With the rapidly changing legislative landscape regarding fluoride additives in drinking water, this article provides dental insurers with key considerations that may help them evaluate potential impacts on claim costs, and highlights actions that may help mitigate the potential negative oral health effects of community water fluoridation (CWF) cessation.

Many decades after the introduction of CWF in the United States, Florida and Utah banned the addition of fluoride to public drinking water in 2025.^1,2 Legislative proposals containing similar provisions are active in additional states. At the federal level, the Make Our Children Healthy Again Commission strategy report, released in early September 2025, directs the Centers for Disease Control and Prevention (CDC) to update recommendations regarding fluoride in water based on data and scientific reviews performed by the National Institutes of Health (NIH) and the Environmental Protection Agency (EPA).³

CWF has been recognized as a top public health achievement of the 20th century, with the CDC noting in 1999 and reaffirming in 2024 that it represents the “most equitable and cost-effective method for delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level.”^4,5 The well-established mechanisms of fluoride benefit dental health by preventing caries (cavities).⁶ According to a 2024 CDC article, drinking fluoridated water at the recommended dosage of 0.7 mg/L reduces dental caries by 25%.⁷

Exposure to fluoride above the recommended levels has been shown to be associated with negative outcomes. A 2025 meta-analysis of published studies reports a statistically significant association between exposure to fluoride at more than double the recommended level and reduced IQ levels in children.⁸ The Make Our Children Healthy Again assessment references this study and goes on to explain that the “EPA is currently conducting a review of additional research that will inform any potential revisions to the federal drinking water standard.”⁹

What should dental insurers consider regarding potential impacts to claims following CWF cessation?

In theory, CWF cessation will increase future dental claim costs. Many published studies project cost savings associated with CWF. For example, one 2013 study used an economic model originally published in 2001 to estimate CWF-related dental cost savings at over $32 annually for each person with access to fluoridated water.^10,11 A 2025 study projected that the cessation of CWF in the U.S. could cost approximately $9.8 billion due to increased caries incidence and associated complications over a five-year period.¹²

For insights into how dental claims patterns could change as a result of CWF cessation, dental insurers could consider the following questions as a starting point.

1. What is the status of CWF in states/counties in which you operate? It is crucial to keep an eye on federal and state legislation in the areas in which you operate to ascertain where your block of business may see effects in the future. As mentioned, the findings from the EPA’s review have the potential to impact the federal drinking water standard. Additional state-level changes may happen ahead of any potential federal changes.
2. How might changes in caries incidence due to CWF cessation differ across the populations you cover? Populations shown to have increased caries risk and/or limited access to dental care could be more vulnerable to increases in caries incidence rates if CWF ends. Consider the following:
• Adults and children of low socioeconomic status (SES) have been shown to have an increased risk of dental caries.^13,14
• Individuals from remote or rural communities experience a range of barriers to oral healthcare (e.g., low provider-to-population ratios) and are more likely to have poor oral health.¹⁵
• Young children in regions of Canada with primary teeth or mixed primary and secondary teeth showed increases in caries incidence following water fluoridation cessation.¹⁶
• Medically complex individuals often take certain medications that may result in xerostomia (dry mouth). Without adequate saliva to keep the mouth clean, caries risk increases.¹⁷
• Aged adults are at higher risk for root caries due to increased medical complexity and increased prevalence of xerostomia, as well as declining manual dexterity that may render at-home preventive care more challenging.¹⁸
3. How might CWF cessation affect the markets in which you operate? Given the differences in population characteristics, the impacts of CWF cessation may vary across dental insurance markets.
• Medicaid generally covers individuals with lower SES. While Medicaid provides dental benefits for children in all states, adult dental coverage is not mandatory and is highly variable by state.^19,20 Individuals with Medicaid coverage may have trouble finding a participating dentist and/or may have to drive long distances to see providers. Furthermore, H.R. 1 (the “One Big Beautiful Bill Act”) is expected to reduce Medicaid enrollment, resulting in more individuals without dental coverage.²¹
• Individuals eligible for Medicare are generally aged or disabled and therefore may experience increased caries risk with removal of water fluoridation as a preventive measure.
• Commercially insured individuals may be less impacted than the Medicaid and Medicare population, based on the typical demographics of covered members.
4. Could increased caries rates affect medical claims? The uninsured population and Medicaid beneficiaries are the greatest users of potentially preventable emergency departments for nontraumatic dental conditions,²² and any worsening of their oral health status could affect emergency department utilization. Additionally, research shows a positive correlation between oral health and both overall bodily health and mental health.²³

What actions can dental insurers take to help mitigate any potential negative effects of CWF cessation on dental health?

According to Canadian studies from 2017 and 2021, caries incidence rates may increase within two to three years after CWF cessation, with larger increases after approximately eight years.^24,25 Since increased caries rates are expected following CWF cessation based on these studies of prior real-world experience, dental claims to treat caries are also expected to increase. Insurers could consider several strategies that have the potential to help mitigate the expected increased claims.

1. If insurers are not already covering evidence-based services shown to reduce caries rates, they could consider doing so, especially for high-risk populations.
   • Silver diamine fluoride: This treatment has been shown to effectively arrest small carious lesions and prevent the need for more expensive dental restorations. It is especially effective for treating early childhood caries (ECC) in primary teeth and root caries in elderly adults.²⁶
   • Fluoride varnish: Application in children has been shown to reduce caries.²⁷ Early research also shows promise that fluoride varnish could also be effective in reducing caries in older adults (>60 years) and other high-caries-risk adults.^28,29
   • Sealants: Application has been shown to reduce occlusal (biting) surface caries in children. Although there has not been substantial research on sealants in adults, considering that young adults (aged 20–34) experience high rates of occlusal caries, sealants could benefit this population as well.³⁰
   • Early preventive visits for children: Studies show that the sooner children are seen by their dentists, the lower their caries experience is in childhood.^31,32 Insurers could consider partnering with providers to encourage dental visits by the age of 1.
2. Insurers could analyze the current dental care patterns of their members and contracted network providers and consider offering incentives to providers who frequently provide preventive services to patients. Early evidence suggests that providers who focus on prevention provide fewer surgical services.³³
3. Insurers could consider championing fluoride outreach programs in schools or other community-based sites. Studies indicate that school fluoride varnish/education programs can reduce caries by 32% in permanent teeth.³⁴ Although not well studied, a similar concept could be applied to community programs to reach people of all ages regardless of insurance status.

While these strategies have the potential to reduce caries incidence, the real-world impact of implementing these approaches, collectively or individually, on dental health and claims patterns in regions of the U.S, post-CWF cessation is unknown. Thoughtful selection and implementation of targeted strategies identified by dental insurers as promising for their covered populations, coupled with robust data collection and monitoring, have the potential to contribute valuable information about the impact of CWF cessation and effective approaches to sustaining and improving dental health across different segments of the U.S. population.

¹ CS for CS for CS for SB 700, 1st Engrossed—2025 Legislature. (2005). Retrieved October 5, 2025, from https://www.flsenate.gov/Session/Bill/2025/700/BillText/er/PDF.

² H.B.81 Fluoride Amendments—2025 General Session. (2025). Retrieved October 5, 2025, from https://le.utah.gov/~2025/bills/static/HB0081.html.

³ Make Our Children Healthy Again Strategy Report. (September 9, 2025). Retrieved October 5, 2025, from: https://static.ewg.org/upload/pdf/MAHA_Strategy_Report_copy.pdf.

⁴ Centers for Disease Control and Prevention. (October 22, 1999). Achievements in Public Health, 1900–1999: Fluoridation of Drinking Water to Prevent Dental Caries. Retrieved October 5, 2025, from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm.

⁵ Centers for Disease Control and Prevention. (May 15, 2024). Statement on the Evidence Supporting the Safety and Effectiveness of Community Water Fluoridation. Retrieved October 5, 2025, from https://www.cdc.gov/fluoridation/about/statement-on-the-evidence-supporting-the-safety-and-effectiveness-of-community-water-fluoridation.html.

⁶ Featherstone, J. D. (February 1999). Prevention and reversal of dental caries: Role of low level fluoride. Community Dentistry and Oral Epidemiology, 27, 31–40. Retrieved October 5, 2025, from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1600-0528.1999.tb01989.x?sid=nlm%3Apubmed.

⁷ Centers for Disease Control and Prevention. (May 15, 2024). About fluoridation. Retrieved October 5, 2025, from https://www.cdc.gov/fluoridation/about/index.html.

⁸ Taylor KW, Eftim SE, Sibrizzi CA, et al. Fluoride Exposure and Children’s IQ Scores: A Systematic Review and Meta-Analysis. JAMA Pediatr. 2025;179(3):282–292. Retrieved October 5, 2025, from https://jamanetwork.com/journals/jamapediatrics/fullarticle/2828425.

