In 1999, fluoridated drinking water was celebrated as one of the ten greatest public health achievements of the 20th century by the Centers for Disease Control and Prevention (CDC), alongside monumental strides like controlling infectious diseases and recognizing the health risks of tobacco. However, in recent years, the role of fluoride in public water systems has come under increased scrutiny from politicians, citizens, and scientists alike.
New research—along with shifts in Washington, DC—has sparked renewed debate over the safety and efficacy of fluoride in drinking water. While some have called for its removal, the majority of dental professionals continue to support its use, citing the well-documented benefits to dental health.
“Fluoride is a naturally occurring mineral that plays a critical role in promoting dental health and preventing tooth decay,” explains Richard Valachovic, clinical professor and executive director of the Center for Oral Health Policy and Management at NYU College of Dentistry. “It strengthens tooth enamel, helps prevent cavities, and has been a cornerstone of dental public health for decades.”
The Origins of Water Fluoridation
Fluoride’s inclusion in public drinking water began with scientific discoveries in the early 20th century. It was initially found in groundwater, often in trace amounts, with some regions, including parts of the western United States, East Africa, India, and China, having naturally higher fluoride concentrations due to local geology.
In Colorado, a dentist discovered that fluoride in the local water caused tooth discoloration but also made teeth more resistant to decay. By the late 1930s, researchers established that lower fluoride levels did not result in staining but still offered protective benefits against cavities. In 1945, Grand Rapids, Michigan, became the first city in the world to fluoridate its drinking water. The results were striking, with children born after fluoridation showing a 60% reduction in dental cavities compared to older children.
This success led other communities to adopt fluoridation, and businesses soon developed fluoride-infused toothpaste and mouth rinses, which became widely available in the 1950s and beyond.
The Benefits and Limits of Fluoridation
The science behind water fluoridation has been well-established over decades. According to the CDC, community water fluoridation reduced cavities in children by 40-70% and tooth loss in adults by 40-60% between 1945 and 1999. The cost of fluoridation is minimal—typically under $1 per person annually in the U.S.—and the return on investment is substantial, with studies suggesting that for every dollar spent, $20 to $50 are saved in dental treatment costs.
However, dental health has improved in other ways since fluoridation was first introduced. The widespread use of fluoridated toothpaste and school-based oral health programs has diminished the impact of water fluoridation on cavity rates. A recent Cochrane review found that while fluoridated water still results in fewer decayed, missing, or filled teeth, the reduction is less pronounced today, partly due to the broader availability of fluoride in other dental products.
Emerging Concerns About Fluoride and Neurodevelopment
More recently, new studies have raised concerns about the potential effects of fluoride on neurodevelopment, particularly in children. A report published in JAMA Pediatrics linked high levels of fluoride exposure to lower IQ scores, though the fluoride levels studied were far higher than those typically found in U.S. drinking water. In the U.S. and Australia, research on fluoride at lower concentrations has not shown a connection to cognitive issues, though more studies are ongoing.
Despite these concerns, experts like Valachovic maintain that the fluoride levels regulated in U.S. water systems, currently set at 0.7 milligrams per liter, are safe. “Fluoride, like many other substances, is beneficial at appropriate levels but can be harmful in excess,” Valachovic says. “The current regulatory levels are well within the safe range.”
The Impact of Stopping Fluoridation
The decision to remove fluoride from public water supplies has had notable consequences. In 2007, Juneau, Alaska, discontinued fluoridation, and a subsequent study found that cavity-related dental procedures in children and adolescents increased by nearly 50%. Similarly, when Calgary, Canada, stopped adding fluoride in 2011, researchers found higher rates of tooth decay compared to Edmonton, which continued fluoridation. As a result, Calgary is in the process of reintroducing fluoride to its water.
In Windsor, Canada, fluoride was removed in 2013, but after an uptick in emergency dental visits, the city council voted to reinstate fluoridation in 2018.
Who is Affected the Most?
The populations most likely to suffer when fluoride is removed from water systems are those who already face barriers to dental care—especially lower-income communities and children. Preventive dental care, including regular fluoride exposure, is far less expensive than emergency treatments like fillings or extractions, but access to care can be limited, especially in rural areas or among those without dental insurance.
Without fluoridated water, children in disadvantaged communities are more likely to suffer from untreated dental decay, which can affect their school attendance and performance. According to Valachovic, “Until there’s universal access to preventive dental care, water fluoridation remains one of the most equitable and cost-effective public health measures available.”
Moving Forward
As the debate over water fluoridation continues, experts urge ongoing research and careful monitoring of fluoride levels to ensure safety and efficacy. While the dramatic impact of fluoridation on cavity prevention has diminished over time due to other advances in dental care, it remains an essential public health tool for preventing tooth decay—especially in communities with limited access to dental care.
As we evaluate new studies and potential risks, the benefits of water fluoridation, particularly for vulnerable populations, continue to make it a valuable asset to public health.
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