Tooth decay starts very early in a child’s life. If five states ban fluoride in drinking water, Medicaid costs for a significant increase in children with cavities could exceed $40 million over three years, a new analysis finds.
The CareQuest Institute for Oral Health, a nonprofit that advocates for fluoridation, used Medicaid claims data and survey responses to predict the outcomes if five states—Florida, Kentucky, Louisiana, Missouri, and Oklahoma—stopped adding fluoride to water systems. Florida has already banned it; Other states have legislation to prohibit it or make it optional.
Over three years, 132,572 additional children needed cavities or tooth extractions, according to the analysis. In Florida, which banned community water fluoridation last year, 52,131 children needed such dental care, more than would normally be expected.
“Water fluoridation is the most broad-based, evidence-based, accessible-to-all tool that children can benefit from,” said Melissa Burroughs, CareQuest’s senior director of public policy. “If you take that away, the impact on children is significant.”
The Centers for Disease Control and Prevention maintains that community water fluoridation is one of the greatest public health achievements of the past century. Supplementing water systems with minerals has reduced tooth decay by 25% in America.
Like vaccines, fluoride has come under attack in recent years. According to the bipartisan National Conference of State Legislatures, at least 21 states, including the five highlighted in the new analysis, have introduced bills to ban additions to community water systems.
Utah and Florida were the first states to ban it entirely. Those laws went into effect last year.
Head of the Department of Population Oral Health at the University of Illinois at Chicago, Dr. Scott Tomer, dentists in those states will see the results of fluoride bans in the next few years — especially in babies whose enamel begins to form before their first tooth erupts.
“Fluoride is incorporated into the enamel, and it makes the tooth structure more resistant to acid attack, essentially making it less likely to be affected by the bacteria that cause tooth decay,” he said. “Once they start getting their teeth, you start to see a lack of prevention.”
Dental health costs can increase
Fluoride has been added to public water supplies in the US for decades. Health and Human Services Secretary Robert F. Kennedy Jr. called fluoride “industrial waste,” though the Trump administration is softening its tone.
“Fluoride is essential for oral health,” said Acting CDC Director Dr. Jay Bhattacharya told the House Appropriations Subcommittee on Tuesday. “The key thing is to make sure the right dose is delivered in the right way,” he said during a National Institutes of Health funding hearing. Bhattacharya is also the director of the NIH.
Too much fluoride “can cause neurological and developmental effects,” he said, without giving specifics.
A 2025 analysis by the National Institute of Environmental Health Studies at the NIH found a link between high levels of fluoride and lower children’s IQ scores, although the researchers did not suggest that the mineral be removed from drinking water.
Dental experts have generally dismissed studies looking at how fluoride might affect children’s brains because they were conducted in other countries with high fluoride levels in the water.
According to the CDC, the optimal level of fluoride in drinking water is 0.7 milligrams per liter, about 3 drops in a 55-gallon barrel.
A CareQuest study estimated that those five states could reach nearly $40 million over three years if they enacted water fluoridation bans.
Half of US children — 37 million — qualify for Medicaid, but half of those children do not receive dental care. Tomar, who was not involved in the CareQuest analysis, suggested that costs could be higher because many families on Medicaid receive care in urgent care centers or hospital emergency departments.
That’s “the most expensive, least efficient place to be,” he said.
