For 80 years, community water fluoridation has been a signature public health initiative in the United States. Indeed, the US Centers for Disease Control and Prevention identified it as among the top 10 public health achievements of the 20th century.
Community water fluoridation was pioneered in Grand Rapids, Michigan, by scientists at the then-named National Institute of Dental Research. The scientists monitored the impact of water fluoridation on tooth decay rates in 30,000 school-aged children. The results were impressive: the caries rate among children born after the introduction of community water fluoridation was more than 60% lower than that of children born before water fluoridation started (older cohorts). This high-impact public health caries prevention intervention led other communities nationwide to adopt community water fluoridation practices. It also spurred the toothpaste industry in the 1960s to develop new fluoride toothpaste products to prevent tooth decay.1
The Fluoridation Debate
The Healthy People 2030 Objectives of the US Department of Health and Human Services have an objective that 77.1% of the US population should receive optimally fluoridated water to prevent tooth decay. Community water fluoridation prevents tooth decay in children and adults and benefits all socioeconomic groups in society.
In 2020, more than 209 million individuals, or 72.7% of the US population received optimally fluoridated water at 0.7 mg/L from public water systems.2 With reductions in tooth decay, water fluoridation has contributed to significant cost savings in dental health expenditures. A systematic review by Ran et al found that per capita annual costs for water fluoridation ranging from $0.11 to $24.38 prevented from $5.49 to $93.19 in associated treatment costs.3
Recent political and scientific developments have reignited debates about community water fluoridation’s safety and efficacy. The Secretary of Health and Human Services, Robert F. Kennedy Jr., has pledged to remove fluoride from the nation’s water supply, alleging health risks, such as reduced intelligence in children and cancer. A monograph4 and related meta-analysis5,6 released by the US National Toxicology Program (NTP) concluded that drinking water with elevated fluoride levels of 1.5 mg/L and higher has neurotoxic effects, a concentration over twice that recommended by the US Public Health Service for optimal fluoridation. The NTP acknowledged the lack of evidence for neurocognitive deficits with the regulated fluoride recommendation of 0.7 mg/L. However, fluoridation opponents have used the NTP monograph and other research evidence misleadingly to assert that community water fluoridation is harming communities and influencing partisan political battles. Just this year, legislatures in at least 10 states introduced bills to ban or limit water fluoridation, and two states, Utah and Florida, enacted a law to ban community water fluoridation in each state.
Social media has become a powerful and often problematic platform for the spread of health-related disinformation and malinformation. Disinformation is false information shared with the intent to deceive, such as social media posts linking fluoridation to unfounded government conspiracies. Malinformation is defined as information used to mislead out of context; an example would be the citing of studies from countries with naturally high fluoride levels to erroneously suggest the harmful effects apply to the regulated community water fluoridation concentration.
Challenges have been made about the methodology of several other studies alleging that prenatal exposure to fluoride, even at recommended levels, may be associated with behavioral changes in young children.7,8 Other studies have not found evidence of this association.9,10 Rather, the findings of studies consistently show that community water fluoridation yields a major decline in tooth decay in children and adults, reducing tooth decay by 25%.11,12 These studies do not estimate the cost savings in terms of reduced pain and suffering in children who do not suffer from dental caries as a result of benefiting from community water fluoridation.
Call to Action
Amidst the erosion of trust in community water fluoridation, communities that have removed fluoride from their water supply report an increase in dental disease when fluoridation is eliminated. For example, Calgary, Alberta, Canada, reinstated community water fluoridation this year in response to the rise in dental disease after its removal in 2011.13 In the United States, Choi and Simon recently found that removing fluoride from public water could result in 25.4 million additional decayed teeth in children over 5 years, with a projected $9.8 billion increase in healthcare costs.14 Removing fluoride from public water systems would disproportionately affect publicly insured and uninsured children who are already at highest risk of unmet dental needs.15
It is essential to support science-based health policy and stand up for community water fluoridation as a safe, effective, and equitable public health intervention. Health professionals, physicians, nurses, dentists, social workers, pharmacies, and public health workers must join together and be more proactive about defending community water fluoridation as a public good. Appeals must be made to policymakers, legislators, and patients about the public and private benefits and value of community water fluoridation at recommended regulated levels. Those in the dental community need to engage parents, children, older adults, and people with disabilities and chronic conditions to attack disinformation and malinformation for what it is. Science-based messages about safety, cost-effectiveness, equity, and trustworthy science must be developed and disseminated to counter national and/or state bans on community water fluoridation. First and foremost is protecting the oral health of all US children, including the most vulnerable populations. Dental advocates can do this by:
• partnering with local, state, and national organizations whose mission aligns with a proactive position about the benefits of community water fluoridation.
