The US Environmental Protection Agency (EPA) announced it will open a new, off-cycle evidence review of fluoride in drinking water — a move that comes amid increasing political pressure, growing state-level activity, and heightened public attention to community water fluoridation (CWF).
Decades of research show that CWF is a safe, effective, and cost-saving public health measure. A recent study found that ending CWF in the US would lead to an estimated $9.8 billion in added health care costs, and another study found that children exposed to recommended levels of fluoride in drinking water performed better on math, reading, and vocabulary tests in secondary school compared to their peers not exposed to those levels.
The EPA’s evidence review will not change fluoride policy immediately, but it will shape the landscape for future federal and state decisions. Now is a critical time for advocates to understand what the EPA is — and is not — reviewing, how this process might affect oral health access for millions of people, and what actions they can take to protect CWF.
The EPA Opens New Evidence Review on Fluoride
On January 28, the EPA released a preliminary plan for public comment to update its Human Health Toxicity Assessment for fluoride through the Office of Water. The Office of Water is the only federal entity with authority to regulate fluoride levels nationally under the Safe Drinking Water Act (SDWA). Under the SDWA, the EPA is prohibited from requiring substances to be added to drinking water for preventive health purposes.
Decisions about fluoridating drinking water remain at the state and local level, provided that fluoride levels stay below the EPA’s toxicity threshold. That threshold is currently set at 4.0 mg/L — well above the 0.7 mg/L level used by most community water systems as the standard for optimal oral health. The purpose of the review is to establish a revised “reference dose,” or level of fluoride exposure at which adverse health effects may occur. Although the EPA does not decide whether communities fluoridate their drinking water, its toxicity assessments can shape future regulatory standards that could effectively bar communities from fluoridating.
The EPA has stated it will focus its assessment on two health outcomes, particularly in children: dental fluorosis and neurodevelopmental effects. The agency will not consider the benefits of fluoride for cavity prevention, nor will it evaluate cancer or bone-related outcomes.
The EPA has opened a 30-day public comment period on the preliminary assessment plan, closing on February 27. After that, the agency will:
- Finalize a systematic review protocol incorporating public input.
- Develop a draft Toxicity Assessment and proposed reference dose.
- Release the draft for external expert peer review and public comment.
- Revise and publish a final assessment, which will establish any next steps for further regulating fluoride or updating national guidance.
Parallel State-Level Momentum
The recent EPA announcement is unfolding alongside growing state-level action. In 2025, Florida and Utah enacted statewide bans on community water fluoridation, and momentum has carried into 2026.
So far this year:
- Fifteen states have introduced legislation to restrict or ban fluoridation.
- New Jersey has taken the opposite approach, advancing protections for CWF.
A recent CareQuest Institute analysis estimates that eliminating CWF in just five states would result in 132,000 additional children developing cavities and nearly $40 million in added Medicaid costs within three years.
Even in states where bills are unlikely to advance, the volume of proposals reflects a shifting political environment. CareQuest Institute is tracking fluoridation-related legislation in real time and regularly updating this map to reflect the political landscape.
How Advocates Can Respond
Dental and medical professionals remain among the most trusted voices on fluoride. Amidst circulating misinformation, clear, evidence-based, and person-centered conversations with patients are essential. But advocacy cannot stop at the provider front.
Fluoride policy wins in 2025 — including preventing the US Food and Drug Administration (FDA) from completely removing fluoride supplements for children from the market, defeating a proposed fluoride ban in Louisiana, and advancing fluoridation protections in Connecticut — demonstrate that coordinated, multi-stakeholder engagement works. In each case, advocates combined strong data, local leadership, and sustained outreach to protect access to fluoridated water and supplements, even in politically complex environments.
At this moment, engagement with the EPA is especially important. Submitting comments on the preliminary assessment plan can help ensure the agency hears from dental, public health, and scientific experts. We urge your organization to act.
Editor’s Note: If you would like more information or resources that can support your organization’s efforts to submit comments, please reach out to info@carequest.org.