As state Surgeon General Joseph Ladapo crusades against water fluoridation across Florida, city after city is reversing decades of public health practice and agreeing to stop adding fluoride to its water. Ladapo’s message: The health risks of fluoride are not worth the protection against tooth decay it offers.

But a South Florida Sun Sentinel analysis shows there are health risks to avoiding fluoride as well. Over the last decade, counties where large majorities of residents drink fluoridated water have consistently posted low rates of emergency room visits for dental conditions, especially in comparison to counties where fluoridated water is relatively scarce.

Almost all water contains some naturally occurring fluoride, but usually at levels too low to prevent cavities. For nearly 80 years, local governments have been adding fluoride to water supplies to prevent tooth decay.

But the tide is beginning to shift. In November, Ladapo held a news conference and released guidance for government leaders to end water fluoridation. His stance mirrors that taken by President Donald Trump’s HHS pick, Robert F. Kennedy Jr., who posted on social media in November that fluoride is linked to various health problems.

Since then, more than a dozen, mostly smaller Florida municipalities, including Winter Haven, Tavares, Longwood and Leesburg, have voted to discontinue adding fluoride to their water. And the legislature will consider bills this session to prohibit cities, counties and water districts from fluoridating.

The Sun Sentinel's analysis shows that counties like Putnam, Gasden and Columbia that do not add fluoride have residents arriving in their hospital emergency departments with dental conditions at high rates. Orange and Seminole Counties, with relatively high rates of fluoridation, have rates of hospital ER visits for dental conditions below the state average.

While water fluoridation may not be the only factor involved, the data indicates it does play a role.

Public health experts have emphasized that the standard amount added, 0.7 milligrams of fluoride per liter of water, is not dangerous and serves an important purpose.

"If you don't add fluoride, you will see a definite increase in the number of cavities, especially in low-income areas where it's more difficult to see a dentist and get fluoride treatments," said Jeff Ottley, president of the Florida Dental Association and a family dentist in Milton.

Both sides of the debate use studies to make their arguments.

Why add fluoride?

The Florida Dental Association has strongly endorsed fluoridation, pointing to research supporting the assertion that brushing with fluoride toothpaste alone is insufficient to curb tooth decay.

"Adding optimal amounts of fluoride into our community water supplies can prevent at least 25% of tooth decay in children and adults, reducing the need for costly dental treatments," the association said in a statement released after Ladapo held a news conference in November and called fluoridation "public health malpractice."

Florida pediatricians also support adding fluoride.

The Florida Chapter of the American Academy of Pediatrics believes this practice is critical to ensuring the health of children, especially those in poor communities.

The pediatricians say research backs up the fact that the level of fluoride in Florida's drinking water is at the level where it doesn't cause harm. "Over 3,000 studies from the U.S. and abroad are available addressing the safety and efficacy of fluoridating the water supply."

Dr. Johnny Johnson, a retired Florida dentist and president of the American Fluoridation Society , said studies conducted in two locations — Juneau, Alaska, and Alberta, Canada — found that when fluoride was removed, the rates of cavities increased dramatically in children.

"Fluoride in toothpaste alone is not enough, he said. "They work together."

The argument against fluoride

Ladapo points to research that fluoride is toxic.

Ashley Malin, assistant professor of epidemiology at the University of Florida, has been researching the health impacts of fluoride exposure since 2013. Her most recent study examined fluoride concentration in the urine of pregnant, low-income Hispanic women in Los Angeles. Her research found that higher fluoride levels in pregnant women were linked to increased odds of their children exhibiting neurobehavioral problems such as anxiety, depression and symptoms of autism at age 3.

Studies in Mexico and Canada also examined neurodevelopmental outcomes in young children, including a negative effect on IQ. Those studies found that each 0.5 milligram per liter increase in fluoride was associated with about a two-and-a-half point IQ reduction.

Marc Edwards , professor of civil engineering at Virginia Tech, has studied fluoride in water samples throughout the United States. Edwards believes that fluoridated dental products can protect children’s teeth without the need for community fluoridation.

“Putting the fluoride in toothpaste has benefits to your teeth, but doesn't have the same problem with ingestion, because you essentially bathe the teeth to get the benefits. You don't swallow the toothpaste or the fluoride in the mouthwash,” Edwards said.

What a Sun Sentinel analysis shows

In 2023, about 113,000 emergency department visits in Florida for patients ages 0 to 64 were due to dental conditions that were potentially avoidable, such as cavities or gingivitis.

The South Florida Sun Sentinel compiled hospital ED visits from dental conditions over a decade and found Florida counties with the lowest rates of visits are those that add fluoride to their water. Most counties with the highest rates of ED visits for dental conditions are those that don't add fluoride.

Specifically, the analysis shows that over the last decade, Florida counties in which 90% or more of their residents received fluoridated drinking water have had lower average rates of hospital ER visits for dental conditions than the state average. In contrast counties in which 10% or less of residents receive fluoridated drinking water have much higher rates of ER visits than average.

According to the Florida Department of Health, over 70% of Floridians have fluoridated drinking water as of 2022. In Central Florida, the percentages for that year were: Lake County, 15%; Orange County, 80%; Osceola County, 98%; and Seminole County, 83%.

Florida residents can learn whether their city or county adds fluoride by visiting the Florida Department of Health's Public Water Systems Actively Fluoridating webpage .

Can Florida cities and counties afford to take a chance?

While advocates on both sides flood inboxes of city commissioners across the state with information on the issue, one fact cannot be disputed: Florida already has a poor track record for dental health.

The state ranks last in the nation for the percentage of children who have seen a dentist in the past year, according to a National Survey of Children’s Health.

In addition, about one in five children in the state are living with untreated cavities.

At least 7 million people in Florida face barriers to accessing preventive dental care, either due to a lack of dentists who accept Medicaid or because they live in areas designated as dental-care deserts.

"Florida has one of the most difficult dental access problems in the country," said Dr. Frank Catalanotto. "Without regular dental care, a population is more susceptible to dental disease."

Catalanotto said Floridians in municipalities that eliminate fluoride will see the effect within a few years: "We are going to have more children with cavities and probably more adults with cavities too."

South Florida Sun Sentinel health reporter Cindy Goodman can be reached at [email protected].