Report Highlights Oral Health Risks Of Removing Fluoride From Drinking Water, Urges Stronger Dental Infrastructure And Planning

Executive Summary
Community water fluoridation has been a cornerstone of U.S. public health for over 75 years and is recognized by the Centers for Disease Control and Prevention (CDC) as one of the ten greatest public health achievements of the 20th century (Koppaka, 2011). Illinois, which has mandated fluoridation since 1967, ranks fourth nationally with over 98% of residents receiving fluoridated water (CDC, 2022). However, scrutiny has intensified. A 2024 federal court labeled current fluoride exposure an “unreasonable risk” (Food & Water Watch, Inc. v. U.S. Environmental Protection Agency, 2024). In 2025, 21 states introduced anti-fluoridation bills, and Illinois HB 4321 would allow local opt-outs (Illinois General Assembly, 2025). This brief examines the potential consequences of removing community water fluoridation for policymakers, public health agencies, health care systems, and residents, with particular focus on Illinois populations at elevated risk for dental caries (i.e., cavities).

What does the evidence show?
Extensive evidence shows that community water fluoridation reduces dental caries in children and adults, even with widespread fluoride toothpaste use, and is highly cost-effective—each dollar invested yields $32 in avoided dental costs, with projected national savings of $6.7B (O’Connell et al., 2016). Oral disease also imposes substantial societal costs, including roughly 51 million lost school hours and 92 million lost work hours annually; more than 100 health organizations endorse fluoridation as an effective population-level intervention (Koppaka, 2011).

At the same time, a 2024 National Toxicology Program (NTP) report concluded that higher fluoride exposures—typically above 1.5 mg/L—are associated with lower IQ in children, though evidence at standard U.S. fluoridation levels (0.7 mg/L) remains mixed. The National Academies found that neurodevelopmental effects at community water levels are not convincingly demonstrated, underscoring uncertainty around dose and cumulative exposure. These uncertainties, combined with the 2024 federal court ruling, have heightened public concern and spurred legislative action nationwide.

What are the implications for Illinois?
If fluoridation policy shifts, Illinois would face distinct challenges. Most residents are currently served by fluoridated water systems

National modeling predicts a 7.5 percentage point rise in decayed teeth—about 25.4 million additional cases—and $9.8B in added dental costs over five years (Choi & Simon, 2025). Evidence from Juneau, Alaska; Calgary; and cities in Israel shows similar patterns, with dental treatment rates rising between 28% and 100% after fluoridation was discontinued.

In 2018–2019, 22.2% of Illinois third graders had untreated cavities versus 15.3% nationally, and access gaps worsen the risk: nearly three-quarters of dentists do not participate in Medicaid, only 55 of 81 rural counties have a Medicaid-registered dentist, and privately insured children are 5.9 times more likely to secure a dental appointment than Medicaid peers (Illinois Department of Public Health, 2020). Capacity for children with severe decay requiring general anesthesia is limited, forcing some families to travel hundreds of miles because pediatric dental–anesthesiology services are scarce. Historical experience shows that the dental workforce and hospital infrastructure were insufficient to manage high levels of untreated decay, and current systems remain ill-equipped to absorb a large increase in disease burden.

Policy Options for Illinois
If Illinois reconsiders its fluoridation mandate, policymakers should proactively address impacts on oral health systems and population outcomes.

• Strengthen the dental safety net. Expand capacity at safety-net providers—including academic health centers and federally qualified health centers—and increase Medicaid reimbursement to boost dentist participation, especially in rural counties with the greatest access gaps. This would better serve Medicaid-enrolled children and adults and rural residents facing barriers to routine and specialty care.
• Invest in alternative prevention strategies. If fluoridation is reduced or eliminated, Illinois could partially offset impacts by expanding school-based dental sealants, increasing fluoride varnish access through pediatric primary care, and strengthening nutrition programs such as WIC and SNAP. These interventions are resource intensive and unlikely to match fluoridation’s reach or cost-effectiveness.
• Plan for increased surgical demand. Anticipating more children needing treatment under general anesthesia, the state should expand operating room capacity, enhance workforce training, and coordinate medical and dental care. Without preparation, children may face prolonged pain, infection, repeated emergency visits, and multiple surgeries, with high rates of recurrent decay within 12–24 months.
• Monitor outcomes and advance equity. Strengthen oral health surveillance to track disease burden and service use, particularly among Medicaid-enrolled children, rural populations, and communities lacking fluoridated water. Linking data to policy decisions allows timely course correction and helps prevent exacerbation of oral health inequities.

What’s next?
The risks and benefits of community water fluoridation continue to be evaluated. Strong evidence supports its oral health and cost benefits, but these must be weighed against emerging neurodevelopmental concerns, rising bottled water use, and political pressures. In Illinois, HB 4321 and media coverage signal growing public and legislative scrutiny. Regardless of policy direction, the key question is whether decision-makers will plan for downstream impacts and invest in capacity, workforce, and reimbursement to meet rising demand—especially for Medicaid-enrolled children and rural communities relying on already stretched safety-net providers.