Fluoride in public water has slashed tooth decay — but some states may end mandates

Kentucky state Rep. Mark Hart has been drinking fluoridated water his entire life. In 1954, five years before Hart was born, his home state mandated adding or adjusting levels of the mineral, which occurs naturally in water, in drinking water systems of populations larger than 3,000.

But after hearing from a constituent a few years ago, Hart believes the matter of what’s in Kentucky cities’ drinking water should be a decision made by those drinking it. He’s been trying to reverse the state’s mandate since 2018, with several unsuccessful legislative attempts.

This year, with more than 20 co-sponsors, his bill has so far passed out of committee on its route to the House floor.

In 1945, Grand Rapids, Michigan, became the first city to fluoridate its water. The decline in tooth decay that followed the widespread adoption of fluoridation has been hailed as one of the greatest public health achievements of the past century. Fluoridation lessens tooth decay in children and adults by 25%, according to the federal Centers for Disease Control and Prevention.

But there’s been pushback against fluoridation, including a lawsuit by advocates seeking the federal government to ban the practice entirely. Some state lawmakers want to reverse or relax requirements for communities to fluoridate, and several localities across the country in recent years have chosen to stop doing it. Health experts say the rise in anti-fluoridation measures is an example of the increased skepticism toward science and public health measures — exacerbated by the mask and vaccine mandates during the pandemic.

“At the heart of these big public health issues — including water fluoridation — is science. But over the past few years, there’s been skepticism of science,” said Jane Grover, senior director of the Council on Access, Prevention and Interprofessional Relations at the American Dental Association.

Roughly 73% of the U.S. population with public water access in 2020 received drinking water with fluoride adjusted to the “optimal” concentration of 0.7 milligrams per liter, according to the CDC.

At least a dozen states have laws mandating that larger communities fluoridate. Among them are California, Delaware, Georgia, Illinois, Kentucky, Louisiana, Minnesota, Mississippi, Nebraska, Nevada, Ohio and South Dakota.

Yet lawmakers in three of those states — Georgia, Kentucky and Nebraska — have filed bills that would reverse the mandates and leave the choice up to a local voter referendum or to the governing body of local water systems.

Three states — Maine, New Hampshire and Utah — require a public vote for fluoridation by municipalities and their public water systems.

What the science says

Hart, a Republican, said he didn’t give much thought to his drinking water until a constituent sent him studies that linked very high levels of fluoridation to lower IQs in rural communities of China and India. (U.S. public health experts say those cases don’t correspond to fluoridation in the United States.)

“I was shocked by all the research I was reading. I hadn’t put much stock into my drinking water when I first joined the [Kentucky legislature],” said Hart.

He’d personally rather avoid fluoridated water altogether, but said at a minimum Kentucky’s statewide mandate ought to be overturned.

“What goes in your drinking water isn’t for the states or big government to decide. That to me is a local control issue — give people a choice on what they’re drinking, you know?” Hart said.

Much of the research used by anti-fluoride activists has been resoundingly debunked by the medical community. Public health officials note that studies touted by anti-fluoridation groups are often cited out of context, may not be peer-reviewed, and often are conducted in countries where fluoridation levels can be several times that of the U.S. Environmental Protection Agency’s recommendation.

“Good public health policy is built on decades and decades of scientific review, not junk science. Because we need reputable, peer-reviewed science to assess what’s necessary to protect public health,” said Kathleen Hoke, a University of Maryland law professor and the eastern region director of the Network for Public Health Law, a professional group that provides technical legal assistance on public health matters.

“The EPA’s recommendation for fluoride levels is based on scientific, peer-reviewed data. It’s up to our public health measures to reflect that same type of reputable science,” she added.

And organizations such as the CDC, the American Dental Association and the National Cancer Institute are in consensus that U.S. fluoridation is safe, and is not linked to lower IQs or critical health problems.

Local debates

For most of the United States, fluoridation already is a matter of local control. Hawaii is the only state that bans fluoridation; most others leave it to individual water systems or localities.

There are bills in Hawaii and New Jersey to mandate water fluoridation statewide, but the legislation is stalled in committee.

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Hawaii state Sen. Stanley Chang, a Democrat, said his concern over the oral health of his newborn daughter inspired the bill, which would require all state suppliers of public water to meet fluoridation levels set by the EPA.

“I think this will prevail in the end. When it comes to health and science, there’s an information plateau if you’re not an expert,” Chang told Stateline. “I’m not an expert. It’s why my job is to ask experts, so that I can be equipped to make that information accessible and reliable for my constituents.”

Debora Teixeira, the oral health systems coordinator at the Vermont Department of Public Health, said her agency will send educators to local communities to talk about fluoridation in the hope of helping residents understand the benefits.

“When requested, we go to the place where fluoridation is being challenged,” Teixeira said.

“It’s less of advocating law, and more of an education and information about the science behind it,” she said. “Because there’s decades and decades of research that supports fluoridation, but we want to engage with those who may be skeptical or have been misinformed.”

This year, local governments in Union County, North Carolina, and Collier County, Florida, prohibited the adding of fluoride to their drinking water.

Last year, State College, Pennsylvania, and Brushy Creek, Texas, stopped adding fluoride to their water systems.

In a September 2023 memo announcing the decision to terminate fluoridation, Shean R. Dalton, general manager of Brushy Creek Municipal Utility District, cited health concerns, personal choice and cost-effectiveness as reasons to forgo the practice.

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A 2022 University of Calgary study showed increases in tooth decay procedures in Calgary, Canada, and Juneau, Alaska, after each city ended water fluoridation.

Last month, a federal court in San Francisco heard arguments in a lawsuit by Food and Water Watch and anti-fluoridation advocacy groups against the EPA, arguing that fluoride ought to be regulated as a toxin. The lawsuit, filed in 2017, is seeking a ban on fluoridation of drinking water “to protect fetuses and children” from the risk of neurodevelopmental problems.

“There is a very real trend of states looking to reverse these mandates. We believe that the court’s ruling — which we hope is in our favor — will give more states cause to look at what we’re doing to our drinking water,” said Stuart Cooper, executive director of the Fluoride Action Network, an anti-fluoride advocacy group that is among the plaintiffs in the case.

Meanwhile, residents of Buffalo, New York, have filed a class-action lawsuit against the city after it quietly ended fluoridation without informing residents. One resident said her elementary school-aged son suffered from oral health problems from a lack of fluoride.

The latest effort at stopping fluoridation was in Rutland, Vermont, where residents this week took their second vote in less than a decade on whether to keep adding the mineral to their drinking water. In 2016, the ballot measure failed.

On Tuesday, it failed again. Rutland will keep its fluoride.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org. Follow Stateline on Facebook and Twitter.