Community Water Fluoridation

       Oral health refers to the health of our teeth, gums, and mouth. Community Water Fluoridation is a health measure that allows the state to observe the conditions supporting oral health in a community. Fluoride prevents tooth decay by 25%, saving money for families’ and the US health care system while also leading to better future physical health. Community Water Fluoridation measures the percentage of the population served by community water systems that are receiving fluoridated water. This metric is collected through the CDC Water Fluoridation Reporting System. Currently 88.8% of Tennessee’s population receives fluoridated water. 

        Community water fluoridation is recommended by the American Dental Association, American Academy of Pediatrics, US Public Health Service, and World Health Organization. Fluoride helps to rebuild and strengthen enamel, which prevents cavities from forming and rebuilding the tooth’s surface.  

        Good oral health is crucial to our physical and mental health. Oral health impacts how we eat, smile, and speak. When an individual suffers from an oral disease such as tooth decay/cavities, gum disease, or oral cancer, there can be real short- and long-term health effects. Poor oral health can affect an individual’s diet, weight, self-esteem, school performance, attendance at work and school, and is also linked to endocarditis, cardiovascular disease, premature birth and low birth weight, and pneumonia. On average, the United States spends more than $124 billion each year on costs related to dental care, and loses more than $45 billion of productivity each year due to poor oral health. Water fluoridation is estimated to prevent 51 million lost school hours due to dental disease. Risk factors that can lead to oral disease include poor dental hygiene (e.g. brushing and flossing), tobacco use, diets high in sugar including gum and soda, diabetes, osteoporosis, and taking certain medications.  

        Geographic and socioeconomic disparities exist when telling the story of oral health in Tennessee. Rural communities in Tennessee experience limited access to dental care due to geographic isolation and workforce shortages. There is an average of only 6 dentists per 100,000 individuals in Wayne County, Tennessee, compared to the U.S. average of nearly 61 per 100,000. Overall, Tennessee has 49.2 dentists per 100,000 people. Nationwide, black, Hispanic, and Native American communities have been found to have higher rates of oral health problems in both children and adults than predominantly white communities. Men have been found to have higher rates of periodontal disease than women, and adults with less than a high school education experience untreated tooth decay at nearly three times the rate of adults with at least some college education. Finally, oral cancer 5-year survival rates are lower for black men than white men. 

Vital Sign Actions Guide

The following are lists of intervention strategies that you, your health council, and other local stakeholders could use to address community water fluoridation in your community.  


1. Evidence-Based Home Visiting 

Evidence Based Home Visiting (EBHV) programs are an early intervention strategy that aims to improve health outcomes for children in their first years of life. These programs improve family functioning and parenting skills, link families to social services, promote early learning, and help new parents provide safe, nurturing environments for their infants. In Tennessee, there are eleven EBHV local implementing agencies funded by the Tennessee Department of Health that operate in 51 counties, in addition to the CHANT program that operates in all health departments and two metro health departments. These EBHV programs are a great opportunity to partner with agencies to improve oral health education for families. Click on the link for a home visiting resource to improve oral health.  


2. Increasing Access to Transportation 

Adequate access to transportation can is an important aspect of an individual's access to oral health services. Programming that increases access to transportation in rural areas can come in a variety of models—public transit, volunteer drivers, coordinated services, ridesharing, etc. There are also ways in which a community can mitigate the effects of lack of transportation, such as mobile health clinics and telehealth, active transportation infrastructure, and home visiting. Click on the link for a list of intervention strategies and promising practices.


3. Remote Area Medical 

Remote Area Medical (RAM) is a nonprofit provider of free mobile health clinics. RAM provides free dental, vision, and medical services to underserved and uninsured individuals. Services are free and do not require ID from patients. Communities that lack health care services can request a mobile RAM clinic event. Click on the link for a list of services provided by RAM and a clinic schedule. 


4. School-Based Healthcare

School-based Health Centers (SBHC) increase access to primary care for children in school settings. The services provided by SBHCs can include primary care, mental and behavioral health care, dental care, health education, and case management. Schools can partner with local health organizations to provide services to students such as referral to a dental clinic and application of fluoride varnish. The Tennessee Department of Health offers school-based dental care to all students who attend qualifying schools (50% or more of students who receiving free and reduced lunch). 


