The love/hate debate over fluoride in water is bubbling in NC

As President-elect Donald Trump announces key members of his next administration, many in the oral health profession across North Carolina are brushing up on the facts and figures in fluoride studies and research.

Robert F. Kennedy Jr., a member of Trump’s transition team who could have an influential health policy role in the 47th president’s next term, recently posted on X (formerly Twitter) that fluoride is “an industrial waste associated with arthritis, bone fractures, bone cancer, IQ loss, neurodevelopmental disorders, and thyroid disease.”

The post, which drew more than 24 million views in 10 days, also links to a video interview on a website created by a conspiracy theorist with an attorney involved with a fluoride-related lawsuit filed by Food & Water Watch, a national environmental group, against the Environmental Protection Agency.

That case garnered a flurry of headlines in September, when a federal judge ruled in California that he had been presented enough evidence to find that, at certain levels, fluoride in drinking water poses potential risk to cognitive decline. Judge Edward Chen, an Obama appointee, added, though, that his finding does not “conclude with certainty that fluoridated water is injurious to public health.”

The American Dental Association quickly responded to the judge’s ruling by reaffirming its posture that “community water fluoridation is safe and beneficial to oral health.”

“The dose makes the poison” is a principle of toxicology. And dentists contend that adding fluoride in small, controlled doses to community water systems does more good than harm — touting it as one of the 20th century’s hallmark public health achievements. The Centers for Disease Control and Prevention describe community fluoridation as “the most cost-effective method of delivering fluoride to all members of the community” and lowering tooth decay in children and adults.

Despite this storied history, Chen wrote in his Sept. 24 order that fluoridation also “has been a source of political discord, at times.”

Here at home

That discord has been on display in North Carolina, especially this year as several western counties and communities debated fluoride bans.

The Union County Board of Commissioners voted 3-2 Feb. 19 for such a ban after a group that called themselves the “fluoride fighters” urged the elected officials to take action.

That vote had reverberations in neighboring Stanly County, where the county’s board of commissioners, and the City Council of Albemarle heard presentations on the topic in March but took no action.

In Davidson County, the Thomasville city council discussed the issue as well, but took no vote.

Kings Mountain in Cleveland County was scheduled to consider a measure last month to remove fluoride from the city’s drinking water, but that didn’t happen.

Brian Helms, vice chairman of the Union County board of commissions, told NC Health News there were a variety of reasons he supported the fluoride ban. His decision, he said, came after listening to people from both sides of the hot-button topic. One driver, he said, was the issue of consent, that a government’s decision to add fluoride to the water was taking the decision about whether to partake away from individuals.

“Fluoride is the one and only chemical that we add to our drinking water that’s designed to treat the person and not the water,” Helms said. “With that in mind, there is emerging science to show that fluoride that you’re getting in your water is not the fluoride you get at your dentist’s office or in a rinse. You’re actually ingesting it.”

Body of research

“There has been a history of anti-fluoridation all over this country, including in North Carolina, particularly in western North Carolina,” Steve Cline, vice president of the North Carolina Oral Health Collaborative, told NC Health News. “Our posture has been ‘Don’t really take them on.’”

Kennedy, a prominent vaccine critic who has built a following based on conspiracy theories and his family’s name, has seen many of his claims debunked by science, leading to Politifact describing his campaign of conjectures as the 2023 Lie of the Year.

A wealth of research has found that adding fluoride to water is a safe way to reduce tooth decay and its severity. The recommended level for the past nine years in the U.S. has been 0.7 milligrams per liter, which the North Carolina Dental Society likens to 70 cents out of $1 million.

“Not only is fluoride proven to reduce decay, but it also reduces the severity of decay,” the dental society representing nearly 4,000 N.C. dentists states in its fluoride position. “Plus, it’s estimated that community water fluoridation saves North Carolina citizens more than $800 million in treatment each year.”

Cline and others are worried about the heightened attention that Kennedy brings to a public health issue that could become more politicized if Trump indeed calls for removing fluoride from water as his new ally has recommended.

“I am worried that these tried and true, very well researched, very low cost ways of preventing tooth decay are under attack,” Cline said.

Studies show fluoride benefits

Gary Slade, a professor in the department of pediatric dentistry and dental public health at UNC Chapel Hill, was an author of a study published in 2018 that evaluated the association between the availability of community water fluoridation and tooth decay in children and adolescents.

Slade and his fellow researchers found that in counties where more than 75 percent of the population had access to fluoridated water, there was a 30 percent decrease in tooth decay in primary teeth and a 12 percent decrease in adolescent teeth compared with county populations that had less access.

The research also found the benefit of fluoridation to be most significant in childhood, in the primary teeth of children 2 to 8 years old.

If communities stopped adding fluoride to their water systems, Slade said, he would expect to see a 10 percent to 30 percent increase in tooth decay among children.

