Utah became the first US state to prohibit the addition of fluoride to public drinking water in March. Following a lawsuit in Florida, US Health Secretary Robert F. Kennedy Jr. urged the Centers for Disease Control and Prevention (CDC) to cease national recommendations for water fluoridation.

As opponents of US water fluoridation voice their concerns, scientists warn that eliminating fluoride may lead to a significant rise in dental decay, potentially costing states billions and disproportionately impacting lower-income communities.

Statements from states like Nebraska, Kentucky, and Louisiana indicate their intentions to remove fluoride from water supplies, raising questions about how quickly these changes will affect Americans.

Fluoride Variation

Fluoride is a naturally occurring mineral found in freshwater, initially added to community drinking water in the United States in a controlled manner in 1945. Effective methods to prevent dental decay.

According to the CDC, community water fluoridation was reported in 1999, promoting the development of baby teeth and safeguarding them through adulthood. This initiative is recognized as one of the 20th century’s greatest public health achievements.

Recently, however, concerns have emerged that adding fluoride through foods, milk, toothpaste, and dental care products could lead to total fluoride intake surpassing safe levels.

The US National Toxicology Program (NTP) released a review of scientific research linking fluoride exposure to neurodevelopment and cognitive function. The findings indicated that elevated fluoride levels, especially drinking water with over 1.5 milligrams of fluoride per liter, are correlated with reduced IQ levels in children.

Nevertheless, the NTP noted that there was insufficient data to establish whether the lower US fluoride level of 0.7 mg/L negatively impacts children’s IQ, admitting that out of 74 international studies evaluated, “52 were deemed low quality (high risk of bias).”

Vida Zohoori, a public health and nutrition professor at Teesside University in the UK, is known for her research on fluoride. She asserts that the studies available do not provide enough data to reach definitive conclusions.

“Most research occurs in regions with fluoride concentrations significantly exceeding US standards, limiting the relevance to community water fluoridation at 0.7 mg/L,” she explains. “Most studies are cross-sectional, not longitudinal or randomized, making it impossible to establish causal links. Furthermore, many did not control for key variables like iodine or lead exposure, malnutrition, and socioeconomic status.

Conversely, there is substantial evidence supporting the addition of safe fluoride levels to drinking water. Based on a systematic Cochrane Review from 2015 (updated in 2024), Zohoori anticipates a notable rise in pediatric decay, known as early childhood tooth decay (ECC), if fluoride is removed from public water supplies. This primarily affects children aged 1-5 and the permanent teeth of those aged 6-12, who are extremely susceptible to damage.

This perspective is echoed by Dr. James Becker, an associate professor specializing in pediatric dentistry at the University of Utah. “No scientifically credible research has demonstrated harmful effects from fluoride when administered at safe doses,” he remarks.

Bekker explains that while toothpaste fluoride provides a topical effect during brushing, small amounts in drinking water and supplements deliver continuous systemic exposure, which reinforces tooth enamel and enhances its resistance to acid.

The CDC states that water fluoridation reduces tooth decay by approximately 25% in both children and adults, with students in fluoridated communities averaging 2.25 fewer rotten teeth.

“Many children lack access to fluoride supplements,” Bekker noted, emphasizing that fluoridation was only present in half of Utah prior to the ban.

“We’ve observed a significant increase in tooth decay in communities without fluoridated water compared to those with it. If left untreated, cavities can enlarge and eventually reach the tooth’s nerves, leading to infections and the loss of teeth.”

If all 50 US states discontinue community water fluoridation programs, it is projected that children and adolescents aged 0 to 19 will incur 25.4 million cavities in the next five years, equating to one new cavity for every three children in America. A recent report indicated this would result in an estimated cost of $9.8 billion (£7.2 billion). Jama Health Forum in May.

“We specifically quantified the increase in dental cavities that could necessitate interventions ranging from fillings to root canals and even extractions,” stated Dr. Lisa Simon, a PhD fellow in Oral Health and Medicine Integration at Harvard Dental School and co-author of the study.

“We accounted for decay in both baby teeth and adult teeth, which began to escalate when the children were around six years old.”

Lessons Learned

With the fluoride ban in Utah now in effect, Bekker anticipates it could take five years to observe its full impact. However, the effects were evident even sooner in Calgary, Canada, which removed fluoride from its drinking water in 2011; three years later, children’s dental decay surged.

In one year, 32 out of Calgary’s 10,000 children underwent general anesthesia for dental treatments, whereas only 17 did so in Edmonton, another city within the same province. Subsequently, Calgary voted to reinstate fluoride.

Despite this, 63% of the US population receives fluoridated water, while most countries do not add fluoride to their drinking water. The reasons vary from natural fluoride presence to safety concerns and the belief that consumption should be a personal choice.

In the UK, only 10% of the population receives intentionally fluoridated water, and natural fluoride occurs at low levels in most drinking water across England and Wales.

However, the UK government announced in March an expansion of water fluoridation in the northeast, targeting disadvantaged areas where it was found that one in five children suffers from tooth decay.

The leading reason for children aged 5 to 9 being admitted to hospitals is treatment for tooth decay.

“Recent studies indicate the benefits of water fluoridation are less pronounced than in the past, particularly since fluoride has become a common ingredient in toothpaste since the 1970s.”

“However, rates of tooth decay are rising, and increased education on dental care is essential. The frequency of sugar intake is key to prevention, which supports water fluoridation initiatives in the UK.”

Dr. Scott Tomar, a professor and associate dean of Prevention and Public Health Sciences at the University of Illinois, Chicago, and spokesperson for the American Dental Association, commends the UK’s fluoridation expansion.

He expresses concern that misinformation about fluoride in the US could induce fear surrounding other sources of minerals, including toothpaste, leading to more bans across various states and communities.

Tomar highlights the overwhelming support for fluoride within the dental community as indicative of its safety and effectiveness, countering any narratives that oppose it driven by the economic interests of dentists.

“So, why do we advocate for this type of water fluoridation?” he inquires. “I’m genuinely worried because there are no alternatives to fluoride, and we can no longer rely on the federal government for guidance.”

In light of this, dentists and industry groups are joining forces to advocate for their cause.

“This appears to be primarily a political issue,” comments Lorna Kosi, chair of the coalition in Davis and program director for a dental clinic serving vulnerable communities. “We firmly believe that water fluoridation is safe. It remains the most effective and cost-efficient method to combat decay.”

Read more: