The rural, wooded highlands of northern Arkansas, where small towns have few dentists, the water officials who serve more than 20,000 people have openly defied state law for over a decade by refusing to add fluoride to drinking water.
For their refusal, the Ozark Mountain Regional Public Water Authority has received hundreds of state fines totaling approximately $130,000, which are kept in a cardboard box and remain unpaid, according to Andy Anderson, who opposes fluoridation and has led the water system for nearly two decades.
This Ozark region is among hundreds of rural American communities facing a dual blow to oral health: a severe shortage of dentists and the lack of fluoridated water, widely considered by dentists as one of the most effective tools for preventing cavities.
But as the anti-fluoride movement gains unprecedented momentum, it could turn out that the people of Ozark were not left behind after all.
"At the end, we will win," said Anderson. "We will be vindicated."
Fluoride, a natural mineral, keeps teeth strong when added to drinking water, according to the Centers for Disease Control and Prevention (CDC) and the American Dental Association (ADA). However, the anti-fluoride movement has gained momentum since a government report last summer found a possible link between lower IQ in children and consumption of higher-than-recommended amounts of fluoride in American drinking water.
Dozens of communities have decided to stop fluoridating their water in recent months, and state officials in Florida and Texas have urged their water systems to do the same. Utah is set to become the first state to ban fluoride in tap water.
Health and Human Services Secretary Robert F. Kennedy Jr., who has long advocated alternative health theories, has called fluoride a "industrial residue" and "dangerous neurotoxin," and has claimed that the Trump administration will recommend its removal from public drinking water.
On the other hand, Republican efforts to extend tax cuts and reduce federal spending could negatively impact Medicaid, exacerbating the shortage of dentists in rural areas, where many residents rely on the federal insurance program for any dental care.
Dental experts warn that the simultaneous erosion of Medicaid and fluoridation could exacerbate a rural oral health crisis and reverse decades of progress against tooth decay, especially in children and people who rarely visit the dentist.
"If people have limited access to professional care and do not have access to water fluoridation, then they are missing two of the fundamental pillars for staying healthy for life," said Steven Levy, a dentist and lead fluoride researcher at the University of Iowa.
Many have already lost them.
Double Crisis: Dental Deserts and "Fluoride Free"
Nearly 25 million Americans live in areas with inadequate dentists—more than double the federal government’s previous estimate—according to a recent study from Harvard University that measured the country’s dental deserts more deeply and accurately than before.
Hawazin Elani, a dentist and epidemiologist at Harvard and co-author of the study, found that many areas with shortages are rural, poor, and heavily reliant on Medicaid. But many dentists do not accept Medicaid because payments can be low, Elani said.
The ADA has estimated that only one-third of dentists treat Medicaid patients.
"I suspect that this situation is much worse for Medicaid beneficiaries," said Elani. "If you have Medicaid and your nearest dentist doesn’t accept it, you’ll probably have to go to the third, fourth, or fifth one."
The Harvard study identified more than 780 counties where more than half of residents live in a water-scarce area. Of those counties, at least 230 also have public water without fluoride, in whole or in part, according to a fluoride data analysis by KFF published by the CDC. This means that people in these areas who cannot find a dentist also do not get protection for their teeth from tap water.
At the center of this group is the Ozark Mountain Regional Public Water Authority, which serves Boone, Marion, Newton, and Searcy counties in Arkansas. It has refused to add fluoride since Arkansas enacted a state mandate in 2011. After weekly fines began in 2016, the water system unsuccessfully challenged the fluoride mandate in a state court, and then lost on appeal.
Anderson, who has chaired the water system board since 2007, said he would like to challenge the fluoride mandate again in court and, if necessary, would present the case himself. In a phone interview, he claimed to believe that fluoride can harm the brain and body to the point of making people "fat and lazy."
Nearby, in the small community of Leslie, Arkansas, which receives water from the Ozark system, the town’s only dentist operates a one-person clinic.
It’s a dentist hidden in the back room of an antique store. Hand-painted letters on the storefront advertise a "good dentist."
James Flanagin, a third-generation dentist who opened the clinic three years ago, said he was drawn to Leslie by the quaint charm and friendly smiles of small-town life. But those same smiles also reveal the unmistakable consequences of refusing to fluoridate, he said.
"There is no doubt that there are more cavities here than there would be under other circumstances," he said. "You’re going to have more cavities if your water is not fluoridated. It’s a fact."
Fluoride, a Great Public Health Achievement
Fluoride was first added to public water in an American city in 1945 and, by 1980, had spread to half the country’s population, according to the CDC. Due to the drastic decline in cavities that followed, in 1999 the CDC classified fluoridation as one of the 10 great public health achievements of the 20th century.
Currently, over 70% of the US population using public water systems receives fluoridated water, with a recommended concentration of 0.7 milligrams per liter, or approximately three drops in a 55-gallon barrel, according to the CDC.
Fluoride is also present in modern toothpaste, mouthwash, dental varnish, and some foods and beverages, such as raisins, potatoes, oats, coffee, and black tea. However, several dental experts stated that these products do not reliably reach as many low-income families as drinking water, which has the added benefit, compared to toothpaste, of strengthening children’s teeth from the inside as they grow.
