C.E. Credit. Truth Decay and Tooth Decay: The Role of Dental Teams in Sharing the Science of Community Water Fluoridation

ABSTRACT

Background

The benefits and safety of community water fluoridation (CWF) are well-established with over eight decades of research. Yet, some communities have ceased CWF due to mistrust in the safety of this program. Public health infrastructure faces a challenge in addressing misinformation and fostering trust in evidence-based recommendation. Understanding individual decision-making can offer clues for why some people in our communities are not comfortable with public health programs. A review of recent data shows the role of dental care providers as trusted leaders in health information in a culture of doubt.

Conclusion

The role of dental providers as trusted leaders requires that they be supported with evidence-based resources. These resources can strengthen their ability to educate patients about the benefits and safety of CWF. Dental providers can build trust in CWF by learning the history of CWF research, addressing concerns about drinking public water, and integrating toolkits to build health literacy and confidence with personal health decision-making. Dental team members can build confidence by sharing the safety and benefits of community water fluoridation. Building comfort in drinking public tap water and fluoridation programs can strengthen population health practices.

Continuing Education Credit Available

The practice worksheet is available online in the supplemental material tab for this article. A CDA Continuing Education quiz is online for this article: https://www.cdapresents360.com/learn/catalog/view/20.

KEYWORDS:

• Oral health
• community water fluoridation
• misinformation
• behavioral health
• fluoride
• oral health policy

Introduction

Public health programs are effective when they reach populations for disease prevention.¹ Community drinking water is one such program where public health invests in safe and clean drinking water for the people they serve.² Community water fluoridation is a population health intervention to equitably decrease the prevalence and severity of dental caries for lasting improvements in the oral health of its residents. The benefits and safety of community water fluoridation are well-established with research of its impacts since 1945.^2,3 Building trust in drinking optimally fluoridated water is imperative to a public health benefit.

The Community Preventive Services Task Force, a national evidence-based group of the Centers for Disease Control and Prevention (CDC) that offers guidance about community programs, recommends community water fluoridation to reduce tooth decay.² The Healthy People 2030 goal OH-11 has a target of 77.1% of people in the U.S. residing in communities with water systems that have the recommended amount of fluoride.^3,4 In 2020, 72.5% of the U.S. population lived in communities with fluoridated water systems.³ California ranks 40th in the country, with 57.5% of the population on public water supplies served by fluoridated community water systems.³

According to data from the CDC, the percentage of the United States population receiving fluoridated water has decreased in the last decade, although this slight drop may reflect changes in how the data are sourced or analyzed.³ However, these metrics do not uncover whether people are drinking their fluoridated water or using it for meal and beverage preparation. According to a 2022 American Water Works Association survey, 1 in 4 people do not perceive their home’s tap water as safe, and more than 20% do not trust their water utility.⁵

The public health and oral health communities face the dual challenges of both expanding community water fluoridation and building trust in public water systems. Many public health programs have untapped potential because the targeted population is not engaged with the program. Dental team members should build trust in their patients and communities by sharing the safety and benefits of community water fluoridation.

According to the 2022 Edelman “Trust Barometer,” fewer than 1 in 3 Americans think government officials are credible, and over 60% of Americans find it hard to assess what is real versU.S. fake news.⁶ The aggregate data of decreasing trust in previously respected sources for facts contributes to “truth decay” or a lack of trust in evidence-based health information.⁶ This paper explores how the dental team can influence decision-making by interacting personally with information and educational dialogue.

Behavioral Health Science

Behavioral health science explores how emotions and trust in health programs impact our decisions.¹ Understanding individual decision-making can offer clues for why some people in our communities are not comfortable with public health programs, from vaccination to community water fluoridation.¹ There are myriad reasons why a population may not be comfortable drinking their public water.⁷ A history of problems with public water due to polluted supplies can lead to a fear of drinking water that carries over generations.⁷ According to a 2023 University of California Los Angeles survey on tap water usage in one Central Valley county, 60% of survey respondents reported “some form of bad experience” with tap water in or outside of their homes.⁷

While not all drinking water supplies in the United States are safe to drink, the U.S. has one of the safest and most reliable drinking water systems in the world.^8,9 Urban planning experts claim that the development of water treatment technology has had a greater impact on global human health than antibiotics and vaccines.⁸ Public water systems with optimal fluoridation are focused on safe drinking water first, then on the added benefit of adjusting their fluoride concentration as a disease preventive benefit.^2,7,9 To promote safe drinking water, Congress passed a law in 2022, championed by the Biden administration, which devotes $50 billion to improve the nation’s water and wastewater infrastructure.¹⁰ This includes $15 billion dedicated to replacing lead service lines.¹⁰

