Community water fluoridation

Evidence Rating  
Scientifically Supported
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  
Decision Makers

Communities that fluoridate water adjust and monitor fluoride in public water supplies to reach optimal fluoride concentrations. As of 2015, the US Public Health Service (US PHS) recommends that community drinking water contain .7 ppm of fluoride, down from the  previous standard, a range of .7 to 1.2 ppm, set in 19621, 2. This change accounts for other sources of fluoride (e.g., toothpaste) and was intended to avoid the unwanted health effects of excessive fluoride1.

Expected Beneficial Outcomes (Rated)

  • Reduced cavities

Evidence of Effectiveness

There is strong evidence that community water fluoridation (CWF) cost-effectively prevents cavities1, 2, 3, 4, 5 across socio-economic groups3. Effects are strongest in low income communities6, and in communities with poor oral hygiene and limited access to oral health care7.

CWF reduces cavities in children’s baby teeth and permanent teeth4. High fluoride intake can increase the risk of mild tooth staining from dental fluorosis3, 8, especially for infants who drink formula instead of breast milk5, 9. Additional study is needed to determine other potential adverse effects of excessive fluoride exposure3, 9, 10.

As of 2013, fluoridation cost an average of 11 cents per person in large US communities and $4.92 per person in very small communities (less than 1000); cost savings range from $29.23 to $73.50 per person in averted dental treatment and productivity losses3, 11

Impact on Disparities

Likely to decrease disparities

Implementation Examples

As of 2012, 74% of Americans live in communities that fluoridate their water5.

Implementation Resources

CDC-Fluoridation - Centers for Disease Control and Prevention (CDC). Community water fluoridation.

CDC-CWF Resources - Centers for Disease Control and Prevention (CDC). Community water fluoridation (CWF): Resources for public health partners and professionals.

ADA-Fluoridation - American Dental Association (ADA). Mouth Healthy: Fluoridation information.

Pew-CWF - The Pew Charitable Trusts (Pew). Promoting community water fluoridation (CWF). 2015.


* Journal subscription may be required for access.

1 US PHS-Fluoride - US Department of Health and Human Services (US DHHS) Federal Panel on Community Water Fluoridation. US public health service (US PHS) recommendation for fluoride concentration in drinking water for the prevention of dental caries. Public Health Reports. 2015;130(4):318-331.

2 Truman 2002* - Truman BI, Gooch BF, Sulemana I, et al. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. American Journal of Preventive Medicine. 2002;23(1 Suppl 1):21–54.

3 CG-Oral health - The Guide to Community Preventive Services (The Community Guide). Oral health.

4 Cochrane Iheozor-Ejiofor 2015* - Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews. 2015;(6):CD010856.

5 CDC-Fluoridation - Centers for Disease Control and Prevention (CDC). Community water fluoridation.

6 Burt 2002* - Burt BA. Fluoridation and social equity. Journal of Public Health Dentistry. 2002;62(4):195–200.

7 Pizzo 2007* - Pizzo G, Piscopo MR, Pizzo I, Giuliana G. Community water fluoridation and caries prevention: A critical review. Clinical Oral Investigations. 2007;11(3):189–93.

8 Whelton 2004* - Whelton HP, Ketley CE, McSweeney F, O’Mullane DM. A review of fluorosis in the European Union: Prevalence, risk factors and aesthetic issues. Community Dentistry and Oral Epidemiology. 2004;32(Suppl 1):9–18.

9 Prystupa 2011* - Prystupa J. Fluorine - A current literature review. An NRC and ATSDR based review of safety standards for exposure to fluorine and fluorides. Toxicology Mechanisms and Methods. 2011;21(2):103–70.

10 Peckham 2014 - Peckham S, Awofeso N. Water fluoridation: A critical review of the physiological effects of ingested fluoride as a public health intervention. The Scientific World Journal. 2014;2014:293019

11 Ran 2016* - Ran T, Chattopadhyay SK, Community Preventive Services Task Force. Economic evaluation of community water fluoridation: A community guide systematic review. American Journal of Preventive Medicine. 2016.

Date Last Updated

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