Two recent surveys have revealed that the majority of Americans support fluoridation, but a considerable minority does not. Surveys by Axios/Ipsos and AP-NORC found that 48% and 40% of respondents wished to maintain fluoride in the public water supply, while 29% and 26% supported its removal.
Chelsea Fosse, a dental health policy expert at the American Academy of Pediatric Dentistry, expressed concern about the unfounded fear of fluoride, which could lead many people to stop using fluoridated toothpaste and enamel, just when Medicaid cuts make it difficult to see the dentist.
This combination, she said, could be devastating.
"It will be evident the impact this has on the prevalence of dental caries," Fosse said. "If we eliminate water fluoridation, if we cut Medicaid, and if we don’t support providers to identify and care for the neediest populations, I really don’t know what we’ll do."
Multiple studies have shown what the elimination of fluoride could look like. In recent years, studies in cities in Alaska and Canada have shown that communities that stopped fluoridation experienced significant increases in cavities in children compared to similar cities that did not.
A 2024 study in Israel reported a doubling in dental treatments for children in the five years after the country suspended fluoridation in 2014.
Despite the benefits of fluoridation, some have fiercely opposed it since its inception, according to Catherine Hayes, a dental expert at Harvard who advises the American Dental Association on fluoride and has studied its use for three decades.
Initially, fluoridation was discredited as a communist plot against the United States, Hayes said, and later fears of possible cancer links surfaced, which were refuted by extensive scientific research.
In the 1980s, hysteria fueled fears that fluoride caused AIDS, which was "absurd," Hayes said. More recently, the anti-fluoride movement seized on international research suggesting that high levels of fluoride could hinder child brain development, and has been driven by major legal and policy victories.
In August, a much-debated report from the National Toxicology Program of the National Institutes of Health concluded, with "a moderate level of confidence," that exposure to fluoride levels higher than those present in American drinking water is associated with lower IQ in children.
The report was based on an analysis of 74 studies conducted in other countries, most of which were considered of "low quality" and involved exposure to at least 1.5 milligrams of fluoride per liter of water—more than double the US recommendation—according to the program.
The following month, in a long-standing lawsuit brought by fluoride opponents, a federal judge in California ruled that the potential link between fluoride and lower IQ was too risky to ignore, and ordered the federal Environmental Protection Agency (EPA) to take unspecified action to reduce that risk.
The EPA began appealing this ruling in the final days of the Biden administration, but the Trump administration could reverse its stance.
The EPA and the Department of Justice declined to comment. The White House and the Department of Health and Human Services did not respond to questions about fluoride.
Despite the National Toxicology Program report, Hayes said that to date, there has been no proven association between low IQ and the amount of fluoride present in the water of most Americans. The judicial ruling could spur additional research in the country. Hayes hopes that they will eventually put an end to the campaign against fluoride.
"It’s one of the great mysteries of my career, what underpins it," Hayes said. "What worries me is that some members of the public, and some of our lawmakers, believe there is some truth in this."
Not all experts dismissed the toxicology program report. Bruce Lanphear, a child health researcher at Simon Fraser University in British Columbia, published an editorial in January stating that the findings should prompt health organizations to "reevaluate the risks and benefits of fluoride, especially for pregnant women and babies."
"Those proposing fluoridation now must demonstrate that it is safe," Lanphear told NPR in January. "That’s what this study does: it shifts the burden of proof, or it should."
Cities and States Reconsider Fluoride
So far this year, at least 14 states have considered or are considering bills that would lift fluoride mandates or ban fluoride in drinking water altogether.
In February, Utah lawmakers approved the country’s first ban. Republican Governor Spencer Cox told ABC4 that he plans to sign it. Both Florida’s director of health services, Joseph Ladapo, and Texas agriculture commissioner Sid Miller have urged their respective states to end fluoridation.
"I don’t want ‘Big Brother’ telling me what to do," Miller told The Dallas Morning News in February. "The government has imposed this on us for too long."
In addition, dozens of cities and counties have decided to suspend fluoridation in the last six months, including at least 16 Florida communities with a combined population of over 1.6 million, according to press reports and the Fluoride Action Network.
Stuart Cooper, executive director of that group, said the unprecedented momentum of the movement would be stronger if Kennedy and the Trump administration comply with the recommendation against fluoride.
Cooper predicted that most American communities will stop fluoridating their water in a few years.
"I think what we are seeing in Florida, where all communities are falling like dominoes, will now happen in the United States," he said. "I think we are witnessing its absolute end."
If Cooper’s prediction is correct, Hayes said, widespread cavities would be visible in a few years. Children’s teeth will decay, she added, although "we know how to prevent it completely."
"It’s unnecessary pain and suffering," Hayes said. "If you go to any children’s hospital in the country, you will see a waiting list of children to go into the operating room and have their teeth fixed because they have severe cavities from not having access to fluoridated water or other types of fluoride. Unfortunately, this will only get worse."
Health News Data Editor, Holly K. Hacker, contributed to this article.
Author: Brett Kelman: bkelman@kff.org, @BrettKelman
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