Dentists in Utah can tell rather quickly whether their patients grew up in the Salt Lake City area or in a different part of the state.
Salt Lake County, neighboring Davis County to the north and nearby Brigham City – home to about half of the state’s population – have been adding fluoride to the public drinking water for decades with local voter approval while other parts of the state generally have not.
“It’s pretty obvious. If I have new patients come into my practice, I can guess probably eight or nine times out of 10 if they’ve grown up in a fluoridated community,” said Dr. Darren Chamberlain, a pediatric dentist who practices a bit farther south in the state. “The reason I know is because, generally, they don’t have cavities.”
But that may soon change. Community fluoridation – considered one of the top public health success stories of the last century – has been banned in Utah, with a new law taking effect Wednesday. The change worries dentists and public health experts, who are concerned that it will lead to a rise in avoidable oral health issues, especially among young children from low-income families.
Fluoride is a mineral that can be found naturally in some foods and groundwater. It can help prevent tooth decay by strengthening the protective outer layer of enamel that can be worn away by acids formed by bacteria, plaque and sugars in the mouth. Adding fluoride to public water systems started in the United States in 1945.
The sponsor of the Utah legislation, Republican Rep. Stephanie Gricius, acknowledged fluoride has benefits, but said it was an issue of “individual choice” to not have it in the water. Discussions about financial costs of community fluoridation were also raised during legislative hearings in the state, as well as recent studies that raise questions about whether high fluoride levels negatively affect brain development in children.
The Trump administration has also ramped up scrutiny of fluoride, and US Department of Health and Human Services Secretary Robert F. Kennedy Jr. has said that he plans to tell the US Centers for Disease Control and Prevention to stop recommending fluoridation for public drinking water in communities.
Utah is the first state to pass a law banning public water fluoridation, and Kennedy championed the move during his visit to the state last month.
“I think it’s a moral imperative that we all believe in freedom of choice in this country,” Kennedy said. “It is one of the bedrock principles of our democracy, and the government shouldn’t be making decisions, intimate decisions about our own lives.”
Other states are also considering the change or taking action; on Tuesday, Florida Gov. Ron DeSantis pledged to sign a bill passed by lawmakers to ban fluoride in municipal drinking water statewide.
Public health advocates stress that the amount of fluoride added to public water systems is far below the amount that would pose any health risk and that there is stronger evidence that removing fluoride from public drinking systems causes harm.
Experts say it may take a few years for the consequences of the change in Utah to become apparent. One study of Medicaid claims from a city in Alaska shows that five years after community fluoridation ended, there was an average of one additional procedure to treat tooth decay per child. And a city in Canada recently voted to add fluoride back into the drinking water after seeing that local second-graders had significantly higher rates of cavities than those in a neighboring city that fluoridated its water.
Action is left up to residents
Health officials and other concerned groups in Utah have been working to get the word out about the change and share information about alternative ways parents can get the protective benefits of fluoride for their children or adults can get it for themselves.
On Friday, the Utah Department of Health & Human Services released guidance encouraging residents to talk to their dentist, doctor or pharmacist about fluoride supplements.
“While community water fluoridation will no longer be available, there are measures that can be taken to reduce the risk of developing cavities,” Dr. Stacey Swilling, state dental director, said in a statement. “We encourage Utahns to have regular checkups with a dentist or healthcare provider to make sure they are doing everything they can to protect their oral health.”
The Utah Oral Health Coalition, a volunteer group of dozens of oral health professionals and advocates, is also launching a public awareness campaign centered around the tagline “My Smile Matters.” It’s a comprehensive initiative focused on steps people can take to keep the teeth and mouth healthy, including regular dentist visits, regular brushing and flossing, and use of fluoride supplements.
“Half of our state will be losing water fluoridation. The other half has not had it. So for half of the state, the message is: ‘You no longer have water fluoridation. Our job has become a little harder, and here are things we need you to know,’ ” said Lorna Koci, program director and chair of the coalition. “To the other half of the state that hasn’t had it, it’s still a wonderful message: ‘Here are the things you need to do to really have good oral health.’ ”
The hope is to use a wide range of partners – including health departments, community clinics, hospital systems, insurance companies, dental schools and school districts – to get the message out in as many different ways and places as possible.
The coalition also plans to partner with local universities to develop a plan to track the impacts of the fluoride ban. The goal is to collect information that many advocates wish the state legislature had before passing the fluoride ban.
“When we asked the governor to veto this bill, we said we really don’t have the information that’s needed to make a decision of this impact,” Koci said. “We wish we had more data available.”
