The long-standing public health practice of adding fluoride to U.S. public drinking water systems faces new challenges and bans in several locations, with experts warning that both child health and health systems will cost a lot of money.
A new modeling study published Friday at the Jama Health Forum estimates that removing fluoride from public water in the US will lead to 25.4 million excess decay teeth within five years, along with 25.4 million decay teeth, in addition to $9.8 billion in medical expenses. Ten years later, these effects will more than double, earning 54 million excess corrupt teeth and a cost of $19.4 billion.
This leads to one additional decaying tooth for every three children in the US, but costs don’t spread evenly, said Dr. Lisa Simon, an internist at Brigham and Women’s Hospital and a co-author of the new study.
“I know that those who benefit from fluoride are those who otherwise struggle to access dental care,” says Simon, who has been studying dental policy for 10 years. “When you think about these 25 million decayed teeth, it’s much more likely that they’ll appear in the mouths of children who are publicly insured by Medicaid or from low-income families.”
Fluorides are minerals that can be found naturally in some foods and groundwater. It helps to prevent tooth decay by strengthening the protective outer layer of enamel, which can be worn by acids formed by bacteria, plaques and sugars in the mouth. Adding fluoride to public water systems began in the United States in 1945 and was welcomed by the US Centers for Disease Control and Prevention in the 20th century as one of America’s greatest health interventions.
In 2022, nearly two-thirds of the US population were provided with community water systems with added fluoride, according to CDC data. But U.S. Department of Health and Human Services Director Robert F. Kennedy Jr. said in April he would direct the CDC to encourage the addition of fluoride to public drinking water, saying lawmakers from two states, Utah and Florida, are banning practice this year.
To estimate the effectiveness of removing fluoride from local water, Simon and co-author Dr. San Un Choi evaluated clinical oral hygiene data from the National Health and Nutrition Test Survey to produce a nationally representative sample of children in the United States.
Baseline showed that one in five children between the ages of 2 to 5 years old are estimated to have tooth decay with dentinosis, a chronic infection that includes tooth decay and tooth decay, and more than half of children between 6 and 12 years old, and more than 57% of teenagers. However, removing fluoride increases these prevalence by more than 7 percentage points, the researchers found.
“This is a huge cost for our country and is all avoidable. There is no better alternative to the trusted use of fluoride during the scheduled period in our community water programs,” Dr. Brett Kessler of the American Dental Association said in a statement. “Good oral health will not change if rural health is lacking in proper nutrition, oral hygiene, optimally fluorinated water, or fluoride supplements.”
On the campaign trail last fall, Kennedy called fluoride “industrial waste” and claimed that exposure caused a wide range of health problems, including cancer. And in April, HHS and the U.S. Environmental Protection Agency announced that they would study the potential health risks of fluoride in drinking water. This is a review centered on government research last year, and concluded that higher levels of fluoride are associated with lower IQ in children.
In a new modeling study, researchers found that only about 1.5% of children in the US in 2016 were exposed to levels of fluoride levels above 1.5 milligrams per liter. This poses a risk of fluorosis, leaving stripes or spots on the teeth, or other harm. Meanwhile, around 40% of children in the US had access to optimal fluoride levels that effectively prevent 0.6-1.5 milligrams of cavities per liter, while about 46% had access to even lower levels.
The authors of the new study did not assess the neurocognitive effects of fluoride as “current federal guidance finds no association” at the level used in public drinking water. They found that removing fluoride can help prevent around 200,000 cases of fluoriasis over five years.
Cataract can mean a lot, Simon said, but their model picked up cases that needed at least filling, along with severe cavities that could turn into root canal or tooth extraction. The costs will be borne by families, insurance companies and government.
“Talking about really important money is just one way to measure that cost,” Simon said. “It’s also a cost that means the child is feeling pain, the child is not eating, the child loses school, or the child is unable to pay attention at school because his teeth hurt.
The predictions of new modeling studies mirror the real-life effects measured in other parts of the world after fluoride has been removed from drinking water. Calgary, Alberta, stopped putting fluoride in water in 2011. The study found that the children there had more cavities than the children in the city who had fluoride. Calgary will resume fluorination this year.
Simon fears the US will be affected even more due to particularly prominent health inequalities in the dental care system.
“We’ve had fluorinated water for a long time and it works so well that we stopped appreciating the amazing things it did,” she said. “When something was a success story for 80 years… I don’t know which child has never gained a cavity due to exposure to fluoride.