Story by Sydney Brainard
Photos by Joe Macia
In March, Utah became the first state in the country to ban fluoride in its public water systems. Several other states, including Montana, North Dakota and South Carolina have also proposed their own state-wide fluoride bans.
For some in North Carolina, it’s a similar story.
Last year, Union County voted to ban the addition of fluoride in their public water system. Only months later, Stanly County Commissioners heard community comments on banning fluoride in the water, although they ultimately didn’t vote on it.
Now, Lincoln County has joined the fray, voting earlier this year to prohibit the addition of fluoride in the county’s water. The system had previously broken, meaning that most of Lincoln County wasn’t receiving fluoride already. Fixing the system would mean an expensive repair, and due to “the widespread availability of fluoride through other means such as toothpaste and bottled water,” as described in the meeting minutes, the county voted to discontinue fluoridation altogether.
Once upon a time, water fluoridation was dubbed one of the ten great public health achievements of the 20th century by the Centers for Disease Control and Prevention. In recent decades, however, the tide of criticism of water fluoridation has risen—and not just from conspiracy theorists, either.
From parents to politicians, anti-fluoride sentiment has hit the mainstream and is making its way into policy decisions across the state and the country. And with outspoken fluoride opponents, like recently appointed Health and Human Services Secretary Robert F. Kennedy Jr., rising to power, community water fluoridation is likely to continue facing the axe.
Groundbreaking origins
Fluoride is a naturally occurring mineral present in soil, water, plants and food. Its effect on teeth began to be explored in the early 1900s, when a dentist named Dr. Frederick McKay opened up a dental practice in Colorado Springs, Colo. He discovered that many of his patients that lived in town had strange brown spots on their teeth.
McKay collaborated with dental researcher Dr. G.V. Black, discovering that these brown-stained teeth were curiously resistant to decay. The stains that McKay and Black observed is what we now know as fluorosis–a dental condition that occurs when teeth are exposed to excessive levels of fluoride. This high level of fluoride was naturally present in the water source of Colorado Springs.
Years later, based on McKay and Black’s early observations, fluoride was researched more closely for its effect on the enamel of teeth. A study was conducted in Grand Rapids, Mich., in 1945. The experiment involved fluoridating the public water supply at a safe level—one that wouldn’t result in fluorosis.
The outcome was groundbreaking: the rate of cavities in Grand Rapids children born after the water fluoridation fell by over 60%. By 1950, community water fluoridation was being recommended by the American Dental Association and the U.S. Surgeon General. Just four years later, 20 million Americans were drinking fluoridated tap water. By 1980, it was half the country.
Current controversy
As of 2022, an estimated 63% of the United States population receives fluoridated water from community water systems. In North Carolina, it’s closer to 67%, according to CDC and U.S. Census Bureau data.
In the decades since fluoride was initially discovered to prevent cavities and decay, the ADA has maintained that fluoride is the most efficient way to prevent cavities and that the practice of fluoridating the public water supply is safe and beneficial for the population.
Fluoride opposition points to studies showing that high levels of fluoride can negatively affect cognitive development in children. During the Union County Board of Commissioners meeting on the issue, Abigail Prado, chair of the Union County Moms for Liberty chapter, said that “fluoride has been found to cause more damage to pregnant women and their growing babies than lead, mercury or arsenic.” It’s a false assertion often repeated by anti-fluoride individuals. The claim seems to have originated online from various charts comparing the lethal doses of the chemicals, which is not comparable with the recommended fluoride concentration level of 0.7 mg/L in public water systems. Prado did not respond to interview requests.
Other studies, like the 2019 JAMA Pediatrics study on pregnant mothers in Canada, did show fluoride having an adverse effect on their children’s I.Q.; however, experts have called out many limitations in the study. The fluoride intake, for example, was measured through the mothers’ self-reported beverage consumption. Others noted the lack of differentiation between postnatal and prenatal exposure effects. It’s also significant that the I.Q. test itself can have its own limitations.
From the current fluoride research available, there is little that suggests adverse developmental effects at the actual recommended fluoride concentration level of 0.7 mg/L, only at higher concentrations.
With Kennedy at the helm of the Department of Health and Human Services, this doesn’t seem to matter.
Late last year, Kennedy wrote on X that the Trump administration would, “advise all U.S. water systems to remove fluoride from public water,” and called fluoride “an industrial waste.”
State lawmakers took note, with this recent flurry of state bans being proposed in the wake of the election. In an interview to Bloomberg Law, Tennessee state Sen. Joey Hensley, who introduced a fluoride ban for Tennessee, said that Kennedy’s anti-fluoride rhetoric is helpful to the cause.
