New study finds community water fluoridation still cost effective

Cyber-The-Vote-Cost-Benefit-Analysis-1A new report on the cost effectiveness of community water fluoridation (CWF) confirms it is still effective. The report is:

Ran, T., & Chattopadhyay, S. K. (2016). Economic Evaluation of Community Water Fluoridation: A Community Guide Systematic Review. American Journal of Preventive Medicine.

This study is a systematic review of the literature.  A total of 564 papers were identified, but after excluding studies which didn’t fit the inclusion criteria, this was whittled down to ten studies (8 peer-reviewed journal articles and 2 reports) published in the period 2001 – 2013. The studies were located in Australia, USA, Canada and New Zealand.

Intervention costs

The review found:

“Per capita annual cost ranged from $0.11 to $4.92 in 2013 U.S. dollars for communities with  >1,000 population. The variation in per capita annual cost was mainly attributable to community population size. Specifically,
per capita annual cost decreased as population size increased, after adjusting for factors such as discount rate.”


“per capita annual cost was the highest when population size was around 1,000. As community population size increased, per capita annual cost decreased. In particular, per capita annual cost for communities with >20,000 population was <$1.”


Intervention benefits

The caries reduction reported in the reviewed studies ranged from 15 – 33%.per capita annual benefits ranged

Intervention benefits included averted healthcare costs and productivity losses. The per capita annual benefits reported in these studies ranged from $5.49 to $93.19

Benefit-cost ratios

As would be expected the reported benefit-cost ratios varied with population size – ranging from 1.12 to 57.21.

So, the authors’ conclusion was:

“In summary, benefit–cost ratios were larger than 1.0 for communities of at least 1,000 people, indicating that CWF was cost beneficial for communities with no fewer than 1,000 people.”

Possible issues

The authors list a number of issues for consideration in future studies of this issue. Interestingly these include two that anti-fluoride campaigners argue have been ignored:

Cost of fluorosis: The authors say this should be included “if there is clear evidence of severe dental fluorosis.”

The only study to have included such costs is that of Ko & Theissen (2014). They included costs of repair or severe dental fluorosis – despite there being no evidence that CWF causes either moderate or severe dental fluorosis. Ko and Theissen made no attmept to justify inclusion of this cost and the “mistake” is not doubt due to the well-known anti-fluoride sympathies of Theissen (see Alternative reality of anti-fluoride “science” for a discussion of this paper).

Political costs: The authors give as an example “expenses associated with promoting CWF.”

Of course, this would also include the legal and referendum costs we have seen imposed on New Zealand local bodies over the last few years. But it should also include the private costs of those who campaign for and against CWF and the larger corporate costs of bodies like the NZ Health Trust which has initiated unsuccessful High Court action. The NZ health trust is a lobby group for the “natural”/alternative health industry and their costs no doubt eventually get passed on to the consumers of their products and services.

It would be interesting to see the breakdown of such political costs for different countries and regions. I imagine it would be hard to predict what these costs could be in an individual situation. Although I can appreciate local bodies may feel obliged to budget for such costs.

And I wonder if one should include the cost of legal justice and democratic consultation in a cost-benefit analysis. This could lead to people questioning parliamentary elections or their rights to challenge corporations and criminals in the courts.

Should anti-fluoride campaigners do their own cost-benefit analysis?

It’s a simple fact that anti-fluoride campaigners lose more of their struggles than they win – even in the USA. It’s also a fact that they see the threat of imposition of legal and consultation costs as a way of pressuring local bodies to avoid the issue. But, I wonder if they have ever undertaken a cost-benefit analysis on their own activities.

For example, given the failures of the High Court action by the campaigners over recent years and the lack of success in referenda held in New Zealand in 2013 and 2015 perhaps they should do a few “back of the envelope” calculations.

If they want to personally enjoy drinking water that is “fluoride free” then what is the most reliable intervention they could apply to achieve that benefit.

