‘One of incredibly few public health measures we have that actually saves money’
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Fluoride continues to make headlines following Utah’s decision to ban its use in the public water supply, while Robert F. Kennedy Jr. pushes federal agencies to reexamine their guidance on the subject.
Public health experts and leaders in the dental industry have spoken out in favor of the benefits of fluoridation. Scott Tomar, DMD, DrPH, associate dean for prevention and public sciences at the University of Illinois Chicago (UIC) College of Dentistry, talked to Dental Bite about fluoride bans, what they could mean for oral health and what dentists can be doing to prepare. -Carrie Pallardy
Utah has become the first state to ban fluoride in its public drinking water, and there are other efforts to do the same in other parts of the country. How could these bans impact public health?
Unfortunately, what I expect to see is what we've seen in other communities that have stopped fluoridation. Probably an increased prevalence of dental caries starting first with young children, an increased rate of treatment for caries and increased costs related to that. That's what we've seen in Juneau, Alaska, in Calgary and in Israel when they stopped fluoridation. And unfortunately, that's what I think we're going to see in places like Utah.
RFK Jr. is a vocal opponent of fluoridation of drinking water. He is moving to direct the CDC to change its recommendations on fluoride. How could a change in the CDC’s guidance make an impact?
I think it will certainly remove what has been a wonderful resource for states and communities that were providing community water fluoridation or thinking of providing it.
I had worked for the [CDC’s] Division of Oral Health earlier in my career and a big part of what that division did was provide technical expertise. In the case of states that received grant support from the CDC, that actually provided support for things like new equipment or replacement of equipment. That is largely gone now. The expertise has gone. The support to states is gone, as well as the source of scientific information that was the Division of Oral Health. That has all been recently eliminated.
So, certainly I think this will not be good for public health in many ways. Certainly for water fluoridation, but also for other community-based prevention programs in the United States.
Under the current administration, the EPA is reexamining research on the potential health risks of fluoride in drinking water. How does the public health community view this move?
In my reading of the science that's out there, including the recent National Toxicology Program report, there is no association between fluoride at the levels that we use in the United States and any impact on neurodevelopment or IQ. It just is not there.
That NTP report, unfortunately, I think, has been largely misinterpreted and misrepresented. And even in the judge’s ruling in the case brought against the EPA, I think that judge reached conclusions that were beyond what the actual science concluded.
In fact, I would say that the preface even says that the report was not intended to reach any conclusions regarding the levels of fluoride associated with community water fluoridation. So, I think that the conclusions that have been reached far exceed what the science supports.
In other countries that have looked at the association between fluoride exposure and IQ, for example, studies done in New Zealand, in Australia, they found no association. This is actually consistent with what independent systematic reviews that have looked at levels relevant to community water fluoridation have also found, again, no association.
Historically, the EPA operated relatively independently from the Department of Health and Human Services and political influence. I think that that has unfortunately changed in recent months. We'll see how the EPA decides to adjudicate the judge’s ruling. It's still a decision that's been in the EPA's court as to how to act on the judge’s ruling that came out this past September.
But again, I think it's unfortunate that the judgments that people are reaching are not supported by the available science.
What role could state agencies potentially play in federal guidance on fluoridation changes?
Community water fluoridation has always, since it started 80 years ago, been a local issue. There are some states that have fluoridation mandates. I think 12 states had state mandates on fluoridation for communities of at least a certain size. But for most of the country, it's always been a local issue.
Depending on the EPA's ruling, I'm not an attorney, I don’t know how this may play out, but states, I suppose, could challenge the EPA's ruling depending on how they come down on this issue.
How can dentists prepare for the potential impact on oral health outcomes? Should they be considering talking to their patients?
It's certainly not too early to start before communities consider stopping community water fluoridation. I do think that dentists have a key role in talking to their patients and, frankly, to their elected leaders to explain that this is a safe and effective measure to help prevent tooth decay.
We are not only dentists, but we're also healthcare providers and scientists. So, we certainly look at the literature, try to stay abreast of the science. And the best available evidence again suggests that this is a safe and effective public health measure.
Not that many years ago, the CDC declared it one of 10 great public health achievements of the last century, and nothing has changed since then. So, I think dentists can assure their patients that this is safe and effective.
For communities that, unfortunately, have already made the decision to change, I think dentists need to take that into account in doing caries risk assessment for their patients because they will not be getting the benefit of water fluoridation, which we know on average has about a 25% prevention effectiveness in caries reduction.
So, I think that they will begin to see more patients developing caries, and it'll probably need to adjust the frequency of things like topical fluoride applications in response to that.
Supplements are an option. I personally don't think that they're a great option. It puts the burden on families for both the cost and to ensure that they're administering the drops or tablets to their children every day. Historically, compliance is pretty low. But I think it's a minimum they can assure their patients that the fluorides that we use in toothpaste, in topical fluorides as well as in fluoridation, are safe and effective.
Is there anything else you are thinking about from a public health perspective as fluoride continues to be a topic of contention?
One of the things that I think many lawmakers are overlooking–and I don't want to get into the politics of it–but clearly there's one side that's driving this push to stop fluoridation. By stopping it, not only do we expect to see an increased rate of disease, but there's a substantial cost that comes with that.
Water fluoridation not only prevents disease, but it's actually one of the incredibly few public health measures we have that actually saves money. The most recent national estimate was about $20 in savings for every dollar invested in fluoridation.
What will happen when fluoridation stops in areas, the cost will be shifted to the residents of those communities and states that stop fluoridation, including their state Medicaid programs as well as the families.
I think it's an artificial savings, if that's part of what's behind this. I've heard this in some communities that have been considering stopping fluoridation, it's like, ‘Oh well, we can save what we're now spending on fluoridation.’ It's really a false savings. What they're actually going to be doing is shifting the cost, at a much higher cost, on to the backs of their residents.
Again, this is exactly what we've been seeing in the communities that have stopped it. It's more treatment and the treatment comes out of the pockets of the residents of those areas.
I would urge lawmakers to really rethink this, certainly from a health perspective, but even from a financial perspective. They're going to drive up Medicaid costs in those areas as well as the cost to their constituents, especially those who have the least resources, because they're the ones who already are experiencing the most disease. The ones that benefit most from fluoridation will be the ones most heavily hit by decisions to stop fluoridation.
Responses have been edited for brevity and clarity.
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