The Metropolitan Water District of Southern California (MWD) began fluoridating its water supply in October 2007, bringing fluoridated water to an additional 18 million people and raising the percent of the population receiving fluoridated water to about 70%.  Healthy People 2010 Objective 21-9 is to increase the proportion of the U.S. population served by community water systems with optimally fluoridated water to 75%.  California is expected to meet this goal. 

In an effort to prevent consumers from receiving more fluoride than necessary, the California Department of Public Health sent a letter to all physicians, dentists and pharmacists in the MWD’s service area recommending they cease prescribing fluoride supplements for one year after the MWD implementation date to allow the local public water systems time to record average fluoride levels in their water. The suspension only pertains to fluoride drops and tablets and does not apply to topical applications such as fluoride foam/gel treatments, fluoride rinses, or fluoride varnish applications.

Click here to view that notice.

ARTICLES

Older Adults Benefit Most From Fluoridation

Fluoride infomation from the National Council Against Health Fraud

What About the Report From the National Research Council?

North Coast News

Michigan voters realize folly and reinstate fluoridation

The Fluoride Deception

HOW CAN WE PROMOTE DENTAL HEALTH IN OUR FAMILIES AND COMMUNITY?

Fluoridation: A Triumph of Science Over Propaganda

Humboldt County Children’s Oral Health Report:
Crisis with Our Children


MORE ARTICLES

Michigan voters realize folly and reinstate fluoridation.

Voters in Mt. Pleasant, MI, voted 63% to 37% last month to once again fluoridate the community water supply. Congratulations to Michigan’s Ninth District Dental Society and the Michigan Dental Assn. for their work over the past year to bring fluoride back to Mt. Pleasant after last year's narrow vote to remove it. Much of the Mt. Pleasant community believed that the confusing nature of last year's ballot language played a major role in the vote to remove fluoride. Dr. Dane Kane, a Mt. Pleasant general dentist, co-chaired the ballot proposal committee and was the driving force behind the successful campaign. The MDA worked closely with Dr. Kane to create a campaign to educate Mt. Pleasant voters, and for the first time the campaign featured a brochure mailed directly to all registered voters. In addition, radio commercials and newspaper ads were created, along with yard signs (another first), postcards and letters to the editor. ADA staff experts on fluoridation provided behind-the-scenes technical assistance and support for Michigan. Read more in the Mt. Pleasant Morning Sun.

In another big courtroom win for fluoridation, the California Sixth District Court of Appeals has upheld a trial court ruling that the state’s fluoridation law preempts a city law created by a voters’ measure intended to ban fluoridation. The court’s discussion of fluoridation is similar to the one in the recent fluoridation victory in Escondido, in that it indicates fluoridation’s benefit is very well settled law. It will be published. Both cases uphold California’s statewide fluoridation law, and recognize that the FDA doesn’t regulate fluoridation, notwithstanding city laws driven by anti-fluoridationists suggesting the contrary. The California Dental Assn. and ADA worked together on this appeal.
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The Fluoride Deception
By Christopher Bryson
Seven Stories Press: 2004, 272 pp.
$24.95

Ann Lindsay, MD
Health Officer, Humboldt County
5/10/05

The Fluoride Deception, by Christopher Bryson, deserves credit for a catchy title but the story he tells ultimately lacks credibility. The book begins as an informative historical expose of the occupational and environmental impact of fluoride use in industry in the 20th century. However Bryson then commits his own “deception” regarding risks and benefits of water fluoridation. He is either scientifically unsophisticated or willingly allowing his politics to trump science. Either way, the last half of the book confuses types of fluoride compounds after cautioning the reader against doing so, carelessly equates the dangers of high dose exposure to the level of fluoride added to water, misquotes scientific articles, and relies on references by authors with questionable credentials, equating opinion to factual evidence. Individuals express their viewpoints at Congressional Hearings, but such testimonials cannot be taken as fact simply because someone said it was so. Bryson presents such testimonials as truth, but there is a large difference between scientific evidence and personal opinion. It is not clear that he understands the difference.

