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  • Water Fluoridation in the USA

    How Much is Too Much?

    For decades the amount of fluoride added to our water supplies (fluoridation), has sparked some heated debate amongst those for and against its application. On one side there are many who believe fluoride in drinking water helps protect dental health from problems such as tooth decay yet on the other side there are those that believe it’s only harming our overall oral health. Since 1962, communities throughout the country have been adhering to the required Drinking Water Standards that regulate fluoridation, however, new scientific data has made people think twice about what’s in their drinking glass.

    New research by the Environmental Protection Agency (EPA) and the National Research Council (NRC) of the National Academies of Science) found an increase in the prevalence of dental fluorosis (white spots on teeth or pitting on the surface of a tooth), the relationship between water intake and outdoor temperature, and new fluoride sources outside of tap water (e.g. toothpaste). This research led the U.S. Department of Health and Human Services to make the first definite change since 1962. The organization is now recommending that 0.7 parts per million (ppm) or mg/L is the ideal fluoride level for communities in order to maintain the benefits of fluoridation and avoid risk of dental fluorosis. Despite this government mandate in April 2015, experts on both sides continue to stand their ground on the benefits and pitfalls of adding fluoride to our drinking water.

    Picture of EPA building

    The USA EPA Building

    A History of Fluoridation

    In 1960s, a report showed that fluoride reduced cavities by 90% - making it an inexpensive method to allow all of the country to combat tooth decay, regardless of their age or socio-economic status. While the recommended levels of fluoridation sat between 0.7 mg/L and 1.2 mg/L, the Department of Health and Human Services concluded that there should be a lower concentration of fluoride in warmer areas because children “drank more water on warm days.” Such studies began to show that the higher the concentration of fluoride in the water (between 0.3 mg/L to 1.2 mg/L), the greater instances of dental fluorosis in those children, increasing from 13.5% to 41.4%. Through the years, the research continued to prove the benefits of fluoride in drinking water when it reported a 60% decline in cavities in 12-19 year olds between 1999 and 2004.

    Need an graphic that shows 60% decline in cavities in 12-19 year olds between 1999 and 2004.

    Current Fluoride Status

    Recent Changes

    More recent studies conducted by the National Health and Nutrition Examination Survey (NHANES), between 1988 and 2004, surveyed more areas throughout the country. New analysis proved that outdoor temperature accounted for less than a 1% variation in water intake, meaning there was no correlation between the two. These findings have led to a change in the federally recommended amount of fluoridation in public water supplies across the US. A level of 0.7 mg/L, was deemed an appropriate, uniform standard in all temperate zones of the country, and would help to maintain a reduction in dental cavities in young people, while minimizing their risk of fluorosis.

    Individual State Levels

    Although this is a federal standard, some states still show a higher level of fluoride that exceeds the recommended 0.7mg/L level. You can check the state levels of fluoride in your county’s water supply using this interactive map created by Waterlogic, an industry-leading bottleless water cooler provider. Waterlogic has used the CDC’s My Water’s Fluoride database, a public database of 27 states that have volunteered their own fluoride information, to put together Waterlogic’s USA Fluoride Level Map (please see About Fluoride Data Collection for more information regarding the collection of data, including states that are not in the CDC’s pop

    According to Kip Duchon, a National Fluoridation Water Engineer with the Centers for Disease Control and Prevention (CDC):

    The world is a different place in 2015 than it was in 1962. Water consumption was shown to be variable in 1962. But, in the current world, water consumption is very uniform throughout the country. Why is that? Because it turns out that houses in Minnesota are better heated than they used to be 50 years ago. Houses in Texas tend to be better air-conditioned than they were in 1962. Plus, we have a more sedentary lifestyle today
    - Kip Duchon

    In addition, more people today receive fluoride from sources outside of their drinking water. “Your primary source of fluoride is from drinking water since you don’t get enough of it from things like toothpaste or food,” continued Duchon. “But we also realize that people were having those other beneficial exposures, so we realized that the lowest level within the recognized beneficial range would be suitable for everyone considering the fact that they would get additional fluoride from other sources:

    Full width image here

    Risk with Fluoridation

    While trying to remain neutral in the fight for and against fluoride in drinking water, the CDC does acknowledge that excessive amounts of fluoride can cause enamel fluorosis, or white spots on the teeth. Combined with the lower recommended quantity of fluoride, the CDC recommended that adults should carefully monitor the fluoride intake of children younger than six years old since this is a critical period for tooth development. The CDC reported that one group that is most critically affected by fluorosis and demonstrating higher sensitivity to fluoride are African Americans and Hispanics. These two groups were shown as having had more severe cases of fluorosis than whites.

