Tooth Decay Rose in Canadian Cities Without Fluoride. RFK Wants This for the US.

It’s not uncommon for Canadian dentist Brandon Doucet to see patients who are in so much pain that they’ve tried to extract their own teeth.

As a dental student, Doucet was inspired by Bernie Sanders’s first presidential campaign and realized that he needed to take action where he was, in Halifax, Nova Scotia. In 2019, Doucet founded a group called the Coalition for Dental Care to advocate for public access to dental health care in Canada.

Canada’s public dental care spending is abysmal: Just 6 percent of all dental spending is public, which puts the country second to last of countries in the Organisation for Economic Co-operation and Development (OECD). At 6 percent, Canada spends almost half of what the United States spends (10 percent). Compare that to the highest spenders in the world — Japan, at 77 percent and Germany, at 64 percent — and Canada’s public dental spending is downright shameful.

Access to dental care is skewed by income. Lower-income Canadians have nearly double the rate of untreated need for oral care than higher-income Canadians have, and lower-income families have outcomes that are two times worse (more dental disease, more pain, more time off work) than higher-income Canadians.

In 2024, the Liberal Party of Canada created the Canadian Dental Care Plan, the country’s first national, public dental care program. Spending on this program will bring Canada close to the OECD average of 32 percent, Doucet says. But as the program onboards more and more people in a phased rollout, debates about what Doucet calls the easiest public health intervention for oral health — fluoride in drinking water — swirl at municipal councils. And in the past few months, these debates have reignited thanks to spurious claims made by Robert F. Kennedy Jr., who has been tapped by Donald Trump to lead the U.S.’s Department of Health and Human Services.

No More Fluoridation in Montreal

On November 27, 2024, the City of Montreal announced that it would no longer add fluoride to drinking water at two of the city’s water treatment plants, Pointe-Claire and Dorval. They processed just 5 percent of the city’s drinking water and were among the very few locations in the province that still fluorinated its water in Quebec. The vast majority of the province (99 percent) does not put fluoride in its water.

Fluoride has long been accepted as the most efficient way to ensure a base-level access to improved dental health for the whole of a population. Even so, curiously absent in the announcement made by the City of Montreal regarding its decision to end fluoridation is any mention of health. While the statement questions the impact of fluoride on aquatic and marine life, it explains, “After a rigorous assessment of the technical, operational and economic data, the agglomeration council decided on November 21, 2024 to discontinue the fluoridation process at the Pointe-Claire and Dorval drinking water production plants.” A 1990 study of the possible impact of water fluoridation on the St. Lawrence River found that it would have no measurable impact on aquatic life.

A City of Montreal spokesperson declined an interview request, sharing instead the November 27 statement in French.

Fluoride was never added to drinking water to improve technical, operation or economic performance — its principal purpose was to reduce the prevalence of dental caries (tooth decay). Fluoride is known to cut the prevalence of tooth decay among children by 25 percent.

Ultimately, the argument over fluoride is less about the conspiracy theories of a few, and more about money and jurisdiction: who saves money, how much, who spends it and who manages the infrastructure.

Almost three-quarters of all U.S. residents have access to fluoridated water, but just 38.8 percent of Canadians do. Between 98.5 percent and 100 percent of the residents of Quebec, British Columbia, Yukon, New Brunswick and Newfoundland and Labrador have no access to fluoride in their drinking water. Whether to fluoridate drinking water has been a long-standing debate raging in municipalities across Canada for decades, driven by different political arguments. The Public Health Agency of Canada declined to be interviewed for this piece.

Disinformation Drives Discussion

Why did the issue resurface in Montreal last year? Local journalists and politicians pointed to a petition circulated by an RFK Jr.-influenced far right activist in Montreal as the catalyst. Ray Coelho, longtime opponent of fluoride and one-time candidate for a far right fringe party, claimed credit for the decision in the Montreal Gazette.

RFK Jr. has suggested that fluoride, a naturally occurring mineral, is akin to industrial waste — a falsehood often repeated by anti-fluoride activists quoted in Canadian media. He claims that fluoride is “associated with arthritis, bone fractures, bone cancer, IQ loss, neurodevelopmental disorders, and thyroid disease.”

