President-elect Donald Trump’s pick to run the nation’s health agency, Robert F. Kennedy Jr., has railed against the practice of adding fluoride to drinking water, a measure that public health experts and dentists credit with reductions in tooth decay. Seven out of 10 Americans who get their drinking water from public water systems receive fluoridated water, according to data from the Centers for Disease Control and Prevention.
Shortly before the election, Kennedy wrote in a post on X that “the Trump White House will advise all U.S. water systems to remove fluoride from public water” on Inauguration Day. His post also repeated debunked claims that the mineral increases the risk of bone cancer.
After research showed that naturally occurring fluoride prevented cavities, some communities began adding it to their drinking water supplies in the 1940s and 50s. By 1980, half of the population received fluoridated water.
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What state and local governments can do
Fluoridation efforts have not followed traditional political lines.
Some of the states with the lowest rates, like Oregon and New Jersey, are run by Democrats and voted for Vice President Kamala Harris. Fluoridation rates top 90 percent in several deep-red states that have long promoted the practice, like Kentucky, South Carolina and West Virginia.
Most communities that add the mineral do so voluntarily, but about a dozen states require fluoridation. A handful of the mandates have been in place for more than 50 years. After Arkansas’ more recent law passed in 2011, the fluoridation rate there rose from 65 percent in 2010 to 87 percent in 2022.
Many of the mandates exempt small or medium water systems, meaning some rural communities in those states remain unfluoridated.
The Trump administration can’t overrule those state laws, said Kathi Hoke, director of the Network for Public Health Law’s eastern region and a professor at the University of Maryland law school. They can’t tell a state “how it can act within its own borders on a public health measure, generally speaking,” she said.
As long as systems have been adding fluoride, activists have been fighting against it, sometimes successfully. In recent months, lawmakers in states including Arkansas, Georgia, Kentucky and Nebraska have introduced bills to repeal their mandates. While none of those attempts have passed, anti-fluoride activists pledge to keep trying.
Even without regulatory change, federal advisories could lead communities to revisit long-standing water treatment decisions.
Florida’s surgeon general, Joseph A. Ladapo, recommended against fluoridation in late November. Several communities, including Naples and Stuart, have since decided to stop adding the mineral or began discussions, citing Ladapo’s guidance. In 2022, 78 percent of the state’s residents on public water systems received fluoridated water.
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What the federal government can do
Though the federal government does not mandate fluoridation or directly control local water systems, the Trump administration could still influence communities across the country to reconsider decades-old fluoridation programs.
Besides issuing warnings like Florida’s, the Trump administration could also remove the federally recommended fluoride level in drinking water, according to Hoke.
“States and local jurisdictions really aren’t in a place to spend the resources and have access to the expertise to know what that optimal level is,” she said.
That federal guideline was most recently revised in 2015, changing from an optimal range of 0.7 to 1.2 milligrams per liter to a single recommended value of 0.7. Changing it again, or completely removing it, could lead to an explosion in fluoridation debates in local governments across the country. Additionally, some of the state mandates are tied to federal recommendations and would need to be amended to remain in full effect if the recommended level is removed or lowered to zero.
The Trump administration could more directly target long-standing military fluoridation rules. Some military bases were providing fluoridated water as early as the 1950s. More recent Department of Defense guidance directed many U.S.-based installations to maintain optimal fluoridation levels beginning in 2016, while additional policies govern military drinking water abroad.
The Army Corps of Engineers runs the Washington Aqueduct, which treats and supplies water for about a million D.C.-area residents and began fluoridating in 1952.
The water agencies for the District and Arlington, Virginia, purchase treated drinking water from the aqueduct. Neither has the ability to fluoridate water on their own and their purchase agreements don’t require the Army to continue fluoridation, according to spokespeople from both local governments.
The Trump transition team did not respond to questions about their plans for fluoride advisories or regulatory changes.
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Dangerous side effects are rare
While Kennedy has repeatedly tied fluoridation to cancer despite years of research showing no link, some side effects have been proved.
