Cost-Effectiveness of Community Water Fluoridation (CWF)
Community water fluoridation (CWF) aims to reduce dental decay by adjusting fluoride levels in public water supplies to an optimal concentration. Economic evaluations generally indicate that, in many settings, the costs of running fluoridation schemes can be offset by reductions in the need for dental treatment and the wider costs of dental disease to health services, patients and society. However, the degree of cost-effectiveness varies between communities and depends on factors such as baseline levels of tooth decay, the use of fluoride toothpaste and dental services, and the costs of setting up and operating schemes.
Cost Savings and Return on Investment
- Studies estimate that for every £1 invested in CWF, approximately £30 is saved in reduced dental treatment costs (Truman et al., 2002; Griffin et al., 2007).
- The per capita cost of fluoridation varies based on system size and infrastructure, generally ranging from £0.50 to £2 per year per person.
- In the USA, fluoridation saves an estimated $6.5 billion annually in dental treatment costs (CDC, 2016).
- A study in New Zealand (Moore et al., 2017) found that CWF resulted in an estimated ROI of 23:1 for large communities and 9:1 for smaller communities.
- Recent analyses of existing water fluoridation schemes in England suggest that, between 2010 and 2020, operating costs averaged around £10 per person over ten years, excluding initial capital costs. Over the same period, NHS dental treatment costs for patients in optimally fluoridated areas were about 5% lower than for comparable patients in non-fluoridated areas, equating to savings of a little over £20 per person, and patients themselves paid slightly less in NHS dental charges. Taken together, these findings indicate that existing schemes produced a positive return on investment, and the studies these estimates are based on may have under-estimated the benefits. Earlier studies/reviews show a better return on investment. More contemporary studies of new schemes will firm up the real returns.
Cost-Effectiveness in Different Community Sizes
The cost-effectiveness of fluoridation depends on population size and infrastructure:
Larger urban schemes usually have lower costs per person because fixed operating expenses are spread across more people. In smaller or more rural systems, per-person costs tend to be higher and the balance between costs and savings can be narrower. As a result, local decisions about fluoridation need to take account of population size, distribution and existing water infrastructure when judging whether a scheme is likely to be good value for money.
Impact on Healthcare Costs
- Reduces need for fillings, extractions, and emergency dental treatments.
- Lowers dental treatment expenditures for public health programs such as NHS dental services and Medicaid in the USA.
- Fluoridation helps prevent costly hospital admissions for dental infections, particularly among children.
- By reducing the frequency and severity of tooth decay, CWF can lower the need for fillings, extractions and other dental procedures. This can reduce dental treatment costs to publicly funded services such as the NHS and can also lessen out-of-pocket expenses for patients. Fewer episodes of dental pain and infection may also help to reduce time lost from work or education and avoid some emergency or hospital-based care for dental conditions, particularly among children and people who face barriers to regular dental attendance.
Reduction in Socioeconomic Inequalities
CWF provides benefits across all socioeconomic groups but is particularly important for reducing oral health disparities.
- CWF disproportionately benefits lower-income groups who face higher rates of dental decay and barriers to accessing dental care.
- By reducing dental disease, fluoridation helps prevent lost productivity from school and work absences due to dental pain or treatment.
- Economic studies show that communities with CWF experience lower dental treatment costs and improved oral health across all socioeconomic groups.
- Until new schemes are implemented, it may be difficult to demonstrate the real effect on inequalities. The effect of new or expanded schemes on inequalities remains uncertain and may vary between communities.
Comparative Cost-Effectiveness
Economic evaluations place CWF among a range of preventive measures that can reduce dental caries at relatively low cost. Fluoridation is not a replacement for other approaches such as daily brushing with fluoride toothpaste, fluoride varnish applied in clinical care or targeted preventive programmes in schools, but it can complement them by providing continuous low-level exposure to fluoride in areas where schemes are in place. The relative cost-effectiveness of fluoridation compared with other interventions will vary according to local levels of tooth decay, how dental services are organised and the costs of implementing and maintaining schemes.
Evidence from Systematic Reviews
- Griffin et al. (2007): Found that fluoridation led to significant reductions in dental caries and associated treatment costs.
- Truman et al. (2002): Concluded that CWF is a highly cost-effective public health intervention.
- Public Health England (2018): Confirmed that CWF reduces NHS dental treatment costs and improves oral health outcomes.
- International reviews of economic evaluations have consistently found that, in most settings studied, CWF is cost-effective when compared with no fluoridation. These reviews highlight that economic benefits are greatest where levels of tooth decay are high and where large populations are served. They also note that many of the earlier studies were carried out in periods and places where dental disease was more common and fluoride was less widely available from other sources, meaning that some older estimates are likely to overstate benefits in contemporary settings.
Conclusion
Overall, current evidence indicates that community water fluoridation can be a cost-effective public health measure, particularly in larger populations with higher levels of tooth decay and where the fixed costs of schemes can be spread across many people. At the same time, modern studies show that the size of both the health benefits and the financial savings may be smaller than previously thought (although those studies have been challenged), and that cost-effectiveness depends on local circumstances, including existing fluoride exposure and patterns of dental service use. Decisions about introducing or extending fluoridation should therefore be informed by up-to-date local data and economic modelling, alongside consideration of other options for preventing dental decay. The introduction of new schemes will help to fill the evidence base gaps and provide more certainty on some of these issues.
References
Mariño R, Zaror C, Mariño E, et al. (2020). Economic evaluations in water fluoridation: a scoping review. BMC Oral Health, 20, Article 101.
Ran T, Chattopadhyay S, Community Preventive Services Task Force. (2016). Economic evaluation of community water fluoridation: a Community Guide systematic review. American Journal of Preventive Medicine, 50(6), 790–796.
Public Health England. (2018). Water fluoridation: health monitoring report for England 2018. London: PHE.
Office for Health Improvement and Disparities. (2022). Water fluoridation: health monitoring report for England 2022. London: OHID.