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A mother and her toddler drink tap water.
The debate over fluoride in public water supplies, reignited by figures like Robert F. Kennedy Jr., Donald Trump’s nominee for Secretary of Health and Human Services, has put this decades-old public health initiative back in the spotlight. Celebrated as one of the greatest public health achievements of the 20th century, fluoridation has dramatically reduced the number of cavities across the country. 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 like Grand Rapids, Michigan, combined with control cities to measure its impact. Over the next decade, studies consistently showed a significant reduction in the number of cavities in children in fluoridated areas. In 1962, fluoride guidelines were incorporated into federal drinking water standards, ensuring consistent dental health benefits across the country.
Fluoridation has been shown to be effective: it reduces the number of cavities by 25% and saves billions in dental treatment costs every year. However, some municipalities, such as Juneau, Alaska, have phased out fluoridation, leading to higher cavity rates and higher costs for dental treatments, highlighting the economic and public health benefits of maintaining fluoridated water.
Benefits of fluoride
Fluoride strengthens teeth by restoring minerals to the enamel, making them more resistant to acid damage and inhibiting the growth of harmful bacteria. In 1956, Crest introduced the first fluoride toothpastewhich has led to the widespread adoption of fluoridated oral care products. Dr. Kevin Boyd, a pediatric dentist in Chicago with 30 years of clinical experience and a master’s degree in nutritional sciences, recommends that “fluoridating our water supply, providing topical fluoride treatments in dental or pediatric offices, and using fluoride rinses at home are all useful strategies that aim to reduce acid destruction of teeth.”
To reduce the risk of ingestion, children from 2 years of age should start using toothpaste with a lower fluoride concentration. The fluoride content in toothpaste is specifically tailored to 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 approximately $38 in dental treatment costs for every dollar spent.
Untreated cavities, especially for people with limited access to care, can lead to infections and emergencies. Premature loss of primary teeth can cause permanent teeth to shift, resulting in crowding, misalignment, and increased cavities due to reduced cleanability. Baby teeth also support jaw development and proper tongue posture, which affects oral and respiratory health. For adults, these problems can lead to tooth loss and the need for dentures.
The American Dental Association endorses water fluoridation as safe and effective for preventing tooth decay. At the same time, the American Academy of Pediatrics recommends that children use age-appropriate fluoride toothpaste and drink fluoridated water.
Disadvantages of fluoride
Dangerous levels of fluoride can lead to both dental and systemic health problems. According to the U.S. Environmental Protection Agency, fluoride concentrations above 2.0 mg/L in drinking water can increase the risk of dental fluorosis, which causes teeth to become discolored or stained.
At concentrations above 4.0 mg/l, fluoride can cause serious systemic effects including bone disease, thyroid damage, neurotoxicity and, in extreme cases, lowered IQ in children.
Public water supplies are carefully regulated, with a fluoride level of 0.7 mg/l to prevent cavities while minimizing the risk of fluorosis or other health problems.
Dr. However, Camille Zenobia, Ph.D., microbiologist and dental product development expert, says, “Fluoride comes from multiple sources, not just water, making it challenging to regulate consumption.”
Fluoride levels in foods 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 due to pesticide use. Additional, black tea is an important source of fluoride, with fluoride levels 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 serving several communities in New Jersey and New York, I have seen that socioeconomic factors often outweigh fluoride levels in determining dental health. In cities like Newark and Paterson, decay of baby teeth persists despite fluoridated water, while nearby Clifton has far less tooth decay. The main difference? Access to preventive care and oral hygiene education and nutritional awareness. Preventing cavities is not only related to sugar intake, but also the type of food consumed; sticky foods stick around and accelerate tooth decay. It is vital that people brush and floss to effectively remove biofilm, but this knowledge is often lacking in underserved areas.
Alternatives and modern approaches
While the historic success of fluoridation is well established, developments in dental care now offer personalized solutions rather than systemic measures.
- Educational campaigns: Promoting oral hygiene and nutrition among families can effectively address cavity prevention. Zenobia emphasizes the importance of public dental information campaigns.
- Targeted fluoride treatments: Using fluoridated toothpaste, mouthwash, floss or receiving professional applications provides local benefits, reducing systemic exposure. “If patients are at clear risk of developing cavities, fluoride is a valuable option, but it should not be swallowed. I also recognize that there are now fluoride-free options available to strengthen teeth,” advises Dr. Jessica Lenderhausen, MPH author of Oral.
- Hydroxyapatite toothpaste: A fluoride-free alternative, hydroxyapatite strengthens enamel and helps prevent tooth decay.
- Dietary changes: Reduce and incorporate sugar consumption tooth-friendly food can significantly reduce the risk of cavities. Dr. Kevin Boyd provided advice to guide public health efforts “to reduce overconsumption of ultra-processed foods and beverages”
- Advanced filter systems: “Reverse osmosis systems offer a solution for those who want to remove 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 and compares it to “mass drug use.” Countries such as Austria, Belgium, Denmark, Finland, France, Germany, Iceland, Italy, Luxembourg, the Netherlands, Norway, Sweden, most of the United Kingdom, Bulgaria, Cyprus, Estonia, Latvia, Lithuania and Slovenia have chosen not to to fluoridate their water. Instead, they fortify products like salt and milk, giving individuals more control over fluoride intake while maintaining dental health benefits.
Kennedy’s statements on water fluoridation brought the issue into the broader public health discussion. Although water fluoridation remains controversial, there are other non-controversial and effective steps that communities can take to improve dental health.