Public health ROI: Fluoridation prevents tooth decay and saves a ton of money

As 2016 comes to a close — and 2017 looms with enormous uncertainty — let’s end the year with some encouraging public health news. This time it’s a study on one of the 10 great public health achievements of the 20th century: fluoridation.

Published this month in Health Affairs, the study is an update on a 2001 study that marked the most comprehensive examination to date of community water fluoridation benefits and costs. This new study found that in 2013, more than 211 million American residents had access to fluoridated drinking water. That fluoridation was associated with the prevention of dental cavities that would have otherwise cost $6,792 million, or $32.19 per capita, in treatment and lost productivity. The cost of providing fluoridated drinking water in 2013 was $324 million, which means the net savings of fluoridation when compared to the costs of tooth decay is a whopping $6,469 million. Talk about a serious public health return on investment.

But wait, there’s more. When breaking down the savings by population size, the study found net savings ranged from $247 million for fluoridated water systems that served 1,000-4,999 people to $3,693 million for systems servings 100,000 people or more. When researchers assumed that fluoridation reduced tooth decay by 20 percent, the return on investment was 16.5; when they assumed a tooth decay reduction of 30 percent, the return on investment was 23.7. And in fact, even when researchers considered the capital costs of drinking water fluoridation, such as construction, as well as the depreciation of such costs, they still found a return on investment of nearly 20.

Study authors Joan O’Connell, Jennifer Rockell, Judith Ouellet, Scott Tomar and William Maas write:

Families, communities, government, health care payers and providers, and private organizations continually evaluate opportunities to improve health outcomes, accounting for the benefits and costs of doing so. The World Health Organization classifies interventions as cost-effective if costs per disability-adjusted life-year (DALY) avoided are less than three times the per capita national annual gross domestic product and highly cost-effective if costs per DALY are less than that value. In other words, cost-effective interventions need not save money. Not only is community water fluoridation effective at reducing caries, it has been found to save money in this and other recent studies. Furthermore, (community water fluoridation programs) might also reduce oral health disparities within communities.

According to the Centers for Disease Control and Prevention, fluoridated drinking water prevents cavities by up to 25 percent in children and adults, though childhood cavities continue to be one of the most common chronic diseases affecting kids. First begun in 1945, fluoridated water reached nearly 75 percent of the U.S. population as of 2014. The nation’s Healthy People 2020 goal is to bring fluoridated water to 79.6 percent of Americans living on public water systems.

“The fact that the United States has not yet met the Healthy People 2020 goal that 79.6 percent of the population served by community water systems have optimally fluoridated water is an indication that public health understanding of water fluoridation and its benefits merits further study,” the Health Affairs study authors wrote. “This study provides updated information on (community water fluoridation programs) costs and savings that could increase such understanding.”

To request a full copy of the fluoridation study, visit Health Affairs.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years.

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We took the computer records for welfare dental care (DentiCal) for two consecutive years and compared the cost of dental care to the amount of fluoride in drinking water. There was no significant difference in dental care for poor people regardless of the amount of fluoride in their drinking water.

The claims of dental benefit are simply is not supportable with valid science.

By David Kennedy DDS (not verified) on 31 Dec 2016 #permalink

David, are you saying that two years of data in one state negates a multi-decade nation-wide study?
Also, did you account for access to fluoride other than in drinking water? Does California offer fluoride mouth wash to elementary school students who live in areas without access to fluoridated water?
Which two years of data did you study? Did you look at children and adults, only children or only adults? What was the difference (total concentration and percentage difference) in fluoride among your groups?

Can you please provide a citation for your published study?

By JustaTech (not verified) on 03 Jan 2017 #permalink

No data from a state with 30 million is absolutely not the totality of the research that supports the premise that adding fluoride or natural fluoride in drinking water alters dental care costs in a significat amount.

You cannot give the reference for a single broad based blinded study valid by today's standards that has ever found a significant reduction in decay of permanent teeth after age 17. I know that some short term surveys do show a slight dip which at younger ages which is likely due to delayed eruption of permanent teeth a sign of injury not benefit.

Af for your change of subject (access to topical fluoride) I want to focus on your original claim and look specifically at what you alleged i.e. Water fluoride is of benefit to humans. Support that with a big broadbased blinded study.

By David kennedy dds (not verified) on 04 Jan 2017 #permalink

In reply to by JustaTech (not verified)

Uh, David, the original post provides that data. And it can't be blinded (at least to the water drinkers) because in many municipalities it is a legal requirement to notify all water users of everything in the water. And if you're on a well you would certainly know that!

And I was under the impression that fluoridated water is most useful for children who's teeth are still developing, not adults, who's enamel has already formed.

Do you object to the fluoridation of water, the use of fluoride at all, or any treatment of caries?

By JustaTech (not verified) on 04 Jan 2017 #permalink

I was responding to the claim that fluoridation saves health care dollars. That is the claim and that claim is not supported by data. Since this is a science blog I expected to hear science as the source of your blog.

The study that this blog reports is 16 years old (2001) and stated: "This study provides updated estimates using an economic model that includes recent data on program costs, dental caries increments, and dental treatments." so they have merely extrapolated from prior claims of benefit and arrived at a number. That is merely an estimate not data.

