Community water fluoridation perceptions and practice in the United States: challenges in governance and implementation

The primary objective of this research is to reveal potential challenges in achieving the finalized water fluoridation recommendation made by the Federal Water Fluoridation Panel in the United States (U.S.) with data extracted from consumer confidence reports. A secondary objective is to understand community water system manager's perceptions of and ability to meet this new standard using a survey instrument. Mean fluoridation levels are above the recommended level. The confidence interval does not capture the nationally recommended 0.7 mg/L. The t-test revealed two statistically significant results: that the sample mean is not equal to 0.7 mg/L and that the sample mean is higher than 0.7 mg/L. Respondents felt engaged in the policy process, but preferred state over federal policymaking. There is evidence that the optimal fluoridation level may not have been reached by water systems and that some water systems are under-fluoridating, while others are over-fluoridating. Several large water systems and pockets across the U.S. are not practicing artificial water fluoridation which reduces the effectiveness of this policy. Regular engagement by states with water system managers and feedback from water management professionals could be encouraged to better understand local constraints in meeting the federal recommendation.