The Trump administration is controversial if nothing else. His cabinet members too are unconventional in their roles, or preparedness for those roles. One particularly so is Robert F. Kennedy Jr. (typically referred to as RFK Jr.), the Secretary of Health and Human Services.

RFK Jr. has some notable points of view that are neither outlandish nor dangerous. One such example is his effort to remove additives and dyes from our foods. Yay, Mr. Secretary. Other of his possible policies are less well-founded in scientific research and data.

So where does Fluoride fall in this scheme of things with the new Health and Human Servies?

As a spoiler alert, upfront I will share that RFK Jr described fluoride as “industrial waste.” Kennedy too offered a spoiler alert on January 20 (2025) when he stated that the Trump White House would advise all U.S. water systems to remove fluoride from public water. He posted on social media X that “Fluoride is an industrial waste associated with arthritis, bone fractures, bone cancer, IQ loss, neurodevelopmental disorders, and thyroid disease.”

Some think any opponent of fluoride is also anti-science. But the science and the issue of Community Water Fluoridation (CWF) is not that simple. Whether you admire or abhor the new secretary, we need to know that there are many components to consider here (‘here’ meaning in the US and worldwide).

What Exactly IS Fluoride?

Let’s take a brief look at what this substance is (if we must). Fluoride is an inorganic chemical ion containing fluorine. And because fluorine is missing an electron it will bond with an element that has an extra. (Really, more than I care to know). These Fluorides are found naturally in food, soil and water (salty and fresh). Not only is it present in almost all water sources, but it’s naturally released from rocks into the water, as well as into soil and air.

While many additives are used by the public water systems, three which often rise to the top of the trepidation list are:

1. Chlorine
2. Flocculates
3. Fluoride

It is difficult to discuss fluoride, or the binary compound of fluorides, in our water supply unemotionally. Generally, everyone has a point of view. But how did it even start? How did we get here?

How Water Fluoridation Started

Even the background and origin of water fluoridation is controversial. Each of the stories may be true, but are cherry-picked to make an argument for or against.

The sympathetic version is that in the early 1900s it was noted that in some areas with naturally high levels of fluoride, children had dark mottled teeth (known as skeletal fluorosis), but more importantly also fewer caries. 1909, two U.S. dentists F. McKay and G. V. Black initiated a 15-year follow-up study in Colorado Springs, Colorado and observed the same – high fluoride, lower cavity rates.

Later, where I lived in the Hudson Valley/Catskill Mountain area of New York there were comparative studies of artificial fluoridation in Newburgh and Kingston; and at a similar time, another study In Michigan compared Muskegon and Grand Rapids. Thus, communities decided that such water would reduce childhood dental problems.

The not-so-sympathetic version of fluoridation beginnings (which RFK Jr. alluded to) is the story that fluoride is a toxic by-product (in large quantities) of the aluminum industry, and which is very expensive for the industry to dispose. After finding that fluoride in water helped children’s teeth, the industry was an active supporter in dumping fluoride into the public water supplies. In more recent phraseology, they might have explained it as a win-win.

In 1950, federal officials endorsed Community Water Fluoridation (CWF) which is the process of monitoring and artificially adjusting the fluoride level in drinking water (hopefully to the optimal amounts) for caries prevention. It has continued to promote CWF despite fluoride toothpaste becoming ubiquitous on the market. Today in the U.S. 72% of the population receive fluoridated public water.

In the United States, from 1962 until 2015 the recommended level of fluorinated water was 1.2 mg/L (reduced from an earlier level). But those standards have now been changed and are reduced to 0.7 mg/L (often represented as 0.7 ppm – ppm meaning ‘parts per million’).

In Europe the first water fluoridation was in “West” Germany and Sweden in 1952, bringing fluoridated water to about 42,000 people. By mid-1962, about 1 million Europeans were drinking fluoridated water. Neither Germany nor Sweden (nor other European countries) fluoridate water today. (See details in the section on countries which restrict it.)

Benefits Spurring Continued US Fluoride Use

There are two major benefits to Community Water Fluoridation (CWF).

1. Makes teeth stronger (by reducing demineralization and protecting surface remineralization, making tooth enamel strong).
2. Inhibits bacterial growth (preventing decay and reducing dental caries).

