What You Should Know About Fluoride

In the aftermath of the 2024 election, there has been much discussion about the potential public policy changes that may occur in President-elect Donald Trump's second administration.

Immigration, reproductive health access and economic plans are unsurprisingly big concerns at the moment, but Trump ally Robert F. Kennedy Jr., whom Trump may turn to for health policy , has also brought a less-expected topic to the national spotlight: fluoride.

"We don't need fluoride in our water," Kennedy said on NPR's "Morning Edition" the day after the election. "It's a very bad way to deliver it into our systems."

"I think fluoride is on the way out," he told NBC News that same day.

But what exactly is fluoride? What does it do? And why are people like Kennedy calling for its removal from public water systems? We asked experts to break down the debate.

What is fluoride? Why is it in drinking water? "Fluoride is a naturally occurring mineral that belongs to a group of chemical compounds containing the element fluorine," said Dr. Jarrett L. Manning , a dentist and founder of JLM Dental Studio. "It exists in various forms: sodium fluoride, stannous fluoride and sodium monofluorophosphate."

Small amounts of fluoride are naturally present in soil, plants, water and certain foods, but it's also added to drinking water and dental products due to its ability to strengthen tooth enamel and prevent cavities.

"Many communities add fluoride to public water supplies, a process known as water fluoridation, to improve oral health and help prevent tooth decay on a population level," Manning explained.

Basically, acid-producing bacteria grows in the mouth, which dissolves minerals on the surface of teeth and can lead to tooth decay, or cavities. Fluoride prevents and stops that bacterial growth and can even reverse early tooth decay, thus reducing the need for treatments, which can be painful and expensive.

"Research over many years has shown that water fluoridation can significantly reduce the incidence of cavities in both children and adults, regardless of access to dental care," said Dr. Cheryline Pezzullo , a clinical associate professor and director of community-based programs at New York University's College of Dentistry. "By adding small, safe amounts of fluoride to the water supply, communities can reduce tooth decay across the board, particularly benefiting those who may not have regular access to dental care."

Grand Rapids, Michigan, became the first city to fluoridate its public water supply, in 1945, and a decade later, the rate of cavities in local children had fallen 60% to 65% . Researchers reported similar findings among both kids and adults as more communities adopted fluoridation in the subsequent decades .

Today, more than 60% of the U.S. population receives fluoridated water.

" The American Dental Association has long been a proponent of water fluoridation since its introduction and study," said cosmetic dentist Dr. Amanda Lewis .

Other public health groups, such as the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC), similarly support this practice due to its benefits to oral and overall health . Preventing tooth decay lowers the need for treatments such as tooth extractions and fillings, and if left untreated, cavities can lead to serious abscesses, infections and even sepsis.

The Public Health Service recommends a concentration of 0.7 milligram of fluoride per liter of water in community systems, which the CDC equates to about three drops of water in a 55-gallon barrel . Communities that already have naturally higher levels of fluoride do not need fluoridation.

What's the controversy? "The controversy around fluoride in water often centers on questions about health risks, personal choice and concerns about overexposure," Pezzullo said. "Although I do not agree, some argue that fluoride ― even in small amounts ― could have potential health risks and question the ethics of adding it to public water supplies."

In recent years, communities across the U.S. have voted to stop fluoridating their water systems. Many experts believe that the anti-fluoridation movement gained more traction amid the growing mistrust of public health authorities and government overall during the COVID-19 pandemic.

"Some people feel that adding fluoride to public water supplies violates their right to choose what goes into their bodies," Manning noted.

In September, a federal judge in California ruled that the Environmental Protection Agency must strengthen regulations around water fluoridation to address concerns about potential health risks, particularly with regard to children's cognitive development.

"There's skepticism from certain groups about the long-term effects, despite decades of research showing its safety and effectiveness when used correctly," Pezzullo said. "Additionally, misinformation and conflicting studies have created more confusion and lead to more public debate."

Many skeptics point to a review from the National Toxicology Program , which concluded "with moderate confidence" that there is an association between higher levels of fluoride exposure and lower IQ in children.

But that analysis is primarily based on studies conducted in other countries and involving fluoride concentrations of 1.5 milligrams per liter of water and above ― which is more than double the recommended limit for drinking water in the U.S.

"More studies are needed to fully understand the potential for lower fluoride exposure to affect children's IQ," the organization stated in its report.

The AAP has also expressed concerns about the limitations of the NTP's review, including the high fluoride levels but also the geographic heterogeneity of the study populations, which hinders the ability to account for other factors that might affect IQ and assess whether the data is "accurate, comparable, or generalizable." The organization noted that similar reviews from other groups have reached different conclusions and that the National Academies of Sciences, Engineering and Medicine rejected two earlier drafts of the report.

Tewodros R. Godebo, an assistant professor at the Tulane University Celia Scott Weatherhead School of Public Health and Tropical Medicine who studies fluoride, told HuffPost there's still a shortage of research on public water fluoridation in the U.S.

