Original Adoption: November 2017; Revised February 2026
(References used in the development of the position statement are shown at the end of the statement.)
Fluoride is a naturally occurring mineral found in water sources, often at levels too low to effectively prevent tooth decay. Community water fluoridation (CWF) is the controlled adjustment of fluoride in public water systems to an optimal level that maximizes oral health benefits while maintaining safety. The U.S. Public Health Service currently recommends a fluoride concentration of 0.7 milligrams per liter (mg/L) supported by decades of research and equivalent to approximately three drops of water in a 55-gallon barrel.
The Black Hawk County Board of Health supports the continued use of community water fluoridation as a safe, effective, and fiscally responsible public health strategy to prevent dental caries (tooth decay) and promote oral health across the lifespan. With more than 75 years of scientific study and real-world application, CWF remains one of the most extensively researched and successful population-based prevention measures in public health.
Public Health Importance
Dental caries is the most common chronic disease of childhood and continues to affect individuals throughout adulthood. Untreated dental disease can lead to pain, infection, missed school and work, and preventable emergency department use. These consequences disproportionately affect children, older adults, and individuals who face barriers to regular dental care.
Local data highlights the ongoing need for prevention in Black Hawk County. More than one-third of children and adolescents experience signs of tooth decay, and emergency department use for dental-related conditions exceeds the state average. Emergency visits for dental pain are costly and typically provide temporary relief rather than definitive care, placing unnecessary strain on families and the healthcare system.
Community water fluoridation is a foundational prevention strategy that helps reduce the incidence and severity of dental disease before treatment is needed.
Safety and Effectiveness
The safety of community water fluoridation at recommended levels has been evaluated through decades of epidemiological research, systematic reviews, and continuous monitoring. Leading scientific and public health organizations-including the Centers for Disease Control and Prevention, American Dental Association, American Academy of Pediatrics, and World Health Organization-consistently affirm that fluoridation at recommended levels is safe and effective.
Community water fluoridation reduces tooth decay by approximately 25 percent in both children and adults, even in communities where fluoride toothpaste and other fluoride products are widely used. While topical fluoride products are effective when used regularly and correctly, community water fluoridation provides safe, continuous, population-wide protection that does not depend on individual access, behavior, or age. Fluoride strengthens tooth enamel and prevents tooth decay, providing continuous protection throughout life.
While public discussion about fluoride periodically resurfaces, comprehensive reviews of the scientific literature have found no credible evidence of adverse health effects associated with community water fluoridation at recommended levels. Studies that raise concerns often examine fluoride exposures significantly higher than those used in U.S. community water systems or rely on methods that limit their applicability to current practices.
Addressing Public Questions with Transparency
The Board recognizes that questions about fluoride safety and effectiveness are part of ongoing public discourse. The Black Hawk County Board of Health remains committed to a transparent, science-based approach and notes the following:
Contemporary relevance: Even with widespread use of fluoride toothpaste, community water fluoridation remains an essential foundation of protection that provides population-wide benefits beyond what individual behaviors alone can achieve.
Population Benefit and Equity
Community water fluoridation benefits all residents who use public water systems, regardless of age, income, insurance coverage, or access to dental care. Because it does not depend on individual action or healthcare utilization, CWF is a passive prevention strategy that reaches the entire community.
Evidence consistently shows that fluoridation reduces disparities in oral health outcomes by providing baseline protection to populations that experience higher rates of dental disease and greater barriers to preventive care.
Fiscal Responsibility
Community water fluoridation is widely recognized as one of the most cost-effective preventive health interventions. The cost of fluoridating water for an individual over a lifetime is less than the cost of a single dental filling, and every dollar invested yields multiple dollars in avoided dental treatment costs.
By preventing decay before it occurs, fluoridation reduces the need for restorative care, lowers avoidable emergency department use, and helps control costs borne by families, employers, insurers, and public programs, including Medicaid.
Board of Health Recommendations
Based on the best available scientific evidence and the ongoing oral health needs of the community, the Black Hawk County Board of Health strongly supports the continuation of community water fluoridation at levels recommended by the U.S. Public Health Service. The Board affirms that community water fluoridation is a sound, evidence-based public health policy that protects oral health, promotes population-wide benefit, and represents a prudent use of public resources.
The Black Hawk County Board of Health encourages policymakers and community leaders to rely on established science and public health expertise when considering policies related to drinking water and oral health prevention and to recognize community water fluoridation as a proven tool that benefits the entire population.
References
1. American Academy of Pediatrics. (n.d.). Fact-checked: Fluoride is a powerful tool for preventing tooth decay.
2. American Dental Association. (2024). Fluoridation facts.
3. American Dental Association. (n.d.). Community water fluoridation sign-on letter.
4. America’s Health Rankings. (2024). 2024 annual report. United Health Foundation.
5. America’s Health Rankings. (2025). 2025 annual report. United Health Foundation.
6. Centers for Disease Control and Prevention. (n.d.). Community water fluoridation recommendations.
7. Centers for Disease Control and Prevention. (2024). Fast facts: Community water fluoridation.
8. Centers for Disease Control and Prevention. (2024, May). Scientific statement on community water fluoridation.
9. Fawell, J., Bailey, K., Chilton, J., Dahi, E., Fewtrell, L., & Magara, Y. (2006). Fluoride in drinking-water. World Health Organization.
10. Griffin, S. O., Jones, K., & Tomar, S. L. (2001). An Economic Evaluation of Community Water Fluoridation. Journal of Public Health Dentistry, 61(2), 78–86.
11. Iheozor-Ejiofor, Z., Walsh, T., Lewis, S. R., Riley, P., Boyers, D., Clarkson, J. E., Worthington, H. V., Glenny, A.-M., & O’Malley, L. (2024). Water fluoridation for the prevention of dental caries. (Cochrane Database of Systematic Reviews, Issue 10, Article No. CD010856).
12. Lanphear, B. P., Den Besten, P., & Till, C. (2024). Time to Reassess Systemic Fluoride Exposure, Again. JAMA Pediatrics.
13. Levy, S. M. (2024). Caution Needed in Interpreting the Evidence Base on Fluoride and IQ. JAMA Pediatrics.
14. McLaren, L., Patterson, S., Thawer, S., Faris, P., McNeil, D., Potestio, M., & Shwart, L. (2016). Measuring the short-term impact of fluoridation cessation on dental caries in Grade 2 children using tooth surface indices. Community Dentistry and Oral Epidemiology, 44(3),274–282.
15. Tobias, G., Mordechai, F., Tali, C., Yaron, B., Beatrice, G. P., Jonathan, M., & Harold, S. C. (2022). The effect of community water fluoridation cessation on children’s dental health: a national experience. Israel Journal of Health Policy Research, 11(1), Article 4.
16. Taylor, K. W., et al. (2024). Fluoride Exposure and Children’s IQ Scores: A Systematic Review and Meta-Analysis. JAMA Pediatrics.
17. U.S. Department of Health and Human Services. (2000). Oral Health in America: A Report of the Surgeon General. National Institute of Dental and Craniofacial Research, National Institutes of Health.
18. U.S. Environmental Protection Agency.(2025, December 29). Drinking water regulations and contaminants.
19. U.S. Public Health Service. (2015). U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries. Public Health Reports, 130(4), 318–331.