By Rick Valachovic, DMD, MPH, Clinical Professor and Co-Executive Director of the NYU Dentistry Center for Oral Health Policy and Management

The community water fluoridation (CWF) tide is turning and it’s happening fast.

• In late March, Utah became the first state to ban CWF.
• Last week, Florida became the second state to ban the practice.
• Bills are pending in at least three more states and circulating in many more to reverse CWF mandates.
• At the federal level, the Environmental Protection Agency announcedit would review the evidence on CWF’s potential risks, and the Centers for Disease Control and Prevention and the Community Preventive Services Task Force are expected to reverse their recommendations in favor of CWF.
• In a related move, the Food and Drug Administration announced last week it will take steps to stop the marketing of ingestible fluoride products aimed at children.

Members of our community are speaking out in response. The American Dental Association, the American Academy of Pediatric Dentistry, and the American Academy of Pediatrics issued a joint statement affirming the safety and efficacy of CWF, and the American Dental Education Association released a separate statement supporting the practice.

While some have argued that CWF is no longer essential given the widespread availability of fluoride via toothpaste and other consumer products, the evidence from communities that have discontinued CWF underscore its continued relevance. In fact, studies strongly indicate that the practice still has a meaningful role to play in preventing tooth decay, especially among children.

The Evidence

Take Calgary, Alberta. When the city’s fluoride injection system broke in 2011 necessitating millions of dollars in repairs, city councilors saw removing fluoride from the water supply as a way to avoid a major expense and respond to public sentiment opposing fluoridation. From a political standpoint, halting CWF was clearly the smart choice. Ten years later, a marked rise in childhood caries shifted public opinion and the political winds. A 2021 ballot measure to reintroduce CWF passed with 62% of the vote.

In Juneau, Alaska, CWF was stopped in 2007. Researchers studying Medicaid data observed a statistically significant increase in caries-related dental procedures and treatment costs for children from low-income families between 2003 and 2012. The increase was most pronounced in children under 7 who had almost no exposure to fluoridated community water during their lifetimes.

A similar rise in decay occurred in Israel after the minister of health ended mandatory water fluoridation in communities of 5,000 or more in 2014. This policy change occurred despite strong evidence that children 3 to 12 years of age in Israeli communities with no fluoride in the water had almost twice as many dental restorations as their counterparts in communities with CWF. What was the effect of eliminating the mandate? Not surprisingly, a study comparing the dental records of military recruits who entered service between 2012 and 2021 found higher rates of caries-related treatment among those with less exposure to CWF during their childhoods. What might surprise some is that the study also found no association between access to free, universal pediatric dental care (introduced in 2010 and extended to teenagers in 2018) and the recruits’ oral health. It appears access to treatment is no substitute for community-based prevention when it comes to dental caries.

Where We Stand Today

Less than a year after changing its fluoridation policy, Israel’s Ministry of Health decided to reverse it. The Knesset approved the change, but funding has yet to be appropriated to support fluoridation’s reintroduction. Calgary is in a similar holding pattern. Four years after voting to restore fluoridation, the city is still working to upgrade its infrastructure to achieve that goal, and the initial estimated cost has almost tripled. Juneau has no plans to reintroduce CWF, so local dental professionals rely on topical fluoride treatments to protect their patients’ teeth.

I hope dental professionals and other clinicians will continue to advocate for CWF at the state and community levels, but in communities where fluoridation is halted, we will need to take other steps to protect our patients’ health.

What We Can Do Moving Forward

In my December post on this topic, I described a variety of steps dental professionals can take to protect our patients’ oral health. These included:

Oral hygiene education. We should make sure our patients know how to properly brush and floss and understand the role of diet in tooth decay.

Encouraging the use of sealants to protect children’s teeth. We need to inform families of their value, especially in communities that discontinue CWF.

Introducing silver diamine fluoride (SDF) in your practice. This effective tool for caries treatment and prevention has yet to be widely adopted. Its wider use could make a major contribution to mitigating the harm to children’s oral health that we anticipate.

Employing other fluoride treatments. Fluoride-containing toothpastes, varnishes, gels, and rinses can also benefit our patients — at least for now. Some of these are also under attack. At the end of April, the Texas Attorney General filed suit against Colgate and Proctor & Gamble claiming that their practice of marketing flavored toothpastes containing fluoride to children and parents is “misleading, deceptive, and dangerous.” 

Sugar taxes are another public health measure that has substantially reduced childhood caries, but Americans have often balked at efforts to reduce their sugar consumption. When then New York City Mayor Michael Bloomberg attempted to restrict the sale of soda in large containers, the backlash was fierce, and two years later, the regulation was overturned by the courts.

Would a similar federal effort by the current administration be more warmly received by some previous objectors? Perhaps. As the number of communities with fluoridated water decline, we may see increased recognition that public health measures to protect American’s oral health are urgently needed.

University of Alaska Anchorage Associate Professor of Public Health Jennifer Meyer, PhD, MPH, CPH, RN, who studied the impact of Juneau’s decision to halt CWF, has eloquently made the case for adding fluoride to the water supply. “We add and supplement beneficial elements in food for many reasons,” Meyer said during a 2019 interview. “It’s an effective and equitable public health strategy. For example, we fortify wheat products with folic acid to prevent spina bifida and other neural tube defects. We add calcium and vitamin D to milk to prevent rickets, and adding iodine to salt has been a primary way of preventing iodine deficiency and goiters. Similarly, fluoride is an important mineral for the development and protection of teeth. Adjusting the availability of fluoride in the community water to an optimal level (0.7ppm) supports a population oral health benefit and mitigates risk.”

I saw the power of CWF firsthand when I was a pediatric dental resident at Children’s Hospital in Boston. When I started, we routinely saw high levels of caries in our patients. After the city introduced CWF, their oral health improved dramatically. I hope the panic surrounding fluoride will subside and efforts to remove this beneficial mineral from water supplies will be successfully countered. In the meantime, history tells us to expect a surge in tooth decay if public fear of CWF continues to dictate public policy.