Key Takeaways
- A new retrospective study examined dental treatment records for approximately 28,000 Israeli 12-year-olds from 2014 through 2022, spanning the end of mandatory community water fluoridation.
- Children in low-socioeconomic-status communities without fluoridated water had a higher mean Missing and Filled Teeth index than children in low-SES communities with fluoridated water, 0.817 compared with 0.660.
- Socioeconomic status showed a much larger statistical relationship with the treatment index than fluoridation status, which suggests that fluoridation represents only one part of a broader inequality problem.
- The study measured fillings, crowns, and caries-related extractions, not untreated decay or total caries prevalence.
- The records came from children who received dental treatment through Maccabi-Dent, so the results may reflect dental-service use as well as underlying disease.
- The retrospective design supports an association but cannot prove that ending mandatory fluoridation caused the observed differences.
- A 2024 Cochrane review found that contemporary fluoridation may provide a smaller benefit than older research suggested and found insufficient evidence about cessation and socioeconomic inequalities.
- Policymakers should consider fluoridation alongside access to dental care, fluoride toothpaste, school-based prevention, diet, surveillance, cost, feasibility, and community circumstances.
Introduction
A dentist demonstrates preventive oral care to a child. A 2026 Israeli study found higher dental treatment scores among children in non-fluoridated, low-income communities.
When a government ends a population-wide preventive program, the consequences may not appear equally across society. Families with regular dental care, preventive treatments, health information, and financial resources may compensate. Families with fewer resources may not.
Israel offers an important case study. The country required community water fluoridation in large municipal systems beginning in 2002, and approximately 70% to 75% of the population received fluoridated water by 2013. The Ministry of Health ended the national mandate in August 2014. Many communities then experienced several years without fluoridated water while political, administrative, and financial barriers delayed reinstatement efforts (Fawarsy et al., 2026).
A new study in the Israel Journal of Health Policy Research examined dental treatment records for approximately 28,000 12-year-old children between 2014 and 2022. The researchers reported more fillings and caries-related extractions in non-fluoridated settings, with the largest difference among children from low-socioeconomic-status communities (Fawarsy et al., 2026).
The finding supports concern about oral-health equity, but the study does not provide a controlled experiment or a complete measure of tooth decay. It tracked treatment, not every cavity. It also could not fully separate fluoridation from income, dental attendance, diet, toothpaste use, migration, or other changes that occurred over the same period.
The central question therefore requires a careful answer: Did the end of mandatory fluoridation worsen childhood dental health in Israel? The new data suggest that it may have increased treatment burden, especially in disadvantaged communities. However, the design cannot establish fluoridation cessation as the sole cause.
Why Did Israel End Mandatory Water Fluoridation?
Community water fluoridation adjusts the natural fluoride concentration in public water to a level that helps reduce tooth decay. Fluoride acts mainly at the tooth surface. It promotes remineralization, slows demineralization during acid attacks, and can interfere with bacterial activity in dental plaque (Centers for Disease Control and Prevention, 2024).
Israel first introduced water fluoridation in 1981 and later expanded it through national requirements. In 2014, the Ministry of Health rescinded the mandate during a political debate involving autonomy, safety, government authority, and public-health policy. The change ended fluoridation across much of the country, although fluoridation status later varied by locality and year (Fawarsy et al., 2026).
This policy shift created an opportunity to compare dental outcomes during the final fluoridation period with outcomes during subsequent years. Researchers often call such events natural experiments because policy changes alter exposure outside a traditional randomized trial.
Natural experiments can provide valuable real-world evidence. They also carry major limitations. Communities do not change only one condition at a time. Dental coverage, treatment availability, family income, migration, sugar consumption, preventive programs, fluoride toothpaste use, and data-recording practices may also change. Researchers must account for those factors before they can make strong causal claims.
How Did the Researchers Conduct the Study?
Fawarsy and colleagues analyzed electronic records from Maccabi-Dent, the dental division of Maccabi Healthcare Services and one of Israel’s major dental-care networks. More than 50 clinics contributed records for 12-year-old patients who received restorative treatment or caries-related extractions between January 2014 and December 2022 (Fawarsy et al., 2026).
The study included approximately 28,000 children with at least one recorded restoration. The database contained 61,066 restorations and 3,327 permanent-tooth extractions related to caries. Girls accounted for 55% of children with restorations, while boys accounted for 45%.
The researchers created an MF index based on the Missing and Filled components of the conventional DMFT index:
- Missing referred to permanent teeth that dentists extracted because of caries.
- Filled included restorations and crowns.
- The study did not reliably capture the Decayed component, which represents untreated cavities.
