Getting to the Root of Water Fluoridation: The Health Equity Context We're Missing

Removing fluoride from water will fall heaviest on those already facing barriers to dental care.

Nov 13, 2024

Fluoride continues to dominate public health discussions. In recent months, we've covered the National Toxicology Program (NTP) report and its findings about fluoride exposure, along with discussing what the science actually tells us about fluoride safety. With RFK Jr. expected to play a key role in the next Trump administration and openly stating his intention to remove fluoride from water supplies, these discussions have taken on new urgency.

(TL;DR on our previous content… The NTP report's findings about IQ impacts were specific to fluoride levels (≥1.5 mg/L) more than double the amount used in U.S. community water fluoridation (0.7 mg/L). To put this in perspective: only about 0.6% of the U.S. population (1.9 million people) are exposed to these naturally high fluoride levels. The benefits of water fluoridation at recommended levels remain clear and well-documented, while the risks cited in recent coverage apply to exposure levels far above what's used in U.S. public health programs.)

We also want to note that we have much more content coming on fluoride, including detailed analyses of topical versus ingested fluoride, data visualizations showing fluoride's public health impact, and a thorough examination of how we assess exposure from multiple sources (water, toothpaste, etc.). But today, we want to address a recent Washington Post opinion piece by Dr. Leana Wen that, while making some accurate observations, misses critical context about health equity.

[Note: We reference this fantastic article authored by Anil Oza in StatNews several times throughout this newsletter. It is worth a read!]

Examining Recent Claims: Context Matters

Let's examine what Dr. Wen cites as key points: She notes that the benefit of fluoridation has decreased since fluoride toothpaste became widely available - from early campaigns showing a 60% reduction in cavity rates to current estimates of about 25%. However, this statistic requires context: a 25% reduction in cavity rates through a single, low-cost, population-wide intervention remains remarkably effective from a public health perspective. The CDC estimates that every dollar spent on fluoridation saves approximately $20 in dental procedures.

Regarding the prenatal exposure studies Wen mentions - it's important to note that these concerns primarily relate to excessive fluoride exposure, not the carefully regulated levels in U.S. public water systems. The studies from Mexico, for instance, were conducted in areas with naturally occurring fluoride levels far higher than what's permitted in U.S. drinking water. As John Fawell, a professor at Cranfield University who has advised the World Health Organization on water quality standards, points out, "There's not a real mechanism" to explain the IQ associations some studies have suggested. The controversial 2019 study linking maternal fluoride exposure to decreased IQ had important limitations, including conducting IQ tests at ages 3 and 4 - before such testing is considered reliable since most children cannot read at that age. (Please read our deep dive on the NTP report for more on this.)

The Real-World Impact: When Communities Remove Fluoride

If only we could see what a future without water fluoridation would look like! Luckily, we do. We have data that tell a compelling story about what happens when communities remove fluoride from their water. In Calgary, which ceased fluoridation in 2011, researchers documented increased social inequities in dental health. The study published this year showed more children in Calgary needed dental surgery during the period without water fluoridation compared to children in nearby communities that maintained fluoridation.

The experience in Juneau, Alaska is equally telling. After removing fluoride from drinking water in 2007, researchers found significant increases in dental procedures related to cavities, with the impact falling disproportionately on children from socioeconomically disadvantaged families. As Jennifer Meyer, who led the Juneau study, notes, "Community water fluoridation is probably our best health equity-oriented public health intervention that we have."

Beyond Toothpaste: The Access Gap

The suggestion that we can simply rely on fluoride toothpaste and regular dental visits oversimplifies a complex reality. As previously noted, the CDC reports that every dollar spent on fluoridation saves approximately $20 in preventing dental procedures– an impressive ROI. This cost-effectiveness is particularly significant for families who can't afford regular dental care or live in areas with limited access to dental providers.

Water fluoridation is associated with better oral health outcomes, particularly in reducing the number of decayed, missing, and filled teeth among children. This effect is observed across different socio-economic groups, with a pronounced benefit in lower education and higher income adequacy households.

Water fluoridation is a cost-effective public health measure that benefits all socio-economic groups, unlike more technology-based dental interventions that tend to favor the socio-economically advantaged.

The Insurance Impact: A Growing Concern

Just today at my children's dental appointment, I witnessed firsthand a troubling trend that perfectly illustrates why the fluoride debate isn't just academic. When asked about fluoride varnish treatment - a standard preventive measure I always approve for my kids - the dentist shared that many parents are now declining it due to recent news coverage about fluoride's supposed dangers. Even more concerning, dentists are worried that if fluoride is removed from water supplies, it could impact insurance coverage for fluoride treatments in the future. The logic is this: if public health authorities and policymakers discredit the safety and efficacy of fluoride in water, what's to prevent insurance companies from questioning the value of fluoride treatments in clinical settings? This domino effect could further restrict access to an essential preventive treatment.

This insurance angle adds another important layer to the health equity discussion. Already, many dental insurance providers stop covering fluoride treatments for adults when they turn 18, despite fluoride being beneficial throughout life. While the Affordable Care Act requires coverage of fluoride varnish for children without cost-sharing - recommended every six months from the emergence of first teeth until age five - adult coverage is far more limited.

The implications are stark: Even as scientific evidence supports fluoride's effectiveness in reducing decay risk, reversing early cavity stages, and treating tooth sensitivity in adults, insurance barriers create yet another divide in access to care.

If water fluoridation is eliminated, we risk creating a system where access to this basic preventive treatment becomes even more dependent on ability to pay - exactly the opposite of what public health measures should achieve.

The European Comparison: What's Missing

While Dr. Wen points to Western European countries that have ended public water fluoridation, this comparison requires context. Many of these nations have universal healthcare systems that include dental care, along with alternative fluoride delivery programs such as salt fluoridation or school-based programs. The United States lacks these systematic alternatives.

The Historical Perspective

The evidence about fluoride's benefits is particularly strong for children. The first city to fluoridate water, Grand Rapids, Michigan, saw a 60% decrease in the number of kids with cavities after 11 years. Today, about 70% of Americans have fluoride in their water, contributing to what the CDC hails as one of the 20th century's ten greatest public health achievements.

Steven Levy, a professor of preventive and community dentistry at the University of Iowa's College of Dentistry, puts it plainly: "People forget that we need to have fluoridation because many people in power don't have a big cavity problem. Most people in Congress or in the state house don't appreciate that a substantial portion of the population still has many dental cavity needs because they themselves aren't having it."

Public health is a victim of its own success.

Looking Forward: The Stakes Are High

As we continue to study and refine our understanding of fluoride's effects, we must remember that public health decisions require balancing population-wide benefits against potential risks while considering who bears the greatest burden of any policy change. The evidence continues to show that at recommended levels, water fluoridation remains a safe, cost-effective, and equitable public health measure.

Before we consider rolling back this fundamental public health intervention, we need to answer a critical question: What's our plan to protect the oral health of our most vulnerable community members? Until we have a comprehensive answer to that question, removing fluoride from water risks exacerbating the very health disparities that public health measures are designed to address.

Stay tuned for our upcoming deep dives into: