A federal judge in California recently ordered the Environmental Protection Agency (EPA) to, “engage with a regulatory response,” on the question of water fluoridation. The American Dental Association (ADA) immediately issued a press release affirming their staunch support for community water fluoridation and emphasizing that the ruling, “does not conclude with certainty that fluoridated water is injurious to public health." The court ruling provides no additional scientific evidence to compel the ADA to change its recommendation. State and national dental societies continue to support water fluoridation as an essential, and extraordinarily successful, public health measure. Water fluoridation is estimated to prevent more than 25% of tooth decay in children and adults over their lifetime.  

The order follows a legislative session in which Georgia legislators considered adjusting laws governing community water fluoridation. Currently, Georgia law requires a community referendum prior to the removal of fluoride from drinking water. Recent uptick in debates over fluoridation suggests a need for continued vigilance, education, and advocacy.  

Is water fluoridation safe and beneficial? 

Water fluoridation is safe and beneficial. Water fluoridation works by providing, “frequent and consistent contact with low levels of fluoride.” Community fluoridation began with a 1945 experiment in Grand Rapids, Michigan. Over the course of the 15-year project, the rate of dental caries among children in Grand Rapids dropped more than 60%. Since then, study after study confirmed this beneficial effect. Not only does water fluoridation prevent tooth decay, it also produces significant savings on healthcare costs as well as economic returns. For communities of 1000 or more people, the return on investment per dollar invested is $20 according to a comprehensive study on community water fluoridation.  

It's important to emphasize that Judge Chen wrote that, “confidence in hazard data and overall strength of the evidence and uncertainties, are largely neutral.” His decision consistently comes across as a cautionary one, and his final instruction ordering, “the Administrator to initiate rulemaking,” throws the question back into the hands of experts at the Environmental Protection Agency. The EPA already has a fluoride standard in place. Its federally enforceable standard is that fluoride in drinking water 4 mg/L, more than 4 times the optimal level of water fluoridation recommended by the U.S. Public Health Service. Furthermore, any community that exceeds 2 mg/L must provide public notice to people in the service area.  

The evidence above paints a picture. Public health regulations are already in place. Water fluoridation has a long history, and it has a demonstrable benefit. In fact, its benefit is significantly more noticeable than many public health interventions proposed and implemented by state and federal governments. Many interventions barely move the needle, but fluoride has been an incredibly effective tool against tooth decay and its downstream effects. As such, the most likely outcome of this decision will be to push the EPA to refine and justify its existing standards. The decision will not, and should not, end community water fluoridation in the United States.  

Why did the judge instruct the EPA to engage with a regulatory response? 

The judge’s finding in Food and Water Watch vs. the United States Environmental Protection Agency turns on the question of whether community water fluoridation presents “unreasonable risk” to some segment of the public. A standard requiring proof of unreasonable risk is a step back from one requiring proof of actual harm. Rather, plaintiffs merely needed to provide evidence that there is some risk from fluoride exposure and that it is unreasonable; with reasonableness determined by the size and susceptibility of impacted populations, severity of the harm, and the frequency and duration of exposure.  

Too much of a good thing can often be a bad thing. Too much iodine can lead to thyroid disfunction, but iodized salt is another significant public health intervention. The introduction of iodized salt in the 1920s largely ended problems associated with endemic iodine deficiency in the United States. Likewise, long-term exposure to fluoride levels above 4 mg/L can cause some disruption, and alternative water sources are recommended for children under age 8 whose main water source contains more than 2 mg/L. In this sense, fluoride may be considered to present a “risk,” and because a large number of people are regularly exposed to fluoride in their environment, regardless of whether or not communities adjust fluoride water levels, Judge Chen found the reasonableness criterion to have been met.  

Much of the judge’s determination of risk turns on the findings of a recent review put out by the National Toxicology Program last August. The review emphasizes in its opening lines that it does not, “address whether the sole exposure to fluoride added to drinking water in some countries is associated with a measurable effect on IQ,” and reviewers sought to evaluate the available literature concerning an association between fluoride and neurocognitive development. They found no evidence to support an association between fluoride and neurocognitive outcomes in adults. For children, the review did find with “moderate confidence” that fluoride exposure in excess of 1.5 mg/L may be negatively associated with IQ; however, reviewers highlighted several methodological shortcomings including a lack of high-quality studies conducted in the United States. Most of the included studies used a cross-sectional design, and the studies’ results could not demonstrate the of persistence associations or assess exposure by development stage. 

The ADA’s expert panel who reviewed the report offered additional commentary. In sum, they said that, “the monograph does not provide any new or conclusive evidence that should necessitate any changes in current community water fluoridation practices for public health policy consideration.” The ADA has raised concerns about the National Toxicology program’s research methods in the past including questions about unorthodox research methods, flawed analyses, lack of clarity, and a failure to follow the norms of peer review. Howard Pollick, an ADA spokesperson, indicated that the National Toxicology Program has not adequately addressed these concerns and others from the National Academies of Sciences, Engineering and Medicine.  

The resulting picture is one which suggests that a subset of the population, in this case children under 8, may wish to moderate their intake of fluoridated water in areas where water has naturally occurring fluoride levels that more than double optimal fluoride concentrations, a recommendation that is already on the books. Further, and hopefully higher quality, studies on water fluoridation will continue. Existing evidence does not suggest that community water fluoridation is unsafe at optimal levels.  

How does this impact Georgia and what happens next? 

Given Georgia’s recent legislative conversation about community water fluoridation, the topic may come up again in the legislature. Georgia Dental Association continues to be vigilant, and we regularly monitor for legislation affecting community water fluoridation. Dentists can help by paying close attention at the local level and advocating for optimally fluoridated water. Mentioned above, communities in Georgia are entitled to hold a referendum on water fluoridation if they choose: This makes water fluoridation a highly localized issue. 

_{Source: Centers for Disease Control and Prevention- My Water’s Fluoride, 2023} 

Too many Georgians are already losing out on the benefits of fluoridation. Only about a third of community water systems report adding fluoride to their water. That third includes most of the Georgia population with access to community water systems, but just over 450,000 people lack access to fluoridated water in these areas. Georgia water typically needs fluoride to be added to bring it up to optimal levels. Dentists can be effective local advocates for the significant public health benefit that community water fluoridation offers.  

Georgia Dental Association provides many opportunities for dentists to advocate for their communities, patients, and themselves. If you would like to get involved, sign up as a contact dentist, consider attending Law Day, or give to GDAPAC. Join GDA in ensuring all Georgians are able to access high quality dental care throughout the state.