The researchers linked each child’s treatment record to fluoridation status in the child’s locality and calendar year. They grouped municipalities into low, middle, and high socioeconomic categories using an Israeli locality index. They then compared mean MF values across fluoridation status, socioeconomic group, and sex.
This approach allowed the team to examine treatment patterns on a large scale. It did not produce a direct clinical examination of a representative sample of all Israeli 12-year-olds.
What Did the Study Find?
The strongest pattern involved socioeconomic status. In fluoridated areas, children from low-SES communities had a mean MF value of 0.660, compared with 0.361 in high-SES communities. In non-fluoridated areas, the gap widened: low-SES children had a mean MF of 0.817, while high-SES children had a mean of 0.395 (Fawarsy et al., 2026).
Within low-SES communities, the mean MF value was significantly higher without fluoridation than with it, 0.817 compared with 0.660. The corresponding comparisons did not reach statistical significance in the middle- and high-SES groups.
The statistical effect of socioeconomic status was large, with a partial eta-squared value of approximately 0.34. Fluoridation status showed a much smaller effect, approximately 0.009. These values should not receive identical emphasis. The results suggest that social and economic conditions explained far more variation in the treatment index than fluoridation status alone.
The study also reported higher MF values among girls. Across the pooled data, girls averaged approximately 0.54 missing or filled teeth, compared with 0.43 among boys. The authors proposed several possible explanations, including earlier eruption of permanent teeth in girls and differences in dental-service use. The study did not directly test those mechanisms.
What Does the MF Index Actually Measure?
The distinction between caries and caries treatment matters greatly in this study.
The conventional DMFT index counts decayed, missing, and filled permanent teeth. A researcher who examines every child can identify untreated cavities as well as past treatment. The Maccabi-Dent database could not reliably identify untreated decay, so the investigators used only the missing and filled components.
As a result, a higher MF value can indicate more disease that required treatment. It can also indicate greater access to diagnosis and restorative care. A child with several untreated cavities but no fillings could appear to have a lower MF value than a child whose dentist restored those cavities promptly.
The study therefore measured documented treatment burden more directly than total caries prevalence. This does not make the findings unimportant. Fillings, crowns, and extractions represent meaningful disease and health-care use. However, the measure does not justify the simple claim that researchers counted all cavities and found more after fluoridation ended.
In my professional view, this measurement issue represents the article’s most important limitation. The findings support concern about treatment demand after policy change, but they cannot provide a complete epidemiological picture of untreated and treated decay across Israel.
Why Did Socioeconomic Status Matter So Much?
Dental caries develops through interactions among frequent sugar exposure, oral bacteria, tooth susceptibility, fluoride exposure, saliva, hygiene, and time. Social conditions influence nearly every part of that process.
Families with greater resources may have easier access to fluoride toothpaste, routine dental visits, sealants, professional fluoride varnish, nutritious food, transportation, flexible work schedules, and health information. They may also obtain treatment before small lesions progress.
Community water fluoridation requires little individual action beyond drinking and using the public water supply. For that reason, advocates view it as an upstream intervention that may provide baseline protection regardless of income or health literacy.
The Israeli findings fit that theory: the fluoridation difference appeared most clearly in low-SES communities. Yet the new study cannot prove that affluent families successfully replaced fluoridated water with other preventive measures. It did not measure toothpaste use, fluoride varnish, sealants, dietary sugar, private dental care, bottled-water consumption, or individual household income.
The large SES effect also prevents fluoridation from becoming the entire explanation. Even in fluoridated areas, low-SES children had substantially higher MF values than high-SES children. Fluoridation may reduce part of an inequality while leaving the deeper structural causes intact.
Does the Study Prove That Ending Fluoridation Caused More Cavities?
No. The study found an association between non-fluoridated settings and a higher MF treatment index, particularly among children in low-SES communities. Several features limit causal interpretation.
First, the retrospective analysis lacked random assignment. Communities and years with and without fluoridation may differ in ways that also influence dental outcomes.
Second, the data came from children who received care through Maccabi-Dent. The analysis did not begin with a representative sample of all 12-year-olds and examine every child. Changes in insurance participation, clinic attendance, treatment-seeking behavior, or provider availability could alter the recorded MF index.
Third, the study used 2014 as the tail end of the fluoridation period and compared it with 2015 through 2022. A stronger interrupted time-series analysis would benefit from several clearly measured pre-cessation years, a well-defined post-cessation period, and a suitable comparison population unaffected by the policy change.
Fourth, locality and calendar year determined fluoride exposure. The researchers did not know each child’s complete residential history, tap-water consumption, bottled-water use, school-water exposure, or other fluoride sources. Families may move between communities, and children may consume water outside their residential locality.
