Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)

Committee Member

Dr. Lori Dickes, Committee Chair

Committee Member

Dr. Bruce Ransom

Committee Member

Dr. William Haller

Committee Member

Dr. Jeff Allen


In 2015, the Federal Panel on Community Water Fluoridation finalized a recommendation setting a fixed 0.7 mg/L optimal water fluoridation level for the United States. The announcement was made in the Federal Register in 2011 and allowed for a period of public comment and scientific review before being finalized. Since the original 1962 optimal range recommendation, community water fluoridation has been a decentralized policy environment allowing for local decision-making in setting water fluoridation levels. The finalized 2015 policy recommendation attempts to centralize policy decision-making to reduce the risk of overexposure while maintaining decentralized implementation. This dissertation addresses the following research question: Why is U.S. fluoridation policy implemented in a decentralized rather than a centralized fashion? The research uses a policy cycle framework approach to understanding the water fluoridation policy process and identifies potential problems with a central policy recommendation in a decentralized policy environment and explores policy alternatives. A mixed methodology was used to analyze the policy formulation and implementation stages of the policy process. A quantitative analysis was utilized to understand policy implementation at the local level. Results indicate that the recommendation was likely effective in narrowing the variability of fluoridation levels. Further, the 0.7 mg/L recommendation was likely met since the policy change. A qualitative analysis addressed potential missed opportunities during the formulation stage of the policy process. Analysis revealed: positive results in stakeholder perceptions of engagement and in meeting the recommendation, a slight preference for state policy recommendations, and mixed results for exploring alternate models, equitability of implementation, and consumer opt-out options.