As with most (if not all) minerals, consuming high amounts of fluoride is bad for human health — there’s a reason why we are told not to swallow our toothpaste, after all. But the amount put into drinking water systems is far lower than the threshold shown to cause side effects. There is overwhelming consensus among oral health professionals that fluoridation is an important and safe public health intervention. When contacted by Truthout, the Canadian Dental Association (CDA) shared a November 26, 2024, statement on its current position on fluoride, which says: “CDA closely monitors scientific developments and remains confident in the current consensus, which is based on evidence provided by quality research, that fluoridation at optimal levels poses no risk to cognitive health, including IQ. Studies suggesting a link between fluoride and cognitive decline are often limited by methodological flaws, and their findings do not apply to the optimal fluoride levels used in Canada (0.7 mg/L), which are carefully regulated by the Federal-Provincial-Territorial Committee on Drinking Water.”

The statement was released just days after the decision made in Montreal’s Pointe-Claire borough.

Yet many Canadian cities are moving in the opposite direction after years of not fluoridating their water has resulted in an increase in oral disease.

Some Cities Return to Fluoride, But Municipalities Face Budget Constraints

Aimee Dawson, a dentist and dentistry professor at Laval University in Quebec City, points to Calgary and Edmonton as two cities that have offered a real-life test in the utility of water fluoridation. She said that there was a clear increase in the number of dental caries that were being treated in Calgary when the city stopped fluoridation in 2011, as compared to Edmonton, which still fluoridates its drinking water. Researchers found that among two cohorts of grade-two children in both cities, the ones in Edmonton had a 55.1 percent prevalence of dental caries while the ones in Calgary had a 64.8 percent prevalence.

And indeed, the impact on public health has been dramatic: After Calgary ended fluoridation, 700 percent more children needed intravenous antibiotics to avoid fatal dental infection. The city is now working to upgrade systems to turn the fluoride back on in 2025 after citizens mobilized to add it back.

The municipal council of Kingston, Ontario, is also in favor of reintroducing fluoride to the water, despite the efforts of local anti-fluoride activists. A spokesperson from Kingston, Frontenac and Lennox & Addington Public Health said that the authority has seen a “significant and concerning rise in tooth decay among children.” The City of Windsor, Ontario, readded fluoride to its system in 2022 after it was stopped in 2013 and dentists saw a subsequent increase in tooth decay among children.

Some critics of fluoride point to Canada’s new dental program as one reason why fluoride is no longer needed. If fluoride is intended to improve the oral health of all Canadians, the most impoverished included, then this new program targeted to poorer Canadians should be all we need, they argue.

But the Canada Dental Benefit isn’t a replacement for fluoridated water. Doucet argues that even with Canada’s new dental care program, the lowest-income people are still unlikely to access dental services — if you live in a community with no dentist, the program won’t help. This is why community fluoridation is such an important intervention: It can help everyone.

While municipal councilors debate the issue, Dawson reminds us, “Water fluoridation is demonstrated to reduce the number of tooth surfaces affected by dental caries. This [public dental care] initiative of the federal government will do that for certain people, but probably not for the people with the greatest need.”

“Every $1 spent on community water fluoridation will save … anywhere between $15 and $35 in reduced dental decay needing to be treated,” Doucet says. “And the dental decay that is reduced is disproportionately in poorer communities who often struggle accessing dental care.”

It isn’t just cost savings, of course. Fluoridation also gives people a stronger start to their oral health, which goes a long way to maintain their oral health over the rest of their lives.

Ultimately, the argument over fluoride is less about the conspiracy theories of a few, and more about money and jurisdiction: who saves money, how much, who spends it and who manages the infrastructure. While the Canadian Dental Care Plan is a federal program, oral health is mostly the responsibility of the provinces. Fluoride, meanwhile, is the responsibility of the groups that manage local water systems, which are mostly municipalities. With 3,342 water treatment facilities in Canada, all managed by local boards or politicians, that’s a lot of different bodies that all have to balance financial pressures and public health through water fluoridation. Dawson says that because decisions are made at the municipal level, “the people making those decisions don’t necessarily have the background, staff with the scientific expertise necessary or the training to make that decision.”

Indeed, in 2021, the water authority in Halifax and Dartmouth stopped adding fluoride consistently to the water but didn’t tell anyone. It was revealed in 2024 that the agency stopped adding it while doing repairs to water infrastructure. The water agency has since promised to inform the province’s association of dentists the next time it decides to quietly stop fluoridating water, and that it should be back in the water sometime in 2025.

Fluoridation costs money, as referenced by the City of Montreal. In Calgary it will cost $28 million to reintroduce fluoride and then $1 million each year to maintain it. In Windsor, it was expected to cost $850,000 to reintroduce it and then an annual maintenance cost of $150,000.

As municipal budgets are increasingly stressed, many communities will decide that fluoridation is just not worth it. And, aided by disinformation campaigns, the decision to avoid fluoridation becomes easier than following the science and adding it to community water systems.