    Dr Kathy Thiessen, Director and Senior Scientist at the Oak Ridge Center for Risk Analysis in Tennessee is strongly opposed to fluoridation. As she explains:

    "[Recent data] ... indicates no significant benefit from water fluoridation, but a significant association with dental fluorosis, a situation that will not be avoided by fluoridating all cities at 0.7.mg/L ... At the very least, even if dental fluorosis is considered only a cosmetic problem, it takes money to treat to improve a person's appearance and perhaps his or her self-esteem ... A growing number of studies indicate associations between dental fluorosis and increased risk of various health problems. Considerable evidence indicates that water fluoridation is an unsafe and unethical practice, with little or no real benefit."
    Dr. Kathy Thiessen, Director and Senior Scientist at the Oak Ridge Center for Risk Analysis in Tennessee.

    The Case For and Against Fluoridation

    Pros and Cons

    Fluoridation has a history as a controversial, divisive issue. On one side, supporters of fluoridation in drinking water tout its benefits to dental health. On the other side, there are several vocal groups and individuals who cite fluoridation as the source of numerous health issues, ranging from thyroid conditions to autism and attention-deficit hyperactivity disorder (ADHD).

    Pros and Cons of Water Fluoridation

    Argument Against

    Laura Pressley, Ph.D., an anti-fluoridation advocate, believes that fluoridation was a factor in her diagnosis of Hashimoto’s Thyroiditis, an autoimmune disorder that affects the thyroid. She had been taking medication for the condition and showed signs of fatigue, brain fog, loss of hair, and weight gain.

    “I started doing the research, and fluoride attacks your thyroid... Fluoride is very similar to iodine electronically because it’s in the same column of the periodic table. Your body uptakes fluoride from your thyroid instead of iodine and it causes your body to function improperly. When that happens, your thyroid wants to work harder to put out the chemicals your body needs. You’re overtaxing your thyroid and it’s exhausted, so you get hypothyroidism.”
    Laura Pressley, Ph.D

    Dr. Pressley mentioned that many people are exposed to significant amounts of fluoride that they may not be aware of, “in your tap water, tea, and actually, sodium fluoride is a pesticide, which gets on fruits and vegetables.” She also noted the difference between naturally occurring fluoride and the fluoride added to water in her home state of Texas, “Because of the oil deposits and geology, you’ll have natural levels of calcium fluoride.

    That is a different chemical than what’s put in the tap water. With calcium fluoride, the fluoride is bound to the calcium. The chemical being put into the tap water is an acid. There’s no calcium associated with it, so the fluoride attacks the calcium in your body. It attacks your bones, it attacks your teeth -- that’s why you get pitting -- and in your bones, you’ll get osteomalacia, a softening of the bones.”

    With this in mind, Pressley made a decision to eliminate fluoride from her diet. After four or five months, her Hashimoto’s Thyroiditis went into remission and has been in remission ever since. “I’m off all of my medications. I’m back to my normal weight. My hair filled out. I regained my energy, and I ran for City Council,” she said. “My health completely rebounded.

    Highest and lowest state

    Argument For

    On the other hand, many still stand for fluoride in drinking water. Kip Duchon, an environmental engineer who provides technical direction to the water fluoridation process with the CDC, has interacted with both pro- and anti-fluoride representatives on both sides of the issue and has pointed to the 2006 National Academy of Sciences Study and a 2015 Cochrane study as evidence that fluoridation in drinking water is safe.

    “Every time the National Academy of Sciences has looked at water fluoridation, they have always come back with the understanding that it’s safe and healthy based on science.” Duchon noted that many of the concerns that anti-fluoride advocates currently espouse were presented prior to the publishing of the study and the National Academy of Sciences had refuted them, deeming fluoridated water as safe. “The report said there was no scientific basis for those concerns.”
    Kip Duchon

    Duchon said that while there have been studies conducted that pinpoint fluoride as a culprit in health issues, these studies may not have been systematic -- meaning, a review of transparent processes that examines all available research in context with each other to tell a story that helps people better understand what’s really happening.

    Bruce Austin, the Statewide Dental Director for the Office of the Chief Medical Officer of Oregon, echoed many of Duchon’s concerns.