These days, toothpaste and mouthwash contain fluoride, and dentists can add a topical gel to a child’s teeth as protective measures. But fluoridated water is a greater protection, most oral health care providers say.

“The one doesn’t cancel out the other,” Slade said. “Those things will help offset the shortage.”

Slade is the principal investigator in a controlled study underway in Lenoir and Wayne counties, where 200 households are asked to drink only bottled water — half with fluoride, half without — to find out if fluoride in bottled water helps prevent tooth decay in young children. Kinston, the largest city in Lenoir County, does not have a fluoridated water system.

For years, scientists have been saying fluoride is good for dental health, and critics will say “that’s all based on observational studies,” Slade said. “We’re now doing a randomized control trial.”

Barriers to access

Rhonda Stephens, a dental public health specialist at the UNC Chapel Hill Gillings School of Global Public Health, stressed that community water fluoridation can help children who might face access barriers to oral health care.

“The greatest concern is not everyone can afford a tube of toothpaste or toothbrush,” Stephens told N.C. Health News. “Not everyone can afford to get to a dentist for topical fluoride.”

If affordability is one issue, access is another. North Carolina has long struggled with dental provider shortages.

A 2023 map posted by the state Department of Health and Human Services showed that 97 of North Carolina’s 100 counties were designated Dental Health Professional Shortage Areas. Counties are given such designations when they don’t have enough oral health professionals to meet the needs of the entire county.

There are multiple reasons for the shortages, especially in the rural reaches where long-established dentists are reaching retirement age. New dental school graduates begin their careers with heavy student debt load that can cause them to gravitate toward urban and suburban areas where larger practices might mean better pay from the start.

Programs that offer student loan forgiveness and other incentives have been created to try to reverse that trend, but oral health providers tout preventative measures such as adding fluoride to water as another bridge to better oral health in underserved communities.

“The whole notion behind water fluoridation is it extends beyond all the boundaries,” Stephens said.

‘It’s important to be empathetic’

It can be difficult to communicate public health benefits when there are competing messages from critics who are not always heeding established science.

With that in mind, Stephens has been working on a grant proposal to help oral health care providers be better prepared to educate and advocate for science that is not always easily understood.

That already was in the works, Stephens said, before Kennedy and others made community water fluoridation a topic of recent debate.

“That was coming down the pipeline, and it just happened to align with what’s going on now,” Stephens said.

Mark Moss, the division director of public health dentistry at the East Carolina University department of foundational sciences, has been active lately trying to make sure people understand the science behind fluoride.

“It’s important to be empathetic,” Moss told NC Health News.

In many cases, Moss said, people already have their minds made up. “What you do is you try to talk to the other people in the room — the people trying to make informed decisions.” he said. “It’s hard to get people to step out of their comfort zone and change their mind.”

One of his talking points is “fluoridation is a good thing. It saves money. It helps prevent tooth decay.”

Another issue Moss said he stresses is similar to one Stephens also makes — that removing fluoride from community water systems is more likely to disadvantage those already facing barriers to oral health care.

State legislators weigh in

Jim Goodman moved to North Carolina this year to become the new executive director and CEO of the North Carolina Dental Society, which represents nearly 4,000 dentists in this state. He stressed the public health aspect in a recent interview with NC Health News. Without fluoridated community water systems, he said, dentists would see more tooth decay and likely benefit financially from filling more teeth, he speculated.

“The NC Dental Society stands by all the valid science, from many sources over many years, that substantiates the safety and efficacy of proper levels of fluoride in water sources,” Goodman said. “Dentists across NC and the country are dedicated to improving oral/overall health, which fluoridated water has been proven to do — even with the financial disincentive to do so.”

North Carolina lawmakers showed an interest in the topic last year, when they included a provision in the state budget calling for the state Commission for Public Health to review a 2022 draft report issued by the National Toxicology Program titled “Monograph on the State of the Science Concerning fluoride Exposure and Neurodevelopmental and Cognitive Health Effects: A Systematic Review” along with other studies “relevant to an assessment of the association between fluoride exposure and IQ in children.”

The Commission for Public Health released that report on Aug. 7, describing an evaluation of the toxicity program report, which is still under review and revision, as “premature.”

The law was amended this year asking the Secretaries’ Science Advisory Board to review the issue, which is scheduled for discussion at the board’s Dec. 4 meeting.

Helms, one of the three Union County commissioners who voted to ban fluoride from the one water system fully under the county’s purview, cited the recent California court decision as evidence that science can change over time.

“We learn every single day that just because something was correct 50 to 60 years ago doesn’t mean that we can’t change,” Helms said. “I think history is going to prove us to be right with this. I think you can already see the perception of fluoride change.”

Oral health advocates caution that some of the studies cited by anti-fluoridation groups are not based on fluoride amounts used in U.S. water systems. Others are based on small sample groups that could be affected by factors not given weight in the research.

“The studies themselves are also something we should be careful about,” Moss said.