An insufficient alternative
The new law in Utah allows pharmacists to provide fluoride directly, without a prescription from a dentist or doctor. While this broadens access for some, experts say supplements are an insufficient alternative to community water fluoridation – and may create new risks.
Fluoride supplements tend to have poor compliance, said Dr. Scott Tomar, professor and associate dean at the University of Illinois College of Dentistry and the American Dental Association’s spokesperson on community water fluoridation. There’s a financial burden as well as a steep logistical burden that falls on the family to administer the supplement every day, he said.
“We’re all just dealing with lots of other demands in our in our daily routine. You’re talking busy parents of young children, expecting them to now add one more thing to their daily routine,” Tomar said. “We just know from experience that the families that would benefit the most from that are probably the ones least likely to ensure compliance with daily administration.”
Fluoride supplements are available in the form of a chewable tablet or a lozenge that is sucked for at least a minute, according to the CDC. They are meant to be used every day and typically geared toward children.
Fluoride supplementation is not indicated for adults, Tomar said, so there’s no strong alternative for adults in areas that are stopping community water fluoridation.
The appropriate dosage for fluoride supplements varies, and experts worry that pharmacists and health care providers who are new to prescribing it – or haven’t had to do so in many years – may not have all the training or information they need.
The CDC has historically put out a report that providers use to assess the baseline level of fluoride in a community water system before supplementing it with tablets or drops, but Trump administration cuts to the federal agency’s oral health department leaves a critical gap.
These challenges could lead to overprescribing fluoride – a key argument for ending community water fluoridation in the first place.
“So now the Utah Dental Association is doing a lot of research to be able to help pharmacists, and we’re hoping to give reports out to say, ‘Hey, this is the natural amount of fluoride in these communities,’ because we are nervous about that,” said Chamberlain, who is a past president of the Utah Dental Association. “We want to make sure that the public is protected and that they’re getting the right amount of fluoride prescribed from whatever source it is from.”
Community water fluoridation was effective at preventing cavities, but now the burden falls on public health for more active messaging about prevention in oral health, said Brian Hatch, the Davis County health director. That will require a lot more public health resources, which are already stretched thin.
“Public health will have to do more in the future to make sure that we reinforce that message going out to every individual in the community,” Hatch said. “There hasn’t been a huge need to do a lot of that outreach, but now there is a need to make sure that it’s a reoccurring message.”
It will require more effort from individuals to support their own health, he said.
“The big shift that I’m probably most concerned about is how we make sure that we get the same bang for the buck by moving people to an active role in their own personal health instead of it being a passive system,” Hatch said.
Simple shift, big impact
The logistics around stopping the flow of fluoride into public water systems in Utah have been simple.
Three water treatment plants in Salt Lake City had already disconnected the system before the May 7 deadline. The fluoride was stored in a large tank and pumped into water in measured doses as it came out of treatment plants and ground water wells.
“The process of removing additional fluoride from the system is essentially just disconnecting the tanks that are used to store the acid from the treatment system,” said Laura Briefer, director of the Salt Lake City Department of Public Utilities. “It’s basically just removing the feed pumps that are used to dose the water. It’s quite simple.”
But the department has been planning for this change for months, she said. Fluoride is bought in bulk like other treatment chemicals, and there are strict regulations around disposing of excess, so it made sense to start tapering off before ordering more.
There is some naturally occurring fluoride in the Salt Lake City water system, but the water company estimates that any additional fluoride will be processed through the system in a matter of days.
The Utah Department of Environmental Quality is in charge of ensuring that water systems across the state are complying with the new law, and it’s requested photo documentation that treatment has been disconnected.
In the weeks since the legislation was passed, the Salt Lake City public utilities department has had a “diversity of feedback from community members,” Briefer said; some residents have called to ask that fluoride be removed immediately while others have suggested that they should go against the law and keep adding fluoride.
“As a public water system, we’re charged with implementing the regulations before us,” she said. “We are also ultimately involved in protecting the public health.”
The Salt Lake City Department of Public Utilities was not supportive of a fluoride ban in Utah and had lobbied legislators for a “compromise bill” that would include some monitoring of fluoride levels instead of “outright prohibition,” Briefer said. And it hasn’t determined whether it will dispose of the equipment used for community water fluoridation or save it for the possibility of future use.
“One of the things that I would like to see as an outcome of this is some additional monitoring about public health outcomes once the fluoride is removed from the systems that has been historically added to in our state,” Briefer said. “Since we’ve taken this action, I feel like, as a community, we have an obligation to understand what those impacts are, so that we can mitigate any negative impacts to the community we serve.”