Consider two scenarios:

1: A political approach. The costs of referendum and consultation campaigns, their personal loss of income and free time in making submissions, organising Paul Connett’s Southern hemisphere holiday tours of New Zealand and Australia. Consider also the costs to the “natural”/alternative health industry in their taking and sponsoring legal actions.  Balance this against the very low likelihood of success – and possibly also consider the negative result of social criticism and discrediting that may represent a financial loss to those who run businesses or are practitioners in the “natural”/alternative health industry.

2: A personal responsibility approach. The cost of  purchasing a relatively cheap and effective water filter to lower the F concentration in their tap water. The capital cost would be a few hundred dollars per household and the annual costs would not be large. In fact, the NZ Health trust may help lower these costs by reinvesting the money they would otherwise lose in paying for unsuccessful court actions. The benefits would be immediate and clear. They would get the “fluoride free” water they have demanded. They would have a lot more free time to devote to their families and businesses. And they would not get the current condemnation they get from local body politicians and voters who resent the increased costs their actions have caused in the past.

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8 responses to “New study finds community water fluoridation still cost effective

  1. Ko and Thiessen is referenced here. Does anyone know who Ko is? The paper just says Oakland, CA. I guess the mailing address is General Delivery. There are no degrees, no associations, no credentials and no address. There are too many people in the phone book to have any chance of finding himr there. It surely must point to an utter lack of editorial oversight if a paper is accepted with zero information about the senior author.


  2. There can be valid reasons why the primary author of a paper may not be given a mailing address.

    I know of three papers where the primary author was a medical student. Since students are not known for their stability in either address or employment, correspondence was directed to a secondary author.

    Since I haven’t read Ko and Thiessen, I don’t know if this applies. Just pointing out it may not be lack of editorial oversight.


  3. “The cost of purchasing a relatively cheap and effective water filter to lower the F concentration in their tap water.”

    Need to do better. A filter may also remove iodine, molybdenum, calcium and other important stuff, even microscope suspended matter.

    Two approaches to people who are vegetarians in your organisation:

    A. Take the meat off the plate.
    B. Provide alternative protein balanced diet.

    B can be costly as two different types of meal are required. However vegetarianism can make less CO2 demands on the environment.

    A can produce malnutrition.

    Unfluoridated water is likely very different chemically from “filtered” fluoridated water.

    Your cost/benefit analysis needs to take into account costs of nutritional deficiencies as a result of water “filtration.”


  4. It’s all in the mind, anyway, Brian. Any anti-fluoride activists worried about removal of nutrients will add “Tibetan” salt to return them together with fluoride. But they think they have “fluoride- free” water and that is what counts because it is only a hangup.



  5. Johnny Johnson

    Hi Ken,
    One interestingly and oft overlooked option for those who do not desire to drink optimally fluoridated water is to simply request a spigot be placed at the water utility for them to have pre-fluoridated water access. Several communities here in the U.S. have done this over the years.

    These “experiments”, if you will, found that those who opposed CWF used the free water offer somewhat at first, less as time went on, and trailed off to zero within a few years, typically 2-4. At that point the utility companies had to make the decision to disassemble the unit. Since it wasn’t being used, it was a potential hazard of bacterial contamination to the water in the spigot.

    The point here is that those who do not want CWF have shown initial interest in a viable alternative, then falling off to no interest.

    Just food for fodder as we kick this around.

    Keep up the great fight, Ken.

    Johnny Johnson, Jr., DMD, MS
    President, American Fluoridation Society
    Twitter: @AFS_Fluoride


  6. We have seen a similar situation in Palmerston North, NZ, recently. A “fluoride-free” tap has been found to be used by only four people a day. This sort of data will make it unlikely that councils provide similar facilities in future.


  7. “A “fluoride-free” tap has been found to be used by only four people”

    Attached to a secluded public toilet in a park, and not sign posted at that time if I remember.


  8. But well-known by anti-fluoride campaigners who do not use it because they already take their own actions such as using a filter.


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