According to Bryson, the root of the “fluoride deception” lies in its usefulness as uranium hexafluoride for isotope enrichment in production of weapons-grade uranium for the top secret Manhattan Project, which developed the atomic bomb used by the United States military on Hiroshima in World War II. As a result of the uranium production, workers and communities were exposed to toxic levels of fluoride, a fact the US government suppressed. At that point in US history, the US government exerted unprecedented control over all industrial production to support the war effort. No automobiles were produced except for those in critical jobs. Clothing manufacturers were ordered to produce suits without lapels. Food was rationed. It was forbidden to manufacture girdles or butter. Rather, the nation’s industrial machinery was focused on the war effort. Production of the atomic bomb was top secret and subject to a desperate timeline. Occupational medicine was a fledgling medical specialty; doctors in the field generally worked directly for industry and there was virtually no independent academic research. In that context, it was not laudable that workers and communities were exposed to high dose fluoride toxicity, but it was not particularly surprising. We need to learn from this history and not repeat or perpetuate such dangers. If Bryson had stopped writing at this point, he would have produced a valuable book on the dangers of placing “national/economic” interest ahead of workers and communities. However, continuing the theme of “fluoride deception”, Bryson makes a wild leap, insisting that the effort to fluoridate water for prevention of dental decay was directly related to the cover up of the industrial hazards of high fluoride exposure in the nuclear industry. This conspiracy is not well referenced and seems exceedingly unlikely. He quotes statements that are out of date, taken out of context, misrepresent legitimate scientific research or draw scientifically invalid conclusions from evidence cited. The most frequent mistake was assuming that one part per million fluoride in optimally fluoridated water presents the same risk as larger amounts, like 100 parts per million, of fluoride given to rats or experienced in industrial settings. This is sloppy journalism, not accurate scientific reporting.
A basic principle in medicine is that effects of substances on the human body depend on the dose to which the body is exposed. A little may be beneficial; a lot of the same substance can be harmful. This is true for calcium, chlorine, iodine, iron and oxygen, as well as fluoride. Bryson refers to research by Phyllis Mullenix, Ph.D., reporting hyperactivity in rats given fluoridated water. When I checked the study referenced, I found Mullinex gave rats water 175 times the concentration of fluoridated water; it is an error to conclude from this research that fluoridated water causes hyperactivity in children. Bryson cites an article by John Featherstone, M.SC. PH.D (Journal of the American Dental Association, Vol. 181, July 2000. 887) as saying fluoride does not work systemically in preventing tooth decay. Bryson’s conclusion is therefore drinking fluoridated water cannot be effective; he says it must be applied topically directly to the teeth to have a benefit. That is clearly not the conclusion of the actual article by Featherstone, which states, “Fluoride, the key agent in battling caries, works primarily via topical mechanisms: inhibition of demineralization, enhancement of remineralization and inhibition of bacterial enzymes. Fluoride in drinking water and in fluoride-containing products reduces caries via these topical mechanisms.”
Fluoride Deception appears to be a well-researched book, with over 100 pages of footnotes and references. However, the majority of the references refer to taped conversations rather than scientific references. Scientific articles referred to are either of poor quality or misquoted to present the case that community water fluoridation is ineffective at preventing tooth decay and is dangerous. Other sweeping statements like, “Fluoride is a poison that accumulates in the body over a lifetime,” are presented without documentation. Bryson repeatedly forces the “facts” in his preconceived analysis.

In 1999, the Sacramento Board of Supervisors asked Health Officer, Dr. Glennah Trochet, to report on water fluoridation. She assembled a scientific panel to review literature submitted to the Board from both sides of the debate. The panel established standards for evaluating the 132 references submitted, then proceeded to review the articles covering 50 years of scientific investigation. Criteria of legitimacy included: publication in an acceptable peer-reviewed journal, pertinence to community water fluoridation, and validity and quality of scientific research. The preponderance of evidence supported fluoridation of community water as a safe and effective method of preventing dental caries. The panel found no verifiable association shown between optimal fluoridation of community water and conditions such as hip fractures, bone cancer, severe dental or bone fluorosis, Alzheimer’s disease or heavy metal poisoning. Sacramento County enacted water fluoridation to advance common good in the absence of identifiable harm.