While no one perspective can uncover why some people are not comfortable drinking their tap water, behavioral science can offer a new lens to this lack of trust.^11–13

A traditional strength of science is that results from quality experimental research can transcend different beliefs and cultural paradigms to gain broad acceptance. Yet recent evidence shows that many adults are doubtful of the science that health practitioners share. According to a Johns Hopkins University civic survey, 46% of people trust science only “some,” “not much” or “not at all.”.¹⁴ In a de Beaumont Foundation poll, 8 in 10 physicians said they trust medical/scientific journals, internet searches, and colleagues, while other adults said they trust internet searches much more than any other source.¹¹ One in 10 Americans turns to social media for health information, as people trust their social circles.^12,13

These findings are troubling because, as physicians have noted, online searches often yield “phony experts, celebrities with armies of Twitter followers” and others who circulate health misinformation about vaccines, fluoridation and other topics.¹⁵ We have a society that is increasingly seeking health information in ways that leave them vulnerable to misinformation, anecdotal evidence or poorly conducted studies.¹⁵

Public health officials and medical practitioners will have a more difficult time resonating with their audience if they are not trustworthy members of their community. The United States performs poorly compared to other countries in its level of public trust in doctors, ranking 24th out of 29 high-income countries.¹³

However, it is important to distinguish between people’s trust in the medical profession and the trust they have in their own doctors. Although the U.S. ranked near the bottom in public trust in the profession, it ranked quite high in the level of satisfaction with the care it most recently received from a medical provider.¹⁶ Although satisfaction does not necessarily equate to trust, this favorable rating suggests that Americans might be more receptive and trusting to scientific information that comes from their own doctor.

If a similar incongruity exists for dentists, this offers hope. In other words, if dentists were to devote time during patient interactions to brief dialogue about fluoride and fluoridation, patients’ understanding could improve.

Community water fluoridation is a technical part of the drinking water treatment process. People have questions about varioU.S. issues, including fluoride’s impact on pH balance, threshold effects, and renal filtration, and they often pose these questions to untrained but trusted advisors, such as family members and friends.¹¹ Medical and dental practitioners can educate patients on these topics at their regular visits. Learning more about fluoridation history and science can prepare medical and dental providers to engage patients. To address a culture of doubt, leaders need to not only read the scientific papers they reference to ensure accurate interpretation of the data, but also understand their role as a trusted source of information. This can start by sharing the story of water fluoridation’s history in the United States from accidental discovery to over seven decades of continued research.

Conversations with patients should reflect a shared decision-making model, meaning that providers recognize their role is to offer recommendations, not instructions. In this model, patients understand that the provider has meaningful information or perspectives, while providers understand that patients ultimately have the autonomy to make decisions about their own treatment or self-care.¹⁷ Shared decision-making is a mutually respectful relationship that is connected to patient-centered care.¹⁷

When talking with patients or others in their communities, dental providers should look for teachable moments that illustrate the importance of population health measures such as fluoridation. For example, providers might point to the lengthy period during the pandemic when dental practices were largely closed and people were unable to receive care for non-emergency conditions. During this period, fluoridated water was one of the few forms of prevention that people were able to access regardless of age, race, ethnicity and income level.

Evidence on Community Water Fluoridation

Understanding the historical roots of fluoridation can enhance the ability of dental and medical providers and public health officials to educate their communities and be viewed as trusted messengers. The evidence of fluoride’s disease-prevention benefits reinforces that science is a honing process, yielding findings that are continually tested, reviewed, and updated or discarded. For example, recent research on water intake habits influenced the U.S. Public Health Service’s decision to update the optimal fluoride level in 2015.¹⁸

The discovery of fluoride’s benefits emerged over many decades, evolving from an investigation of dental fluorosis in Colorado in the early 1900s.^19,20 In 1931, Dr. H. Trendley Dean, founder of the National Institutes of Health (NIH) Dental Hygiene Unit and a U.S. Public Health Services officer, began a series of long-running epidemiologic studies exploring the relationship between fluoride intake, dental fluorosis, and tooth decay.²¹ In 1942, the NIH published his study of 7,200 children aged 12 to 14 from 21 cities in Colorado, Illinois, Indiana, and Ohio. The study found the children in cities with more fluoride in the community water supply had fewer cavities and less severe decay necessitating treatment that included tooth extraction.²¹ This effect plateaued at concentrations greater than 1.0 ppm.²¹