After Utah enacted its ban, Kennedy visited the state for a victory lap. “I’m very, very proud of this state for being the first state to ban it, and I hope many more will come,” he said to reporters during the visit.
Debate comes home
In North Carolina, nearly one in five kindergarteners has untreated tooth decay, according to the NC Department of Health and Human Services. Children and older adults are still particularly prone to dental decay, and the accompanying symptoms of pain and sensitivity. In fact, it’s still the most common chronic childhood disease. At the same time, fluoride bans have continued to be introduced and discussed across the state. Last year, the North Carolina legislature even requested a report on the matter from the NCDHHS, although no finalized report has yet been made.
“As far as a public health measure and community health, fluoride does affect everybody. It impacts everybody and helps everybody,” Dr. Meg Lochary, a pediatric dentist who works near Union County, said. Lochary spoke at the same Union County Commissioner meeting that Prado did, arguing in favor of fluoride in the water.
“There were no dentists that were against it,” Lochary said of the anti-fluoride crowd at the meeting. “They weren’t doing what I do every day, taking care of kids that have rotten teeth and abscesses.”
The opposing side cited the “medical freedom” argument, asserting that the government shouldn’t be allowed to put any “medical substance” in the water without the consent of residents. Lochary disagrees with this line of thought.
“I still have to wear seat belts because it helps me protect myself against a brain injury that would be costly to society,” she said. “It’s just about protecting the good of public health so that we can all benefit.”
Lochary also points out that fluoride is naturally occurring in water, and fluoridating the water supply is just enhancing a mineral already present in the water.
Dr. Rhonda Stephens, a board certified dental public health specialist and professor at the UNC Gillings School of Global Public Health, thinks the medical freedom argument is a dangerous line of thought.
“I think the more we see people take on this argument, the more disease, injury and harm we’ll see in populations – whether it’s opting against a vaccine and seeing spikes in measles cases and deaths or discontinuing water fluoridation and seeing a rise in tooth decay/cavities,” she said in an email.
In Lincoln County, the decision to prohibit fluoride seemed to be based more on the cost of replacing the old water system—especially considering that many Lincoln County residents drink private well water anyway—and a feeling that fluoride was already widespread enough in other products, rather than the medical freedom standpoint.
“We just didn’t think it was something to put on the taxpayers to pay for, when they’re getting it otherwise,” Jamie Lineberger, chair of the Lincoln County Board of Commissioners, said. “My personal opinion, you brush your teeth, you get fluoride, you get water from other systems, so you’re getting that.”
The ADA says that even in an era of widespread fluoride availability, water fluoridation is still effective in reducing decay by at least 25%. Lochary emphasized the importance of community water fluoridation for individuals that don’t have easy access to transportation or dental care, including special needs adults or those who don’t have good dental insurance.
Cities like Calgary, Canada, and Juneau, Alaska, ceased water fluoridation in recent decades. Both areas saw increased dental decay in their residents, particularly affecting children, according to studies by Community Dentistry and Oral Epidemiology and BMC Oral Health. While Juneau has no plans to reinstate fluoride, Calgary plans to reintroduce fluoride into its water supply this year.
‘Already affecting dental public health initiatives’
Public trust in science and public health measures has declined overall since the pandemic, according to a 2024 Pew Research Center Poll. With the mass funding cuts to significant health and science agencies by the Trump administration, public health agencies and initiatives are continuing to be destabilized.
“Unfortunately, these narratives are already affecting dental public health initiatives, and not just those related to water fluoridation,” Stephens said. “Because fluoridation opponents have been so vocal with misinformation, and now that same sentiment is coming from the federal administration, people are very confused as to what to say and think about fluoride in general.”
Even within her own work, Stephens says, the current anti-fluoride sentiments are having an effect.
“I have been working on a project specifically to improve water fluoridation education and advocacy across NC but in light of the administration’s recent announcement about water fluoridation, I may have to change my approach or the nature of the project entirely, which is unsettling,” she said. “I won’t know to what extent I’ll need to pivot until I talk with funders.”
It remains to be seen how far reaching the fluoride fear will be, or if other North Carolina counties will follow in the path of Union and Lincoln County and ban the mineral altogether. Regardless, the rhetoric of the medical freedom crowd and the “Fluoride Fighters,” as the Union County anti-fluoride group called themselves, isn’t going to die down anytime soon.
“I think there will be some more communities that take fluoride out,” Lochary said. “But I think eventually science will prevail. It may take a few years, but I think we will eventually go back to fluoridating and common sense.”