Had Bryson stayed with the historical expose of industrial toxicity, Fluoride Deception would have been a useful lesson rather than the potentially destructive book he authored. One wonders about his motivation. If controversy sells books, he may have accomplished his goal.
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HOW CAN WE PROMOTE DENTAL HEALTH IN OUR FAMILIES AND COMMUNITY?
By John Sullivan, MD

 Dental and gum disease is totally preventable, and is can cause lifetime pain, ill health, disability, and gets worse and more expensive to treat the longer it goes on.  Resources for treatment are limited; this is especially true for people with low income, without good dental insurance, seniors on public benefits, young children, and disabled people unable to participate easily for office exams and treatment.  Statewide, the scarcity of providers and funding is not expected to improve any time soon. Simple advice to brush and avoid sweets is unfortunately insufficient to promote dental health especially in high-risk populations

PREGNANCY: Get dental and gum disease treated and practice good dental care before you get pregnant to prevent medical complications for you and baby.

INFANCY:  Try to avoid passing your dental germs to your baby (especially if you have decay- prone teeth, you probably still have specific decay-causing germs in your mouth that may be passed on to him or her).  Try not to share spoons, lick pacifiers, etc.  Try to breast-feed.  Try to get the baby in the habit of falling asleep without the nipple in the mouth especially if formula feeding.  Avoid bottle propping.  When teeth erupt start cleaning them regularly (begin by wiping the infant’s gums with a cloth and when you begin to us a toothbrush, use a soft brush). Go easy on sweets, especially sticky ones, when introducing solids.  Avoid excessive juice in bottles.  Try to wean your baby from bottle to cup early as possible.

TODDLERHOOD and PRESCHOOLERS: Gradually let the child get accustomed to you touching her around the mouth, then inside.   Brush teeth regularly with a soft brush- toothpaste is not necessary at first, but some kids prefer it.  Replace brush when worn or old.  Use toothpaste without fluoride if the child does not rinse and spit well.  Then use a pea-sized amount of fluoridated toothpaste when she is old enough to not to swallow it.  Allow child to “help” brush or “pre-brush” when interested, but teach her that adult needs to finish up. Begin getting your child used to floss when there are many teeth especially if crowded. Floss holders may help for small mouths.
Prepare your child behaviorally for dental exams—for example, you may want to read books, play with dolls and toy instruments, visiting the dental office without exam, parent touching mouth and putting brush inside.  Think about how you talk about the dentist to generate positive expectations.  Medical provider should carefully examine teeth with well child checkups and may recommend dental referral or professionally applied topical fluoride in high risk cases.  Get a child in for a medical examination if you suspect decay as it may take a while to schedule your child with a dentist who sees young children.   Go ahead and get on a waiting list for the dentist as it could take many months to get in. Your medical provider, the Child Health and Disability Prevention Program, or Headstart program may be able to help with appointments; be patient and persistent. Make the first visits to dentist comfortable and positive and communicate to the dental office staff how your child does the best.

 Ensure your child’s diet is adequate in calcium. Ensure child is getting adequate fluoride after 12 months of age. If you live where there is community water fluoridation, your child will receive fluoride from drinking and food preparation water. If you are unsure if your water is fluoridated, telephone your water district. If you live in a community with non-fluoridated water, your child’s medical provider or dentist can prescribe the correct dose of supplement as drops or chewable tablet. Chewable tablets are more effective when chewed than swallowed whole.  If you move, find out if your new water contains fluoride or not.  If your child spends a long time in daycare with fluoridated water, decrease at home supplement.  Keep supplements (like medications, or iron containing vitamins) out of reach to avoid accidental overdose. It takes about 80 fluoride tablets for a 20-pound toddler to overdose.

  Try to get your child used to treats that are non-sugary. Try to set an example yourself as children copy what you do.  Get the child used to limited juice and rare sodas, and to accept water if thirsty.  Try to get in the habit of giving sweets, especially sticky ones, seldom.  Give sweets with meals not between and not around bedtime.

Dental fluorosis or spotting occurs during pre-eruption tooth mineralization.  In the case of permanent front teeth visible to the public, this is before age 6 or 8.  It is caused by excessive intake of fluoride from naturally or supplemental fluoridated water, prescribed supplements, prepared foods and beverages made with high fluoride water, certain foods, or from swallowing fluoridated toothpaste. In the US in people consuming water at 0.7 to 1.0 ppm fluoride (as in fluoride supplemented community water), one can occasionally see white spots on strong, decay-resistant teeth, although it is rare to see cosmetically significant white spots on front teeth.  This becomes more common when concentrations exceed 4 ppm (upper limit set by EPA for drinking water), and brown stains and pitting become a problem in naturally fluoridated water about 10 ppm, as does medically significant skeletal fluorosis.

