimated by using target hazard quotient (THQ). THQ values of F- showed that children are at high risk than adults in both clusters of the study area during both seasons. Pictorial representation is used to show the dental fluorosis cases in children of the study region.

State-of-the-art of research progress on adsorptive removal of fluoride-contaminated water using biochar-based materials: Practical feasibility through reusability and column transport studies

Fluoride (F^-) is one of the essential elements found in soil and water released from geogenic sources and several anthropogenic activities. Fluoride causes fluorosis, dental and skeletal growth problems, teeth mottling, and neurological damage due to prolonged consumption, affecting millions worldwide. Adsorption is an extensively implemented technique in water and wastewater treatment for fluoride, with significant potential due to efficiency, cost-effectiveness, ease of operation, and reusability. This review highlights the current state of knowledge for fluoride adsorption using biochar-based materials and the limitations of biochar for fluoride-contaminated groundwater and industrial wastewater treatment. Biochar materials have shown significant adsorption capacities for fluoride under the influence of low pH, biochar dose, initial concentration, temperature, and co-existing ions. Modified biochar possesses various functional groups (-OH, -CC, -C-O, -CONH, -C-OH, X-OH), in which enhanced hydroxyl (-OH) groups onto the surface plays a significant role in fluoride adsorption via electrostatic attraction and ion exchange. Regeneration and reusability of biochar sorbents need to be performed to a greater extent to improve removal efficiency and reusability in field conditions. Furthermore, the present investigation identifies the limitations of biochar materials in treating fluoride-contaminated drinking groundwater and industrial effluents. The fluoride removal using biochar-based materials at an industrial scale for understanding the practical feasibility is yet to be documented. This review work recommend the feasibility of biochar-based materials in column studies for fluoride remediation in the future.

Influence of climate on groundwater fluoride in different climatic domains in a hard rock terrain of Sri Lanka: implications to community health

Health risks associated with excessive intake of fluoride through drinking water are one of the geoenvironmental health problems observed in many parts of the world, mainly in countries of the humid tropical belt, including Sri Lanka. Fluoride-related health problems are widespread in the dry climatic region compared to the wet climatic zone of Sri Lanka. The potential health risks of fluoride for communities in a river basin which drains through two climatic zones, viz. wet and dry zones, were investigated in this study. Sixty-three groundwater samples were collected from wells in the Walawe river basin during pre- and post-monsoon periods. From collected samples, ten selected samples were analyzed for their tritium (³H) levels to find out the approximate resident time of groundwater. In the river basin, the dry zone segment is characterized by elevated levels of fluoride (> 1.0 mg/L) in groundwater. Groundwater fluoride in the region was primarily of geogenic origin. The tritium values showed older groundwater contained higher fluoride levels, showing a increased dissolution of fluoride-bearing minerals. The hazard quotient (HQ_fluoride) showed that about 45% of pre- and 55% of post-monsoon groundwater samples in the dry zone area were unsuitable for drinking purposes for school children who are vulnerable to non-carcinogenic risks and dental fluorosis. This study emphasizes the need for continuous water quality monitoring and mitigation measures to ensure the health of residents.

Judging the sources of inferior groundwater quality and health risk problems through intake of groundwater nitrate and fluoride from a rural part of Telangana, India

Evaluation of groundwater quality and related health hazards is a prerequisite for taking preventive measures. The rural region of Telangana, India, has been selected for the present study to assess the sources and origins of inferior groundwater quality and to understand the human health risk zones for adults and children due to the consumption of nitrate ([Formula: see text])- and fluoride (F^-)-contaminated groundwater for drinking purposes. Groundwater samples collected from the study region were determined for various chemical parameters. Groundwater quality was dominated by Na⁺ and [Formula: see text] ions. Piper's diagram and bivariate plots indicated the carbonate water type and silicate weathering as a main factor and man-made contamination as a secondary factor controlling groundwater chemistry; hence, the groundwater quality in the study region is low. According to the Groundwater Quality Index (GQI) classification, 48.3% and 51.7% of the total study region are excellent (GQI: < 50) and good (GQI: 50 to 100) water quality types, respectively, for drinking purposes. However, [Formula: see text] ranged from 0.04 to 585 mg/L, exceeding the drinking water quality limit of 45 mg/L in 34% of the groundwater samples due to the effects of nitrogen fertilizers. This was supported by the relationship of [Formula: see text] with TDS, Na⁺, and Cl^-. The F^- content was from 0.22 to 5.41 mg/L, which exceeds the standard drinking water quality limit of 1.5 mg/L in 25% of the groundwater samples. The relationship of F^- with pH, Ca²⁺, Na⁺, and [Formula: see text] supports the weathering and dissolution of fluoride-rich minerals for high F^- content in groundwater. They were further supported by a principal component analysis. The Health Risk Index (HRI) values ranged from 0.20 to 20.10 and 0.36 to 30.90 with a mean of 2.82 and 4.34 for adults and children, respectively. The mean intensity of HRI (> 1.0) was 1.37 times higher in children (5.70) than in adults (4.16) due to the differences in weight size and exposure time. With an acceptable limit of more than 1.0, the study divided the region into Northern Safe Health Zone (33.3% for adults and 28.1% for children) and Southern Unsafe Health Zone (66.7% for adults and 71.9% for children) based on the intensity of agricultural activity. Therefore, effective strategic measures such as safe drinking water, denitrification, defluoridation, rainwater harvesting techniques, sanitary facilities, and chemical fertilizer restrictions are recommended to improve human health and protect groundwater resources.