According to the CDC and the ADA (American Dental Association), fluoride can decrease tooth caries in the permanent teeth of children by 26%. Even if the percentage varies, it is clear that Fluoride DOES protect children’s teeth.

Fluoride is considered “one of the greatest public health achievements in 100 years”, according to the US Center for Disease Control (an opinion held at least until the most recent political appointments). It’s often added that fluoride is the most cost-effective way to prevent tooth decay on a large scale. We will see that this might be debatable.

According to the CDC, the CWF programs have been instrumental in the overall global reduction in dental caries. (We will see that most countries no longer agree with this analysis.)

In Utah where it is being discontinued the Utah Dental Association warns that the elimination will have a disproportionately negative effect on low-income residents who may rely on fluoridated water as their only source of preventative dental care.

What Concerns do Opponents State?

The most recent concern was highlighted in an upstate New York town that for one summer I called home (Yorktown Heights). On January 6^th of this year, CNN reported on a nine-year research review examining the relationship between fluoride and intelligence. It caused the residents of Yorktown Heights to reject fluoridation after the system was repaired following 12 years of inactivity.

The study (reported widely) found every one part per million increase in fluoride in urine was associated with a roughly one-point drop in a child’s IQ score. The study of this neurological effect, published in JAMA showed that the lower IQ was especially noted in boys, but seen in both sexes. These results were based on levels generally higher than what is now recommended.

For years there have been strong opponents of F-water. Often, it’s difficult to know if the studies quoted were well done or not. (See post on evaluating research – A Magic Elixir for Everlasting Life? — 3 Warning Tips from California Researcher.) One researcher quoted repeatedly is Dr. Dean Burk, MD the former chief chemist of the National Cancer Institute in Washington, D.C.  Burk published more than 250 scientific articles; he also became head of the National Cancer Institute’s Cytochemistry Sector in 1938. After retiring from the NCI in 1974, Dean Burk remained active, devoting himself to his opposition to water fluoridation. He and a coauthor published an analysis of cancer mortality in 10 cities that fluoridated the drinking water supply and 10 that didn’t. On a video from the Irish Inquiry, he was quoted as saying “In point of fact, fluoride causes more human cancer deaths and causes it faster than any other chemical.”

I mention him because you can barely review fluoridation opposition without coming across his name. Yet, the paper he is famous for has been criticized for using overly broad grouping and making assumptions about variations in racial composition of cities. Epidemiologists from the National Cancer Institute state that an analysis of the findings found no significant increase in cancer mortality associated with fluoridation. Burk considered ingested fluoride as “mass murder on a grand scale.” The only problem with the proclamation and with the criticism is that the study has not been repeated to determine if Burk’s findings have any credibility or not.

Concerns Continued

There are other reasons given to oppose fluoridation. The list below is taken from the US NIH article “Fluoride Debate” (see reference section). Both pros and cons are included in this article, and the concerns have varying levels of seriousness.

While not yet updated, according to this paper in January 2012, over 4,000 professionals have signed a memorandum to end water fluoridation worldwide. It also states that the US Food and Drug Administration have classified fluoride as an “unapproved new drug” (although not new).

Reasons to Oppose Fluoridation

1. Fluoride intake through fluoridated water is uncontrollable, since people are receiving varying doses regardless of age, health status, and individualized therapy.
2. Water might get contaminated with toxic chemicals while being fluoridated.
   Not all countries provide certificates of analysis and the amounts of contaminants in chemicals added to water.
3. Excessive fluoride intake may cause dental fluorosis. [50 ]
4. Studies on animals and humans concerning fluoride intake showed neurotoxic, nephrotoxic, and other adverse effects even when small doses are administered. [ 39, 40, 43, 48]
5. Fluoride can be received from sources other than fluoridated water, including ingested (mechanically deboned meat, pesticide residue, and tea) and non-ingested products (fluoridated toothpaste). [52, 53, 55]
6. The fluoride benefit is topical rather than systemic, so it is better to be directly delivered to the teeth. [56]
7. In fluoridated low-income countries, tooth decay is widely spread and is mainly caused by the absence of dental care and poor hygiene. [34]

One of my own personal concerns is the question of how a community can regulate the intake of F-water when some drink so little and others so much. Individuals are not statistics, so the fluoride intake can be very different.