⁹ The MAHA Report. (September 9, 2025). Retrieved October 6, 2025, from: https://www.whitehouse.gov/wp-content/uploads/2025/05/MAHA-Report-The-White-House.pdf.

¹⁰ Griffin, S. O., Jones, K., & Tomar, S. L. (July 2001). An economic evaluation of community water fluoridation. PubMed. Retrieved October 6, 2025, from https://pubmed.ncbi.nlm.nih.gov/11474918/.

¹¹ O'Connell, J., Rockell, J., Ouellet, J., Tomar, S. L., & Maas, W. (December 2016). Costs and savings associated with community water fluoridation in the United States. Health Affairs, 35(12), 2163–2171. Retrieved October 6, 2025, from https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0881?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed.

¹² Choi, S. E., & Simon, L. (May 30, 2025). Projected outcomes of removing fluoride from US public water systems. JAMA Health Forum, 6(5), 1–12. Retrieved October 6, 2025, from https://jamanetwork.com/journals/jama-health-forum/fullarticle/2834515.

¹³ Vasireddy, D., Sathiyakumar, T., Mondal, S., & Sur, S. (November 1, 2021). Socioeconomic factors associated with the risk and prevalence of dental caries and dental treatment trends in children: A cross-sectional analysis of National Survey of Children's Health (NSCH) data, 2016–2019. Cureus, 13(11), e19184. Retrieved October 6, 2025, from https://doi.org/10.7759/cureus.19184.

¹⁴ Costa, S.M., Martins, C.C., Bonfim, Mde. L., Zina, L.G., Paiva, S.M., Pordeus, I.A., & Abreu, M.H. (October 10, 2012). A systematic review of socioeconomic indicators and dental caries in adults. Int J Environ Res Public Health. 2012 Oct 10;9(10):3540-74. Retrieved October 6, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC3509471/.

¹⁵ National Conference of State Legislatures. (July 8, 2020). Boosting oral health care in rural communities. Retrieved October 6, 2025, from https://www.ncsl.org/health/boosting-oral-health-care-in-rural-communities.

¹⁶ McLaren, L., Patterson, S.K., Faris, P., Chen, G., Thawer, S., Figueiredo, R., Weijs, C., McNeil, D., Waye, A., & Potestio, M. (2021). Fluoridation cessation and children’s dental caries: A 7-year follow-up evaluation of Grade 2 schoolchildren in Calgary and Edmonton, Canada. Community Dentistry and Oral Epidemiology. Retrieved October 6, 2025, from https://onlinelibrary.wiley.com/doi/10.1111/cdoe.12685.

¹⁷ American Dental Association. (April 24, 2023). Xerostomia. ADA Library: Oral Health Topics. Retrieved October 6, 2025, from https://www.ada.org/resources/ada-library/oral-health-topics/xerostomia.

¹⁸ Gati, D., & Vieira, A. R. (July 6, 2011). Elderly at greater risk for root caries: A look at the multifactorial risks with emphasis on genetics susceptibility. International Journal of Dentistry, 2011, 647168. Retrieved October 6, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC3133477/.

¹⁹ DeSilver, D. (June 24, 2025). What the data says about Medicaid. Pew Research Center. Retrieved October 6, 2025, from https://www.pewresearch.org/short-reads/2025/06/24/what-the-data-says-about-medicaid/.

²⁰ Centers for Medicare & Medicaid Services. Dental care. Medicaid.gov. Retrieved October 6, 2025, from https://www.medicaid.gov/medicaid/benefits/dental-care.

²¹ Ortaliza, J., McGough, M., Cox, C., Pestaina, K., Rudowitz, R. & Burns, A. (June 18, 2025). KFF. Retrieved October 6, 2025, from https://www.kff.org/affordable-care-act/how-will-the-2025-budget-reconciliation-affect-the-aca-medicaid-and-the-uninsured-rate/.

²² Kim, P. C., Zhou, W., McCoy, S. J., McDonough, I. K., Burston, B., Ditmyer, M., & Shen, J. J. (September 20, 2019). Factors associated with preventable emergency department visits for nontraumatic dental conditions in the U.S. International Journal of Environmental Research and Public Health, 16(19), 3671. Retrieved October 6, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC6801501/.

²³ Tiwari, T., Kelly, A., Randall, C., Tranby, E. & Franstve-Hawley, J. (February 7, 2022). Association between mental health and oral health status and care utilization. Frontiers in Oral Health, 2:732882. Retrieved October 6, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC8859414/.

