To Fluoridate or Not to Fluoridate?

Water fluoridation stands amongst the 20^th century’s greatest public health achievements. Introduced in 1945, this practice has strengthened tooth enamel and prevented millions of cavities, particularly benefiting children from communities with limited access to dental care. Studies show it reduces tooth decay by 26% in permanent teeth and 35% in baby teeth.

However, a landmark federal court ruling in 2024 has forced a national rethinking of this long-accepted practice. The ruling deemed current fluoridation levels an “unreasonable risk” to children’s health, fueling debates in communities across the country.

Fluoride is currently added to the tap water of more than 200 million U.S. residents, though coverage varies dramatically by region. While Kentucky fluoridates water for 99.7% of its residents, Hawaii serves just 8.5% of its population with fluoridated water. Several major metropolitan areas—including Portland, Oregon; Honolulu, Hawaii; Tucson, Arizona; and Wichita, Kansas—have opted against fluoridation entirely. Their stance aligns with most European countries, where water fluoridation is rare. Nations like Germany, France, and Sweden have rejected mass fluoridation, citing concerns about individual choice in medical treatment and the availability of alternative fluoride sources.

While water fluoridation has demonstrated public health benefits, its role in modern society is being questioned.

A 2024 National Toxicology Program review of 72 human health studies found that fluoride exposure above 1.5 mg/L is associated with lower IQ scores in children. While U.S. fluoridation typically maintains lower levels (0.7 mg/L), the findings have raised concerns about cumulative exposure through multiple sources, including formula prepared with fluoridated water. The findings prompted a federal lawsuit against the Environmental Protection Agency (EPA), the body responsible for regulating drinking water contaminants. In response, a federal judge ordered the EPA to take actions ranging from banning fluoridation to issuing public health warnings.

The benefits of fluoridation appear less crucial in modern contexts. A Cochrane review confirmed fluoridation’s cavity-preventing effects, but most studies predated the widespread adoption of fluoride toothpaste in the 1970s. Today’s abundance of fluoride sources—including toothpaste, mouth rinses, and professional treatments—may reduce the need for fluoridated water. Cavity rates have fallen sharply in both fluoridated and non-fluoridated communities, suggesting that improved nutrition and dental care play significant roles.

At standard U.S. fluoridation levels, about 12% of the population develops dental fluorosis significant enough to cause aesthetic concerns. When including milder cases, approximately 40% of Americans aged 12-15 show some form of fluorosis, ranging from faint white lines to, in severe cases, brown staining and pitting of teeth.

Nearly 20 communities have halted fluoridation since October 2024, and 60 more are considering similar measures. Arkansas and Kentucky lawmakers have introduced bills to end fluoridation mandates. Unlike water purification, which removes harmful contaminants, fluoridation adds an industrial byproduct to treat the population—a key point in debates about personal medical choice. Public health officials warn that removing fluoride will disproportionately harm low-income communities.

While water fluoridation has demonstrated public health benefits, its role in modern society is being questioned. The EPA’s decisions could reshape how communities approach this long-standing public health practice.