Dental caries remains the most common chronic disease among children, even though it is largely preventable. Untreated tooth decay causes pain, infections, and tooth loss, harming not only oral health but also overall well-being.1 It can lead to school absenteeism, difficulty concentrating, and financial strain on families due to dental care costs.1 In the United States, approximately 46 percent of children aged two to nineteen have experienced cavities,2 with higher rates among Hispanic (57 percent) and non-Hispanic Black (48 percent) children.3 About one in four children living below the federal poverty level suffers from untreated tooth decay,1 highlighting health disparities linked to socioeconomic, racial, and ethnic factors.
The Centers for Disease Control and Prevention (CDC) actively supports community water fluoridation and school-based dental sealant programs as evidence-based preventive strategies.1 Community water fluoridation, the controlled addition of fluoride to community water systems to the level recommended for caries prevention, represents the most practical and cost-effective approach.1 It benefits entire communities, regardless of age, income, or education level.
Researchers first identified fluoride’s role in reducing tooth decay in the early 1900s. In 1901, Dr. Frederick McKay noticed fewer cavities among Colorado residents affected by "Colorado brown stain," now known as dental fluorosis.4 Dental fluorosis is a cosmetic condition, characterized by white, chalky, or brown spots caused by excessive fluoride intake.5 Dr. H. Trendley Dean conducted further research in the 1930s, confirming fluoride’s protective effects.4 The federal government first issued recommendations for fluoride levels in drinking water in 1962 and revised them in 2015 to recommend a consistent level of 0.7 milligrams per liter (mg/L).4 This optimal level balances cavity prevention with minimal health risk and has been endorsed by the CDC, the American Dental Association (ADA), and other major health authorities.
Children in fluoridated communities typically have about 2.25 fewer decayed teeth than children in non-fluoridated areas.1 Community water fluoridation reduces cavities by approximately 25 percent across all age groups, leading to annual savings of about $32 per person, totaling roughly $6.5 billion nationwide.<sup>6</sup> Research shows that children from low-income families especially benefit from fluoridation, needing fewer dental treatments than peers who lack access to fluoridated water. Multiple systematic reviews, including a Cochrane review of 20 studies, consistently find reductions in dental caries for both primary and permanent teeth.7 Additionally, a systematic review by the Community Preventive Services Task Force reports that initiating fluoridation reduces cavities by 30 to 50 percent among children aged 4 to 17, while discontinuing fluoridation increases cavities by about 18 percent.8
Despite these benefits, public safety concerns about fluoridation persist, prompting ongoing scientific reviews. A 2024 report by the National Toxicology Program associated high fluoride exposure (above 1.5 mg/L) with lower IQ scores in children but found no evidence of similar effects at the recommended level (0.7 mg/L). The report called for additional research to clarify risks at lower fluoride exposures.9 Similarly, a 2025 meta-analysis published in JAMA Pediatrics identified a statistically significant association between a 1 mg/L increase in urinary fluoride and a 1.63-point reduction in IQ scores.10 However, these studies primarily occurred outside the United States and did not show causation at recommended levels. No credible evidence links optimally fluoridated water to health conditions such as cancer, Down syndrome, heart disease, or kidney disorders.1 Decades of research confirm that community water fluoridation remains safe at recommended fluoride levels.
Professional organizations, including the ADA and the American Association for Dental, Oral, and Craniofacial Research, continue to endorse community water fluoridation as a safe and effective way to prevent tooth decay. An ADA Health Policy Institute survey reported that 82 percent of U.S. dentists strongly support fluoridation as a critical public health measure.11
In 2025, Utah became the first state to enact a statewide ban on fluoridation,12 and the U.S. Environmental Protection Agency (EPA) announced plans to review new scientific evidence regarding fluoride safety in drinking water.13 Despite recent debates, community water fluoridation’s longstanding effectiveness remains clear. For nearly eighty years, fluoridation has significantly reduced dental caries rates and has been recognized by the CDC as one of the ten greatest public health achievements of the 20th century.14 Maintaining and expanding this preventive measure are essential for protecting public health and ensuring equitable, cost-effective cavity prevention for all communities.
Author Bio:
Anupama Grandhi, BDS, DDS
Dr. Anupama Grandhi is an Associate Professor in the Department of Oral & Maxillofacial Surgery at the School of Dentistry and Assistant Professor in the Department of Pathology & Human Anatomy at the School of Medicine. She is a Diplomate of the American Board of Oral and Maxillofacial Pathology and a Fellow of the American Academy of Oral and Maxillofacial Pathology. Her research interests include oral cancer and wellbeing.
Reference:
- https://www.cdc.gov/fluoridation/about/statement-on-the-evidence-supporting-the-safety-and-effectiveness-of-community-water-fluoridation.html
- https://www.cdc.gov/nchs/fastats/dental.htm
- https://www.cdc.gov/nchs/products/databriefs/db307.htm
- https://www.cdc.gov/fluoridation/timeline-for-community-water-fluoridation/index.html
- Oral and Maxillofacial Pathology, 5th Ed. Neville BW, Damm DD, Allen CM, Chi AC.
- https://www.cdc.gov/oral-health/media/images/6.5b.jpg
- Iheozor-Ejiofor Z, Worthington HV, Walsh T, O'Malley L, Clarkson JE, Macey R, Alam R, Tugwell P, Welch V, Glenny AM. 2015. Water Fluoridation for the Prevention of Dental Caries. Cochrane Database Syst Rev. (6): p. Cd010856.
- Truman BI, Gooch BF, Sulemana I, Gift HC, Horowitz AM, Evans CA, Griffin SO, Carande-Kulis VG, Task Force on Community Preventive Services. 2002. Reviews of Evidence on Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries. Am J Prev Med. 23(1 Suppl): p. 21-54.
- https://ntp.niehs.nih.gov/research/assessments/noncancer/completed/fluoride
- 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. doi:10.1001/jamapediatrics.2024.5542
- https://adanews.ada.org/ada-news/2025/march/what-is-the-future-of-community-water-fluoridation/
- https://adanews.ada.org/ada-news/2025/march/utah-becomes-first-state-to-ban-community-water-fluoridation/
- https://www.epa.gov/newsreleases/epa-will-expeditiously-review-new-science-fluoride-drinking-water
- Centers of Disease Control. 1999. Ten Great Public Health Achievements -- United States, 19001999. MMWR Morb Mortal Wkly Rep. 48(12);241-243.