• sharing community water fluoridation talking points and frequently asked question handouts in their office reception areas during dental visits and with collaborating organizations.
• collaborating with community stakeholders to host community outreach events at schools, community centers, and faith-based settings to educate populations on the benefits of community water fluoridation.
• promoting good oral hygiene by encouraging brushing with fluoridated toothpaste and flossing twice per day every day for 2 minutes.
• integrating the use of fluoride varnish and silver diamine fluoride treatments as preventive agents for dental and well-child visits.
• collaborating with public school systems to host programs for applying sealants in school settings, especially in communities with limited access to regular dental care.
• participating in legislative action days to educate their legislators and staff members about the value of community water fluoridation.
Banding Together
Health professionals should unite to use these strategies to influence the debate about the benefits of community water fluoridation at the national, state, and local levels, and in communities where people live and experience the impact of actual or proposed bans on community water fluoridation. These bans will increase dental disease, oral pain, and suffering as rates of dental caries increase. Community water fluoridation, coupled with other preventive measures, can diminish the risk for poor oral health for both children and adults, especially for people across the lifespan coping with the challenges of access, nutrition, chronic conditions, and affordability.
About the Authors
Judith Haber, PhD, APRN-BC
Professor Emerita and Executive Director, Oral Health Education and Practice Program, New York University Rory Meyers College of Nursing, New York, New York; Member, Santa Fe Group
Nicholas G. Mosca, DDS, DrPH
Associate Professor, Diagnostic Sciences, Louisiana State University Health School of Dentistry, New Orleans, Louisiana; Member, Santa Fe Group
Linda C. Niessen, DMD, MPH, MPP
Vice Provost for Oral Health Affairs, Professor and Dean, College of Dental Medicine, Kansas City University, Joplin, Missouri; Member, Santa Fe Group
References
1. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for prevention of dental caries. Cochrane Database Syst Rev. 2015:(6):CD10856.
2. Hung M, Mohajeri A, Chiang J, et al. Community water fluoridation in focus: a comprehensive look at fluoridation levels across America. Int J Environ Res Public Health. 2023;20(23):7100.
3. Ran T, Chattopadhyay SK; Community Preventive Services Task Force. Economic evaluation of community water fluoridation: a community guide systematic review. Am J Prev Med. 2016;50(6):790-796.
4. Goldstein J. The anti-fluoride movement vaults into the mainstream. The New York Times. November 15, 2024. https://www.nytimes.com/2024/11/15/nyregion/fluoride-water-nyc-rfk-jr.html. Accessed August 8, 2025.
5. National Toxicology Program. NTP monograph on the state of the science concerning fluoride exposure and neurodevelopment and cognition: a systematic review. NTP Monogr. 2024;(8):NTP-MGRAPH-8.
6. Taylor KW, Eftim SE, Sibrizzi CA, et al. Fluoride exposure and children’s IQ scores: a systematic review and meta-analysis. JAMA Pediatr. 2025;179(3):282-292.
7. Malin AJ, Eckel SP, Hu H, et al. Maternal urinary fluoride and child neurobehavior at age 36 months. JAMA Netw Open. 2024;7(5):e2411987.
8. Green R, Lanphear B, Horung R, et al. Association between maternal fluoride exposure during pregnancy and IQ scores in offspring in Canada. JAMA Pediatr. 2019;173(10):940-948.
9. Guichon JR, Cooper C, Rugg-Gunn A, Dickinson JA. Flawed MIREC fluoride and intelligence quotient publications: a failed attempt to undermine community water fluoridation. Community Dent Oral Epidemiol. 2024;52(4):365-374.
10. Levy SM. Caution needed in interpreting the evidence base on fluoride and IQ. JAMA Pediatr. 2025;179(3):231-234.
11. Chou R, Pappas M, Dana T, et al. Screening and interventions to prevent dental caries in children younger than 5 years: updated evidence report and systematic review for the US Preventive Task Force. JAMA. 2021;326(21):2179-2192.
12. Kumar JV, Moss ME, Liu H, Fisher-Owens S. Association between low fluoride exposure and children’s intelligence: a meta-analysis relevant to community water fluoridation. Public Health. 2023;219:73-84.
13. McLaren L, Patterson SK, Faris P, et al. Fluoridation cessation and children’s dental caries: a 7-year follow-up evaluation of grade 2 schoolchildren in Calgary and Edmonton, Canada. Community Dent Oral Epidemiol. 2022;50(5):391-403.
14. Choi SE, Simon L. Projected outcomes of removing fluoride from US public water systems. JAMA Health Forum. 2025;6(5):e251166.
15. Choi SE, White J, Mertz E, Normand SL. Analysis of race and ethnicity, socioeconomic factors, and tooth decay among US children. JAMA Netw Open. 2023;6(6):e2318425.