Where is Water Fluoridation Most Common?

United Kingdom (UK), Australia and United States fluoridate a great deal of their water. In UK approx. 10% have access to fluoridated water; in Australia, about 90% have access, and in the U.S. about 72% receive fluoridated public water. These figures may not include naturally occurring fluoride but represent supplies from public water systems.  (See details about Canada below.)

In Europe, only Southern Ireland, Serbia, and parts of Spain have not rejected fluoridation. In Spain, while moving away from the practice, they technically have a water fluoridation program, but (according to Fluoride Action Network) only 11% of its residents receive fluoridated water.

Most Countries Ban or Restrict Fluoridation

After various degree of studies, most countries have either stopped or banned water fluoridation systems. Some had to consider levels of naturally occurring fluoride in their water. Further, a large amount of their data shows no difference in children’s cavities (now with other topical applications of fluoride available) between areas which receive fluoridated water and those that do not.

Those rejecting fluoridation programs include the following countries:

• Canada: the country has regional and municipality differences, some with bans. Most of Ontario fluoridates its water as well as Alberta and Manitoba, while British Columbia, Newfoundland and Quebec have rejected it. [Recent Nova Scotia story below shows it is still controversial).
• Austria
• Belgium
• China: Fluoridation is banned or “not allowed.” Naturally high fluoride levels in water are a serious problem in China.
• Czech Republic: not used and not under consideration because this form of supplementation is considered “uneconomical, unecological, unethical and debatable”.
• Denmark
• Egypt
• Finland
• France
• Germany
• Greece
• Holland
• Hungary
• Iceland
• India
• Ireland:  Northern Ireland only (where fluoride was added to water for almost 30 years until 2000, the addition was ceased for “operational reasons” but has not been restarted.)
• Israel
• Italy
• Japan
• Luxembourg
• Mexico: While Mexico has no water fluoridation program, instead it has a table salt fluoridation program; similar to the iodine added to much table salt. (See more on this later).
• Netherlands
• Norway
• Poland
• Scotland
• Spain
• Sweden: Drinking water fluoridation is not allowed in Sweden which claimed that scientific documentation of benefits to dental health has not been conclusive. (Note elsewhere the high level of naturally occurring fluoride in Sweden.)
• Switzerland: Basel, the only city in Switzerland or western Europe to fluoridate water stopped the practice in 2003.

Long list, eh?

Note: Countries that take particular care because naturally occurring fluoride in water is already above optimal levels include (but are not limited to) Sweden, Sri Lanka, Finland, Zimbabwe and Gabon. Controlling treatment levels in fluoridated water can be difficult. The World Health Organization (WHO) has said that treatment need not be any higher than 0.5-1.0 mg/L.

Recent Changes in North America

There are small towns changing their use of CWF; I mentioned Yorktown Heights above, only because I had lived there. The numerous changes don’t mean it is no longer controversial. In September 2024 the council of New Glasgow in Nova Scotia voted to discontinue fluoridation, which “will save the community around $20,000” annually, according to the staff report from the town’s assistant director of engineering and public works. It had been fluoridating its water since 1975. The Nova Scotia Dental Association opposes the decision.

In March 2025, Utah Republican Gov. Spencer Cox signed legislation barring cities and communities from deciding whether to add the mineral to their water systems. The first state in the U.S. Why? Some legislators said it was a matter of ‘individual choice’ when the public health benefit might be achieved some other way. Several Utah lawmakers referenced the cost of fluoridated water as too expensive, while residents seem more concerned about health.

A Utah teenager claimed to legislators that in Sandy, Utah, a fluoride pump malfunctioned in 2019 releasing excessive amounts of the substance into drinking water and sickening hundreds of residents. But the NIH reminded people that it’s “virtually impossible” to get toxic doses of fluoridated water when standard levels of the mineral are adequately controlled.

Governor Cox was reported to explain that many people in Utah, including himself and his own children, grew up without fluoridated water. On an interview with ABC4 in Salt Lake City, he stated “You would think you would see drastically different outcomes with half the state not getting it. We haven’t seen that, so it’s got to be a really high bar for me if we’re going to require people to be medicated by their government.” The Utah and American Dental Association strongly oppose.