As for blinding, the investigators have to be blinded in order to avoid bias. It is totally possible to bring people for examination and not disclose the F level in their drinking water. The NIDR in 1985-7 did a broad based survey of 39,000 children and in a press release claimed, as does the article you cited, that fluoridation was beneficial. After fighting the freedom of information request for the data on decay and dental fluorosis the NIDR was ordered by the court to give up their data. The NIDR then claimed to have "lost" the data on dental fluorosis but did hand over their tooth decay data. It showed no significant difference in permanent tooth decay.

10 years later Heller et al in 1997 published the dental fluorosis data. Hiding discoverable data is considered obstruction of justice. Lying in court is perjury. This is the behavior of the guilty trying to hide and not the normal behavior of scientists.

When did they find it? No one seems to know but that study also shows more dental fluorosis with each incremental increase in water fluoride. At that time 30% of the children exhibited DF and more recently they now find 40% or greater.

So even if there were a reduction in tooth decay that would have to be balanced against the damage to enamel and cost of repair. This estimate did none of that and thus their grand conclusion is not valid at all.

By David Kennedy, DDS (not verified) on 06 Jan 2017 #permalink

You wrote, "And I was under the impression that fluoridated water is most useful for children who’s teeth are still developing, not adults, who’s enamel has already formed."

The CDC stated "[F]luoride's predominant effect is posteruptive and topical." - Centers for Disease Control and Prevention. (2001). Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. Mortality and Morbidity Weekly Review. August 17, 50(RR14):1-42.

"Fluoride incorporated during tooth development is insufficient to play a significant role in caries protection." - Featherstone, JDB. (2000). The Science and Practice of Caries Prevention. Journal of the American Dental Association. 131: 887-899.

Thus the claim that systemic fluoride incorporated in enamel is beneficial is not supported by today's evidence.

By David Kennedy, DDS (not verified) on 06 Jan 2017 #permalink

You asked, "Do you object to the fluoridation of water, the use of fluoride at all, or any treatment of caries?"

Of course I do not object to treating tooth decay but I can see no logical reason to swallow a substance that has adverse systemic effects and only works to prevent decay topically. Adding low levels of fluoride to the public drinking water will clearly overdose infants on a bottle and at the same time provide no benefit to offset the injury.

What is added to the public drinking water is a manmade compound (hydrofluosilicic acid) from the pollution scrubber systems of the phosphate fertilizer mining industry that is about 17% fluoride and contaminated with arsenic and other toxic substances. The arsenic alone according to estimates by California EPA will produce one additional cancer of bladder or lung per 15,000 water drinkers.

In addition, two huge broad based blinded studies (Masters and Coplan 1999, 2000) and two blinded animal studies (Sawan 2010 and leite 2011) have linked this compound (HFSA) to dramatic increases in blood lead levels especially in dark skinned people. This seems like an inappropriate use of the public drinking water as it demonstrably harms subsets of the population disproportionately.

I am all for prevention and/or treatment of tooth decay. Iodine has been shown to be far more effective than F in baby bottle caries inhibition likely due to its antibacterial activity (Lopez 2002). Many other countries have achieved better oral health and do not allow HFSA to be added to the public drinking water.

They spend less on oral health and have had better results. It is well past time for the US to reconsider their singleminded approach to oral health using a 60 year-old theory that has consistently been proven seriously flawed.

No one questions that systemic fluoride produces harm. The question is at what dose the harm may occur. If you look at table 8-2 of the National Research Council's 2006 review of fluoride in drinking water you will note that altered thyroid function occurs at doses as low as 0.03 to 0.05 mg/kg/day.

An average bottle fed infant drinks its weight in water every 3 to 4 days. A 4 kg baby thus may be dosed at 0.175 mg/kg/day or 5 fold higher than the NRC identified altered thyroid function. Does that seem fair to you?

FYI 3 out of 4 babies are formula fed but It is mostly poor people who feed their babies reconstituted formula because it is the cheapest way to feed a newborn if mother dies or perhaps has to return to work. Breast milk has almost no fluoride.

I can send a PDF of these studies if you are interested.

By David Kennedy, DDS (not verified) on 06 Jan 2017 #permalink

Sorry, David, I'm not the author of this blog piece (that's Kim Krisberg). I'm just a reader.

If you are saying that fluoride provides no protection against the development of caries, well, I'm going to have to go with my personal dentist, (and several before him) who has told me that my non-exposure to fluoridated water as a child has been at least part of the reason I have bad teeth that all the brushing in the world won't protect.

This sure is a topic people seem very passionate about, compared to other parts of public health. It's very interesting.

By JustaTech (not verified) on 06 Jan 2017 #permalink

You dentist could have been myself some years ago as I too was taught that systemic fluoride was beneficial. However science moves on and as the true story about the impact of systemic fluoride has unfolded the numerous claims of benefit have steadily been debunked. I no longer recommend any exposure to fluoride but do recommend the highest quality of prevention.

Your dentist will likely recommend some form of topical fluoride however I found that measuring the oral level of the bacteria now thought primarily responsible for decay (Strep mutans) and then disinfecting the mouth is far more effective in stopping tooth decay than swabbing fluoride on teeth. Economically if you want to use fluoride it is more cost effective to buy toothpaste and DIY.

By David Kennedy (not verified) on 06 Jan 2017 #permalink

In reply to by JustaTech (not verified)

Another quackershill site

don, if you're referring to David Kennedy - yes, quack is an appropriate term.

If you're referring to the author on this site - you don't know what you're talking about.

don @10, Uh, what is being sold in this article? Can you please be more specific?

By JustaTech (not verified) on 20 Jan 2017 #permalink