| | ![Leana S. Wen]() | | Opinions columnist | | My column this week was very different from what I anticipated. I had listened to a NPR interview
in which Robert F. Kennedy Jr., who is expected to play a key role
overseeing health policies in Donald Trump’s coming administration, said
his Day 1 priority would be to stop municipalities from adding fluoride
to public water systems. | | My first reaction was: “This is nuts.” Kennedy has a long history of trafficking in antiscience conspiracy theories; surely, this was one of them. I planned to write a column that would debunk his arguments and explain why fluoridation is sound public health policy. | | When I delved into the research, I was shocked: The data clearly indicates that conventional wisdom needs to be revisited. | | As
I explained in my column, the benefit of continuing to fluoridate
drinking water is unclear given the widespread availability of
fluoride-containing toothpaste. In addition, emerging research raises
concerns for fluoride’s negative impacts on developing brains. | | Several
readers took issue with the research I cited. “Are you really saying
that we should upend public health policy based on a few cherry-picked
papers?” John from Virginia asked. | | Anna
from Massachusetts, a pediatric dentist, worries that ending
fluoridation would increase dental cavities. “Poor dentition causes
pain, results in school absenteeism and can impact other body systems
including the heart,” she wrote to me. | | To John’s question, the studies demonstrating fluoride’s impacts are well-conducted, peer-reviewed and published in prestigious journals such as JAMA. Earlier this year, the National Toxicology Program, which is part of the Department of Health and Human Services, concluded with “moderate confidence” that fluoride in drinking water is linked with lower IQ in kids. | | Critics
have pointed out that the association is seen at fluoride levels either
at or higher than 1.5 milligrams per liter, which is more than twice
the optimal level recommended by the U.S. Public Health Service. But as a 2023 paper published in Nature found, nearly 3 million Americans live in areas with tap-water fluoride levels at or above this threshold. The Environmental Protection Agency’s top limit for fluoride is 4 milligrams per liter, far above the level associated with harm. | | At
the very least, the federal government’s report should have prompted a
warning to people who live in areas with high fluoride concentrations. In
particular, there should have been an advisory to pregnant women to
decrease their total intake by using fluoride water filters and avoiding
products that have high fluoride concentrations, such as black teas. The EPA should also lower its acceptable limit. | | None
of this has happened. I suspect a key reason is because of the issue
Anna rightfully brought up: Tooth decay is very serious. In a country
that does not have nearly enough dental care, it is especially important
to have public health measures that reduce the risk of cavities. | | But government officials must consider the totality of a policy’s effect on the population, not just one aspect of health. | | It might be true that stopping fluoridation will increase caries. A 2021 Canadian study found that after Calgary stopped fluoridating its water in 2011, it saw an increase in cavities. A 2024 Cochrane review
of studies, however, concluded the evidence wasn’t clear as to whether
there were “any effects on tooth decay” when localities remove fluoride
from the water supply. | | In any case, the possible increase in dental problems has to be balanced against the possible harm to the developing brain. If given the choice of what is more important to their kids — preventing cavities or saving IQ points — many people would probably choose the latter. Cavities can be treated, but effects on the brain are often irreversible. | | Plus, there are other, more targeted ways to protect teeth. People living in areas without fluoridated water should use fluoridated toothpaste. This is already the case for most countries in western Europe, many of which have long decided to stop public water fluoridation. | | All of this led me to conclude that it’s not the worst thing if water fluoridation were to end in the United States. | | This was not an easy decision to reach.
It went against my preconceptions and, frankly, I felt very
uncomfortable disagreeing with major medical associations such as the American Academy of Pediatrics and the American Dental Association,
which continue to affirm the safety of community water fluoridation. I
also expected some readers to be angry that I am seemingly taking the
side of a notorious anti-vaccine activist. | | At the end of the day, I decided to write my column, and this newsletter, because I have to follow the science. As unexpected as the conclusions might be, my duty to readers is to report what I’ve found.
Something isn’t automatically wrong because I didn’t know about it
before or because it’s espoused by people with whom I have other
disagreements. | | Since
last week’s election results, I’ve been reflecting a lot on how I will
cover medicine and health policy developments from the incoming Trump
administration. This fluoride situation was an unexpected early test
case. I anticipate I will vehemently oppose many of the administration’s decisions. I might also agree with some. My promise is that I will strive to be as objective as I can and always base my analysis on a careful evaluation of the science. | | | |