The New York State Department of Public Health proposed the first caries-fluorine hypothesis in 1945 through a classic epidemiological study.²² The communities of Newburgh and Kingston were compared through the principles of a community clinical trial.²² The study was conducted over 11 years and observed children ages 6 to 9 from Newburgh and Kingston.²² Children from Newburgh, who were exposed to fluoridated water throughout their lives, had a rate of decayed, missing and filled permanent teeth 58% lower than the children of Kingston who were not exposed to fluoridated water.²² The safety and effectiveness of water fluoridation have been reevaluated as research techniques evolved, and no credible or replicated evidence supports an association between optimal fluoridation and any adverse health conditions.²³ Similar results were found in that period in other longitudinal epidemiological studies in Grand Rapids-Muskegon, Michigan, Evanston-Oak Park, Illinois, and Brantford-Sarnia, Ontario.¹⁸

After adoption of the Clean Water Act in 1972 and Safe Drinking Water Act in 1974, new research techniques re-affirmed the safety and efficacy of fluoridated drinking water.^21,24 In 2015, recommendations for optimal fluoride concentration were adjusted to consider total fluoride exposure in oral care products and evidence on fluid intake of children. The U.S. Public Health Service recommendation for community water fluoridation changed from a climate-dependent range of 0.7–1.2 mg/L to a standard 0.7 mg/L (or 0.7 ppm) across the whole United States.²¹ The American Dental Association’s 2018 publication Fluoridation Facts compiled over 70 years of research that offers evidence-based answers to address common questions about community water fluoridation.²⁵ The overwhelming weight of credible scientific evidence has consistently indicated that fluoridation of community water supplies is effective, safe, and cost-effective across the whole community.²⁵

Information Must Be Accessible

In biostatistical research, the power of the significance test increases as a sample size increases.²⁶ In individual decision-making, this is not quite the case. When an individual shares a personal story, it can paint an emotional picture that is more powerful than a study with a sample size of thousands. Beyond stories or anecdotes shared by their peers, people can learn about research through social media or other vehicles that ignore or misrepresent key aspects of these studies. Dental, medical and public health professionals should be mindful of this dynamic as they seek to communicate and build trust.

In 2019, a scientific paper was published in JAMA Pediatrics that looked at the association between maternal fluoride exposure during pregnancy and IQ scores in offspring.²⁷ This one study, which concluded that neurotoxicity associated with exposure to fluoride remains unclear, led to many news articles and radio shows that touted “fluoride reduces IQ”.²⁷ This was not only a misinterpretation and generalization of the publication but had power to influence entire communities’ comfort with drinking their public water. The association in the publication was only found in boys and only on one of the two tests that were administered; girls had a slightly insignificant increase in IQ.²⁷ Other studies looking at this same association found no such link between fluoride in drinking water and IQ.²⁸ A 2023 meta-analysis between fluoride in drinking water exposure below 1.5 mg/L and children’s intelligence found no statistically significant difference.²⁸ In another 2023 analysis, researchers examined 30 IQ-related studies and found that the only study with a low risk of bias showed no association between fluoride exposure and lower scores.²⁹ The best available research shows no association between optimal fluoride in drinking water and neurodevelopment.^2,3,29 Despite this, some people make their own causative associations rooted in accessible, but misleading, news articles.^11,13,26

Belief in these associations is not based in reporting the best science but is rooted in fear, trauma, and medical mistrust in our societies.^11–13,26 Public health systems, including water fluoridation, are threatened as the lines between fact and fiction become more blurred.³⁰ Public health leaders can ask if they earned the public’s trust to believe in the science in which they are so confident.^13,26,30

To combat truth decay, our data systems that are rooted in quality research and aggregate data findings ought to be more accessible to the public through greater transparency and health literate dissemination or plain language use.^6,30,31 For example, integrating concepts of data decolonization include presenting data with the necessary context to tell complete stories.³¹ There is greater transparency with published scientific research that adds context to the findings of the study and how it impacts population health.³¹ According to the Urban Indian Health Institute, organizations can work to achieve data equity and justice through strengths-based data collection, analysis, and dissemination.^31,32 If the strongest data are not accessible to the populations that would benefit the most from these findings, then truth decay will accelerate. Oral health organizations have created accessible resources to assist dental teams in educating their communities on the latest fluoridation research.²⁵

Building Trust

Tools are available to build trust among our communities. The first step is admitting that we live and work in communities that face a culture of doubt and inaccessible scientific data and have been harmed by some community programs.^6,24,31–33 Dental teams can rectify these relationships and learn more about their role within the greater goal of population health. Health literacy is a tool to strengthen not just discussions about community water fluoridation but all health recommendations.