Preventing excessive intake of fluoride in the first 6 years of life can minimize significant dental fluorosis.  Breast milk contains minimal fluoride and breast fed infants have less fluorosis.  Formula concentrates which are now required to be made with low concentrations of fluoride, can be prepared with non-fluoridated water.  Oral supplements should be given only as directed and not if the child drinks fluoridated water and possibly in lower doses if the child drinks many prepared beverages made with fluoridated water.  Children should not swallow fluoridated toothpaste. 

 SCHOOL CHILDREN:  Continue to reinforce proper brushing at least twice a day (especially after last food before bed) with fluoridated toothpaste when your children are old enough to spit it out instead of swallowing it. To be sure to brush all teeth, brush front, back, upper, lower, right, left, inside and outside; this method should take about 3 minutes, a timer may be useful. Invest in a new toothbrush every couple months or when the bristles are worn or frayed.  Some children are educated or motivated by trying “disclosing tablets” which color teeth until well brushed. The disclosing tablet shows clearly areas that child is missing when brushing. Some hygienists like child to show them how she brushes at home.  Promote flossing.   Find treats that are the least sticky and sugary you can. Make sodas a very occasional treat. Get child used to sugarless gum only.  Talk to your school about snacks and meals they provide, and “fundraisers” and vending machines.  Think again about eating that you are modeling. Xylitol gum or chewables are mildly protective especially at times when child is unlikely to brush.   Get regular dental checkups.  If on supplemental fluoride by mouth, ensure children are taking it as directed, and keep asking for refills till at least 11 years old.

 TEENS:  Adolescents need to be encouraged to practice good habits and to continue to get regular dental care. Discourage smoking or chewing tobacco, encourage use of mouth guards for sports activities. Ensure that they get established with regular dental care after leaving home. Make good dental care a lifetime habit.

SPECIAL RISK FACTORS:  Some children are at higher risk for dental disease and require even more diligence and monitoring.  Examples:  children in families with low income, members of disadvantaged minorities, immigrants, children adopted from adverse circumstances, children with behavioral, medical, or developmental obstacles to maintaining good oral hygiene and/or cooperating with exams and treatment, children requiring supplemental (usually sweet) formulas after infancy, people requiring tube feeding with little oral intake, children with gastroesophageal reflux, children with dental or medical conditions associated with decay prone teeth, children chronically  taking medications which reduce saliva such as antihistamines and some psychiatric drugs, children with reduced access or participation in medical or dental care.
Some parents find it is easier to get the teeth well cleaned using an electric brush (e.g., small mouth, limited dexterity of caregiver, child cooperative only very briefly for brushing, child is orally sensitive and vibration is easily tolerated, child is more prone to use electric brush than manual).

 ADVOCACY:  Currently in California, Denti-cal funding is very limited. There are several disincentives for dentists to accept Denti-cal patients. Dental provider reimbursement in many cases is below the cost of providing care and paper work and requirements for authorization are high. Covered restorative treatment is in many cases adequate, but in others below what most dentists would prefer to provide. Additionally provider supply and reimbursement issues severely restrict access to hospital dentistry. 

Few specialists in pediatric dentistry are being trained and are especially scarce in rural areas.  Many general dentists feel inadequately trained or uncomfortable treating young children or adults who have difficulty cooperating. There is a scarcity of dental hygienists.

In response to limited reimbursement and scarcity of providers, the medical system has made increasing use of mid-level providers to increase efficiency; this process is in a very early stage in dentistry.

Public Health, medical, dental, educational, and early childhood educational professionals are collaborating on many community measures (education, health promotion, enhanced access to care, obtaining grant funding, etc) to promote dental health in Humboldt County. 

The media relentlessly bombards children with millions of dollars worth of messages to eat unhealthily including foods promoting dental disease and obesity. In the US, most children, even toddlers, watch way too much TV.  Older kids need to know how to be informed consumers of media messages and information.

