A mother and her young drink tap water.
The debate over fluoride in public water supplies, reignited by figures such as Robert F. Kennedy Jr., Donald Trump’s nominee for secretary of Health and Human Services, has once again brought this decades-old public health initiative into the spotlight. Celebrated as one of the greatest public health achievements of the 20th century, fluoridation drastically reduced tooth decay nationwide. But as our understanding of dental care and overall health evolves, is it time to reassess this approach or ensure it continues for future generations?
History of water fluoridation
Water fluoridation began in 1945 in cities such as Grand Rapids, Michigan, paired with control cities to measure its impact. Over the next decade, studies consistently showed a significant reduction in tooth decay among children in fluoridated areas. By 1962, fluoride guidelines were included in federal drinking water standards, ensuring consistent dental health benefits nationwide.
Fluoridation has been shown to be effective, reducing cavity rates by 25% and saving billions in dental treatment costs annually. However, some municipalities, such as Juneau, Alaska, have discontinued fluoridation, leading to increased cavity rates and higher dental treatment costs, underscoring the economic and public health benefits of maintaining fluoridated water.
Benefits of fluoride
Fluoride strengthens teeth by restoring minerals to enamel, making them more resistant to acid wear and inhibiting the growth of harmful bacteria. In 1956, Crest introduced the first fluoride toothpasteleading to the widespread adoption of fluoride oral care products. Dr. Kevin Boyd, a pediatric dentist in Chicago with 30 years of clinical experience and a master’s degree in nutritional science, recommends that “Fluoridating our water supply, providing topical fluoride treatments at dentist offices or pediatricians, and using home fluoride rinses are all helpful strategies that target in the reduction of acid destruction of the teeth”.
To reduce the risk of swallowing, children should start using toothpaste with a lower fluoride concentration starting at age 2. The fluoride levels in the toothpaste are specifically tailored to meet the needs of children and adults, ensuring safety and effectiveness for every age group.
According to the CDC, fluoridation is a cost-effective public health measure, saving about $38 in dental treatment costs for every dollar spent.
Untreated cavities, especially for those with limited access to care, can lead to infections and emergencies. Premature loss of baby teeth can cause permanent teeth to shift, resulting in crowding, misalignment and increased cavities due to reduced cleaning ability. Baby teeth also support jaw development and proper tongue position, which affects oral and airway health. For adults, these issues can lead to tooth loss and the need for dentures.
The American Dental Association supports water fluoridation as safe and effective in preventing tooth decay. Meanwhile, the American Academy of Pediatrics advises children to use age-appropriate fluoride toothpaste and drink fluoridated water.
Disadvantages of fluoride
Dangerous levels fluoride can lead to dental and systemic health problems. According to the US Environmental Protection Agency, fluoride concentrations above 2.0 mg/L in drinking water can increase the risk of dental fluorosis, which causes discoloration or staining of the teeth.
At concentrations above 4.0 mg/L, fluoride can cause serious systemic effects, including bone disease, thyroid damage, neurotoxicity and in extreme cases, reduced IQ in children.
Public water supplies are carefully regulated, with fluoride levels set at 0.7 mg/L to prevent tooth decay while minimizing the risk of fluoridation or other health problems.
However, said Dr. Camille Zenobia, Ph.D., microbiologist and dental product development expert, “Fluoride comes from many sources, not just water, which makes it difficult to regulate consumption.”
Food fluoride levels have increased over the past century due to water fluoridation, fluoride-based pesticides and food processing, with white grape juice averaging 2.1 mg/L from pesticide use. Additional, black tea is an important source of fluoride, with fluoride content in tea bags ranging from 1.6 to 6.1 mg/L, with an average of 3.3 mg/L.
The Importance of Public Dental Health Education
As a dentist practicing in various communities in New Jersey and New York, I have seen that socioeconomic factors often trump fluoride levels in determining dental health. In cities like Newark and Paterson, rampant decay in primary teeth persists despite fluoridated water, while nearby Clifton has much lower rates. The key difference? Access to preventive care, oral hygiene education and nutritional awareness. Preventing tooth decay isn’t just about sugar intake, it’s also about the type of foods eaten — sticky foods linger, accelerating enamel decay. It is vital for people to brush and floss to effectively remove biofilm, yet this knowledge is often lacking in underserved areas.
Alternative and Contemporary Approaches
While the historical success of fluoridation is well established, advances in dental care now offer individualized solutions over systemic measures.
- Educational Campaigns: Promoting oral hygiene and nutrition among families can effectively address caries prevention. Zenobia emphasizes the importance of public dental education campaigns.
- Targeted fluoride treatments: Using fluoridated toothpaste, mouthwash, flossing, or taking professional applications ensures local benefits by reducing systemic exposure. “If patients have a clear risk of developing tooth decay, fluoride is a valuable option, but it should not be ingested. I also recognize that fluoride-free options for strengthening teeth are available now,” advises Dr. Jessica Lenderhausen, MPH author Oral.
- Hydroxyapatite toothpaste: A fluoride-free alternative, hydroxyapatite strengthens enamel and helps prevent tooth decay.
- Dietary Changes: Reducing sugar consumption and incorporating tooth-friendly foods can significantly reduce the risk of tooth decay. Dr. Kevin Boyd offered advice to guide public health efforts “to reduce overconsumption of highly processed foods and beverages.”
- Advanced Filtration Systems: “Reverse osmosis systems offer a solution for those who wish to eliminate fluoride from their drinking water. Many health departments and private companies offer free water testing,” Dr. Susan Maple advises in her book Brave Parent: Raising Healthy, Happy Children Against All Odds in Today’s World.
Critics of fluoridation argue that it eliminates individual choice, likening it to “mass medication.” Countries like Austria, Belgium, Denmark, Finland, France, Germany, Iceland, Italy, Luxembourg, Netherlands, Norway, Sweden, most of the UK, Bulgaria, Cyprus , Estonia, Latvia, Lithuania and Slovenia chose not to fluoridate their water. Instead, they fortify products like salt and milk, giving people more control over their fluoride intake while maintaining the dental health benefits.
Kennedy’s statements on water fluoridation have brought the issue into the broader public health debate. While water fluoridation remains controversial, there are other non-controversial and effective steps communities can take to improve dental health.
