5 Alabama cities recently removed fluoride from water: ‘It’s not a pretty picture’

In one of the worst states in the nation for dental health, more and more Alabama cities are considering whether to remove fluoride from public drinking water.

In the last year, five cities in Alabama, have removed fluoride. Madison could soon become the sixth.

“Unfortunately, it has become a situation where it’s no longer a surprise when I’m notified that somebody is considering removing fluoride,” said Tommy Johnson, the state dental director at the Alabama Department of Public Health.

Different cities have cited different reasons for the move – from financial strains to safety concerns.

But dentists and public health officials say water fluoridation has been beneficial to the state, both in terms of reducing tooth decay and saving money on dental treatments.

“Fluoride has gotten a bad rap and there is nothing wrong with looking to see if there are other alternatives for people who do not wish it,” Johnson told AL.com. “But at the same time, we know the benefits – it is considered one of the top 10 greatest achievements of public health in the 20th century – and there is no question that it’s effective.”

‘It’s for everybody’

Alabama has the second lowest ratio of dentists to patients in the country. A number of rural counties either don’t have dentists or their few remaining dentists are on the verge of retirement. And the wait time for kids to get into an operating room for a dental surgery in Alabama is around a year.

In 2022, the Alabama health department did dental screenings on students from 52 schools in the state to monitor tooth decay.

In rural schools, Johnson said he saw so much decay in a child’s mouth that “you can’t even tell they’re teeth.” He said some students told him they don’t even have a toothbrush at home.

“So when people comment that we don’t need fluoridation in the water system because you’re going to get it at the dentist, well not everybody has that opportunity,” Johnson told AL.com. “Access to care is a huge problem in Alabama so, socioeconomically, community water fluoridation is the most ideal situation you can have because it’s for everybody.”

Data gathered and analyzed by the state health department and the University of Alabama at Birmingham shows that children in Blount County have experienced significantly more tooth decay than kids in Jefferson County.

Though the two counties border one another, Jefferson’s water is 99% fluoridated while Blount County’s water is only 18% fluoridated. While Blount County is more rural than its neighbor, it’s still home to a number of dentists.

Researchers found that 34.5% of kindergartners and third graders in Jefferson county experienced tooth decay from 2020-2022, compared to 57.5% in Blount county.

“That’s profound and paints a bleak picture,” said Stephen Mitchell, a pediatric dentist and director of the Sparks Clinic at UAB.

In recent years, Blount County removed most of the fluoride in its drinking water. Mitchell told AL.com that many of the current high schoolers in the county benefited from fluoride when they were growing up.

“They don’t have the same levels of tooth decay we’re seeing in the young kids.”

Reducing cavities and tooth decay, which is the most common chronic illness in children in the U.S., is only one benefit of fluoride.

According to a recent ADPH report, one year of fluoridating water at the optimal level saves $6.5 billion in dental costs nationally. That comes out to about $32 a year for every single person in the country. On average, every dollar spent on fluoride yields a $20 return on investment, the report found.

National debate

The debate around whether drinking water should be fluoridated is picking up steam nationally. Robert F. Kennedy Jr., the secretary of Health and Human Services, last month announced plans to ask the Centers for Disease Control and Prevention to stop recommending fluoridation in water.

Just last week Kennedy, who has repeatedly pushed controversial and questionable health claims, said the more fluoride you drink, “the stupider you are, and we need smart kids in this country, and we need healthy kids.”

Kennedy’s comment came while praising Utah for becoming the first state to ban fluoride in their public water systems. The Utah ban took effect Wednesday, and dentists there say they’re already bracing for the impact on their most vulnerable residents.

Mitchell told AL.com that there are about 19 published studies deemed “high quality” by the National Institutes of Health that show a correlation between fluoride and a reduction in IQ.

But Mitchell pointed out that all of those studies were conducted overseas in areas where the water fluoridation was twice or even four times the recommended amount that is used in Alabama or across the U.S.

“If you have four times the amount of water you’re supposed to,” Mitchell said, “that would create problems for you too.”

Johnson echoed those caveats.

“If you read those studies, inevitably the opening statement will say ‘in levels in excess of the recommended amount,’” he told AL.com. “And when I say excess, I mean it’s at least double what’s recommended and sometimes up to 10 times what’s recommended.”

One recent study out of Florida made a connection between fluoride and autism. The study looked at state Medicaid data and found that kids who drank fluoridated water in the first 10 years of their life were more likely to be diagnosed with autism and other disabilities than kids in non-fluoridated areas.

“That’s been a shock study that has hit the news circles and Facebook, but there’s some real concerns about how they selected their study population and that it may not be a representative sample,” Mitchell added.

At the Sparks Clinic, Mitchell works with patients with developmental and intellectual disabilities.

“Teeth are important but the brain is more important. So I understand the concern because that’s my area, those are the patients and families I work with,” said Mitchell.

“But if we jump to conclusions and make rash decisions to start getting rid of fluoride, I know that my population of patients are going to suffer the most tooth decay increase because they suffer from behavioral challenges that make providing routine dental care difficult,” Mitchell said. “So we want to be careful and not throw these families into bigger difficulties by overreacting too quickly.”

According to ADPH, the recommended, optimal level for fluoride in drinking water is .7 parts per million.

Fluoride exists naturally in virtually all water supplies. Fluoridation doesn’t mean adding a medication to the water – it’s simply adjusting the fluoride to the optimal level to prevent tooth decay.

“It’s natural,” Johnson said. “Even if you have a well, well water will have naturally occurring fluoride in it because it comes from rocks.”

‘We don’t have the resources’

Alabama doesn’t mandate that water systems fluoridate their water, so the public health agency can only offer guidance. Instead, local authorities have the power to decide whether to add the mineral or remove it.

The state health department monitors the levels in each water system, and will let local authorities know if their fluoride is lower or higher than what is recommended. He said they if it’s too high, they alert them immediately.

“If it’s too low we let them know they’re wasting their money because it’s not effective,” he said.

Since March of 2024, Abbeville, Childersburg, Sylacauga, Orange Beach and Grand Bay have removed fluoride from their water. Madison Utilities recently moved to do it, too.

“Most of the time we are not made aware of it until the decision has already been made,” said Johnson with the state health department.

In Madison, the utility board last month quietly decided to end fluoridation, saying it would cost $500,000 to repair their corroding fluoride treatment system.

The news came as a surprise, even to the city council in Madison. No members of the public were present when the utility board voted to end fluoridation beginning June 16.

Shortly after the news became public, about two dozen people showed up to a city council meeting to raise concerns about the utility’s decision.

The utility board could possibly revote after a public hearing on May 13.

According to Johnson, he’s getting calls from even more cities, including some of the “larger, more significant systems,” about whether to discontinue fluoridation in their drinking water.

He wouldn’t name names but warned that the state doesn’t have the resources to fill the void.

The Alabama health department currently only has two people in its central dental office, including Johnson and a community dental health coordinator. Of the 65 county health departments managed by ADPH , only one – Tuscaloosa County – has a dental facility. Jefferson and Mobile counties have their own departments with dental facilities.

“We don’t have the resources here when it comes to public health and there aren’t a lot of people we can fall back on given our access to care problem,” said Johnson. “We are so dependent on anything we can get as far as preventative treatments like fluoride. So I just have to scratch my head at how this’ll work because we’re already not in a great situation.

“It’s not a pretty picture to paint but it’s what we’re faced with.”