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MILITARY INSTITUTE OF

SCIENCE AND TECHNOLOGY


Seminar Report
NSE6001

Submitter By:
Fahmida Haque
ID: 1015280012
M.Sc. In NSE
Department of Nuclear Science and Engineering
Military Institute of Science and Technology (MIST)
Date of Submission: 30-July-2016

Water Treatment Plant


Introduction
Clean, safe water is vital for everyday life. Water is essential for health, hygiene and the productivity of our
community. Water treatment is any process that makes water more acceptable for a specific end-use. The end
user may be drinking, industrial water supply, irrigation, river flow maintenance, water recreation or many other
uses including being safely returned to the environment. Water treatment removes contaminants or reduces their
concentration so that the water becomes fit for its desired end-use; A Water Treatment Plant aims to ensure that
water is:
Safe for human consumption
Pleasant to consumers
Provided at a reasonable cost
Water Treatment Plants have many processes and steps before a household turns on their tap and receives water.
From the dam to the tap there is a vigorous process with many steps that are all essential in assuring high quality
water for drinking.
Treatment of water is so important that we can avoid many possible water borne diseases like cholera, typhoid,
jaundice and so on. It's true that water borne infections are responsible for more than 80% of the diseases in all
over the world. Whenever there is contamination of drinking water sources and water logging after rain there is
in an outbreak of infection.
Water may be treated differently in different communities depending on the quality of the water which enters the
plant. Groundwater is water located underground and typically requires less treatment than water from lakes,
rivers, and streams. These lakes, rivers and streams water we purified by processing with some plants. Though
the water treatment process may vary slightly at different locations, depending on the technology of the plant and
the water it needs to process, the basic principles are largely the same. This section describes standard water
treatment processes.

Literature Review
The first references to clean water or sweet water and for water to be good for use after passage over a certain
number of stones date back about 3000 years to Biblical times. The Roman aqueducts are well-known later
landmarks in Europe as testimony of conveying clean water to cities. By the eighteenth century the removal of
particles from water by filtration was known as an effective way of clarifying water and the first municipal water
filtration plant started operating in Scotland in 1832. However, the main objective at that time was simply to
supply clear water because the germ theory and the knowledge that diseases could be spread by water were still
unknown. It was only in 1855 that Dr John Snow, an epidemiologist showed empirically that a cholera outbreak
in London was caused by drinking water contaminated by faucal wastes from a cholera patient. However, the
concept of disinfection as a disease preventing measure and a practical disinfection process only developed much
later. Pasteur demonstrated his germ theory only in the 1880s and chlorination as treatment process was
developed after 1905.
By the early 1900s the large increase in the number of water supply systems without proper treatment in the
USA contributed to major outbreaks in water-borne diseases. However, it was only with the introduction of
chlorine as a treatment process to disinfect water in 1908 that the spreading of diseases through contaminated
water could be controlled. Chlorination was rapidly accepted as an essential part of water treatment and this
resulted in a substantial decline in the number of deaths due to water-borne diseases.
Research on coagulation-flocculation, sedimentation and filtration as basic water treatment processes during the
early part of the previous century contributed to a better understanding of these processes and much improved
performance. New processes were also developed during that time in Europe. The use of ozone for disinfection
and taste- and color enhancement was introduced early in the century in France and Germany.

The most significant process development since the introduction of chlorine during the previous century was the
development of synthetic membranes as treatment process. The first practical reverse osmosis membranes for the
desalination of seawater were developed in the 1960s. Later, other types of membranes were developed,
including nanofiltration (NF), ultrafiltration (UF) and microfiltration (MF) membranes. These membranes find
application in water treatment other than just desalination. For example, NF and UF membranes are used to
replace some conventional treatment processes for removal of natural organic substances and micro-organisms
from water.
In South Africa water treatment and supply followed the pattern of the western world and in some aspects South
Africa actually lead the way. For example, the concepts of water reclamation and reuse were pioneered in South
Africa and Namibia. South Africa is also known as a world leader in the field of biological nutrient removal in
advanced wastewater treatment.
Sadly, the supply of clean and safe water in South Africa was until recently limited to formal municipalities.
Most rural areas and many townships had no (or limited) water supply and poor sanitation. In many rural areas
in the country water is abstracted from a river, stream, borehole or well and consumed without any treatment or
with only limited treatment. In these situations, the health of consumers is often at risk. Often the erection of a
conventional treatment plant and the effective running of such processes may not be possible in many rural areas
and alternative approaches have to be followed.
The situation with respect to water supply has however, improved dramatically over the last number of years and
it is a clear objective of government (and it is stated as a basic human right in the RSA Constitution) that every
citizen must have access to clean water and basic sanitation. Many ambitious programmers are currently under
way for water supply and sanitation in previously disadvantaged communities and in rural areas.
The result of these developments is that the need for engineers and trained operators and process controllers has
increased and special efforts are needed to provide appropriately trained people at all levels in the water
treatment and supply industry.
The main challenges facing the water industry today include:
Deterioration in the quality of many raw water sources
Removal of potentially harmful synthetic organic substances in water sources
Removal of resistant micro-organisms from water
Improved training of process controllers for new processes and process optimization