While it is only one component of dental health promotion, community water fluoridation is the single most effective and cost- effective preventative dental public health measure. This is especially for those in high-risk groups who have the majority of dental decay and the least access and resources for treatment.  In the last half-century community water fluoridation has made a major difference in dental health in the US. Currently 140 million people are served by fluoride naturally occurring in ground water, or by community water supplies supplemented with fluoride to a concentration sufficient to cut down substantially on decay. The careful supplementing of fluoride to community water has minimized risks of cosmetic dental fluorosis and made medically significant skeletal or dental fluorosis nearly unheard of. Community water fluoridation continues to confer additional protection even in people with reasonable dental hygiene who use topical fluoride, and benefits the elderly who are at risk for root caries as their gums recede. Community water fluoridation has a long record of safety and effectiveness. Public health and dental scholars, government, and international agencies rightly periodically review water fluoridation in view of new circumstances and research.  In the past, California was one of the states with the least fraction of people served with community water fluoridation, but recently enacted legislation requires water systems with more than 10,000 hookups to provide fluoride supplementation. 
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Fluoridation: A Triumph of Science Over Propaganda
October 1, 1996

Community water fluoridation (herein called simply "fluoridation" or "water fluoridation") is the precise adjustment of the concentration of the essential trace element fluoride in the public water supply to protect teeth and bones. In 1945 Grand Rapids, Michigan, became the first city in the world to fluoridate its public water supply. Since then, communities throughout the United States have adopted the practice. Water fluoridation is similar to food fortification and enrichment, which encompass the addition of iodine to table salt; vitamins to fruit drinks, milk, and various kinds of pasta; and vitamins and minerals to breakfast cereals and bread. Water fluoridation is the perfect public health intervention, particularly for children. Whole towns are protected in a nondiscriminatory manner. The protection is continuous and effortless to obtain. The fluoride in the water is incorporated into the enamel of developing teeth in children below the age of 16, making their teeth more resistant to decay for a lifetime. It also promotes remineralization of early decay in adults and interferes with the life cycle of decay-causing bacteria present in the mouths of both children and adults.
Water fluoridation is remarkably simple to implement and mimics nature: Virtually all sources of drinking water in North America naturally contain some fluoride. Fluoride levels in the United States are adjusted to about one part fluoride per million parts of water — a minute concentration.

The Antifluoridationists
While only a minuscule percentage of Americans opposes water fluoridation, an extremist minority urges avoidance of water fluoridation. These antifluoridationists or flurophobics falsely allege that it is unsafe, ineffective, or costly. They assert that exposure to fluoridated water increases the risk of contracting AIDS, cancer, Down's syndrome, heart disease, kidney disease, osteoporosis, and many other health problems in children and the general popluation. But the overwhelming weight of scientific evidence confirms water fluoridation's safety and effectiveness, and hundreds of peer-reviewed studies on fluoride have discredited antifluoridation propaganda. Almost at the moment Grand Rapids became the first community to adjust the fluoride content of its water supply, small groups of ill-informed people began objecting to water fluoridation. Early opponents included chiropractors, health food advocates, and members of fringe political and religious groups. The convergence of such individuals and groups led to the formation of small but highly active regional societies whose primary mission was to fight water fluoridation. Most of these organizations lacked the funds, political expertise, or scientific credibility to have an impact outside their respective communities. Eventually, however, a few better-funded national organizations appeared whose agendas included opposition to water fluoridation. By exploiting scientific illiteracy, common phobias, paranoia concerning communist plots and Big Brotherism, and occasional acceptance of folk medicine, these organizations persuaded a minority of Americans. Their tactics included attracting the media; holding demonstrations at the local-government level; promoting referenda; lobbying public health agencies, state legislatures, and the United States Congress; and litigating at state and federal levels. The effects of such activities did not have lasting importance, and antifluoridation efforts have diminished significantly in recent years. Today, most fluoridation initiatives are successful; court challenges by antifluoridationists are rare; and effective antifluoridation lobbying at both state and federal levels is virtually nonexistent. A latter-day antifluoridationist highspot was the movement's extensive campaign in 1995 to prevent enactment of mandatory statewide fluoridation in California. The campaign failed.