5. Teledentistry

One way to combat disparities in oral health outcomes is through the use of teledentistry. Using technology to diagnose and plan treatment increases access to care for low-income individuals and those living in remote, rural areas. Research has shown that screening for dental caries through a school-based teledentistry program is as reliable as in-person screening. A teledentistry program can also be used to overcome barriers associated with scope of practice for dental hygienists. 


1. Appalachian Rgional Commission

Purpose: Grants and funding are awarded by the Appalachian Regional Commission (ARC) focusing on economic opportunities, ready workforce, critical infrastructure, natural and cultural assets, and leadership and community capacity. Oral health is an important aspect of decreasing missed days of work and workforce efficiency. Tennessee (Eastern Appalachian region) is among 12 other states that are eligible to receive funding from ARC.

Duration: Varies

Amount: Up to $4,000,000; varies 


2. BlueCross BlueShield Grants 

Purpose: BlueCross BlueShield of Tennessee awards funding for programs that help to create active, healthy spaces across the state. BCBS manages two funding opportunities—BlueCross Healthy Place and Community Trust grants. See the source below for specific funding criteria and exclusions. 

Duration: Varies

Amount: Varies


3. Community Foundation 

Purpose: Community Foundations offer small grants that focus on community-driven change in Tennessee. The Community Foundations in Tennessee include Appalachian Community Fund, The Community Foundation of Greater Chattanooga, Community Foundation of Greater Memphis, Community Foundation of Middle Tennessee, Knox County Community Foundation, and East Tennessee Foundation. Most of these foundations consider healthy youth development as a focus area of grant funding.

Duration: Varies 

Amount:  Varies 


4. RHIhub Oral Health Grant Opportunities 

Purpose: The Rural Health Information hub lists funding opportunities related t oral health initiatives in rural communities. These grants include sources such as DentaQuest, HRSA, the Dental Trade Alliance Foundation, American Dental Association, and more. 

Duration: Varies

Amount: Varies


5. Robert Wood Johnson Foundation 

Purpose: These grants are focused on health systems, “healthy children, healthy weight”, healthy communities and healthy leadership. Funding is aimed at activities that include planning and demonstration projects, policy analysis, public education and strategic communications, community engagement, and technical assistance among other activities. 

Duration: One to three years 

Amount: $50,000- $300,000 (average) 


6. Tennessee Drinking Water State Revolving Fund Loan Program 

Purpose: Similar to the USDA Water & Waste Disposal Loan Program, the Tennessee Local Development Authority operates a loan program to provide low interest loans to local governmental agencies and utility districts for the planning and construction of drinking water facilities. 

Duration: Varies 

Amount: Varies 


7. The HCA Foundation

Purpose: The HCA Foundation promotes health and wellbeing, childhood and youth development, and the arts in middle Tennessee communities through grant funding administration. Organizations must be 501(c)3 nonprofits in the Middle Tennessee area (see the website for eligible counties) to apply. 

Duration: Varies 

Amount: Varies 


8. Tobacco-Free Generation Campus Initiative Grant Program 

Purpose: The Tobacco-Free Generation Campus Initiative Grant Program is administered by the American Cancer Society, with support from the CVS Health Foundation. The goal of this program is to increase the number of 100% smoke- and tobacco-free college and university campuses across the United States. 

Duration: One Year 

Amount: $8,000- $20,000


9. USDA Water & Waste Disposal Loan and Grant Program 

Purpose: The USDA awards funding to local governmental entities and private nonprofits in qualifying rural areas to fix or maintain water systems. Clean and safe drinking water that has been properly fluoridated is essential to maintaining proper oral and physical health. Technical assistance is also offered to nonprofit entities to aid in the maintenance of water facilities. 

Duration: Varies 

Amount: Varies 


1. Bringing Tap Back/Rethink Your Drink Campaign 

A tap water campaign like Bringing Tap Back (Tennessee Clean Water Network) or Rethink Your Drink (CDC) encourages students in schools to replace sugar sweetened beverages (SSB) with water and increase the use of refillable water bottles and drinking tap water. Adolescents who drink SSB every day are at much higher risk of obesity than their peers who drink water or unsweetened beverages. One study showed that after a one-month soda-free campaign, students’ water consumption increased by 19% and SSB consumption decreased from 2.32 average servings per day to only 1.32 average servings per day. This campaign can include educational posters, student challenges and classroom prizes, and installing water bottle refill stations to encourage drinking water from reusable bottles. 