Demands for process integration and flexibility

Necessity of Water Treatment


Treatment of water is very important for us. Naturally the waters we found form different water resources are not
always pure and it contains many dissolved and suspended impurities. So to remove impurities we need to go for
water treatment. We need water treatment:
Removing dissolved and suspended impurities (chemicals, sand particles, organic matter,
microorganisms and minerals).
Removing Alkalinity and Hardness from Water.
Maintaining Low BOD (Biochemical oxygen demand) and Low COD (Chemical Oxygen Demand) for
sewage, Industrial Sewage and sea water treatment.

Avoiding many possible water borne diseases like cholera, typhoid, jaundice and so on.

Water Quality
General aspects of water quality
Water is a unique substance and one of its unique characteristics is its capacity to dissolve a variety of
substances. As water moves through its cycle, called the hydrological cycle, comprising of rainfall, runoff,
infiltration, impounding, use and evaporation, it comes into contact with many different substances that may be
dissolved by the water to a greater or lesser extent or that may be suspended in the water. The type and amount of
the dissolved substances together with suspended and colloidal substances (very small suspended particles)
collectively determine the overall quality of the water and its fitness for domestic use.
The types of contaminants or substances of concern that may occur in water sources vary over a wide spectrum
and include inorganic salts, micro-organisms, clay particles and organic material. Those with similar
characteristics that can be treated by the same type of treatment process are normally grouped together for design
purposes and for general discussion. It is normally not possible to consider each individual substance of concern
with the view to treatment. There are exceptions; however, for example the removal of a toxic substance from
water is often specific for the particular substance.
The kind of treatment water needs strongly depends upon the composition and quality of the water. Now the
Water quality depends to the four indicators:

Chemical Indicators (pH, Biochemical oxygen demand (BOD), Chemical oxygen demand (COD),
Dissolved oxygen (DO), Total hardness (TH) etc.)

Physical Indicators (Water Temperature, Conductivity, Odor, Color, Taste of water, etc)

Biological Indicators (Biological contamination results from disease-producing organisms )

Radiological Indicators (Radiological contamination results from the mining and the use of radioactive materials.)

Research Methodology:

OVERVIEW OF WATER TREATMENT PROCESSES

The principal objective of a water treatment plant is to produce water that is fit for domestic use at a reasonable
cost. Many treatment processes (sometimes called unit processes and unit operations) are linked together to form
a treatment plant in order to produce water of the desired quality. The main factors that must be taken into
account when developing a treatment process train include:
The source water quality (normally referred to as the raw water quality)

The seasonal (and other) variations in the raw water quality


The required treated water quality
Regulatory requirements
Other factors such as plant size (capacity), site conditions, availability of skilled labour, degree
of automation required, economics and many other factors.

Figure 1: Schematic diagram of a general water treatment plant.


Water Treatment Plants have many processes and steps before a household turns on their tap and receives water.
From the dam to the tap there is a vigorous process with many steps that are all essential in assuring high quality
water for drinking. The seven major steps in the treatment of our water are:

Raw Water Intake

Water is drawn into the plant via the use of pumps from the river or lake through large metal grills
called screens and trash racks. These block large objects such as wood, leaves and other forms of debris
from entering the treatment plant along with the water.
Coagulation-Flocculation
The first step toward water treatment is the Coagulation-Flocculation .