Bioaccumulation of Fluoride in Plants and Its Microbially Assisted Remediation: A Review of Biological Processes and Technological Performance

Fluoride is widely found in soil–water systems due to anthropogenic and geogenic activities that affect millions worldwide. Fluoride ingestion results in chronic and acute toxicity, including skeletal and dental fluorosis, neurological damage, and bone softening in humans. Therefore, this review paper summarizes biological processes for fluoride remediation, i.e., bioaccumulation in plants and microbially assisted systems. Bioremediation approaches for fluoride removal have recently gained prominence in removing fluoride ions. Plants are vulnerable to fluoride accumulation in soil, and their growth and development can be negatively affected, even with low fluoride content in the soil. The microbial bioremediation processes involve bioaccumulation, biotransformation, and biosorption. Bacterial, fungal, and algal biomass are ecologically efficient bioremediators. Most bioremediation techniques are laboratory-scale based on contaminated solutions; however, treatment of fluoride-contaminated wastewater at an industrial scale is yet to be investigated. Therefore, this review recommends the practical applicability and sustainability of microbial bioremediation of fluoride in different environments.

Meta-analysis and risk assessment of fluoride contamination in groundwater

This study aimed to carry out a systematic review of meta-analysis and risk assessment of the global pooled concentration of fluoride and identify the influencing factors of fluoride loads in groundwater. The study extracted data from 36 most prevalent regions of 20 countries in the world through various search engines using keywords as well as Boolean operators and follows the PRISMA statement in every phase of literature searching. The study illustrated the pooled concentration of fluoride in the selected 20 countries was 2.1267 mg/L (1.650, 2.604) at 95% confidence interval, which was higher than the WHO standards limit of 1.5 mg/L. The results of the meta-analysis suggested that pH, Na, HCO₃ and rainfall was significantly positively correlated (r = ~0.4; p ˂ 0.05) to fluoride and has a weak correction with the other parameters such as local temperature, altitude, water depth, EC, Ca, and Mg (r = -0.064 to +0.214; p ˂ 0.05). Concerning, the risk assessment through oral and dermal route exposure revealed that the consumers in most of the regions were at considerable risk, and the children were more vulnerable than the adults (THQ > 1). The study findings would help to take measures for safe water supply in the affected areas. PRACTITIONER POINTS: The calculated pooled concentration of fluoride was 2.1267 mg/L (1.650, 2.604) at 95% CI in groundwater of the study areas. Climatic conditions and lithological composition are the key controlling factors for groundwater fluoride contamination. Semi-arid and arid regions are significantly affected by fluoride rather than humid areas. Regarding fluorosis in selected regions, children (78%) are more vulnerable than adults (23%).

Health risks associated with fluoride intake from rural drinking water supply and inverse mass balance modeling to decipher hydrogeochemical processes in Vattamalaikarai River basin, South India

Preliminary investigation reveals that fluorosis is reported due to the continuous intake of fluoride-rich groundwater in Vattamalikarai River basin, Tamil Nadu, India. A detailed study was attempted for evaluating the health risks associated with the intake of fluoride-rich groundwater supplied to the rural community. Groundwater samples were collected from 60 and 58 dug and tube wells during winter and southwest (SW) monsoon seasons respectively. The samples were analyzed for the determination of fluoride and other chemical parameters to examine the fitness for drinking water. Spatio-temporal variation maps reveal that fluoride concentration is high during SW monsoon season when compared with the winter season in this region. The fluoride bearing minerals present in hornblende-biotite gneiss and charnockite rock formations leached into the groundwater during rock-water interaction. To understand the subsurface hydrogeochemical reactions, inverse mass balance model was developed using NETPATH code. The model output indicates that calcite dilution, silicate (hornblende and biotite) weathering, ion exchange (Ca/Na and Mg/Na) and illite precipitation are the dominant processes controlling the groundwater chemistry along the flow paths. Non-carcinogenic risks to children and adults (women and men) were evaluated by working out intake exposure of groundwater. Hazard quotient (HQ) based on fluoride intake was calculated for children and adults. It varied from 0.08 to 2.21 with an average of 1.07 for adults. For children, it varied from 0.01 to 2.99 with the mean of 1.44. About 78%, 69% and 61% of the samples fall under the risk category for children, women and men during winter season. However, more number of samples possessed health risks (83% of samples for children, 73% of samples for women and 64% of samples for men) during SW monsoon season.