"Before we make a policy decision to remove fluoride from U.S. public water supply systems, we need to get some questions answered," he said. "We need more studies in the U.S. if we are going to make policy here, and the science is not yet consistent enough to make a decision."

He pointed to the lack of data on fluoridation's effect on adults and the inconsistent conclusions about any potential association between fluoride in developed countries' community water systems and children's cognitive development.

"If we find there is some association between IQ points and low fluoride exposure, then the next critical step would be to do a risk-benefit analysis because there is a benefit to water fluoridation in terms of dental health," Godebo said.

"What would be the cost in terms of treating dental decay and associated diseases because it's linked to our overall health and things like heart disease. What would the total IQ loss be in a child ― would it be one point? Then is our first step to reduce water fluoridation? Do we cut that 0.7 in half? This decision has to be based on strong science."

These decisions might also have to vary on the local level in accordance with area-based data, which will likely differ across the U.S. Many fluoride studies are also limited by the challenge of accounting for other sources of fluoride exposure beyond water supply systems.

Critics have argued that adding fluoride to drinking water may no longer be as effective as it was when the practice first began due to the increased use of fluoride toothpaste over time. Some point to the large number of countries that do not fluoridate their public water but have still seen reductions in tooth decay. Future data from the American communities that have removed fluoride from their systems will presumably provide more clarity.

Meanwhile, misleading claims about fluoride's potential harms have gained momentum. On Nov. 2, Kennedy asserted in a social media post that the mineral is associated with thyroid disease, arthritis and bone-related issues such as bone cancer and bone fractures.

Medical experts have responded by emphasizing the lack of rigorous U.S.-based research linking fluoride to thyroid disease and arthritis. As for bone health, repeated fluoride exposure above the recommended level can lead to skeletal fluorosis, which causes weakened bones, joint pain and stiffness, but that condition is extremely rare in the U.S.

Excessive fluoride exposure in children whose permanent teeth are still developing (usually up to the age of 8) can result in a cosmetic condition called dental fluorosis, which gives the teeth white spots, flecks or lines but does not cause pain or impair tooth function.

To address concerns about dental fluorosis, the U.S. government amended its recommendations on public water fluoridation in 2015. Though the previous guidance recommended 0.7 milligram per liter in warmer climates and 1.2 milligrams in cooler places, the standard became 0.7 everywhere.

Similarly, the ADA recommends very small amounts of fluoride toothpaste for young children to limit excess ingestion and prevent dental fluorosis.

Here's what you should know if you're concerned about fluoride in water. Headlines can be alarming, so if you're feeling overwhelmed by the fluoride debate taking place online and in the news, talk to your doctor, your dentist or your child's pediatrician.

"For those who are new to the topic, it's helpful to know that fluoride has been safely added to water supplies across many parts of the world since the 1940s, with a significant decrease in cavities as a result," Pezzullo said.

She emphasized that fluoride levels in public drinking water are carefully regulated and monitored.

"While it's good to be cautious, substantial amounts of scientific research have shown that fluoride at these regulated levels is safe and does not cause harm," Pezzullo explained. "I give fluoridated water to my own toddler and brush his teeth with fluoridated toothpaste! I can always tell when a child is not exposed to fluoride when they sit in my chair as they always have more cavities than they should."

Water fluoridation is a "simple but powerful health measure" that has been particularly beneficial for children and communities with limited access to dental care, she added. "As a dentist, I see the difference fluoride makes every day, especially in vulnerable populations."

Assessing the relative benefits and risks of water fluoridation is crucial for making policy decisions at the government level and personal choices on an individual level.

Although the data has not been conclusive, preliminary research suggests that fluoride exposure during pregnancy could potentially lead to neurobehavioral issues in children. Experts who have studied this possible link are notably not calling for an end to water fluoridation, but they have suggested that pregnant women might want to opt for filtered water.

"Those who prefer to avoid fluoride can choose to use fluoride-free dental products or install home water filters that remove fluoride," Manning said. "There are alternatives to fluoride and complementary approaches for maintaining strong teeth and good oral health. Some of those alternatives are xylitol, hydroxyapatite and recaldent, just to name a few."

Lewis similarly advised reading the labels on your dental products if you want to cut down on your fluoride intake while opting for toothpastes and mouth rinses with other decay-preventing ingredients. She noted that the time and manner in which we eat, sleep and breath can also affect our oral health and thus overall health and wellness.

"If you live in a city with fluoride, exposure will be inevitable," Lewis said, listing sources like washed produce, showers and restaurant coffee, tea and water. "You can filter your water at home or purchase filtered water from a number of locations, but it is unlikely that you can completely eliminate your exposure."

It's worth reiterating, however, that there has not been sufficient data to determine if the 0.7 milligram fluoride standard in the U.S. is linked to the health concerns critics have raised.

And although Kennedy believes that the Trump administration will "advise all U.S. water systems to remove fluoride from public water" on the day the president-elect assumes office, the federal government ultimately cannot decide whether a community fluoridates its water supply. That decision remains at the state and local level.

Related...