Fifth, the analysis did not adjust for several important individual-level confounders. The report did not provide multivariable models that incorporated diet, oral hygiene, fluoride toothpaste, dental attendance, household income, preventive treatment, health conditions, or migration.
The evidence therefore supports a plausible relationship, not definitive proof that the policy change alone produced the observed treatment differences.
How Does This Compare With the Broader Evidence?
The broader literature gives a more nuanced answer than either enthusiastic advocacy or complete dismissal.
A 2024 Cochrane review evaluated 157 studies of community water fluoridation. All used nonrandomized designs. Contemporary studies suggested that starting fluoridation may produce a small reduction in decay in primary teeth, approximately one-quarter of a tooth per child, but the confidence interval included the possibility of no benefit. The reviewers found very low-certainty evidence on cessation and insufficient evidence to determine whether fluoridation changes socioeconomic inequalities (Iheozor-Ejiofor et al., 2024).
That review does not prove that fluoridation provides no current benefit. It shows that modern effect estimates remain uncertain and likely smaller than estimates from the era before widespread fluoride toothpaste.
A 2026 global scoping review examined 19 studies of fluoridation cessation. Outcomes varied across jurisdictions. Communities without strong replacement programs more often reported increased caries or dental-treatment use, while communities with alternative fluoride programs and broader preventive infrastructure sometimes maintained stable or improving outcomes. The review identified greater burdens in some vulnerable groups but called for more rigorous comparative research (Hung et al., 2026).
The Israeli study adds useful contemporary evidence to a question for which Cochrane previously found very little eligible cessation research. At the same time, its treatment-based measure and observational design do not resolve the underlying uncertainty.
Are the Authors’ Conclusions Stronger Than Their Data?
The authors describe fluoridation as an unequaled preventive measure and call reinstatement essential. Their policy position may prove reasonable when policymakers consider the full evidence base, local disease burden, feasibility, cost, safety standards, and available alternatives.
However, this single study cannot establish that conclusion on its own. The observed fluoridation effect was modest compared with the SES effect. The data captured treated disease rather than total caries. The analysis lacked detailed individual confounders and a robust controlled time-series design.
The study also received funding from Maccabi-Dent Dental Health Services, the organization that supplied the treatment records. The authors declared no competing interests. Institutional funding does not invalidate the results, but transparent reporting allows readers to evaluate the context.
The most defensible conclusion is narrower: after Israel ended mandatory fluoridation, Maccabi-Dent records showed a higher MF treatment index in non-fluoridated settings, with the clearest difference among low-SES children. The pattern supports additional surveillance and policy evaluation but does not prove that fluoridation cessation alone caused the change.
What Does the Study Mean for Patients and Parents?
Parents should not interpret the study as a reason for panic or as evidence that drinking water alone determines whether a child develops cavities.
Regardless of local water policy, children benefit from brushing twice daily with an age-appropriate amount of fluoride toothpaste, limiting frequent sugar exposure, receiving regular dental assessment, and obtaining risk-based preventive care such as fluoride varnish and sealants when appropriate.
Families should learn whether their public water contains fluoride and at what concentration. Bottled water, home filtration systems, and private wells can change fluoride exposure. A dentist or pediatric clinician can help families evaluate the child’s total fluoride exposure and caries risk.
Parents should not start high-dose fluoride products or supplements without professional guidance. Clinicians must consider age, local water levels, other fluoride sources, swallowing ability, and individual risk.
What Should Policymakers Take From the Findings?
The study provides a strong argument for better surveillance. Policymakers need representative clinical examinations that include untreated decay, restorations, extractions, fluorosis, preventive treatment, individual exposure, and socioeconomic information.
If a jurisdiction stops fluoridation, it should not assume that toothpaste and individual dental care will automatically replace the population-level intervention. Officials should fund alternatives before cessation, ensure that disadvantaged families can access them, and monitor whether treatment needs and inequalities change.
Potential alternatives and complementary programs include:
- School-based fluoride varnish and sealant programs
- Affordable fluoride toothpaste
- Earlier dental access for high-risk children
- Nutrition and sugar-reduction policies
- Community oral-health education
- Mobile and school-based dental services
- Ongoing caries and fluorosis surveillance
Fluoridation should not replace these measures, and policymakers should not evaluate it in isolation from them. Public-health decisions require a comparison of expected benefit, safety, cost, feasibility, acceptability, and equity in the local setting.
What Research Should Come Next?