Geochemical evaluation of fluoride contamination in groundwater from Shanmuganadhi River basin, South India: implication on human health

In order to assess the geochemical mechanism liable for fluoride contamination in groundwater and its health effects on the people of the Shanmuganadhi River basin, Tamil Nadu, India, 61 groundwater samples were collected during post- and pre-monsoon seasons from the wells used for drinking purposes. Collected samples were analysed for various physico-chemical parameters. The parameters estimated in the present study are hydrogen ion concentration (pH), total dissolved solids, electrical conductivity, calcium (Ca²⁺), magnesium (Mg²⁺), sodium (Na⁺), potassium (K⁺), bicarbonate (HCO₃^-), chloride (Cl^-), sulphate (SO₄^2-), nitrate (NO₃^-), phosphate (PO₄^3-) and fluoride (F^-). The fluoride ion concentration in the groundwater samples of this region varied from 0.01 to 2.50 mg/l and 0.01 to 3.30 mg/l during post- and pre-monsoon seasons, respectively. Out of 61 groundwater samples, 14 samples of post-monsoon season and 16 samples of pre-monsoon season represented high, very high and extremely high classes of fluoride, which cause dental fluorosis in this region. The fluoride-bearing minerals in the granitic and gneissic rocks such as apatite, hornblende, muscovite, biotite and amphiboles are the major sources for fluoride contamination in this area. In addition to the geogenic sources, applications of synthetic fertilizers in the agricultural fields also contribute significant amount of fluoride ions to groundwater. The spatial distribution of fluoride in different geological formations clearly indicate that the wells located in charnockite terrain were possessing very low fluoride concentration when compare with the wells located in the hornblende-biotite gneiss formation. Therefore, dental fluorosis risks are mostly associated with rock types in this region. People living over the basement rock comprising of hornblende-biotite gneiss are prone for fluorosis. Fluoride exhibited good positive correlation with bicarbonate in groundwater. As fluoridated endemic regions normally acquire lot of bicarbonate in groundwater samples, Shanmuganadhi basin falls under fluoride endemic category. The present study identified 26 villages in Shanmuganadhi basin as probable fluorosis risk areas where attention should be given to treat the fluoride-rich groundwater before drinking water supply. The groundwater level fluctuation study also designates that rise in water level reduces the concentration of fluoride due to dilution mechanism. Therefore, recharge of groundwater by artificial methods will definitely improve the present scenario.

Groundwater fluoride contamination, probable release, and containment mechanisms: a review on Indian context

Fluoride contamination in the groundwater has got great attention in last few decades due to their toxicity, persistent capacity and accumulation in human bodies. There are several sources of fluoride in the environment and different pathways to enter in the drinking water resources, which is responsible for potential effect on human health. Presence of high concentration of fluoride ion in groundwater is a major issue and it makes the water unsuitable for drinking purpose. Availability of fluoride in groundwater indicates various geochemical processes and subsurface contamination of a particular area. Fluoride-bearing aquifers, geological factors, rate of weathering, ion-exchange reaction, residence time and leaching of subsurface contaminants are major responsible factors for availability of fluoride in groundwater. In India, several studies have reported that the groundwater of several states are contaminated with high fluoride. The undesirable level of fluoride in groundwater is one of the most natural groundwater quality problem, which affects large portion of arid and semiarid regions of India. Rajasthan, Andhra Pradesh, Telangana, Tamil Nadu, Gujarat, and West Bengal are the relatively high-fluoride-contaminated states in India. Chronic ingestion of high doses of fluoride-rich water leads to fluorosis on human and animal. Over 66 million Indian populations are at risk due to excess fluoride-contaminated water. Therefore, groundwater contamination subject to undesirable level of fluoride needs urgent attention to understand the role of geochemistry, hydrogeology and climatic factors along with anthropogenic inputs in fluoride pollution.