Coagulation
It is at this stage the chemicals Alum or Aluminum Sulphate (a coagulant), liquid polymer (a flocculent) and
chlorine (disinfectant) are first introduced. The headwork is designed to ensure rapid mixing and uniform
distribution of the chemicals with the raw water. The Alum reacts rapidly with the waters alkalinity to produce a
gelatinous (jelly-like) precipitate of Aluminum Hydroxide called microfloc that entraps and absorbs impurities.
The liquid polymer aids coagulation by enlarging the floc particles through bridging. Chlorine is sometimes
added at the headwork to prevent algae growth on the wall of the flocculation and sedimentation basins.
Aluminium sulphate, or alum, Hydrate Lime, Ferric Chloride are the commonly used Coagulant.

Figure 2: Coagulation process


Flocculation
Flocculation is the operation in which the coagulated water must be gently mixed to promote the growth of larger
and heavier floc at a faster rate. The design of the flocculation basin facilitates the gentle, constant mixing of the
microfloc formed during coagulation. This stirring promotes contact and the formation of larger and heavier floc
at a faster rate.

Figure 3: Flocculation process


Sedimentation
Sedimentation involves the removal of solids from water by gravity settling.
Water flow is greatly reduced allowing the heavy floc to settle to the bottom of the basin where it is referred to as
sludge.
Sedimentation involves the removal of solids from water by gravity settling. Water flow is greatly reduced
allowing the heavy floc to settle to the bottom of the basin where it is referred to as sludge. This sludge is
channeled to sludge lagoons where further settling takes place. Supernatant water from the lagoons is then
returned to the headworks.

Figure 4: Sedimentation process


In general, clarification may be classified as four types based on the concentration of particles and their ability to
interact.
Type 1 Clarification occurs in a dilute suspension when discrete particles that resist flocculation settle
individually and exhibit no interactions. An example of Type 1 clarification is the pre-sedimentation of sand.
Type II Clarification involves the removal of a dilute suspension of particles that are known to flocculate during
settling. An example of Type II clarification is the settling of chemically flocculated waters in which particles
continue to increase in size as they interact and settle at a faster velocity.
Type III Clarification usually refers to hindered or zone settling and occurs when sludge concentrations at about
500 mg/l. Inter-particle electromagnetic forces hinder the settling of neighboring particles forming a mass that
settles as a blanket. This inter-particle electromagnetic force is the result of similarly charged particles repelling

each other. A distinct interface is evident between the settling sludge and the supernatant. An example of Type III
clarification would occur in concentrated suspensions of flocculated material at an intermediate depth in a
clarifier.
Type IV Clarification occurs at the bottom of a sedimentation basin where settling occurs by the slow
compression of the settled sludge. This process is also known as .compression settling.

Filtration
After leaving the sedimentation basin, the water is then filtered. This facilitates the final and complete removal of
any finely divided suspended matter, plus any floc carryover that remain after the coagulation and sedimentation
processes. The filtration system is a monotype constant rate gravity filter system. The filter media consist of six
feet of sand. Periodic backwashing of the filters is required to remove any accumulated suspended materials.
Often, the particles generated by the precipitation reactions described above are too small to settle efficiently by
sedimentation. One strategy that is frequently employed to remove these solids is gravity filtration. In this
process, water containing solid impurities (e.g., precipitates from water softening) is passed through a porous
medium, typically layers of sand and gravel. The force of gravity is used to push the water through the medium.
The small water molecules pass through the holes between sand and gravel pieces. However, the solids (from
precipitation) get stuck in the holes, and are thus retained in the porous medium. The water that passes through
the bottom of the filter no longer contains those solid impurities. The filtration system is a monotype constant
rate gravity filter system. The filter media consist of six feet of sand. Periodic backwashing of the filters is
required to remove any accumulated suspended materials.

Figure 5: Multi-layer Filtration process


Gravity filters at water-treatment plants have a pipe feeding into the under drain, the bottom layer where the
clean water is collected. By adding water to the filter through this pipe, clean water can be forced upward
through the filter to remove the solids that have collected in the filter. This process is used to clean the filter.

