Fluoridation Facts

I stole the above title from a newly released American Dental Association (ADA) pamphlet on the controversy about fluoridation of public drinking water. This is another area where people with little understanding of science have spread falsehoods leading to some resistance to a beneficial practice. A brief review of the executive summary makes it quite clear; fluoride prevents cavities.

Although I have never had doubts about the safety of adding fluoride to drinking water, twice a year I am faced with the question of whether to pay an extra $35 at the dentist for a fluoride treatment. I know there is evidence that these treatments, along with the fluoridation of drinking water and toothpaste, are beneficial for children’s teeth, but I wondered about the effectiveness for adults. 

The fact that my insurance company doesn’t pay for it raises some suspicion. Coverage decisions may be based on cost factors, but one cost factor they must consider is higher future dental bills. Normally they would prefer to pay for prevention than to pay more later.

I began my research on the effectiveness of fluoride treatment for adults at a site billing itself as “the top magazine for dental hygiene professionals.” One hygienist, whose boss wants her to push the treatment to increase business, asks directly whether every patient needs fluoride.

The answer goes to an ADA publication from 2007. (The advisor didn’t know of any more recent updates.) A patient whose risk is low “may not receive additional benefit from professional topical fluoride application.” Low risk is defined as "No incipient or cavitated primary or secondary carious lesions during the last three years and no factors that may increase caries risk." It goes on to say there are other factors to consider, but generally “blanket mandates of fluoride for everyone are not appropriate.”

Consumer Reports gives basically the same answer (with less dentist jargon). “Extra fluoride may be helpful if you’re at increased risk of developing cavities, indicated by frequent tooth decay in recent years, dry mouth caused by medications or disease, or gum recession that exposes the vulnerable tooth roots.” 

They go on to say that home treatments are not effective, and that those in the low risk category should do fine by brushing twice a day with fluoride toothpaste “especially if your water is fluoridated.”

The National Center for Biotechnology Information site reviews a compilation of research on the “effectiveness of fluoride in preventing caries in adults.” They believe that the authors' conclusions favoring the use of fluoride treatments for adults “appear to follow from the results presented, although the paucity of more recent studies and poor quality of the included studies limit their reliability and relevance to current populations.” This vague recommendation (also from 2007) is not very compelling.

A Healthline.com page from 2018 asks: “What Are the Benefits, Side Effects, and Recommendations for Fluoride Treatment?” Again the emphasis was on children and adolescents with some discussions of minor side effects of treatments and real dangers of fluoride supplements. A little new information was that it was “best to get fluoride both topically [gel or toothpaste] and systemically [ingested]” from drinking water.

With several references to the 2007 ADA advice, I went there next. In addition to brushing twice a day, flossing and regular dental examinations, a “key to good oral health is fluoride.” Maximum benefit “is achieved when fluoride is available both topically and systemically.” Treatments from a dentist are recommended for adults with high risk factors such as poor oral hygiene, active caries, eating disorders, drug or alcohol abuse, lack of regular professional dental care, high levels of bacteria in the mouth, exposed root surfaces” and a few others.

In my case it seems I have been correct in saving $35 per visit. I eat most of my meals at home, so I am able to brush three times a day. We use fluoridated tap water for cooking food and drinking. (Bottled water is non-existent in the house.) I have not had a cavity in at least ten years. (Knock on wood.) Nor do I have any of the other critical factors or habits.

It’s interesting what a little research – a factor in critical thinking – can do to help with everyday decisions. 

Considering Insurance

Yesterday I received a letter in the mail from my dentist.  It warned me not to miss out.  I may lose some dental benefits if they are not used by December 31.  They wanted me to "call the office today!"  Needless to say, I didn’t call the office, but I did wonder about how people think about insurance.

Part of the problem is that people who get insurance through an employer don’t pay the full premium.  Coverage is a benefit of employment.  If they don’t collect it all, they may feel like they’ve lost out, left money on the table.  Otherwise, if they do pay the full premium, this artificial year-end deadline highlights the amount they could have claimed.  Again, it may feel like lost money.  People don’t want to feel cheated, and this dentist is trying to take advantage of that feeling to drum up business.

Unfortunately there are two factors that offset that cheated feeling.  First, most dental insurance has a deductible and/or co-pay for any work that’s not purely preventive.  I would not be able to use up the available money without paying something myself, plus I get to have my teeth worked on.  Neither of those prospects sounds enjoyable.  Second, if everyone used all available benefits every year, the cost of insurance would go up.  When they calculate premiums they take into account the level of usage, the fact that some people don’t go to the dentist as often as they should and that few use their entire allowance.  This gets back to magic-money-tree thinking.  Insurance companies can only pay out money they have and they get that from us and/or our employers.   It’s not just sitting there waiting to be spent.

Finally, this way of thinking seems a little strange overall.  I don’t feel bad at the end of the year because I paid for homeowner’s insurance and my house didn’t burn down, or because I paid for car insurance and I didn’t have a crash.  I want to use most insurance only when necessary, and then I’d rather that the need hadn’t arisen.  I even do things to ensure that I didn’t need to call on the insurance company, install smoke alarms, drive carefully, eat right, exercise, not take unnecessary risks, etc.  This keeps my personal premiums (and premiums in general) low.  Why should it be any different for dental insurance?

Perspective: Substantial vs. Superficial - Dentists and Deer

A failure in the dimension of Perspective is the superiority of the superficial over the substantial when choosing criteria for decision-making.  Simply put, we tend to value appearance over function when we decide how to act, how to vote, what to value and how to spend our money.  We substitute values based on appearance and popularity for our stated values of family, faith, charity, etc.  Evidence is everywhere.

A few days ago I caught the local news on TV and saw an advertisement for a dentist.  The emphasis was not on your teeth, but on your smile.  I’ve noticed this trend other places and even at recent trips to my own dentist.  More are promoting teeth whitening and straightening.  Not long ago dentists were mostly concerned about flossing, gum disease, and cleaning and filling teeth – substantial stuff.  I’m sure these items are still very important to them, but now they have discovered that to attract customers takes a superficial appeal, how bright and attractive your smile is.

Later in the same broadcast the news anchor reported on a deer jumping through a glass window.  She commented that fortunately no people were injured, but the deer had to be put down – “poor deer.”  Now if it had been a rat or a skunk, I’m sure I wouldn’t have heard “poor rat.”  Deer in populated areas are pests, causing more damage and potential disease than rats, but deer are cute.  People will protest the killing of deer (but not rats).  It’s a double standard based on appearance.

How does this carry over?  We often get the more attractive or charming, rather than the more competent candidates for office.  Attractive people tend to get lighter legal sentences, faster promotions and are hired more readily.  With indirect encouragement from the news media, we put as much stock in the opinions of movie stars and singers as those of known experts.  We are underwater on our houses but continue to buy more toys or products to impress our friends.  We trade a car that is not yet paid off for a newer model and go further into debt.  We forget to value people and things for what they are and judge instead based on whether they are cool or in.  As I say, examples are everywhere, some trivial and some important, but they all represent failures in the same dimension of behavior, Perspective.