Researchers should conduct repeated, representative dental examinations before and after policy changes. They should measure the full DMFT index, including untreated decay, and collect individual information on residential history, water intake, bottled water, filtration, fluoride toothpaste, varnish, sealants, diet, dental attendance, and household socioeconomic conditions.
A controlled interrupted time-series design could compare Israeli communities with different implementation timelines while accounting for preexisting trends. Researchers should also examine younger children whose primary teeth developed entirely after fluoridation cessation.
Future studies should distinguish disease from treatment use. Combining clinical examinations with health-service records would show whether higher restoration counts reflect more cavities, better access, different treatment decisions, or some combination of these factors.
Finally, researchers should evaluate what happens when communities resume fluoridation. If the MF index or total caries burden subsequently declines, that reversal would strengthen the causal argument.
Final Thoughts
The new Israeli study addresses a timely and consequential public-health question. Its large administrative dataset shows that 12-year-old children in non-fluoridated, low-SES communities had a higher missing-and-filled treatment index than their counterparts in fluoridated, low-SES communities. It also shows that socioeconomic status had a much larger statistical relationship with treatment burden than fluoridation status.
The findings should influence the debate, but they should not end it. The study did not measure untreated decay, did not clinically examine a representative national sample, and did not control for many individual factors that shape caries and dental-service use. Its design cannot prove that the 2014 policy change caused the later differences.
The most important lesson extends beyond fluoride. Population-level prevention may matter most when families cannot easily replace it through private resources. When governments remove an upstream intervention, they should evaluate who can compensate, who cannot, and whether the replacement strategy protects the children at greatest risk.
Frequently Asked Questions
Did Tooth Decay Increase After Israel Ended Mandatory Fluoridation?
The study found a higher Missing and Filled Teeth treatment index in non-fluoridated settings, especially among children from low-SES communities. It did not measure untreated cavities, and its observational design cannot prove that fluoridation cessation caused the increase.
Why Did the Study Focus on 12-Year-Old Children?
Researchers commonly use age 12 for international caries comparisons because most permanent teeth, apart from wisdom teeth, have erupted by that age. The first permanent molars have also experienced several years of exposure to diet, plaque, fluoride, and preventive care.
Does Fluoridated Water Replace Toothbrushing?
No. Children still need twice-daily brushing with fluoride toothpaste, appropriate interdental care, limited frequent sugar exposure, dental examinations, and individualized preventive treatment.
Did the Study Examine Fluoridation Safety?
No. The study examined caries-related treatment patterns after a policy change. It did not evaluate neurodevelopment, bone health, thyroid outcomes, dental fluorosis, or other safety questions.
Does the Study Prove That Fluoridation Reduces Oral-Health Inequality?
No. The study found a pattern consistent with a greater benefit among low-SES children, but its design cannot establish causation. A 2024 Cochrane review found insufficient evidence to determine fluoridation’s effect on socioeconomic disparities (Iheozor-Ejiofor et al., 2024).
What Should Parents Do If Their Water Is Not Fluoridated?
Parents can ask their dentist or pediatric clinician to assess the child’s caries risk and total fluoride exposure. They should use fluoride toothpaste correctly, limit frequent sugar intake, maintain regular dental care, and discuss varnish, sealants, or supplements when clinically appropriate.
References
Centers for Disease Control and Prevention. (2024). CDC scientific statement on community water fluoridation. https://www.cdc.gov/fluoridation/about/statement-on-the-evidence-supporting-the-safety-and-effectiveness-of-community-water-fluoridation.html
Fawarsy, R., Chackartchi, T., Findler, M., Haim, D., Mann, J., & Tobias, G. (2026). Effect of community water fluoridation cessation on dental caries in 12-year-old Israeli children: A retrospective analysis of socioeconomic disparities (2014–2022). Israel Journal of Health Policy Research, 15, Article 37. https://doi.org/10.1186/s13584-026-00782-z
Hung, M., Ward, C., Marx, J., Nelson, M., Chriss, H., Smit, Z., Shah, A., Newman, J., Parry, A., & Mohajeri, A. (2026). The impact of community water fluoridation cessation on health equity and service utilization: A global scoping review. BMC Oral Health, 26, Article 1723. https://doi.org/10.1186/s12903-026-09007-w
Iheozor-Ejiofor, Z., Walsh, T., Lewis, S. R., Riley, P., Boyers, D., Clarkson, J. E., Worthington, H. V., Glenny, A.-M., & O’Malley, L. (2024). Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews, 2024(10), CD010856. https://doi.org/10.1002/14651858.CD010856.pub3
Conflict of Interest
The author declares no conflict of interest relevant to this article.
Funding
The author received no external funding for this article.