Disinfection
In many water supplies, the most serious health threats are posed not by chemicals, but by infectious organisms
(bacteria) in the water. Chlorine (Cl 2) is a major disinfectant that is cheap and kills most of the serious diseasecausing bacteria in the water. However, chlorine disinfection results in a wide variety of by-products. One class
of chlorination by-products, known as trihalomethanes (THM's), are suspected carcinogens. Because of concern
about these by-products in the water supply, chlorine is now kept to minimum levels, and other methods of
disinfection are being used more frequently. Chloramines form more stable disinfectants and pose less risk of
harmful by-products, but cost more to use. Other methods focus on removing the organisms through coagulation,
sedimentation, and improved filtration.
Other disinfectants include ozone, chlorine dioxide and other chlorine compounds such as calcium hypochlorite
(HTH), sodium hypochlorite (bleach) and monochloramine.

Disinfection by means of ultra-violet (UV) irradiation is becoming more and more popular because no byproducts are formed in the process. UV radiation kills or inactivates micro-organisms provided each organism
receives a minimum amount of irradiation.
Ozone is a very powerful disinfectant. The concentration and reaction times are substantially lower than those
required for free chlorine. Because of its extreme reactivity, ozone gas must be produced onsite. It is a product of
the action of electrical fields on oxygen ozone is transferred from the gas phase into the water by injecting at the
bottom of the water tank where it is free to react with the contaminants.

Sludge Drying treatment and disposal


Sludge from a sedimentation tank has a large pollution potential because it contains all the suspended material
removed from the water together with the chemicals used for coagulation. It must therefore be disposed of in a
proper manner to prevent contamination of water sources.
The sludge is withdrawn from the sedimentation tank in a diluted form (2-5% m/v solids) and is sometimes
thickened (excess water removed) before disposal.

Figure 6: Sludge disposal process.


At smaller treatment works sludge is disposed of in sludge lagoons. The lagoons are large holding dams in which
the sludge compacts and clear water accumulates on top of the sludge. The clear water may be recycled to the
inlet of the plant. Water from the backwashing of sand filters have similar characteristics (although much more
dilute) and must be treated and disposed of in the same manner as sludge from sedimentation tanks. In trucked
communities, three methods for disposal are available:
Direct discharge to the sewage treatment facility;
Co-disposal in the modified landfill; or
Landfilling in a mono-fill facility.
Choice of any one of these alternatives depends on the cost of operation, the leachability of the alum sludge, and
the approval of the regulatory authority.

Fluoridation
Fluoride is added to drinking water (fluoridation) in some Plants to reduce tooth decay. Fluoridated water has
fluoride at a level that is effective for preventing cavities; this can occur naturally or by adding fluoride.
Fluoridation does not affect the appearance, taste, or smell of drinking water. It is normally accomplished by
adding one of three compounds to the water: sodium fluoride, fluorosilicic acid, or sodium fluorosilicate. But
this is controversial process. For several decades, fluoride has been added to water in efforts to prevent tooth
decay. This in many areas is accepted as fact, and to not fluoridate water would be an obstruction to public
health. However, many are rethinking the safety and success of such measures. Perhaps before any definite
decisions are made regarding fluoride, we should investigate what pros and cons exist with water fluoridation.

It may also increase bone density, but it does not decrease fracture risk [Source: Banting]. In fact, fluoride may
actually weaken the bones [Source: Limeback, Phipps]. Fluoride is also known to cause a cosmetically damaging
effect called fluorosis, a staining of the teeth that experts say does not attribute to any physical problems. The
National Institutes of Mental Health did suggest that fluoride damaged teeth may cause psychological and
behavioral problems [Source: Coffel]. This problem has a significantly higher rate of occurrence if fluoride
supplements are used in the first six months of life [Source: Pendrys]. Fluoride may affect dietary allergies and
protein digestion and intolerance [Source: Butler]. Fluoride has also been linked to symptoms of stomach pain
and indigestion [Source: Gupta]. Unfortunately, this means that many people may be experiencing digestive
problems due to fluoride and have no idea what the problem is. This leads to further medication and doctor visits
to treat symptoms while the underlying problem persists. Fluoride may also damage joints, connective tissue, the
brain and the testicles [Source: Navak, Giachini].

Desalination
Desalination is a process that removes minerals and salts from saline water to produce fresh water.
The Reverse Osmosis Process is generally used for desalination of Sea water treatment and Brackish Water
treatment for its conversion into pure water. Desalination/distillation is one of mankind's earliest forms of water
treatment, and it is still a popular treatment solution throughout the world today. In ancient times, many
civilizations used this process on their ships to convert sea water into drinking water. Today, desalination plants
are used to convert sea water to drinking water on ships and in many arid regions of the world, and to treat water
in other areas that is fouled by natural and unnatural contaminants. Distillation is perhaps the one water treatment
technology that most completely reduces the widest range of drinking water contaminants .

