Cochrane review and international comparisons

You may not think of fluoride as a drug, but it fits the bill: The FDA classifies fluoride as a drug, an essential nutrient to human health, and regulates its use. So yeah. It’s a drug.

Fluoride used to be boring. 75% of US water is fluoridated, and it has greatly reduced the rate of tooth decay in this country and worldwide. Fluoridation has been among the biggest success stories in medical history.

But like a lot of medicine these days, fluoride is suddenly controversial. Again. Here and there, governments - the whole state of Utah, towns all over Florida - have removed fluoride from water. And predictably, the rate of tooth decay in children soars afterwards.

Still fluoride is also a riddle. Because while the US has had a lot of success with fluoride, most countries do NOT add it to their water - and many non-fluoridated countries have much the same rate of tooth decay as the US. Is fluoride toothpaste enough?

What is going on with fluoride?!

4 out of 5 dentists recommend you listen to this episode!

Sources for this episode 

[1] Dentition of a Mesolithic Population (1967) American Journal of Physical Anthropology: Pre-industrial populations experienced significantly lower rates of dental caries, demonstrating the impact of modern diet and environment on oral disease.

[2] Toothache (1994) Poetry Foundation: William Greenway: William Greenway’s visceral portrayal of dental pain.

[3] A Colorado Story (2015) Colorado Dental Association: Naturally fluoridated water was definitively linked to reduced tooth decay, establishing the scientific basis for fluoridation policy.

[4] The Story of Fluoridation (2024) National Institute of Dental and Craniofacial Research: Fluoridation emerged from observed natural fluoride exposure and was adopted as a nationwide preventive health strategy.

[5] Pipe Dreams: America’s Fluoride Controversy (2011) Science History Institute Museum & Library: Water fluoridation sparked decades of political and scientific conflict, becoming one of the most contested public health interventions in U.S. history.

[6] Big Hopes for Little Teeth (2024) National Institute of Dental and Craniofacial Research: Fluoridation significantly reduced childhood tooth decay and became a foundational population-level prevention strategy.

[7] Community Water Fluoridation in Focus: A Comprehensive Look at Fluoridation Levels across America (2023) International Journal of Environmental Research and Public Health: Access to fluoridated water varies widely across the U.S., reinforcing geographic and socioeconomic disparities in preventive oral health.

[8] Water fluoridation less effective now than in past (2024) Cochrane: Fluoridation still reduces cavities, but the magnitude of benefit is smaller than in the mid-20th century.

[9] Water fluoridation for the prevention of dental caries (2024) Cochrane Library: Fluoridation consistently lowers rates of tooth decay across populations, though evidence quality and modern applicability vary.

[10] Research review contends fluoride in water is less effective than in 1970s (2024) American Dental Association: The marginal benefit of water fluoridation has decreased due to widespread fluoride exposure from toothpaste and other sources.

[11] Out of Pocket: A Snapshot of Adults’ Dental and Medical Care Coverage (n.d.) CareQuest Institute: Lack of dental coverage forces many adults to delay or forgo care, increasing reliance on low-cost public health interventions like fluoridation.

[12] Health Disparities in Oral Health (2024) CDC: Oral health outcomes are consistently worse for low-income and minority populations due to structural barriers and uneven access to prevention.

[13] Two Cities Fluoride Removal Evidence (2025) Science News: Discontinuing fluoridation results in measurable declines in dental health outcomes.

[14] What happened when Juneau took fluoride out of the drinking water? (2019) University of Alaska Anchorage: Removing fluoridation leads to increased tooth decay and higher rates of dental procedures, especially in children.

[15] The Fluoride Wars Rage On (2021) nature: Fluoridation remains politically and culturally polarizing despite decades of scientific support.