To fluoridate, or not to fluoridate?

When the clock struck 4 p.m. in Grand Rapids, Michigan in 1945, something historic happened: Engineers in a water filtration plant added a controlled amount of fluoride into the water, making Grand Rapids the first city to implement fluoridation.

It was a reaction to three decades of investigation into the effects of fluoride in reducing tooth decay and preventing cavities. As of 2022, more than 330 million Americans receive fluoridated water, but that number may be under threat.

Robert F. Kennedy Jr., President-elect Donald Trump’s pick to lead the Department of Health and Human Services, has declared the administration will advise against the use of fluoride in water systems — but getting rid of the mineral would be a challenge in Pennsylvania.

Kennedy Jr. recently decried fluoride as an “industrial waste,” adding that the Trump administration would advise “all U.S. water systems to remove fluoride from public water” in a post on X, formerly Twitter. Trump has vowed to let Kennedy “go wild” on health issues.

The decision to fluoridate or not has largely been determined at the local level. In Pennsylvania, water systems in most of Pennsylvania’s 67 counties fluoridate public drinking water. However, service areas can vary and do not necessarily follow county lines.

To find out if your water contains fluoride, check this interactive map recommended by the state Department of Environmental Protection.

Pittsburgh Water, formerly Pittsburgh Sewer & Water Authority, serves more than 500,000 customers in the city and has fluoridated its water for decades.

“In the coming months we expect this topic to become more prevalent in conversations
associated with public health and drinking water,” said Frank Sidari, Pittsburgh Water’s chief environmental compliance and ethics officer, in an email. “At this time, we do not anticipate changes to our treatment process and will continue to follow state regulations.”

Pittsburgh Water sources from the Allegheny River, which has a low level of the naturally-occurring mineral already, but additional fluoride is added to meet a recommended range.

Some water systems serving Allegheny County do not have fluoridated water including Moon, Cheswick, and Shaler. Shaler Township supervisors voted more than 20 years ago to keep the water fluoride free.

Statewide, the DEP oversees the process and requires a permit to add or modify the amount of fluoride. Local water authorities must issue a public notice to consumers and medical professionals prior to starting or stopping fluoridation.

The Centers for Disease Control and Prevention hailed fluoridation as one of the great public health interventions of the 20th century, alongside safer workplaces and recognizing tobacco as a health hazard.

But in recent months, debates over its use have escalated in city halls and state capitals across the country, giving rise to some officials recommending that the mineral be removed.

The Florida surgeon general late last month advised water systems across the state to stop adding fluoride. In Arkansas, legislators introduced measures that could lead to reduced or no use of fluoride.

The Pennsylvania chapter of the American Academy of Pediatrics supports the use of fluoride in drinking water.

“There's been a large body of research that has found support for this and that has found that putting fluoride in the water can lead to better oral health,” said Dakota Peterson, a pediatrician and oral health advocate speaking on behalf of the organization.

“It's a natural mineral. It can slow cavities from forming. Unfortunately, untreated cavities are one of the greatest unmet health consequences affecting children.”

The DEP does not require that fluoride be added as a part of safe drinking water regulations and does not encourage or discourage its use in water, but it does regulate how much can be added.

The state Department of Health’s Oral Health Program encourages the use of fluoride in water, citing its power to reduce tooth decay and prevent cavities.

The U.S. Public Health Service’s current recommendation for fluoride levels in drinking water is 0.7 mg/L to maximize benefits and reduce the risk of dental fluorosis, a condition that affects the appearance of children’s teeth.

The recommendation is also in place to prevent skeletal fluorosis, which can lead to joint pain and osteoporosis. Skeletal fluorosis may occur after many years of fluoride overexposure, Peterson said.

In his X post about fluoride, Kennedy warned of a list of negative side effects, including arthritis and lowered IQ.

While arthritis is a potential side effect of skeletal fluorosis and there has been some research indicating a risk of lowered IQ, those effects are seen at high levels of fluoride, sometimes over double the recommended amount.

“At excessive amounts, that's when there is a potential to see negative side effects,” Peterson said. “The benefits to this really, really do outweigh the risks, and especially when it is monitored. Too much of anything is not a good thing. And so, of course, that's why the recommendations are in place.”

Pennsylvania’s maximum contaminant level is 2 mg/L of fluoride, meeting the Environmental Protection Agency’s guidelines. Public water systems must issue a notice to consumers if they exceed the maximum contaminant level.

Pennsylvania American Water, which serves about 680,000 customers statewide, follows the direction of the DEP and local communities to determine whether to add fluoride to the water supply, said Gary Lobaugh, director of government and external affairs

“Should local or state regulations change, the company will modify its treatment accordingly to comply with revised regulations,” he said in an email.

About 240,000 Pennsylvania American customers live in areas that receive fluoridated drinking water, including Indiana County, New Castle, and Pittsburgh.

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