Florida has just banned fluoride in public water, becoming the second state to do so. It’s part of decadeslong battle that has heated up in recent years. Local governments debate whether it belongs in the water supply. Parents question safety. Pseudoscience clouds public perception. Often, the conversation is framed as a domestic ideological battle between personal liberty and public health mandates.
As a dentist trained in India and a global health researcher based in the United States, I have observed the fluoride debate from a broader, global lens. In many parts of the world, fluoride is not controversial — it is simply unavailable. Millions suffer from preventable tooth decay because they lack access to fluoride, and therefore the protection it provides against oral disease.
In India, I treated patients who represented both extremes of the fluoride spectrum. Some rural communities were exposed to naturally high fluoride levels, leading to debilitating skeletal fluorosis. But in many urban and peri-urban settings, especially among low-income populations, fluoride exposure was virtually nonexistent. The consequences were visible: advanced cavities in children as young as 6, chronic gum infections in adults, and widespread tooth loss among the elderly.
In these settings, fluoridated toothpaste was not always affordable or available. Water systems were rarely fluoridated. The absence of fluoride was not a health preference — it was a systemic failure. My patients were not debating the merits of fluoridation. They were living with the consequences of its absence.
This duality shaped my understanding of fluoride not as a universal good or evil, but as a tool — one that must be managed carefully and distributed equitably.
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Today, working as a public health researcher in the United States, I continue to examine the health implications of oral care disparities. In many ways, fluoride remains the only preventive dental measure that reaches vulnerable populations who lack regular access to clinical care.
Yet opposition to fluoride in the U.S. is often strongest in well-resourced communities — where alternative dental services are abundant, fluoride toothpaste is affordable, and public skepticism, political mistrust, or misinformation can take hold. For many of these people, unfluoridated water may not pose an immediate risk — they have the means to compensate through private care. But the bans they advocate for extend far beyond their communities, stripping others of a preventive tool they cannot easily replace. Low-income and marginalized populations, particularly Black and Latino communities, experience disproportionately high rates of dental disease and already lack sufficient access to both fluoridated water and affordable care.
In these communities, fluoride is not an ideological question. It is a practical intervention that can reduce the burden of oral disease, which in turn is linked to systemic conditions like diabetes, cardiovascular disease, and pregnancy complications.
In my current work on HIV and tuberculosis care among displaced and migrant populations in Central Asia, oral health is rarely part of the care conversation. Yet oral infections and tooth loss affect nutrition, self-esteem, immune function, cardiac health, and the ability to adhere to treatment plans.
This is where American public health conversations can benefit from international perspective. While debates rage about potential overexposure to fluoride, millions worldwide still lack basic access to it. The Global South continues to experience high rates of untreated dental disease due to infrastructural, economic, and policy barriers.
The fluoride debate, therefore, is not only about chemistry — it is about context. The privilege of questioning fluoride’s role exists only where other forms of care are already accessible. Elsewhere, fluoride represents a critical line of defense.
It is important to question and study every public health intervention, including fluoride. But the dominant narrative in the U.S. — often influenced by misinformation — is prioritizing some people over others.
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Rather than focusing solely on personal autonomy, public health leaders should consider proportionate universalism: making fluoride available to all but targeting the greatest benefits to those most in need. If fluoride is removed from public water systems, there must be a viable, equitable alternative, such as subsidized fluoride toothpaste, school-based varnish programs, or community dental sealant initiatives. Otherwise, the people most affected will be those least able to afford private care. (This problem is compounded by the new effort to ban some fluoride supplements.)
The World Health Organization and numerous peer-reviewed studies continue to support fluoride as a safe and effective public health measure, particularly where preventive care access is limited. From Canada to the United Kingdom to India, governments continue to struggle with balancing public concern against health equity.
I believe the United States has an opportunity to lead — not by abandoning fluoride, but by anchoring the discussion in data, equity, and empathy. We must not allow policy to be shaped by those with the loudest voices at the expense of those with the greatest need.
Public health is not about perfection — it is about progress. Fluoride remains one of the few tools that, when implemented with care, can meaningfully reduce health disparities. To retreat from it without replacement is not cautious. It is unjust.
Mannat Tiwana is a dentist trained in India and a master of public health candidate at California State University, Long Beach. Her research focuses on global oral health disparities, health equity, and migrant health systems.
