As the battle over water fluoridation continues, rural Americans are at risk for higher rates of tooth decay

Thirteen states and the counties in gray don't report data on fluoride and drinking water to CDC.
(Map by Brett Kelman, Harvard University study from Census and CDC data)

As states consider banning tap water fluoridation mandates, rural America may be at risk for higher rates of tooth decay and its accompanying health problems. "Dozens of communities have decided to stop fluoridating in recent months, and state officials in Florida and Texas have urged their water systems to do the same," reports Brett Kelman of KFF Health News. "Utah is poised to become the first state to ban it in tap water."

Advocates for banning water fluoridation often cite "a government report last summer that found a possible link between lower IQ in children and consuming amounts of fluoride that are higher than what is recommended in American drinking water," Kelman explains. "The report was based on an analysis of 74 studies conducted in other countries, most of which were considered 'low quality' and involved exposure of at least 1.5 milligrams of fluoride per liter of water — or more than twice the U.S. recommendation."

Even as the battle over fluoridation continues, rural Americans already struggle to access basic dental care. Kelman reports, "Republican efforts to extend tax cuts and shrink federal spending may squeeze Medicaid, which could deepen existing shortages of dentists in rural areas where many residents depend on the federal insurance program for whatever dental care they can find."

Removing fluoride from rural water sources could exacerbate dental decay and the numerous other health problems it causes. "Dental experts warn that the simultaneous erosion of Medicaid and fluoridation could exacerbate a crisis of rural oral health," Kelman writes. "The changes could reverse decades of progress against tooth decay, particularly for children and those who rarely see a dentist."

Rural America already has large pockets with few dentists and unfluoridated water. A Harvard study "identified over 780 counties where more than half of the residents live in a [dentist] shortage area. Of those counties, at least 230 also have mostly or completely unfluoridated public drinking water," Kellman explains. "That means people in these areas who can’t find a dentist also do not get protection for their teeth from their tap water."

Several peer-reviewed studies give a glimpse into what ending water fluoridation could look like. Kelman writes, "Studies of cities in Alaska and Canada have shown that communities that stopped fluoridation saw significant increases in children’s cavities when compared with similar cities that did not."

Many Americans favor fluoridation, but "a sizable minority does not," Kelman notes. "Polls from Axios/Ipsos and AP-NORC found that 48% and 40% of respondents wanted to keep fluoride in public water supplies, while 29% and 26% supported its removal."

Adding dental care to regular checkups is helping people with little access to dentists get needed care and referrals

Dr. Braun, left, and dental hygienist Valerie Cuzella work in tandem
to add dental care to regular medical checkups. (KFF photo)

As the number of dentists who serve low-income and Medicaid patients dwindles, primary care providers such as pediatrician Patricia Braun and her team are stretching their skills to include dental care, reports Kate Ruder of KFF Health News. "Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists."

Private and federal money has financed more options for medical providers to deliver dental care during routine medical checkups. Braun and her colleagues launched their integration with help from a five-year, $6 million federal grant. The collective group "has helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona," Ruder writes. "Similar projects are being funded by the federal Health Resources and Services Administration’s Maternal and Child Health Bureau in Illinois, Michigan, Virginia, and New York. . . . Embedded dental hygienists become part of their practice."

Ruder reports, "Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations."

In big, more rural and sparsely populated states, having a primary doctor address dental needs is ideal. "Because of Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Some counties don’t have a single dentist who takes Medicaid," Ruder reports. "Montana ranks near the bottom for residents having access to fluoridated water, which can prevent cavities and strengthen teeth."

To address its lack of dentists, "Colorado enacted a law to alleviate workforce shortages by allowing dental therapists — midlevel providers who do preventive and restorative care — to practice," Ruder reports. "But Colorado does not have any schools to train or accredit them."