The debate over adding fluoride to public drinking water is gaining intensity in the United States. Formerly thought of as a great public health success, water fluoridation is being increasingly challenged by intensified concerns and legislative prohibitions in a few states. New evidence, however, published in JAMA Health Forum cautions that dis-fluoridation of community water systems could carry a high price tag — for children's oral health as well as the country's health care system.Fluoride, a naturally occurring mineral in some foods and groundwater, is referred to as "nature's cavity fighter." Fluoride hardens tooth enamel, the hard, outer layer of the teeth, making them more resistant to the acids formed by bacteria in the mouth that lead to tooth decay. Tooth decay, or dental caries, is still one of the most prevalent chronic illnesses in children and teenagers in the US, impacting millions.Fluoride was first added to public water in the US in 1945 and has been recognized by the Centers for Disease Control and Prevention (CDC) as being among the 10 greatest public health successes of the 20th century. Fluoridated water gives both systemic and topical protection, the kind that makes teeth more resistant to decay before they even come up through the gums and protects enamel throughout life.Researchers Dr. Lisa Simon of Brigham and Women's Hospital and Dr. Sung Eun Choi of Harvard School of Dental Medicine recently examined national oral health data to simulate the effect of fluoride removal from US public water supplies. The results are sobering.They calculate that eliminating fluoride would cause 25.4 million more decayed teeth among children and teens just in five years, while health care expenses would balloon to $9.8 billion. In a decade, those numbers could almost double to 54 million extra decayed teeth and $19.4 billion in dental care costs.To give it some perspective, the study estimates one additional rotten tooth per three children in the US — a public health regression that's astounding.Not all populations would share the burden equally. Dr. Simon points to disparities, pointing out that children from poorer backgrounds and from disadvantaged communities would increasingly depend on fluoridated water to help prevent cavities because they have limited access to dental services. Stripping fluoride away would exacerbate oral health gaps.Currently, approximately two-thirds of the US population is getting fluoridated water, with nearly 40% of children being exposed to optimal levels of fluoride to prevent tooth decay very effectively. Only nearly 1.5% of children have fluoride levels high enough to endanger fluorosis — a cosmetic dental condition that results in mild discoloration of the teeth.The Canadian city of Calgary provides a cautionary tale. In 2011, Calgary's city government took fluoride out of its public water system amid public outcry. Within a decade, dental health officials noticed a notable increase in cavities in children, leading to the city reinstating water fluoridation in 2021.This example provides the real-world illustration backing the new study's projections.How Fluoride Protects Tooth Decay?Cavities result when bacteria in the mouth infect sugars and release acid that destroys tooth enamel. Fluoride acts by incorporating itself into the structure of the enamel, making the enamel resistant to acid attack and able to repair early damage caused by decay.In infants, fluoride is important even before the eruption of teeth. It gives a systemic effect by making developing teeth in the gums harder by ingestion of fluoride-rich water and food. For adults and older children, fluoride's local action—via toothpaste, mouth rinses, and water—preserves enamel resistance.The US Department of Health and Human Services now recommends that fluoride in public water be adjusted to 0.7 milligrams per liter, a scientifically proven level to achieve the optimal balance of cavity prevention with minimal fluorosis risk.Fluoridation is similar to other public health interventions like the addition of iodine to salt or vitamin D to milk, which are intended to avoid widespread deficiencies of nutrients and improve population health.Yet, political and public opinion changes have prompted legislative measures in certain states such as Utah and Florida prohibiting water fluoridation. Health and Human Services Secretary Robert F. Kennedy Jr. announced in April 2024 that he would recommend that the CDC discontinue the recommendation of fluoride in public water, which further heated the current debate.What Are The Alternatives Available?Although fears regarding the safety of fluoride have continued in some quarters, the dental and medical communities' consensus is clear: that water fluoridation at recommended concentrations is safe and beneficial. The danger of fluorosis, usually mild and superficial, is small and commonly outweighed by the advantages of prevention of cavities.For families concerned about dental health without fluoridated water, alternatives include fluoride toothpaste, professional fluoride treatments at the dentist, and fluoride-containing mouth rinses—though these depend on access to dental care and adherence to proper use.Children under six should not use fluoride mouthwash without dental supervision due to the risk of swallowing.The economic consequences of rising cavities from fluoride loss are substantial. Treatment expenses for untreated cavities—fillings, root canals, and extractions—can be burdensome on families and health care systems. Untreated dental disease also has an adverse impact on children's quality of life, resulting in pain, infection, eating difficulties, and lost school days.The projected $9.8 billion in additional dental care costs within five years, escalating to nearly $20 billion over a decade, represents a substantial burden on families, insurance providers, and public health programs.The fluoride in water debate captures wider public health policy challenges where scientific truth converges with public opinion and politics. As some places consider banning fluoridation, the new study serves as a reminder of the possible unintended effects.For now, fluoride remains a cornerstone of dental public health in the US and many countries worldwide. Continuing public education on its benefits, addressing misinformation, and ensuring equitable access to dental care remain critical components in safeguarding children’s oral health.Fluoride's removal from public drinking water may spark a dental emergency for an estimated million American children, resulting in additional cavities and increased health care expenditures. The data from this new study, along with the real-life experience of Calgary, confirms fluoride's central part in preventing tooth decay.