America’s $10 Billion Dental Disaster: What Happens If We Stop Fluoridating Water?

Eliminating fluoride from America’s public water systems would trigger a dental health crisis costing nearly $10 billion over five years, according to new research that models the economic consequences of proposed policy changes.

The study, published in JAMA Health Forum, projects that tooth decay would surge by 7.5 percentage points among children if fluoridation programs ended nationwide.

Using data from over 8,400 children tracked through federal health surveys, researchers created a sophisticated computer model to predict what would happen if the United States abandoned a public health practice that began in 1945. The results paint a stark picture of deteriorating oral health and skyrocketing treatment costs.

The Hidden Costs of Policy Changes

The analysis reveals that removing fluoride would increase decayed teeth by 25.4 million cases over five years, with treatment costs reaching $9.8 billion. These figures reflect only direct healthcare expenses—the true societal cost would be much higher when accounting for missed work and school days.

What makes these projections particularly concerning is how the burden would fall disproportionately on vulnerable populations. Children with public insurance or no insurance would bear the heaviest impact, compounding existing health disparities in dental care access.

Currently, 40.4% of American children have access to optimal fluoride levels in their drinking water, while 45.7% receive less than optimal amounts. The remaining children either lack fluoridated water entirely or, in rare cases, are exposed to excessive levels that can cause dental fluorosis.

A Tale of Two Scenarios

The research team, led by Harvard Medical School scientists, examined multiple scenarios using data from the National Health and Nutrition Examination Survey. Their microsimulation model tracked 10,000 virtual children from birth through age 19, accounting for factors like family income, insurance status, and geographic location.

In the most dramatic scenario—completely eliminating fluoride from all water systems—dental caries prevalence would jump significantly across all age groups. Children aged 2 to 5 would see decay rates rise from a baseline of 21.3% to nearly 29%. For teenagers aged 13 to 19, rates would climb from 57.2% to over 64%.

The study also modeled an opposite scenario: optimizing fluoride levels in all currently fluoridated areas. This approach would prevent 22 million decayed teeth and save $9.3 billion over five years, demonstrating the potential benefits of improving rather than abandoning fluoridation programs.

The Equity Question

Perhaps the most troubling finding involves how fluoride removal would worsen existing health disparities. The researchers found that publicly insured and uninsured children would experience the greatest increase in tooth decay, precisely the populations already struggling with limited dental care access.

This disparity exists because fluoridated water acts as a population-wide preventive measure that doesn’t depend on individual behavior or healthcare access. When that protection disappears, children without regular dental care suffer most.

Key Research Findings:

• Dental caries would increase by 7.5 percentage points among all children
• 25.4 million additional decayed teeth would occur over five years
• Healthcare costs would rise by $9.8 billion in the same period
• Publicly insured children would face the heaviest burden
• Effects would worsen over time, reaching $19.4 billion over 10 years

Beyond Simple Cost Calculations

The study’s methodology reveals important nuances often missing from policy debates. The researchers calibrated their model against real-world data from federal health surveys, ensuring their projections reflect actual patterns of dental disease across different populations.

Importantly, the analysis takes a conservative approach by focusing only on children and excluding potential adult benefits. It also doesn’t account for the “halo effect”—the observation that even communities with suboptimal fluoride levels may still receive some protective benefits.

The researchers conducted extensive sensitivity analyses to test their assumptions. Even when they assumed fluoride was only 7.5% effective at preventing decay—far below the 25% used in their main model—removing fluoride would still cost $2.08 billion and result in significant health losses.

The Neurotoxicity Debate

The study deliberately avoided modeling potential cognitive effects of fluoride exposure, noting the ongoing scientific uncertainty. While some research has linked high fluoride levels to lower IQ scores, current evidence doesn’t support neurocognitive effects at the concentrations used in public water systems.

The researchers acknowledge this limitation but point out that current federal guidance from the CDC and National Toxicology Program doesn’t find harmful neurobehavioral effects at recommended fluoridation levels. Public water systems are safely fluoridated 99.99% of the time using Environmental Protection Agency thresholds.

This approach reflects the challenge policymakers face: balancing established dental health benefits against theoretical risks that remain scientifically unproven at current exposure levels.

Real-World Evidence

The modeling results align with real-world experiences. Calgary, Alberta, removed fluoride from its water supply in 2011, only to reintroduce it in March 2025 after observing increased dental disease in children. This natural experiment validates concerns about the consequences of abandoning fluoridation.

The study also highlights an important equity consideration: while affluent families can compensate for lost water fluoridation through private dental care and topical treatments, low-income families often cannot. This means policy changes that seem neutral actually worsen health disparities.

Policy Implications

As political discussions about fluoride intensify, this research provides concrete data about the potential consequences of policy changes. The $9.8 billion price tag represents only healthcare costs—the broader economic impact including lost productivity and educational disruption would be substantially higher.

The study suggests that rather than eliminating fluoridation, policymakers might consider optimizing current programs. Bringing all fluoridated areas up to optimal levels could prevent millions of cavities while maintaining safety standards.

For families concerned about fluoride exposure, the research underscores the importance of considering population-level effects. Individual choices about fluoride use occur within a broader public health context where removing community-wide protections disproportionately harms vulnerable children.

What emerges from this analysis is a clear picture: fluoridated water remains one of public health’s most cost-effective interventions, with removal carrying consequences that extend far beyond individual families to impact entire communities and healthcare systems nationwide.