Figure 7: Desalination process


MEMBRANE FILTRATION
Membrane filtration is a relatively new water technology with respect to municipal water treatment. Membrane
filtration can replace the clarification, coagulation and flocculation steps of the water treatment process. Also,
depending on the pore size of membrane, filtration can replace the initial disinfection step as well. Note that
chlorination will always be required in order to maintain disinfection beyond the water treatment plant.
Membrane filters typically consist of series of hollow polymer tubes inserted into the water. A vacuum process
sucks the water through the pores on the sides of tubes, removing the particles larger than the pore size. The
filtered water usually proceeds to the disinfection step, while the dirty water containing the filtered solids is

back-flushed from the system. This is a typical membrane process; however, the process depends on the
type and manufacturer of the membranes used.
The figure below, taken from the EPA Membrane Filtration Guidance Manual, illustrates the ability of each type
of membrane process to remove various drinking water pathogens and provides the filtration size range of each
process.

Figure 8: Different types of membrane filtration process.


Microfiltration
Microfiltration only removes bacteria and cysts, but not viruses, it is not suitable as a disinfection step, but rather
its main use is in particulate removal.

Ultrafiltration
Ultrafiltration can be classified as both a clarification and initial disinfection step since it will remove all
microorganisms. Chlorination will still be required in order to maintain a residual.

Nanofiltration
Nanofiltration is designed to remove multivalent cations such as calcium, iron and magnesium as well as
disinfection and clarification. Chlorination will still be required in order to maintain a residual.

Nanofiltration
Nanofiltration is a replacement for conventional iron and manganese removal methods such as greensand
filtration.

Reverse Osmosis (RO)


Reverse osmosis process involves water being forced under pressure (Osmotic Pressure) through a semi
permeable membrane. The membrane allows the water molecules to pass through, while blocking up to 99% of
the contamination. The main application of Reverse osmosis (RO) is to remove dissolved substances, including
ions such as Na+ and Cl- from solution. RO is a general desalination process being used to desalinate seawater,
brackish water and high-TDS effluents. The membranes are continuous in the sense that they do not have any
pores. The smallest size of dissolved ions and organics that can be removed by RO is in the order of 0.1 nm
(nanometer), which is equal to 0.0001 micrometer, or 0.0000001 mm. RO therefore removes all particulate
matter including all bacteria and viruses, all organic macromolecules and most organic molecules with molecular
mass of larger than about 150 Daltons (mol mass units). RO therefore produces product water of extremely good
quality.

Figure 9: Reverse osmosis process

Distillation
Distillation of salt solution can be used to obtain very pure water by involving the evaporation of water. The
water boils off leaving any dissolved substances behind as a solid residue. The steam is condensed to give pretty
pure water.
Distillation is a water purification process that uses a heat source to vaporize water and separate it from
contaminants and other undesirable elements commonly found in ground and surface water. Distillation heats
raw (untreated) water until the water reaches its boiling point and begins to vaporize. The heat is then kept at a
constant temperature to maintain water vaporization while prohibiting other undesirable elements from
vaporizing. Water has a lower boiling point than salt and other mineral sediments. This process also separates the
water molecules from microscopic, disease-causing organisms. Once all of the water has vaporized, the vapor is
led into a condenser, where, upon cooling, the water reverts to the liquid form and runs into a receiving
container. The remaining elements, whose boiling point was too high to permit vaporization, remain in the
original container and constitute the sediment (Holland, Siqueiros, Santoyo, Heard, & Santoyo, 1999). Because
the distillation process can never ensure a complete separation between water and other materials, it is often
repeated one or more times with the treated water. Many alcoholic beverages, like brandy, gin, and whiskey, are
distilled, using an apparatus similar in constitution to the water distillation apparatus.

Figure 10: Distillation process

pH correction
Distilled water has a pH of 7 (neither alkaline nor acidic) and sea water has an average pH of 8.3 (slightly
alkaline). If the water is acidic (lower than 7), lime, soda ash, or sodium hydroxide is added to raise the pH. For
somewhat acidic waters (lower than 6.5), forced draft degasifies are the cheapest way to raise the pH, as the
process raises the pH by stripping dissolved carbon dioxide (carbonic acid) from the water.

