The impact of community water fluoridation cessation on health equity and service utilization: a global scoping...

Community water fluoridation (CWF) is a widely used population-level intervention for preventing dental caries. However, CWF discontinuation is increasingly debated globally, often without a comprehensive synthesis of the subsequent clinical, service-related, economic, and equity implications. We aimed to systematically map and synthesize empirical evidence regarding dental health and service-based outcomes following CWF cessation.

For this scoping review, we searched 17 bibliographic databases and grey literature from inception through Oct 31, 2025. Eligible studies reported empirical dental outcomes, including caries indices, service utilization, and treatment costs, before and after CWF cessation or compared outcomes in ceased communities with those in appropriate control communities. Data were extracted independently by multiple reviewers, and overlapping cohorts were linked into evidence clusters to avoid double-counting findings.

Nineteen studies (1970-2025) conducted in Europe, North America, Australia, and Israel were included. Findings were heterogeneous across settings and study designs. Jurisdictions without active fluoride replacement programs more frequently reported increases in caries measures, including up to a 75% increase in mean DMFT, and increased treatment utilization, particularly restorative procedures. By contrast, settings with alternative fluoride strategies or broader preventive infrastructure often reported stable outcomes or continued improvements over time. Several studies also reported greater treatment burden and costs, including a 32% increase in caries-related expenditures, among younger children and selected vulnerable populations, including socioeconomically disadvantaged groups and publicly insured children.

Oral health outcomes following CWF cessation varied across settings and populations. Little change or continued improvement was more commonly observed in settings with broader preventive supports or alternative fluoride strategies, whereas greater treatment burden and less favorable outcomes were more frequently reported among younger or vulnerable populations and in settings with limited preventive supports. More rigorous comparative research is needed to clarify these relationships and inform policy decisions.