The California Oral Health Literacy toolkit is the premier set of resources for health providers to offer an overview of what oral health literacy is and why it matters.³³ Personal health literacy is the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others.^32,33 Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.^32,33 The World Health Organization recommends health literacy as an instrument for achieving several key targets listed in the Sustainable Development Goals Scientific, but evidence is still rarely presented in health literate or accessible formats.³² The oral health literacy toolkit includes a checklist and guide for implementing health literacy in dental practices and how to 1) improve relationships with patients and 2) increase patient loyalty in the practice. The toolkit includes six steps for motivational interviewing that can be applied to fluoridation confidence in both drinking water and treatments such as fluoride varnish.

The California Fluoridation Manual from the California Oral Health Technical Assistance Center is another tool rooted in building trust and learning the role of community when advocating for this public health program.²⁴ The manual offers clear strategies for discussing community water fluoridation and how to get meaningfully involved in local fluoridation advocacy. A key element of the manual is the importance of the local water borough in maintaining a safe fluoridation program for consumer safety. Appendix A of the manual offers a sample script for how dental or medical providers can use a few brief questions as a catalyst for engaging and educating patients. In 2020, the Arcora Foundation developed a patient engagement guide for dental and medical professionals with typical questions patients may ask and how to respond. Figure 1 includes additional prompts for common questions about community water fluoridation to support your role in empowering informed patient decision-making while building trust.

Figure 1. Common fluoridation questions and sample answers for providers.

These tools and recommendations can be used to foster trust and strengthen health communications. Practitioners, physicians, parents, teachers and leaders across the U.S want to foster wellness for their communities and the people they serve.

Acknowledgments

Thank you to the American Dental Association and the California Oral Health Technical Assistance Center for creating resources and toolkits to assist with fluoridation education and advocacy.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/19424396.2024.2348079.

Additional information

Notes on contributors

Tooka Zokaie

Tooka Zokaie, MPH, MAS, CPH, is a Senior Health Policy Analyst for the California Dental Association and Doctorate in Public Health Candidate at University of Illinois, Chicago. She earned her Masters in Public Health from University of California, Davis School of Medicine, Masters in Population Health from Johns Hopkins School of Public Health, and has been a Certified Public Health Practitioner since 2020. Ms. Zokaie’s work involves collaborating on public health topics including community water fluoridation, substance use disorders, school-based oral health, interprofessional collaboration, behavioral health sciences, and dental care access. She is a Section Councilor of the Oral Health Section and Governing Councilor of the Alcohol, Tobacco, and Other Drugs Section of the American Public Health Association.

Matt Jacob

Matt Jacob, BA, is a public health communications consultant who has worked with numerous state health agencies, foundations and nonprofits to strengthen communication. His consulting clients have included the American Academy of Pediatrics, American Fluoridation Society, Arcora Foundation, and California Department of Public Health. Mr. Jacob has authored several articles about health communication or policy that have been published in peer-reviewed journals, such as the Journal of Dental Research and Population Medicine. His work has been honored by HealthLiteracyMonth.org and the Association of State and Territorial Dental Directors.

Howard Franklin Pollick

Howard Franklin Pollick, BDS, MPH, is a health sciences clinical professor, Department of Preventive & Restorative Dental Sciences, School of Dentistry at the University of California San Francisco. He earned his BDS from Manchester, England, and his MPH from UC Berkeley. A diplomate of the American Board of Dental Public Health since 1985, Dr. Pollick is an American Dental Association expert spokesperson on fluoridation since 2004, a member of the ADA National Fluoridation Advisory Committee and a fluoridation consultant to the California Department of Public Health. He is the recipient of the 2010 Fluoridation Special Merit Award from the Association of State and Territorial Dental Directors, the 2015 recipient of the UCSF Chancellor’s Award for Public Service, and the recipient of the 2017 John W. Knutson Distinguished Service Award in Dental Public Health from the American Public Health Association’s Oral Health Section.