Community water fluoridation: Untangling facts from fear

How to talk with patients about common misconceptions

Community water fluoridation has long been at the forefront of public health discussions, with most dentists and other health experts praising its role in effectively and safely preventing tooth decay. However, the practice has also garnered criticism among skeptics who claim it is unsafe and unethical. Misinformation and myths about fluoride have spread rapidly — especially online — fueling confusion and mistrust among dental patients and the public. 

ADA News is exploring some of the most common myths surrounding fluoride, including its effectiveness and potential neurocognitive impacts, by consulting with experts on how dentists can talk to patients about separating myth from fact and making informed decisions about their dental health.

Neurocognitive impacts

One of the most recent claims is that community water fluoridation causes neurocognitive decline, due in part, to a mix of scientific misinterpretation, misinformation and fear. However, Jayanth Kumar, D.D.S., former state dental director of California, said this is categorically false.

“No study has shown that fluoride reduces IQ in fluoridated communities. We have several studies and no association at all,” Dr. Kumar said, adding that the cross-sectional studies that do indicate that high fluoride could have an effect are from countries like China and India, where the concentration is “very high.” 

The National Toxicology Program released a report in 2024 summarizing the available literature about a possible relationship between fluoride exposure, neurodevelopmental and cognitive health, and IQ. The report found that fluoride in drinking water at more than twice the recommended limit is associated with lower IQ in children. 

The report’s authors acknowledged the findings are limited to fluoride exposures that are more than double the more than or equal to 1.5 milligrams per liter what the Centers for Disease Control and Prevention recommends for community water fluoridation, 0.7 milligrams per liter. The authors also noted that only 22 of the 74 studies they based their conclusions on were of high quality and low risk of bias, thus reporting their finding with only a moderate degree of confidence.

“No recognized authority has said that fluoride reduces IQ at levels for water fluoridation,” Dr. Kumar said, noting that even the National Toxicology Program report highlights that association should not be conflated with causation. Dentists can point patients to the fact that the ADA strongly supports the practice and that the CDC has proclaimed community water fluoridation as one of the 10 great public health achievements of the 20th century.

Effectiveness

The question of whether community water fluoridation is effective is a resounding yes, said pediatric dentist Jessica Robertson, D.M.D., chair of the ADA Council on Advocacy for Access and Prevention. Dr. Robertson — who works at several sites in Arizona, only one of which is currently fluoridated — said one of the most common questions among her patients is why kids are getting cavities. They claim to brush and floss consistently, according to Dr. Robertson, but when she says fluoridation provides protection throughout the day, she is often met with surprise.

“I’m like, ‘Well, because we don’t have fluoride in our water.’ And they’re like, ‘Oh, that really makes a difference?’ And I tell them yes,” she said of why cavities are more prevalent in unfluoridated areas.

Dr. Kumar said fluoridation both reduces cavities and saves money. The best example of this comes from Calgary, Canada, he said, which stopped fluoridation in 2011. Follow-up studies revealed that cavities increased, the treatment costs for cavities in operating rooms increased, and IQ scores did not increase. A decade later, the city decided to add it back.

Similarly, a 2019 study found that children with Medicaid in Juneau, Alaska, who did not have access to optimally fluoridated water had more dental caries-related procedures than kids who grew up before the city ceased its fluoridation program. There are many fluoridation-related resources for dentists, including the ADA’s newest edition of “Fluoridation Facts,” which was published in June.

“Dentists should get the ‘Fluoridation Facts’ book and make it available to their patients. I think we’ve answered almost all questions in that book,” Dr. Kumar said.

Fluoridated toothpaste

Many people who are skeptical of community water fluoridation are also skeptical of fluoridated toothpaste. For the patients who desire to “go natural,” Dr. Robertson said dentists can remind them fluoride is not only naturally occurring but is also one of the most common minerals in the world.

In an effort to be more natural, many patients will purchase charcoal toothpaste. This comes with a slew of issues, including degrading enamel, Dr. Robertson said, instead encouraging patients to consider the myriad companies that offer toothpastes with minimal ingredients.

“It’s hard to know where they’re getting this information sometimes. They’re relying on unsubstantiated resources and they’re not questioning them, but they’re questioning doctors and dentists,” Dr. Robertson said.

For patients who are concerned about fluoridated toothpaste, she suggested starting small. Dentists can ask patients if they’d consider starting on fluoridated toothpaste, at least in small amounts. This is especially important if they’re getting cavities and if they’re located in unfluoridated areas.

“[Dentists can say], ‘If you don’t want to use fluoridated toothpaste at this time every day, let’s just try it at night and protect those teeth at night. Would you consider using it a couple times a week?’ So, we start small and see if we can work it up and get them out of this disease process,” Dr. Robertson said.

Spreading the word

Consistency is key when it comes to educating patients on community water fluoridation and fluoride toothpaste, according to Dr. Robertson. She highlighted the importance of organizations banding together through coalitions to drive a purpose, and of dentists regularly discussing fluoride during patient visits.

“Just talking about it every single time. [Dentists can say], ‘I know you’re not using fluoridated toothpaste. At this point it’s working, but if it doesn’t, let’s see what we can do to prevent this in the future,” Dr. Robertson said.

She also encouraged dentists to tell personal stories and anecdotes to instill a sense of trust in patients. She’s found it highly effective to say she wants what is best for their children and that she wouldn’t suggest anything she isn’t already doing in her own family.

“People still trust their doctors, even though they have a lot of mistrust out there. But when it comes down to it, they still listen to the dentists. They might not change their mind today; it might be something that changes over time,” she said. “[But you’re] planting the seeds and you’re working towards a goal.”