2. Colgate Bright Smiles, Bright Futures

Colgate’s Bright Smiles, Bright Futures campaign provides educational materials for parents, children, teachers, and dental professionals. These materials include posters and handouts, games, videos, curriculum, and other printable materials. This campaign aims to promote healthy dental care habits in children and families.


3. Let's Go! 5-2-1-0 Campaign 

The Let’s Go! 5-2-1-0 campaign promotes healthy nutritional habits and physical activity in school-aged children. The premise of the campaign is to educate parents and teachers that children need at least 5 servings of fruits or vegetables, less than 2 hours of screen time, 1 hour or more of physical activity, and 0 sugar-sweetened beverages per day. One study has shown that children’s consumption of sugar-sweetened beverages (a major driver of tooth decay) decreased after this campaign was implemented along with widespread policy changes in multiple settings in a community.  


4. Live Sugarfreed Campaign 

The “Live Sugarfreed” campaign promotes swapping sugar-sweetened beverages for water. Drinks that are high in sugar content contribute to dental carries and poor oral health. For print and social media resources, click on the link.


5. National Children's Dental Health Mouth

February is National Children’s Dental Health Month. This health observes is a great opportunity to distribute information about good dental habits or materials to children in underserved communities. Click on the link for resources related to National Children’s Dental Health Month. 


6. National Nutrition Month 

National Nutrition Month is promoted by the Academy of Nutrition and Dietetics during the month of March. See the source below for games, quizzes, handouts, and media materials that can be used to promote National nutrition Month. 


7. Oral Health America Campaign

Oral Health America supports several campaigns with the eventual goal of increasing access to care and health literacy, and promoting policies that improve oral health care. These campaigns include Smiles Across America (for school-aged children), Campaign for Oral Health Equity (for underserved communities), and the Wisdom Tooth Project (aimed at older adults).  


8. Promote Safety Net and Charitable Care Dental Clinics 

Charitable care clinics and safety net clinics provide care at little to no cost to qualifying low-income or uninsured individuals. These clinics help to expand access to emergency dental care for adults and dental services to children. For a list of safety net clinics and charitable care clinics, click on the link.


9. Promote the TN Quitline and Smokefree TXT

The TN Quitline is a resource for Tennesseans who wish to quit using tobacco products. The Quitline provides counseling to smokers as young as age 13 through a toll-free phone line, and online resources such as tips and a smoking calculator. See page 49 of the CDC Best Practices guide for Comprehensive Tobacco Control Programs in the sources below for ways to support state Quitline capacity. 


10. Promote TN State Loan Repayment Program 

The Tennessee State Loan Repayment Program (TSLRP) recruits health professionals to rural communities that qualify as Health Professional Shortage Areas (HSPA) by offering educational loan repayment in exchange for two years of service. Health professions that are eligible for the TSLRP program include Primary Care Physicians, dental professionals (DDS or DMD), Advanced Practice Nurses, Physician Assistants, and mental health professionals. Promoting this program to recent dental professional graduates may increase access to quality care in underserved Tennessee communities. 


11. Protect Tiny Teeth 

The Protect Tiny Teeth campaign is promoted by the Centers for Disease Control. This campaign targets pregnant women and mothers. Pregnant women are at higher risk of oral disease, which has been associated with poor birth outcomes including low birth weight and pre-term birth. 


12. Tenenssee Quit Week 

Tennessee Quit Week is held each year in February and is supported by the Tennessee Department of Health. This campaign aims to encourage current tobacco users to quit using tobacco products. Click on the link for materials and resources.


13. Through With Chew Week

Through With Chew week encourages individuals to “break up with tobacco” the week of Valentine’s Day. The objective of this campaign is to educate people about the dangers of smokeless tobacco, which is one major driver of dental disease. 