    “As for public education, the internet is a huge source of disinformation and false information. The best facts tend to come from the consensus of science done by expert panels and groups of researchers, rather than cherry-picked data from individuals. I do feel that a sound education campaign based on science will only help the public’s understanding of the safety, efficiency, and cost-effectiveness of community water fluoridation."
    Bruce Austin, the Statewide Dental Director for the Office of the Chief Medical Officer of Oregon

    While the question of whether to fluoridate or not remains a state and local issue, the CDC provides the science to support the states and does not play a role in managing fluoridation. It was science that prompted the CDC’s reassessment of the 1962 recommendation with public health in mind.

    “We actually did that over a 10 year period, there was a lot of research that we did going into that. We actually started that work in 2005. We did a lot of new research on water consumption. The fact is that we’ve been doing water fluoridation for 70 years -- and for every one of those years, the number of people who are getting fluoridated water increases. And that’s a good thing, to increase the access to fluoridated water to people. There’s still a big need for it.”
    Kip Duchon

    In addition to a Harvard study linking fluoridation to autism and ADHD, some of the concerns the public has about fluoridation’s impact on overall health stem from uncertain evidence of fluoride causing bone cancer. According to the American Cancer Society, population-based studies examined the risk between water fluoride levels and cancer, comparing cancer rates in communities with lower versus higher levels of fluoridation. However, the organization recognizes that there are other factors that make it hard to conclusively prove that fluoride is the source of adverse health effects. On their website, the American Cancer Society poses the question: “If fluoridation is a risk factor, is the type of fluoride used important? Also, is there a specific level of fluoride above which the risk is increased, or a certain amount of time or an age range during which a person would need to be exposed?”

    On the flipside, several studies have shown fluoridation has provided significant benefits to dental health. The U.S. Task Force on Community Preventive Services concluded that fluoridated water reduced tooth decay by a median rate of 29% among children of ages 4 to 17. Similarly, the Journal of Dental Research concluded that fluoridation reduced decay in adult teeth by 27%, making fluoride the most effective and practical method for reducing the gap in decay rates between low-income and upper-income Americans.

    While the CDC has pointed to research that indicates fluoridation is safe, others are concerned about the amount of fluoride in drinking water and whether it is appropriate for people of all ages and sizes. Laura Pressley stated that, “When a family goes to a doctor and they all have strep throat, the doctor doesn’t give them all the same dose of an antibiotic. They give a dose per weight, and per history and sensitivity of the patient.”

    Pressley questioned even the new, lower, recommended dose of fluoride in public water supplies, asking, “Why would we be medicating people with this fluoridated water, one-size-fits-all to a child versus a man that’s 6’ tall? That makes no sense to me. We should not be putting any type of water to treat any type of disease because people have different sensitivities. Those who have hypothyroidism are going to be more negatively affected than those that don’t. Children, babies -- they’re going to be more affected.”

    Fluoride State Regulations

    Although the CDC spearheaded extensive studies over a ten-year period to re-evaluate the 1962 recommendations, water fluoridation in a community’s drinking supply is managed at a state level -- not a national one.

    Water fluoridation is not a hard and fast rule. To date, 15 states (along with Washington, D.C. and Puerto Rico) have mandatory fluoridation regulations where if a water system in that state is serving a specific minimum population, that system is required to fluoridate its drinking water. Arkansas, for example, must fluoridate if the system is serving 5,000 people or more.

    Other U.S. states that mandate water fluoridation based on population include:

    Image of states that enforce fluoride levels

    While some states have mandatory fluoridation regulations, individual towns, cities, and even counties throughout the U.S. who have called for a ban on fluoride in their water supplies because of the uncertainty around it's benefits.

    What does fluoridation mean for you?

    Want to Get Involved in the Debate?

    Regardless of where you stand on the issue of fluoridation, you can take an active role within your state in advocating for or against adding fluoride to their community water supply:

    For starters, take a look at Waterlogic’s USA Fluoride Level Map and learn just how much fluoride is in your state and local drinking water supply. If you have questions about the levels of fluoride in your area's drinking water, get in touch with your local public water system. The CDC has listings for 39 states that participate in its My Water's Fluoride program, making it easy to find your county and its contact information if you have questions regarding fluoridation.

    Further Education

    If you want to further educate yourself on the topic of Fluoridation below is a list of resources available.

    • Talk to your state representatives about your findings and make them aware of what matters to you as their constituent.

    Waterlogic Fluoride Level Map

    If you’re looking to remove fluoride from your drinking water, as you advocate for your cause, one way to do it is through the purchase of a reverse osmosis, deionizer, or activated alumina water filter. These three types of filters are able to remove about 90% of fluoride from tap water. However, not all water filters are effective for this purpose. For instance, activated carbon filters do not remove fluoride.

