Public Health Service Recommendation

The U.S. PHS Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries is science-based guidance on the optimal level of fluoride in community water supplies to prevent tooth decay in children and adults while reducing the risk for children to develop dental fluorosis. Starting in 2015, the recommended level is 0.7 milligrams of fluoride per liter of water. The recommendation is not an enforceable federal regulation. Individual jurisdictions make their own decisions on whether to fluoridate their community’s water supplies. Some states, however, mandate fluoridation for communities of a specific size.

An optimal level of fluoride in drinking water provides enough fluoride to prevent tooth decay in children and adults while limiting the risk of dental fluorosis, which is the only unwanted health effect of community water fluoridation. Dental fluorosis is a change in the appearance of the dental enamel that occurs in children whose teeth are forming under the gums. The risk of dental fluorosis increases as children ingest higher levels of fluoride. The most common impact of fluorosis is faint white spots on teeth that usually only a dental professional would notice.

National survey data show that prevention of tooth decay can be maintained at the recommended level of 0.7 milligrams of fluoride per liter of drinking water. This recommended level updates and replaces the previously recommended range of 0.7 to 1.2 milligrams per liter.

Sources of fluoride have increased since the early 1960s. At that time, nearly all fluoride intake came from drinking water and from food and beverages prepared with fluoridated water. Today, water is one of several sources of fluoride. Other sources include dental products such as toothpaste and mouth rinses, prescription fluoride supplements, and professionally applied fluoride products such as varnish and gels. Because it is now possible to receive enough fluoride with slightly lower amounts of fluoride in water, the PHS developed a new recommendation for the level of fluoride that is to be used in community water fluoridation. See U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries for more information.

In September 2010, the Department of Health and Human Services convened a panel of scientists from across the U.S. government to review new information related to fluoride intake and to consider a new recommendation for community water fluoridation. The federal panel reviewed the best available information, including changes in the occurrence and severity of tooth decay and of dental fluorosis in U.S. children and adults. The panel also studied the U.S. Environmental Protection Agency's (EPA) scientific assessments of the major sources of fluoride intake and risk of severe dental fluorosis among children. Severe dental fluorosis is rare in the United States. Based on this review, the federal panel proposed changing the recommended level for community water systems to 0.7 milligrams per liter (the low end of the prior recommended range of 0.7 to 1.2 milligrams per liter). The proposed change was published in the Federal Register. Public comment on the proposed new level was sought—and considered carefully by the Panel—before finalizing the new recommendation. In addition, the proposed recommendation was submitted to a Peer Review Process, a step required by the federal government for influential scientific information. Comments received from these peer reviewers will be available from the HHS Office of the Assistant Secretary for Planning and Evaluation.