Figure 11: pH Scale


Lime is commonly used for pH adjustment for municipal water, or at the start of a treatment plant for process
water, as it is cheap, but it also increases the ionic load by raising the water hardness. Making the water slightly
alkaline ensures that coagulation and flocculation processes work effectively and also helps to minimize the risk
of lead being dissolved from lead pipes and lead solder in pipe fittings. Acid (HCl or H2SO4) may be added to
alkaline waters in some circumstances to lower the pH. Having alkaline water does not necessarily mean that
lead or copper from the plumbing system will not be dissolved into the water but as a generality, water with a pH
above 7 is much less likely to dissolve heavy metals than water with a pH below 7. The simplified pH
adjustment system is shown below. An actual system will be far more complex and detailed. In the system shown
above there are a treatment tank, mixer, acid and caustic metering pumps and a pH probe with a controller. The
influent flow enters the tank at the bottom and exits the tank, through a distant port at the top. The objective with
port placement is to create the longest possible path between the inlet and discharge ports.

Figure 12: Simplified pH adjustment system.


Clear Water Storage Reservoirs
The preventive maintenance procedures related to clear water reservoirs are listed below:
Water level recorder should be kept in working order at all times.
During the pumping of water the water level in the reservoir should be maintained at the lowest level as
possible so that overflow and wastage of water when the pump is suddenly shut down could be
prevented.
Roof of the clear water reservoir is always kept at least 60 cm above the surrounding ground level to
prevent rainwater flooding over the roof.
Roofing should be periodically checked to ensure that no leakage is there so that pollution can be
prevented. Top of roof should be sloped in such a way to prevent stagnation of rainwater;
Ventilator outlets should be regularly checked and cleaned to guard against mosquito breeding and bird
droppings.

Cleaning of sump and reservoirs should be done regularly at least once in six months.

Figure 12: Treated water reservoir.


Conclusion
Water that is fit for domestic use (drinking water) must comply with specific requirements. The most important
requirement is that it must be safe to drink. Many raw water sources contain harmful micro-organisms or other
substances in concentrations that make the water unsafe to drink or in other ways unfit for domestic use. These
organisms and substances must be removed from the water by means of treatment processes to make the water fit
for domestic use. In addition to the requirement that water must be safe to drink, water for domestic use must
also be aesthetically pleasing (have a clean appearance, taste and odor) and it must furthermore be chemically
stable (i.e. it must not cause corrosion or form deposits in pipes or fixtures such as geysers).
The principal objective therefore of water treatment is to produce water that is fit for domestic use reliably and
consistently from a raw water source at a cost that is reasonable to the consumers. A water treatment plant
employs many individual treatment processes (sometimes called unit processes and unit operations) that are
linked in a process train to produce water of the desired quality.

REFERENCES

Coffel, Steve. The Great Fluoride Fight., Garbage, May/June 1992;32-37.


Banting, David W. The Future of Fluoride: An Update One Year After the National Toxicology
Program Study. Journal of The American Dental Association, August 1991;122(86-91).
Limeback, Hardy, BSc, Ph.D., DDS. Fluoride Accumulation in Human Teeth and Bones: Is Dose
Adjustment Now Required?. Canadian Journal of Public Health, March-April, 1993;84(2):78-81.
Butler, J.E., et al, Fluoride: An Adjuvant For Mucosal and Systemic Immunity. Immunology Letters,
1990;26:217-220.
Gupta, I.P., et al. Fluoride as a Possible Etiological Factor in Non-Ulcer Dyspepsia. Journal of
Gastroenterology and Hepatology, 1992;7:355-356.
Pendrys, David G. and Katz, Ralph V. Risk of Enamel Fluorosis Associated With Fluoride
Supplementation, Infant Formula and Fluoride Dentifrice Use. American Journal of Epidemiology,
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Navak B, Roy MM, Das B, Pal A, et al. Health effects of groundwater fluoride contamination. Clin
Toxicol (Phila). 2009 Apr:47(4):292-5.
Giachini M, Pierleoni F. Fluoride Toxicity. Minerva Stomatol. 2004 Apr;53(4):171-7.
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