Moderate levels can cause dental fluorosis, a cosmetic condition that affects the appearance of the teeth.
The most serious complications occur from long-term exposure at very high levels found naturally in some parts of the world, not at the low levels added to drinking water. One, skeletal fluorosis, can lead to bone and joint problems, but the condition is almost nonexistent in the United States.
The Environmental Protection Agency limits fluoride to four milligrams per liter in community water systems to avoid serious health risks, meaning systems with naturally very high levels have to take steps to reduce it. Hardly any private well owners remove the mineral.
Such high levels are rare in the United States. A 2020 CDC analysis found that less than 1 percent of people on community water systems receive water with at least 1.5 milligrams per liter, more than twice the amount recommended by American health officials.
Naturally high levels in the United States are mostly concentrated along the High Plains aquifer that runs from West Texas through Nebraska, and the Dakotas, according to a Swiss study that modeled fluoride in groundwater globally based on water samples.
Map of the continental US showing where fluoride in groundwater is high, defined as greater than 1.5 milligrams per liter. These areas are mostly in western Texas, the Oklahoma panhandle, western Nebraska, the Dakotas, and parts of New Mexico, Arizona, and southeastern California.
An August report from the National Toxicology Program analyzed prior research, primarily from countries with much higher levels of fluoride than is typically found in American drinking water, and found that high levels are associated with lower IQ in children. The authors were careful to note that “more research is needed to better understand if there are health risks associated with low fluoride exposures.”
Weeks later, a federal judge ordered the EPA to further regulate fluoride in drinking water, citing that report and others.
Though Kennedy promised that the new administration would warn against fluoridation on its first day, realities of governance may slow any action.
Kennedy and Trump have also pledged to tackle food safety, chronic illness and vaccine regulation. “Where are they going to spend their political capital with Congress?” Hoke said. “Where are they going to spend their political capital with the community? Where do they have the resources and support? They’re not going to be able to do everything that they claim they intend to do.”
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State fluoridation mandates
Fluoridation rates as of 2022.
Arkansas: 87%. A 2011 statute requires community water systems serving at least 5,000 people to fluoridate, contingent on funding being provided to do so. As of 2022, 33 of 35 previously non-fluoridated systems subject to the mandate had begun fluoridating, according to a state report.
California: 58%. Water systems with at least 10,000 connections are required to fluoridate if provided funding to do so under a 1995 law.
Connecticut: 90%. Water systems serving at least 20,000 people have been required to fluoridate since the 1960s.
Delaware: 70%. Municipalities are required to fluoridate.
Georgia: 95%. Incorporated communities are required to fluoridate their drinking water. The mandate, revised over the years, first became law in 1973.
Illinois: 98%. Community water systems are required to fluoridate under a state law first enacted in 1967.
Kentucky: 100%. Community water systems serving 3,000 or more people are required to fluoridate. Kentucky has near-universal fluoridation.
Louisiana: 38%. A 2008 state law mandated that systems with at least 5,000 connections fluoridate their water if the state provides funding to do so. In the years since, very little money has been allocated for new fluoridation efforts. Communities that were already fluoridating water before the 2008 law would need to hold a referendum to stop fluoridating their water. Louisiana has one of the lowest fluoridation rates in the country.
Minnesota: 99%. Municipal water systems have been required to fluoridate since 1970.
Mississippi: 47%. State law requires community water systems serving at least 2,000 people to fluoridate if provided funding to do so.
Nebraska: 74%. Cities and villages with at least 1,000 people are required to fluoridate unless the community voted to prohibit it.
Nevada: 74%. Large water systems in Clark County, home to 73 percent of Nevada’s population, have been required to fluoridate since 2000 under state law. A 2017 proposal would have expanded the mandate to Washoe County but the bill did not receive a floor vote.
Ohio: 93%. Community water systems serving at least 5,000 people have been required to fluoridate since the 1970s.
South Dakota: 94%. Community water systems serving at least 500 people have been required to fluoridate since the 1970s.
(c) 2024, The Washington Post · Hannah Recht