    When phasing out fluoride from her own diet, Laura Pressley turned to reverse-osmosis water: “If I go to a restaurant and all they have is tap water, I will not drink it. I’ll have fresh-squeezed orange juice, if they have it. I won’t drink black tea with tap water. I won’t drink coffee with tap water. I will bring a bottle of reverse osmosis water into a restaurant. That’s how I deal with it.” Pressley also looked to eating organic foods whenever possible to avoid traces of fluoride due to foods treated with pesticides.

    Distillation units can also help to remove most, if not all fluoride. These units range from $200 for a small countertop distillation unit to over $1,000 for a much larger unit.

    The Future of Fluoridation

    Although the CDC has provided a nationwide maximum of 0.7 mg/L of fluoridation in public water supplies, these levels can vary by state and locality. Geographical factors also play a role in levels of naturally occurring levels of fluoride. If you'd like to learn more about levels of fluoride in your area's drinking water, the Waterlogic’s USA Fluoride Level Map is a helpful resource to garner accurate, at-a-glance information and compare your locality to surrounding areas or states throughout the country.

    While these recommended levels of fluoride have been proven to reduce dental cavities and are considered the most effective way to provide widespread dental protection to the greatest number of citizens, there are a still number of people who are worried that regular exposure to fluoride may have adverse effects on health.

    However, individuals who believe the concerns associated with fluoride outweigh its benefits are able to take action for themselves, either by calling for more research to be conducted on the subject, or personally taking steps to eliminate fluoride from their drinking water.

    “The CDC will continue to encourage additional research on water fluoridation because we want to be the first to say that we don’t know everything. We will still continue to work with partners to identify what research is important and to better understand what the salient issues are. I think the knowledge base will continue to grow as to what we need to know about water fluoridation.”
    - Kip Duchhon


    About Fluoride Data Collection

    Since Fluoridation in communities is managed at a state level and not a national level, not all states are included in the CDC’s My Water’s Fluoride database.

    For states that did not participate in the CDC’s database, we contacted each of these states’ Department of Health directly, speaking with officials about the most recent fluoride data available to the public ranging from 2011 to 2015. As mentioned, not all states are required to collect and report fluoride data on a yearly basis, which accounts for gaps in the reporting years available for this data.

    The fluoride levels reported in the Waterlogic Fluoride Database are considered the “final levels” in public drinking water from a specific public water system which include both natural and manual fluoride concentrations, which are added at water treatment plants.

    Since public water systems can serve multiple cities and there are many water systems in a given county, we included a weighted average for counties and states that takes into account the population for those areas. Our goal was to report the fluoride concentration at the point of public consumption, regardless of the exact source of the fluoride. In doing this, we’re reporting a more accurate measure of the amount of fluoride the public is consuming.

    What causes high fluoride levels?

    Some regions have higher, naturally occurring levels of fluoride in the water supply than others. Groundwater typically contains more fluoride than surface water. Dry regions generally have higher fluoride levels in their water than regions that have higher average rainfall amounts. Two of the Top 3 states with fluoride levels above the .7 mg/L recommended limit -- Texas and Arizona -- have dry, arid climates.

    According to Rae Nadler-Olenick, an advocate for Fluoride Free Austin and the Texas coordinator for the Fluoride Action Network, “Looking at average concentration by county, Texas has more areas than other states that are above the limit. Natural fluoride is high in parts of Texas, such as El Paso.”

    Unique conditions to a specific area -- from climate to the type of soil or clay prevalent throughout the terrain, play a role in how fluoride concentrates in groundwater within a given state, as well as spatial variability of fluoride. For instance, a report from the Arizona Department of Environmental Quality stated that:

    “Elevated fluoride concentrations may occur throughout Arizona but tend to be most common in the southeastern and west central portions of the state. Fluoride concentrations above 5 mg/L are controlled by calcium through precipitation or dissolution of the mineral fluorite. In a chemically closed hydrologic system, calcium is removed from solution by precipitation of the calcium carbonate and the formation of smectite clays; high concentrations of dissolved fluoride may occur in groundwater depleted in calcium if a source of fluoride ions is available for dissolution (Robertson, 1991). Thus, wells having soft, sodium-dominated, older water, such as artesian wells drawing from deep aquifers in southeastern Arizona, are likely to have elevated fluoride concentrations.”
    Arizona Department of Environmental Quality