²⁴ McLaren, L., Patterson, S., Thawer, S., Faris, P., McNeil, D., Potestio, M. L., & Shwart, L. (May 2017). Exploring the short-term impact of community water fluoridation cessation on children's dental caries: A natural experiment in Alberta, Canada. Public Health, 146, 56–64. Retrieved October 6, 2025, from https://www.sciencedirect.com/science/article/pii/S0033350616304656.

²⁵ McLaren, L., Patterson, S. K., Faris, P., Chen, G., Thawer, S., Figueiredo, R., Weijs, C., McNeil, D., Waye, A., & Potestio, M. (July 26, 2021). Fluoridation cessation and children’s dental caries: A 7-year follow-up evaluation of Grade 2 schoolchildren in Calgary and Edmonton, Canada. Community Dentistry and Oral Epidemiology. Retrieved October 6, 2025, from https://onlinelibrary.wiley.com/doi/10.1111/cdoe.12685.

²⁶ Crystal, Y.O., & Niederman, R. (January 2019). Evidence-based dentistry update on silver diamine fluoride. PMC. Retrieved October 6, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC6500430/.

²⁷ Weyant, R.J., Tracy, S.L., Anselmo, T., Beltrán-Aguilar, E.D., Donly, K.J., Frese, W.A., Hujoel, P.P., Iafolla, T., Kohn, W., Kumar, J., Levy, S.M., Tinanoff, N., Wright, J.T., Zero, D., Aravamudhan, K., Frantsve-Hawley, J., Meyer, D.M., & American Dental Association Council on Scientific Affairs Expert Panel on Topical Fluoride Caries Preventive Agents. (November 2013). Topical fluoride for caries prevention. The Journal of the American Dental Association. Retrieved October 6, 2025, from https://jada.ada.org/article/S0002-8177%2814%2960659-0/fulltext.

²⁸ Chan, A.K.Y., Tamrakar, M., Jiang, C.M., Tsang, Y.C., Leung, K.C.M., & Chu, C.H. (October 2022). Clinical evidence for professionally applied fluoride therapy to prevent and arrest dental caries in older adults: A systematic review. Journal of Dentistry. Retrieved October 6, 2025, from https://www.sciencedirect.com/science/article/pii/S0300571222003293.

²⁹ Jurasic, M.M., Gibson, G., Orner, M.B., Wehler, C.J., Jones, J.A., & Cabral, H.J. (March 9, 2022). Topical fluoride effectiveness in high caries risk adults. Journal of Dental Research. Retrieved October 6, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC9266354/#:~:text=Conclusion,and%20effectiveness%20requires%20further%20evaluation.

³⁰ CDC. (May 15, 2024). Dental sealant facts. CDC. Retrieved October 6, 2025, from https://www.cdc.gov/oral-health/data-research/facts-stats/fast-facts-dental-sealants.html.

³¹ Nowak, A.J., Casamassimo, P.S., Scott, J., & Moulton, R. (November–December 2014). Do early dental visits reduce treatment and treatment costs for children? PubMed. Retrieved October 6, 2025, from https://pubmed.ncbi.nlm.nih.gov/25514078/.

³² Nowak, A.J., Dooley, D., Mitchell-Royston, L., Rust, S., Hoffman, J., Chen, D., Merryman, B., Wright, R., Casamassimo, P.S., & Mathew, T. (November 15, 2020). A predictive model for primary care providers to identify children at greatest risk for early childhood caries. PubMed. Retrieved October 6, 2025, from https://pubmed.ncbi.nlm.nih.gov/33369556/.

³³ North Carolina Oral Health Collaborative. (August 29, 2025). The collaborative effect: Transforming oral health in North Carolina. Foundation for Health Leadership & Innovation. Retrieved October 6, 2025, from https://foundationhli.org/2025/08/29/the-collaborative-effect-transforming-oral-health-in-north-carolina/.

³⁴ Griffin, S.O., Lin, M., Scherrer, C.R., Naavaal, S., Hopkins, D.P., Jones, A.A., Alexander, T., Black, V.A., Clark, E., Cofano, L.K., Garcia, R.I., Goddard, A., Grover, J., Kansagra, S.M., Kottke, T.E., Lense, E.C., Zokaie, T., & The Community Preventive Services Task Force. (July 2025). Effectiveness of school fluoride delivery programs: A community guide systematic review. American Journal of Preventive Medicine. Retrieved October 6, 2025, from https://www.ajpmonline.org/article/S0749-3797(25)00114-X/fulltext.