20 l © 2025 American Dental Association
Section 1: Effectiveness and Benefits
United States: Galesburg, Illinois (Way, 1964)
A study108 that reported the association between fluoridated water and tooth decay prevalence
focused on the city of Galesburg, Illinois, a community whose public water supply contained naturally
occurring fluoride at 2.2 mg/L. In 1959, Galesburg switched its community water source to the
Mississippi River. This alternative water source provided the citizens of Galesburg a sub-optimal level
of fluoride at approximately 0.1 mg/L. In the period of time between a baseline survey conducted in
1958 and a new survey conducted in 1961, data revealed a 10% decrease in the percentage of decay-
free 14-year-olds (oldest group observed), and a 38% increase in mean tooth decay experience.
Two years later, in 1961, the water was fluoridated at the then-recommended level of 1.0 mg/L.108
Scotland: Wick (Stephen et al., 1987)
In 1979, fluoridation in the northern Scotland town of Wick was discontinued after 8 years. The water
was returned to its sub-optimal, naturally occurring fluoride level of 0.02 mg/L. Data collected to monitor
the oral health of Wick children clearly demonstrated a negative health effect from the discontinuation of
water fluoridation. Five years after the cessation of water fluoridation, the prevalence of decay in primary
teeth had increased by 27%. That increase in decay occurred during a period when there had been a
reported overall reduction in decay nationally and when fluoride toothpaste had been widely adopted.
Those data suggest that decay levels in children can be expected to rise where water fluoridation is
interrupted or terminated, even when topical fluoride products are widely used.109
Scotland: Stranraer (Atwood and Blinkhorn, 1991)
In a similar evaluation, the prevalence of tooth decay in 5- and 10-year-old children in Stranraer,
Scotland, increased after the discontinuation of water fluoridation. That increase in tooth decay was
estimated to result in a 115% increase in the mean cost of restorative dental treatment for decay.
Those data support the important role water fluoridation plays in the reduction of tooth decay.110
United States: Juneau, Alaska (Meyer et al., 2018)
A 2018 study111 used Medicaid dental claims records to assess the consequences of community water
fluoridation cessation in Juneau, Alaska. Dental caries procedures and restoration costs were measured in
2003, when water was optimally fluoridated, and compared to all claims for the same age group in 2012,
5 years after the cessation of fluoridation. Patients ages 0–18 years in the suboptimal fluoride group
were found to have a higher mean number of caries-related procedures. The study also reported that
patients born after fluoridation cessation underwent the most dental caries procedures on average.111
Israel (Tobias et al., 2022)
Israel began implementing water fluoridation in 1981 as a public health measure to prevent dental
caries. However, in 2014, the country discontinued mandatory fluoridation following a policy change,
citing environmental and ethical concerns. The cessation has since prompted studies examining its
impact on oral health outcomes, particularly among children. A 2022 retrospective study112 assessed
the impact of discontinuing water fluoridation in Israel. It focused on children aged 3–12 years in areas
where fluoridation had ceased, using populations from regions that never had optimal fluoridation as
a control. No significant age-related changes in dental treatments were observed from 2014–2015.
However, following fluoride cessation, dental treatment nearly doubled between 2016 and 2019,
with the number of treatments increasing with age. Compared to areas with partial or no fluoridation,
regions with optimal fluoride levels were found to consistently have fewer dental treatments.112
Section 1: Effectiveness and Benefits
United States: Galesburg, Illinois (Way, 1964)
A study108 that reported the association between fluoridated water and tooth decay prevalence
focused on the city of Galesburg, Illinois, a community whose public water supply contained naturally
occurring fluoride at 2.2 mg/L. In 1959, Galesburg switched its community water source to the
Mississippi River. This alternative water source provided the citizens of Galesburg a sub-optimal level
of fluoride at approximately 0.1 mg/L. In the period of time between a baseline survey conducted in
1958 and a new survey conducted in 1961, data revealed a 10% decrease in the percentage of decay-
free 14-year-olds (oldest group observed), and a 38% increase in mean tooth decay experience.
Two years later, in 1961, the water was fluoridated at the then-recommended level of 1.0 mg/L.108
Scotland: Wick (Stephen et al., 1987)
In 1979, fluoridation in the northern Scotland town of Wick was discontinued after 8 years. The water
was returned to its sub-optimal, naturally occurring fluoride level of 0.02 mg/L. Data collected to monitor
the oral health of Wick children clearly demonstrated a negative health effect from the discontinuation of
water fluoridation. Five years after the cessation of water fluoridation, the prevalence of decay in primary
teeth had increased by 27%. That increase in decay occurred during a period when there had been a
reported overall reduction in decay nationally and when fluoride toothpaste had been widely adopted.
Those data suggest that decay levels in children can be expected to rise where water fluoridation is
interrupted or terminated, even when topical fluoride products are widely used.109
Scotland: Stranraer (Atwood and Blinkhorn, 1991)
In a similar evaluation, the prevalence of tooth decay in 5- and 10-year-old children in Stranraer,
Scotland, increased after the discontinuation of water fluoridation. That increase in tooth decay was
estimated to result in a 115% increase in the mean cost of restorative dental treatment for decay.
Those data support the important role water fluoridation plays in the reduction of tooth decay.110
United States: Juneau, Alaska (Meyer et al., 2018)
A 2018 study111 used Medicaid dental claims records to assess the consequences of community water
fluoridation cessation in Juneau, Alaska. Dental caries procedures and restoration costs were measured in
2003, when water was optimally fluoridated, and compared to all claims for the same age group in 2012,
5 years after the cessation of fluoridation. Patients ages 0–18 years in the suboptimal fluoride group
were found to have a higher mean number of caries-related procedures. The study also reported that
patients born after fluoridation cessation underwent the most dental caries procedures on average.111
Israel (Tobias et al., 2022)
Israel began implementing water fluoridation in 1981 as a public health measure to prevent dental
caries. However, in 2014, the country discontinued mandatory fluoridation following a policy change,
citing environmental and ethical concerns. The cessation has since prompted studies examining its
impact on oral health outcomes, particularly among children. A 2022 retrospective study112 assessed
the impact of discontinuing water fluoridation in Israel. It focused on children aged 3–12 years in areas
where fluoridation had ceased, using populations from regions that never had optimal fluoridation as
a control. No significant age-related changes in dental treatments were observed from 2014–2015.
However, following fluoride cessation, dental treatment nearly doubled between 2016 and 2019,
with the number of treatments increasing with age. Compared to areas with partial or no fluoridation,
regions with optimal fluoride levels were found to consistently have fewer dental treatments.112