TNSTRONG (Tennessee Stop Tobacco and Revolutionize Our New Generation) is an anti-tobacco campaign targeting youth in Tennessee that is supported by the Tennessee Department of Health. This campaign involves youth ambassadors that help spread messaging, a three day youth summit each summer, and additional messaging such as the “Strike Out Tobacco” campaign that targets youth baseball teams. 


15. Tobacco Campaign for Youth 

The Stanford School of Medicine offers free resources for educational lessons that can be taught to youth in various settings, including school, after-school programs, faith-based programs, etc. The Tobacco Prevention Toolkit includes lessons on general tobacco use, e-cig use, smokeless tobacco, the dangers of nicotine addiction, and positive youth development skills. Additionally, the CDC provides free campaign materials and ads through the Media Campaign Resource Center.


16. Water Fluoridation Campaign 

The Centers for Disease Control supports community water fluoridation as a way to improve oral health outcomes across communities. Fluoride is a safe and effective way to prevent tooth decay by 25%, saving families money and leading to better physical health in the future. The spread of misinformation about the safety of fluoride has been detrimental to the number of individuals served by fluoridated water supplies in recent year. Click on the link for infographics that support community education of water fluoridation practices.


1. Advocating for a Sugar-Sweetened Beverage Tax (Soda Tax)

There are currently nine cities or counties in the United States that have implemented an excise tax on sugar-sweetened beverages. These taxes range from 1 cent to 2 cents per ounce of soda. Research supports soda taxes as a method to decrease consumption of sugar-sweetened beverages in a community. Sodas are a major driver of dental carries in children and adults. Additionally, the increased tax revenue can be used by a local government to fund oral health services or other initiatives that help to mitigate the financial effects felt by low-income families who are more likely to consume sugar-sweetened beverages. 


2. Gold Sneaker Policies

The Gold Sneaker initiative is a voluntary certification program that provides policy and programming recommendations to licensed child care facilities in Tennessee. These policies aim to set standards regarding daily physical activity, nutrition requirements, screen time limits, and other health-promoting behaviors in schools and child care facilities. Policies that promote diets that are low in sugar can help to reduce the probability of tooth decay in children. Gold Sneaker is managed and funded through the Tennessee Department of Health.


3. School Policies that Promote Helathy Food and Beverage Options 

Children spend the majority of their time at school and in after-school programs. Policies in these spaces can influence the majority of a child’s healthy behaviors through food options and beverages available during breakfast, lunch, snack time, and vending machines. School boards and individual schools can promote access to nutritional foods and beverages in a variety of ways. Some examples of school policies include pricing healthy food options at a lower cost, placing healthier food options in front of less healthy food options, ensuring access to water throughout the day, and placing point-of-decision signs promoting healthy choices. 


1. Advocating Dental Coverage of Pregnant Women under Medicaid 

Poor oral health has been associated with poor birth outcomes, primarily premature labor and low birth weight. Oral health should be considered an important part of prenatal care to ensure the best possible outcomes for both the mother and the child. Currently, Tennessee’s Medicaid and other insurance programs only cover dental care for children, but not for adults. One way communities can increase access to oral care is by advocating for dental care coverage under TennCare for pregnant women to state legislators. 


2. "Lift the Lip" Referral Policy 

“Lift the Lip” encourages health care providers to assess the status of a child’s oral health by lifting the top lip to check teeth for signs of decay. If signs of dental decay are observed, the clinician may refer the child or family to a school dental service or dental practice.  This policy can be implemented in any clinical setting, especially those with pediatric services. 


3. Screening for Tobacco Use/5 A's or 2A's and R 

Tobacco use, both smoking and smokeless products, lead to oral diseases. Clinicians should screen for tobacco use in all patients. Policies should ensure that care providers follow the CDC’s recommended “5 A’s” approach to assessing tobacco use and promoting cessation. Additionally, patients’ caretakers that use tobacco should also be referred to cessation counseling. The CDC also recommends an abbreviated version of the 5A’s—the 2A’s and R screening methods. 


*State employees are prohibited from engaging in
political activity not directly a part of that person’s employment during any
period when the person should be conducting business of the state (Tenn. Code
Ann. § 2- 19-207). For further information on State Employee Political
Participation, please visit: 

This document is not a Department endorsement of legislative policy.