Other states have rejected the change, like New Hampshire, North Dakota and Tennessee. Yet, Florida, South Carolina, Kentucky and Ohio are considering similar measures to Utah.

Studies Vary

The report that started the most recent controversy that I mentioned under the concerns section has been explained as showing “with moderate confidence” that there is a link between higher levels of fluoride exposure and lower IQ in kids. Less emphasized is the phrase “higher levels.” The National Toxicology Program constructed its conclusions on studies which had almost twice the recommended limit for drinking water.

A federal judge has ordered the U.S. EPA to regulate fluoride in drinking water due these possible risks to the intellectual development of boys and girls. While it is difficult to know if a political aspect to the controversy is raising its head, Florida’s surgeon general has recommended against CWF due to its “neuropsychiatric risk.” I assume this is similar to a neurotoxin risk.

From the other side of the issue, and other side of the continent, we turn to Canada. After a 2023 Canadian expert health panel examined the potential neurocognitive risks and effects of fluoride in drinking water, they found that although fluoride has been reported to affect various enzymes and their regulation, no specific mechanism for that was found that would affect learning, memory or other cognitive neurodevelopment. While they noted that ingesting large amounts of the substance can lead to skeletal fluorosis, it’s rare in Cananda.

These Canadian finding led to a study out of Calgary, an area that had removed fluoride in 2011. (Remember that about half of Canada is fluorinated and half not). Community heath scientist, Linsay McLaren ran a large study of thousands of kids in Calgary without CWF and Edmonton having CWF. Seven to 8 years later, a larger percentage of tooth decay (65%) was seen in Calgary as opposed to Edmonton (55%). They are considering returning to the system. On the PBS NewsHour, she explained that there are other ways to address tooth decay but we need to build public support so that all children have care.

European studies in non-fluoridation areas still find complications. Alternatives may be the answer.

In April 2025, (under RFK Jr.) the EPA put out a press release stating they Will Expeditiously Review New Science on Fluoride in Drinking Water. According to the press release, they hint at open-mindedness when administrator Lee Zeldin says: “Without prejudging any outcomes, when this evaluation is completed, we will have an updated foundational scientific evaluation that will inform the agency’s future steps to meet statutory obligations under the Safe Drinking Water Act.”

Inequity for Lower Income Strata

Water fluoridation may be the norm in North America, but it doesn’t have to be the norm in your own life if you don’t want it to be AND if you have the funds to modify your water supplies. Still, there are solutions from other countries that meet public health standards without fluoridating water.

On the expensive side is the personal home water-filtration system. Many (not all) of these will eliminate fluoride from water, but they’re not always affordable to lower income families much less where water itself is barely available

The good thing is that we do have a choice (whether rich or poor) to use our collective voice to make certain that alternatives to CWF are provided to everyone. This is particularly important for children. Ingesting fluoridated water will protect against caries, but in areas with considerably low levels of naturally occurring fluoride, there are alternatives.  Public health may also include, or switch to, the application of dental fluoride treatments, fluoride tablets, fluoride toothpastes and mouth washes and the inexpensive and highly effective fluoridation of SALT.

Fluoridated Salt

Blog readers, you’re welcome to read the dry information below about this fluoridation solution. Or you can just accept that it is a solid system common outside the U.S. with lots of advantages. However, reading on might introduce you to new information.

The addition of fluoride to salt (similar to how we add iodine to salt) has become a well-established public means of fluoride delivery in most countries (other than the US). It has been used for decades in public health in most of Europe, Central and South America (other than Brazil, Chile and Panama). More recently it has been adopted by many African and Asian countries.

According to numerous studies (some of which I reference at the bottom) salt fluoridation is an effective “automatic” caries prevention similar in success when compared to ingesting fluoridated water. It’s also more controllable than CWF systems which may have machine breakdowns or other accidents (as the fluoride additive can sometimes be unstable).

Those beyond their adolescent years might choose a plain salt product, as you can today with non-iodized salt. The formula used for most F-salt products is a mixture of potassium fluoride and sodium fluoride to table salt to accomplish a concentration of about 250-300 mg of fluoride/kg salt. This is considered a good balance as the “acceptable” level of fluoride for caries control is most often cited at 200 mg/kg salt. One concern about this method of dental protection is hypertension from too much salt. This needs more research but limiting one’s salt amount, even for children will more than likely still supply enough fluoride protection.