. . . And Justice for All
Despite the decrease in antifluoridation activities, they remain a factor — albeit a minor one — in the success or failure of profluoridation efforts in most American cities. The tactics of contemporary antifluoridationists tend more to delay fluoridation than to stop it, but in some areas of the United States fluoridation remains in limbo. This lack of implementation translates into tooth decay, pain, infection, and dental-care expense (see sidebar). Moreover, antifluoridation efforts cost taxpayers money by compelling defense of water fluoridation to legislators, judges, and the media. But litigation, which antifluoridationists once considered the ultimate solution to the "fluoridation menace," has failed as an antifluoridation tactic. No American court of last resort has ever ruled against community water fluoridation. And court decisions that uphold water fluoridation as an acceptable public health measure within the police powers of state and local government have bolstered profluoridation efforts. Furthermore, with only two exceptions, American courts have never ruled on the scientific merits of water fluoridation but have allowed the scientific method — which includes clinical research and peer review — to determine whether community water fluoridation is acceptable. In both of the exceptions, higher courts overruled lower-court judges and decreed continuance of water fluoridation in the communities in question.

"Quackery" versus Science
Fluoride is harmless at the levels necessary for maximum benefits. Thousands of studies on fluorides and fluoridation have been completed in the last 50 years — more than 3,700 since 970 alone. Over 50 peer-reviewed epidemiological studies have dealt with the claim that fluoridation increases cancer risk. None has substantiated the claim. A number of nationally and internationally recognized scientific organizations, including the National Cancer Institute, have reviewed all the available scientific studies on the health of populations with fluoridated water supplies and the health of fluoride-deficient populations. These reviewers have declared fluoridation safe. Indeed, no legitimate epidemiological, laboratory, or clinical study has demonstrated that lifelong ingestion of fluoride at optimal levels in water causes disease in any form. We now have over fifty years' experience with water fluoridation. Moreover, many generations of Americans have spent their lives in areas whose water supplies had naturally occurring fluoride levels 800 to 1,300 percent higher than the levels in fluoridated water. There is no evidence that members of communities with fluoridated water supplies, or with naturally high concentrations of fluoride in their water supplies, have had a higher incidence of any disease than have their contemporaries in areas with water supplies low in fluoride. In 1978 Consumer Reports magazine summed up the situation well: "The simple truth is that there's no 'scientific controversy' over the safety of fluoridation. The practice is safe, economical, and beneficial. The survival of this fake controversy represents, in our opinion, one of the major triumphs of quackery over science in our generation." Nearly 145 million Americans can avail themselves of water whose fluoride concentration is optimal. Of the 50 largest municipalities in the United States, 43 have fluoridated water supplies, including four of the five largest cities. Eight states, the District of Columbia, and Puerto Rico have mandated fluoridation throughout their respective territories. Three states and the District of Columbia have fluoridated all of their treatable community water supplies. Viable options to community water fluoridation as a public health measure do not exist. There are other community-based methods of fluoride delivery — school-based programs that involve rinsing the mouth with a fluoride preparation, ingesting fluoride tablets, or submitting to professional dental application of fluoride, for example. But these methods cost considerably more than community water fluoridation, are much more difficult to implement, and are available only to limited numbers of people and only under special circumstances. Such methods are useful to populations without public water systems but decidedly are second-rate.

The Bottom Line
In recent years public resistance to water fluoridation has waned across the United States, partly because of a higher level of education among voters and partly because of consumers' positive experiences with fluoride (as an ingredient in fluoride toothpastes, for example). Healthcare reform movements have made all Americans aware of the importance of disease prevention. Federal, state, and local officials have acted on this awareness, and the pace of efforts to fluoridate America's remaining deficient water supplies has increased markedly. Fluoridation is the high-water mark of efficient public health intervention.


Michael W. Easley, DDS, MPH, is an associate professor in the Department of Oral Health Services and Informatics, School of Dental Medicine, State University of New York at Buffalo.


Dollars and Sense
The dental benefits — and concomitant cost savings — from fluoridation have been documented for more than half a century. Here are a few facts:
* People who drink fluoridated water for a lifetime will develop up to 70 percent fewer cavities (occurrences of tooth decay) than they would have without fluoridation.
* Because the technology is so simple and the fluoride supplement so inexpensive, fluoridation is extremely cost-effective. Studies indicate that a $100,000 investment in water fluoridation prevents 500,000 cavities.
* Each dollar invested in fluoridation prevents over $80 of dental treatment. Few disease-prevention efforts, and even fewer government-sponsored programs, achieve that level of return on investment.
* The average per capita cost of fluoridating America's public water supplies is 54 cents per year (or $40.50 over a lifetime). The cost of an average single-surface dental restoration is $55. Thus, provision of fluoride in water for a lifetime costs less than one small dental filling.
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