Tooth decay can begin very early in a child’s life. If five states ban fluoride in drinking water, the costs to Medicaid for a significant increase in kids with cavities could top $40 million within three years, a new analysis finds.
CareQuest Institute for Oral Health, a nonprofit which advocates for fluoridation, used Medicaid claims data and survey responses to predict the outcomes if the five states — Florida, Kentucky, Louisiana, Missouri and Oklahoma — stopped adding fluoride to water systems. Florida has already banned it; the other states have legislation in the works to ban it or make it optional.
Within three years, 132,572 additional children would need a cavity filled or a tooth pulled, according to the analysis. In Florida, which banned community water fluoridation last year, 52,131 children beyond what would normally be expected would need such dental care.
“Water fluoridation is the most broad-based, evidence-based, available-to-everyone tool that children can benefit from,” said Melissa Burroughs, CareQuest’s senior director of public policy. “If you take that away, the impact on kids 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 the mineral has driven down tooth decay in America by 25%.
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 spotlighted in the new analysis, have introduced bills to ban it from being added to community water systems.
Utah and Florida were the first states to ban it outright. Those laws went into effect last year.
Dr. Scott Tomar, head of the department of population oral health at the University of Illinois in Chicago, said dentists in those states will see the outcome of fluoride bans in the next few years — especially among babies because enamel starts to form long before they sprout their first tooth.
“Fluoride is incorporated into the enamel, and it makes that tooth structure more resistant to acid attack, essentially making it less likely to be affected by the bacteria that causes tooth decay,” he said. “Once they start getting their teeth, you will start to see the lack of prevention show up.”
Dental health costs could soar
Fluoride has been added to public water supplies in the U.S. for decades. Health and Human Services Secretary Robert F. Kennedy Jr. has called fluoride “industrial waste,” although the Trump administration appears to be softening its tone.
“Fluoride is essential for oral health,” acting CDC director Dr. Jay Bhattacharya told a House Appropriations subcommittee Tuesday. “The key thing is making sure the right dose is delivered in the right way,” he said during the hearing on National Institutes of Health funding. Bhattacharya is also the director of the NIH.
Too much fluoride “can have neurological and developmental impacts,” he said, without offering specifics.
A 2025 analysis from the National Institute of Environmental Health Studies at the NIH did find an association between higher levels of fluoride and lower children’s IQ scores, although the researchers didn’t suggest that the mineral be removed from drinking water.
Dental experts have generally dismissed studies looking at how fluoride may affect children’s brains as they were conducted in other countries with much higher fluoride levels in water.
According to the CDC, the optimal level of fluoride in drinking water is 0.7 milligrams per liter, amounting to 3 drops in a 55-gallon barrel.
The CareQuest study estimates Medicaid costs could reach nearly $40 million within three years if those five states were to enact water fluoridation bans.
About half of U.S. kids — 37 million — qualify for Medicaid, but nearly half of those children don’t get dental care. Tomar, who was not involved with the CareQuest analysis, suggested the costs could go much higher because many families on Medicaid seek care at urgent care centers or hospital emergency departments.
That’s “about the most expensive, least effective place to go,” he said.