According to the Pan America Health Organization and as stated in the Salt Fluoridation review “If salt fluoridation is identified as the preventive method to use in a country, it is necessary to do a thorough assessment of drinking water sources to identify communities or regions where fluoridated salt should not be distributed. For example, in Mexico, which has a national salt fluoridation program, fluoridated salt is not distributed in four Mexican states that tend to have appreciable concentrations of fluoride in their drinking water sources.” They suggest not using fluoridated salt where there are CWF programs still in use.

Highlights of Fluoridating Salt

Salt as a solution to impacting community health dental care (and coverage of those receiving it) is obviously affected by several factors that CWF is not, specifically distribution, marketing and pricing. Both must deal with matters of implementation methods.

Here are some highpoints of Salt Fluoridation around the world. (They are taken from The Fluoride Debate: The Pros and Cons of Fluoridation – PMC -NIH National Publication of Medicine)

1. Salt Fluoridation was initiated in Switzerland in 1955.
2. It’s supported by community trials WHO, FDI World Dental Federation and recommended by others
3. Presently, more than 300 million people worldwide use fluoridated salt.
4. During operation, the estimated cost of fluoridated salt is 10-100 times LOWER than that associated with water fluoridation programs.
5. In some circumstances salt fluoridation is a more cost-effective caries prevention for children than either fluoride in items such as water, milk or mouth rinses.
6. While it is ‘shown’ to inhibit dental caries around the word, opponents say there have not been randomized clinical trials to prove F-salt efficacy.
7. Fluoride concentration ranges from 250-300 mg/kg of table salt. Minimal best effect on caries is a concentration of 200 mg/kg. These figures tend to be less than community water fluoridation programs, especially in areas where there is additional naturally occurring fluoride.
8. No side effects of significantly mottled enamel were shown in groups using salt containing 200 or 250 mg /kg in comparison with groups not consuming F-salt.
9. There has been no adverse impact identified when combing iodine and fluoride in salt.

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FINAL THOUGHT

More data probably IS needed, but I have felt for decades that topical fluoride treatment with solutions, tablets and toothpaste is better than large quantities ingested from our water. Now, with the addition of fluoridated salt, the CWF or community water fluoridation programs seem more controversial (both in health and cost).

There is no question that fluoride hardens teeth. The remaining query is how do we best ensure that benefit for all children, at what levels of fluoride, and while taking the health of adults and seniors into consideration.

One more thing…

A sodium atom undergoes a vigorous reaction with fluorine…
How do you feel?” Asks the fluoride ion.
“Positively shell shocked” the sodium ion replied.

And if you get that joke, I applaud you, you’ve really been paying attention.

Keep smiling – with that tooth-healthy grin!

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Resources:

Canada regional varieties 2022: The State of Community Water Fluoridation across Canada – Canada.ca

For more on salt fluoridation used by refer to this article at the NIH National library of Medicine. The Fluoride Debate: The Pros and Cons of Fluoridation – PMC

Additional references on salt:

Marthaler TM. Salt fluoridation and oral health. Acta Med Acad. 2013;42:140–155. doi: 10.5644/ama2006-124.82. [DOI] [PubMed] [Google Scholar]

Barker JC, Guerra C, Gonzalez-Vargas MJ, Hoeft KS. Acceptability of salt fluoridation in a rural Latino community in the United States: an ethnographic study. PLoS One. 2016;11:e0158540. doi: 10.1371/journal.pone.0158540. [DOI] [PMC free article] [PubMed] [Google Scholar]

Salt Fluoridation: a review by Howard F. Pollick, bds, mph

Estupiñan-Day S. Overview of salt fluoridation in the Region of the Americas, Part I: Strategies, cost-benefit analysis and legal mechanisms utilized in the national programs of salt fluoridation. In: Proceedings of Salt 2000– 8th World Health Symposium, The Hague, The Netherlands, 2000

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Picture credit: Sprouting Water statue Photo by Catherine Ryan on Unsplash

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