Distribution and health risk assessment of natural fluoride of drinking groundwater resources of Isfahan, Iran, using GIS

Fluoride (F) contamination in groundwater can be problematic to human health. This study evaluated the concentration of fluoride in groundwater resources of Isfahan Province, the central plateau of Iran, and its related health issues to the inhabitant populations. For this purpose, 573 drinking groundwater samples were analyzed in 2016 by using the spectrophotometric method. Non-carcinogenic health risks due to F exposure through consumption of drinking water were assessed using the US EPA method. In addition, the associated zoning maps of the obtained results were presented using geographic information system (GIS). The results indicated that F content in drinking water ranged from 0.02 to 2.8 mg/L. The F contents were less than 0.50 mg/L in 63% of the drinking groundwater samples, 0.51-1.5 mg/L in 33.15%, and higher than 1.5 mg/L in 3.85% (Iran and World Health Organization guidelines) of the drinking groundwater samples. The F levels in the west and the south groundwater resources of the study areas were lower than 0.5 mg/L, which is within the recommended values for controlling dental caries (0.50-1.0 mg/L). Therefore, these places require more attention and more research is needed to increase F intake for health benefit. The HQ index for children, teens and male and female adults had health hazards (HQ > 1) in 51, 17, 28, and 18 of samples, respectively. Groundwater resources having a risk of more than one were located in the counties of Nayin, Natanz, and Ardestan. So, in these areas, there are potential risks of dental fluorosis. The most vulnerable groups were children. The F levels must be reduced in this region to decrease endemic fluorosis.

Variation in Groundwater Quality with Seasonal Fluctuation in Jharia Coal Mine Region, Jharkhand, India

Jharia coal mining areas is one of the most important coal mining areas in India. It is roughly elliptical or sickles – shaped, located in Dhanbad district of Jharkhand. For the assessment of groundwater quality, Twenty Nine groundwater samples were collected from Jharia coalfield. The pH of the analysed water samples is slightly acidic to slightly alkaline in nature in both the season. The quality assessment of groundwater shows that in general, the water is suitable for domestic purposes with some exceptions. In majority of the samples, the analyzed parameters are well within the desirable limits and water is potable for drinking purposes. However, concentrations of EC, TDS, TH, SO42-, Na+, Ca2+ and Mg2+exceed the desirable limit at few sites. The water level fluctuation shows in the study area for year 2013 is 1.29 to 6.9 mbgl. West and some part of the northern area are facing extreme scarcity due to lower availability of groundwater resource. However, eastern region of the study area has sufficiently available of groundwater resources in the Jharia coalfield. This study is useful for utilization of groundwater resources in mining area and helps in future water resource planning for the area.

A study to investigate fluoride contamination and fluoride exposure dose assessment in lateritic zones of West Bengal, India

To assess the status of severity of fluoride contamination in lateritic Bankura and Purulia districts of West Bengal, concentrations of fluoride in different water sources and agricultural field soils were investigated. The fluoride content (mg/l) was observed to differ with aquifer depths: 0.19-0.47 in dug wells, 0.01-0.17 in shallow tube wells, and 0.07-1.6 in deep tube wells. Fluoride within the World Health Organization (WHO) prescribed range (1.0-1.5 mg/l) was estimated only in ~17% of the total collected water samples while ~67% showed <0.7 mg/l fluoride and thus may impede in the production and maintenance of healthy teeth and bones of the residents, especially children. Fluoride in water was found to be significantly correlated (r = 0.63) with pH. The exposure dose of fluoride (mg/kg/day) from drinking water in infants, children, and adults was estimated in the ranges 0.02-0.53, 0.01-0.24, and 0.01-0.14, respectively against the standard value of 0.05. A clear risk of dental fluorosis is apparent in infants and children of the study area. The fluoride in soil (55-399 mg/kg) was detected to be significantly correlated with the fluoride content in deep tube wells and soil pH (r = 0.56 and 0.71, respectively). The relationships of soil fluoride with total hardness and that with phosphate were not significant. There is a high possibility of bioaccumulation of fluoride from contaminated soil and water of the study area to cultivated crops. This will enhance the quantity of fluoride intake into human food chain in addition to drinking water pathway.

