Water Fluoridation

Water Fluoridation in United States

United States

Community water fluoridation, the addition of an optimal amount of fluoride to a public water supply, effectively prevents tooth decay in children and adults. Fluoride inhibits mineral loss and enhances remineralization in tooth enamel. Tooth decay, also called dental caries, is the result of bacteria dissolving a tooth’s enamel. Dental caries is one of the biggest threats to oral health and one of the most common chronic diseases in the United States. Untreated dental caries can lead to pain and bacterial infection. 

Children with dental caries have nearly 3 times the odds of missing school due to dental pain than children with good oral health and, on average, have poorer school performance. Children from low-income families have a higher prevalence of tooth decay, experience more barriers to accessing dental care and are less likely to have private dental insurance. Community water fluoridation is one of the primary methods of addressing this disparity — it can improve the oral health of large populations without adding time or cost burdens to individuals.

Roughly 73% of the U.S. population with public water access in 2018 received water fortified with fluoride to the recommended concentration of 0.7 milligrams per liter. However, those using private wells — an estimated 23 million American households, according to the 2021 U.S. Census American Housing Survey — may not be getting the recommended amount of fluoride and may experience higher rates of tooth decay or other health concerns than individuals receiving fluoridated water through public water systems. A recent study found that children in low-income families just above the poverty level were less likely to live in a community where at least 75% of the population was served by a fluoridated water source, compared with children in both higher- and lower-income groups.

Community water fluoridation is a safe and cost-effective intervention to widely deliver fluoride to all community members, regardless of age, socioeconomic status and race/ethnicity. The Centers for Disease Control and Prevention (CDC) named community water fluoridation one of the Ten Great Public Health Achievements of the 20th century.

Community water fluoridation saves money for both individuals and communities. The return on investment varies by community size, but even small communities experience economic benefits. Estimates suggest that community water fluoridation saved an average of $32.19 per person in 2013. Among children, water fluoridation is effective at reducing the prevalence of tooth decay. One community found that ceasing community water fluoridation led to a 51% increase in dental caries among young children ages 0-6.

Healthy People 2030 has an objective to increase the proportion of people served by optimally fluoridated community water systems.

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Centers for Disease Control and Prevention. 1999a. “Ten Great Public Health Achievements -- United States, 1900-1999.” MMWR. Morbidity and Mortality Weekly Report 48 (12): 241–43. https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm.

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Hannan, Casey, and Lorena Espinoza. 2018. “Statement on the Evidence Supporting the Safety and Effectiveness of Community Water Fluoridation.” Atlanta, GA: Centers for Disease Control and Prevention, Department of Health and Human Services. https://www.cdc.gov/fluoridation/guidelines/cdc-statement-on-community-water-fluoridation.html.

Iheozor-Ejiofor, Zipporah, Helen V. Worthington, Tanya Walsh, Lucy O’Malley, Jan E. Clarkson, Richard Macey, Rahul Alam, Peter Tugwell, Vivian Welch, and Anne-Marie Glenny. 2015. “Water Fluoridation for the Prevention of Dental Caries.” Cochrane Database of Systematic Reviews, no. 6. https://doi.org/10.1002/14651858.CD010856.pub2.

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Meyer, Jennifer, Vasileios Margaritis, and Aaron Mendelsohn. 2018. “Consequences of Community Water Fluoridation Cessation for Medicaid-Eligible Children and Adolescents in Juneau, Alaska.” BMC Oral Health 18 (1): 215. https://doi.org/10.1186/s12903-018-0684-2.

O’Connell, Joan, Jennifer Rockell, Judith Ouellet, Scott L. Tomar, and William Maas. 2016. “Costs and Savings Associated With Community Water Fluoridation in the United States.” Health Affairs 35 (12): 2224–32. https://doi.org/10.1377/hlthaff.2016.0881.

Sanders, Anne E., William B. Grider, William R. Maas, John A. Curiel, and Gary D. Slade. 2019. “Association Between Water Fluoridation and Income-Related Dental Caries of US Children and Adolescents.” JAMA Pediatrics 173 (3): 288. https://doi.org/10.1001/jamapediatrics.2018.5086.

U.S. Department of Health and Human Services. 2000. “Oral Health in America: A Report of the Surgeon General.” Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf.