‘Times have changed’: Debate over fluoridated water resurfaces across U.S.

Two New York towns on either side of the Hudson River experimented in 1944: Newburgh would add fluoride to its water and Kingston would not.

The results were striking. Newburgh children had half as much tooth decay as those in Kingston.

Today, more than 70% of the U.S. population receives fluoridated drinking water. The Centers for Disease Control and Prevention hails water fluoridation as one of the top 10 achievements in health in the 20th century, alongside vaccinations, workplace safety and the recognition of tobacco’s dangers.

The impact of fluoridated water alone has declined with the reliance on increasingly available toothpastes, rinses and fluoride supplements. The CDC says fluoridated water can reduce the prevalence of cavities by an average of 25%.

Fluoride-laden alternatives and a movement to elevate personal choice are stirring debate over the value of fluoride programs.

“Times have changed. The urgency of people getting fluoride in 2024 is not what it was in 1950 because there are so many ways to get it. It’s kind of common knowledge, and there are so many products with it,” said Jeffrey A. Singer, a working surgeon and a senior fellow at the Cato Institute. “It’s time to revisit this. Do we need to be doing this?”

Studies about the potential link between high levels of fluoride and lower IQ in children, plus comments from President-elect Donald Trump’s nominee for health and human services secretary, are fueling the debate to the chagrin of dental experts who say fluoridated water is irreplaceable.

Abilene, Texas, stopped adding fluoride to city water in September after a federal judge in California ordered the Environmental Protection Agency to draft regulations in response to plaintiffs’ concerns that levels of the mineral might pose a risk to pregnant women or the IQ levels of their children.

The judge did not conclude that fluoride is “injurious to public health” but ruled that an “unreasonable risk of injury” requires a response.

Robert F. Kennedy Jr., whom Mr. Trump nominated for health secretary, called for the end to fluoridation after the Jan. 20 inauguration. He said fluoride is an “industrial waste” capable of causing bodily defects such as bone cancer and thyroid issues.

“This has always been a political issue since Day One,” said Catherine Hayes, chair of the Department of Oral Health Policy and Epidemiology at the Harvard School of Dental Medicine. “There’s always been this argument it causes cancer. There is no evidence of that.”

Fluoride is a chemical ion of fluorine, a common element found in soil, rocks and water but added to food, beverages and oral care products. It strengthens dental enamel by fighting mouth bacteria that produce harmful acids.

Fluoridated toothpaste and mouthwash weren’t prevalent when the water program began in the mid-20th century. Fluoride is also found in some foods, such as russet potatoes and black tea leaves.

The American Cancer Society says there is no demonstrated link to cancer, and the American Dental Association promotes fluoridated water as effective and safe.

Some public health experts, not necessarily Mr. Kennedy’s allies, say the fluoridation program is worth scrutiny, given warning signs in research and the availability of alternate sources of fluoride.

“The safety of low-level fluoridation has been demonstrated by decades of research, though emerging studies suggest it could be a risk to pregnant women,” Leana Wen, a former Baltimore health commissioner, wrote in a recent op-ed for The Washington Post. “Moreover, although the data are clear that community fluoridation dramatically reduced cavities before fluoride toothpaste became available, the current benefit is much smaller.”

Ms. Wen pointed to a 2019 JAMA Network study that found a link between Canadian women who drank fluoridated water during pregnancy and lower IQ in children ages 3 and 4 and Mexican studies that suggested a link between prenatal exposure and lower test scores and ADHD in their children.

The National Toxicology Program found higher levels of fluoride exposure, such as drinking water containing more than 1.5 milligrams of fluoride per liter, are associated with lower IQ in children.

The authors said their review “was designed to evaluate total fluoride exposure from all sources and was not designed to evaluate the health effects of fluoridated drinking water alone.”

Mr. Singer said he is skeptical of papers indicating neurotoxicity from fluoride.

“They are very weak studies, and they’re all associations. Correlation is not causation,” he said, adding that “IQ is not a good metric of neurotoxicity.”

He said he agreed with Mr. Kennedy for a different reason: personal choice.

“There’s plenty of other ways for people who want fluoride to get it,” Mr. Singer said. “As a matter of public policy, I don’t think we have a right to put fluoride in the water supply so long as some people might not want it. It’s violating the doctrine of informed consent.”

Experts say most common water filters, such as Brita, do not remove fluoride. Other filters, particularly those involving reverse osmosis, effectively remove fluoride.

Policymakers from both sides of the political aisle have grappled with the proper amounts of fluoride in the modern age.

The federal government revised fluoride levels as recently as 2015. The recommended level of water fluoridation changed from 0.7 to 1.2 milligrams per liter to strictly the lower end, at 0.7 milligrams per liter, equivalent to about three drops of water in a 55-gallon barrel.

In 2019, the CDC urged parents to monitor toothpaste use among children to ensure they are not swallowing large amounts and causing dental fluorosis, marked by discoloration and pitting in the teeth.

This year, authors of the federal National Toxicology Program report said its review “was designed to evaluate total fluoride exposure from all sources and was not designed to evaluate the health effects of fluoridated drinking water alone.”

U.S. District Court Judge Edward M. Chen, an appointee of President Obama, cited the study in ordering the EPA this fall to take regulatory action to address any “unreasonable risk” from fluoride levels in water. His ruling didn’t prescribe what steps must be taken.

Dental experts are worried that politicians will go too far by eliminating fluoridated water instead of considering the correct amount or guidance for specific populations.

They also fear policymakers will lean on alternate sources of fluoride without recognizing the unique benefits of having the mineral in drinking water.

While toothpaste is an essential part of daily oral hygiene, it “doesn’t get into the tooth as it’s forming,” Ms. Hayes said.

“So our children benefit most from community water fluoridation, but there’s lots of evidence to show that adults also benefit as well because of the strong topical benefits of community fluoridation,” she said. “Getting the fluoride into the tooth structure is a systemic benefit which is lasting, and the topical benefits you need to have on a daily basis.”

Another benefit, she said, is that fluoridated water is accessible to all.

“The best argument for keeping fluoride in the water is that we have over 70 years of research showing that it’s safe and effective and it’s an equitable public health measure,” Ms. Hayes said. “People don’t have to have access to a dentist or the health care delivery system in order to benefit.”

Others say tooth-destroying diets make the water program essential.

“Although fluorides are more available today, unfortunately our diet has changed a lot since the 1940s. Most of what we consume has added sugars these days. So while toothpastes and mouth rinses are available to consumers, sugars are also omnipresent,” said Athanasios Zavras, a professor at Tufts University School of Dental Medicine.

Local entities decide whether to fluoridate their water, and fluoridation is required in large communities in a dozen states: California, Delaware, Georgia, Illinois, Kentucky, Louisiana, Minnesota, Mississippi, Nebraska, Nevada, Ohio and South Dakota.

In some places, the natural level of fluoride is high, so communities do not add it.

Mr. Kennedy’s push to eliminate fluoride appears to be an attempt to persuade local governments through the bully pulpit. His social media post said the administration would “advise” towns to drop fluoride. Mr. Trump has tried to avoid heavy-handed federal actions and said issues such as abortion and education standards should be left to the states.

Dr. Zavras said he opposed Mr. Kennedy’s push not because of politics “but rather due to the deleterious public health consequences that I foresee this policy will bring about — especially for the poor, the vulnerable, the disabled and children.”

“I am concerned about the removal of fluoride from the water supplies,” he said. “As a practicing pediatric dentist, I see the devastating effects of dental disease every day.”