Characterization of fluoride-tolerant halophilic Bacillus flexus NM25 (HQ875778) isolated from fluoride-affected soil in Birbhum District, West Bengal, India

A new Gram-positive, nonpigmented, rod-shaped fluoride-tolerant bacterial strain, NM25, was isolated from waterlogged muddy field soil collected from the fluoride endemic area of Rampurhat II block (average fluoride in water, 4.7 mg/l, and in soil, 1.5 mg/kg) in Birbhum District, West Bengal, India. The study was undertaken to characterize the fluoride-tolerant bacterial isolate, to determine its role in bioaccumulation of fluoride, and to analyze the water and soil quality of the bacterial environment. The isolate was positive for catalase, lipase, urease, protease, oxidase, and H2S production, but negative for indole production, nitrate reduction, and Vogues-Proskauer test. The organisms were sensitive to recommended doses of ofloxacin, kanamycin, rifampicin, levofloxacin, vancomycin, gatifloxacin, gentamicin, doxycycline, streptomycin, and nalidixic acid but resistant to ampicillin. Based on the phenotypic characteristics, 16S rRNA gene sequence, and phylogenetic analysis, the bacterial isolate NM25 was identified as Bacillus flexus. The G+C content of the 16S rDNA was 53.14 mol%. This strain tolerated up to 20% (w/v) NaCl in nutrient agar medium and was grown at the pH range 4-12. It reduced fluoride concentration up to 67.45% and tolerated more than 1,500 ppm of fluoride in brain-heart infusion agar medium.

Geological sources of fluoride and acceptable intake of fluoride in an endemic fluorosis area, southern Iran

The present study is the first attempt to put forward possible source(s) of fluoride in the Dashtestan area, Bushehr Province, southern Iran. In response to reports on the high incidence of dental fluorosis, 35 surface and groundwater samples were collected and analysed for fluoride. The results indicate that dissolved fluoride in the study area is above the maximum permissible limit recommended by the World Health Organization (WHO). An additional 35 soil and rock samples were also collected and analysed for fluoride, and rock samples were subjected to petrographic investigations and X-ray diffraction. The results of these analyses show that the most likely source for fluoride in the groundwater is from clay minerals (chlorite) and micas (muscovite, sericite, and biotite) in the soils and rocks in the area. We also note that due to the high average temperatures all year round and excessive water consumption in the area, the optimum fluoride dose level should be lower than that recommended by the WHO.

Assessment of fluoride contamination in groundwater as precursor for electrocoagulation

The Present study was conducted in January 2010, in order to assess the fluoride contamination in the Thirupathur Taluk. The major objective of this study was to locate the vulnerable areas in terms of fluoride contamination. The range of fluoride concentration varied between .26 and 2.75 mg/L. 60 % of the samples were above the permissible limit. Good correlation was observed between pH, Na, HCO(3), CO(3) TDS and NO(3). A negative correlation showed by Ca and K. The results show that Geochemistry of these ions controls the Fluoride concentration in the study area. All the samples exceeded the permissible limit of F was characterized by Na-HCO(3) type of water. A fairly good correlation between F and NO(3) suggest an anthropogenic input of F, mainly from the agricultural fields. Spatial distribution map of Fluoride shows very high concentration in the SW part of the study area.

Geochemical modeling of high fluoride concentration in groundwater of Pokhran area of Rajasthan, India

The groundwater is the only major source of drinking water in western part of Rajasthan, India. The study was carried out to locate and decipher hydrogeochemical reactions responsible for elevated concentration of fluoride. The concentration of fluoride ranged from 0.6 to 4.74 ppm in groundwater of study area. Since the area is a desertic terrain and no industries are present thus possibility of anthropogenic input of fluoride is all most negligible thus the enrichment of fluoride in groundwater is only possible due to rock-water interaction. The highly alkaline conditions indicated fluorite dissolution as major process responsible for high concentration of fluoride in Pokhran.

Dose-dependent Na and Ca in fluoride-rich drinking water--another major cause of chronic renal failure in tropical arid regions

Endemic occurrence of chronic kidney disease with unknown etiology is reported in certain parts of the north central dry zone of Sri Lanka and has become a new and emerging health issue. The disease exclusively occurs in settlements where groundwater is the main source of drinking water and is more common among low socio-economic groups, particularly among the farming community. Due to its remarkable geographic distribution and histopathological evidence, the disease is believed to be an environmentally induced problem. This paper describes a detailed hydrogeochemical study that has been carried out covering endemic and non-endemic regions. Higher fluoride levels are common in drinking water from both affected and non-affected regions, whereas Ca-bicarbonate type water is more common in the affected regions. In terms of the geochemical composition of drinking water, affected households were rather similar to control regions, but there is a large variation in the Na/Ca ratio within each of the two groups. Fluoride as shown in this study causes renal tubular damage. However it does not act alone and in certain instances it is even cytoprotective. The fine dividing line between cytotoxicity and cytoprotectivity of fluoride appears to be the effect of Ca(2+) and Na(+) of the ingested water on the F(-) metabolism. This study illustrates a third major cause (the other two being hypertension and diabetes) of chronic kidney diseases notably in tropical arid regions such as the dry zone of Sri Lanka.