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Cost Effective? Is Water Fluoridation Worth the Expense for Sonoma County?


Cost Effective?
Is Water Fluoridation Worth the Expense for Sonoma County?

by Elena DuCharme, Esq.

Water fluoridation appears to be cheap compared to more targeted alternatives.  But in Sonoma County it would cost more than it saves. It would cost more for residents, cities, and the county as a whole.  

Our County Health Department has adopted the oft-cited claim that for every dollar spent on fluoridation, $38 would be saved on dental care annually for every individual – essentially a 38:1 return on investment (ROI). If this were true, it would be easy to see why it seems so appealing to local governments compared to other alternatives for preventing tooth decay.   

But it’s not true, according to a new peer-reviewed article by Ko and Thiessen, published in the International Journal of Occupational and Environmental Health (March 2015).  The study examines water fluoridation’s cost-effectiveness, specifically the basis for the 38:1 ROI claim.  The authors found that merely by correcting for flawed assumptions in the original calculations, the ROI dropped to 3:1.  And when they factored in the cost of treating “dental fluorosis” (defective tooth enamel commonly caused by drinking fluoridated water), the cost savings of water fluoridation completely vanished

The study also identified a range of typical, foreseeable costs local governments rarely consider in fiscal projections for water fluoridation, including costs of system failures and overfeeds of fluoride chemicals, public relations to promote fluoridation, environmental consultants, legal and political challenges through lawsuits or ballot initiatives, costs to local businesses and municipalities that will need to filter fluoride out of their water, and medical and dental expenses associated with toxicity and health impacts of drinking fluoridated water. For a list of such costs, see the bottom of this article.

Almost none of these costs are included in the county’s projections. And thus, what the Health Department claims would give us 38:1 return on investment could easily turn into a financial boondoggle for county taxpayers.        

But beyond even these unaccounted-for costs, the cost-effectiveness of water fluoridation at the county level would be further undermined by a number of practical factors. 

For the purpose of this discussion, let’s set aside the question of whether fluoridation is safe or effective and just look at the logistics and costs.  

How much fluoridated water would be consumed by those it’s intended to help?

Less than 1% of Sonoma County water is used for drinking. So, of the estimated $380,382 per year that would be spent to purchase fluoridation chemicals, only 1% - or only $3,804’s worth – of those chemicals would actually be consumed by county residents. [1]  The rest would be essentially wasted – they would go down the drain and into gutters, lawns, and gardens – before ultimately flowing down into the soil, groundwater, creeks and streams. This seems a pointless waste of $375,000 per year, money that could be instead used for dental care and education.

Moreover, not only do many people in Sonoma County live on wells or receive water entirely from non-county sources, but those who do drink tap water often don’t drink very much. And ironically, according to the 2012 SMILE report, the children most at risk of dental caries in Sonoma County are low-income kids from Hispanic families, 86% of whom do not drink unfiltered tap water at all, according to county water agency surveys. 

Thus, many of the children who need cavity prevention most would not even be reached by water fluoridation.   

The County’s estimates leave out the exponential costs of providing “optimally” fluoridated water to residents.  

Delivering tap water with an “optimal” concentration of fluoride is an essential underlying assumption of the 38:1 ROI claim.[2] To see the expected reduction in cavities, residents would have to receive and drink tap water that contains the right concentration of fluoride. 

And this is where it gets complicated. Delivering optimally-concentrated tap water across the county would require an expensive feat of engineering, not to mention extensive local government cooperation and coordination.

Why is this? Because of Sonoma County’s complex multi-party water distribution system. Each city and water district in the county has its own wells or reservoirs. Most buy some water from the county (which comes from the Russian River), and supplement it with their local water, in unpredictable and varying amounts.  

Currently, Santa Rosa, Windsor, Sonoma, Rohnert Park, Cotati, Petaluma and Valley of the Moon Water District depend in part on county water. The Marin and North Marin Water Districts also purchase water from Sonoma County. 

If the county fluoridates at the top of this chain of water distribution, then each city and water district that receives county water would mix it with its own pure water. Then, to attain the optimal concentration of fluoride, each city and water district would have to adjust the fluoride levels locally before sending it on to its residents

This would require fluoridation startup, maintenance and monitoring locations all across the county, an extensive and financially onerous undertaking that the county so far has not factored in to its cost projections.

Fluoridation can’t be effective unless residents get the right amount of fluoride in their water. And that comes at a cost.  

If a city or water district can’t afford to monitor and adjust fluoride levels -- or if it doesn’t want to -- and simply dilutes varying amounts of county water with its own pure water, it’s impossible to estimate how much fluoride would actually reach or be consumed by residents; perhaps some, perhaps very little, perhaps the “optimal” dose, if they drink enough tap water.  

When this problem was raised in 2013, then County Health Officer, Dr. Lynn Silver Chalfin, said essentially that it didn’t matter if residents got the optimal concentration, because “any fluoride is better than none.” 

That doesn’t make sense from a cost-effectiveness perspective.       

If residents don’t get enough fluoride in their water, the county can’t legitimately promise fluoridation would reduce tooth decay. Random, sub-optimal doses cannot result in any quantifiable benefit. Unless we receive – and drink - a sufficient, regular dose of fluoridated water, there is no scientific basis from which to conclude that fluoridating the county water would result in a significant reduction in tooth decay – let alone a 38:1 return on investment.  

How does the county propose to deal with this problem of dose? Would it place the burden on cities and water districts to maintain the right fluoride levels?  And if so, who would bear the cost of installing and maintaining the county-wide infrastructure to accomplish this?      

And what if a city or water district refuses to participate in fluoridation, as they are legally free to do? (Indeed, the cities of Cotati and Sonoma have already informed the county that they do not want fluoridated water.) What if a city chooses to filter out the fluoride from the county water? Who would finance that cost? 

The County’s cost projections leave out a host of typical and costly fluoridation-related expenses that other municipalities have struggled with.     

As the Ko and Thiessen study points out, the full range of foreseeable costs have never been factored into the economic analyses local governments rely on when deciding whether to fluoridate their water.  

Sonoma County’s 2014 fiscal projections are no different. According to the its 2014 Preliminary Engineering Report on water fluoridation, we could expect an initial capital outlay of $4.5 million just to build the fluoridation system, and future operations and maintenance costs of $581,000 each and every year thereafter. [3] 

These cost projections are strictly at the county level, and do not include any initial or ongoing costs to cities and water districts. They also leave out the very real engineering, employee, public relations, legal, environmental, social and business costs that would be incurred at both the county and local levels. 

Lessons from Sacramento

Fluoridation cost overruns have been faced by many cities nationwide, including Sacramento, which began fluoridating in 2000, and has since struggled with ballooning infrastructure costs that far exceed original estimates.  

In Sacramento, major infrastructure replacements were required less than ten years from the implementation of fluoridation, despite the 20-year lifespan projected in Sacramento’s initial cost estimate. Ko and Theissen describe a 2010 budget crisis meeting in Sacramento where then-Director of the Department of Utilities, Marty Hanneman, informed the City Council:     

The City of Sacramento has been fluoridating its water supplies just over 10 years. Within that time, the actual cost of operating and maintaining the fluoridation systems has proven to be considerably more than the initial estimate.

Fluoridating water is a very costly and labor intensive process and requires constant monitoring of fluoride concentrations to ensure proper dosages. ...

The chemical is very corrosive, so all equipment that is used in the fluoridation process has a very short life expectancy and needs to be replaced frequently. ... but also causes frequent and complex system failures.

It’s Not Worth the Expense.

In sum, even if water fluoridation is safe and works as it’s claimed to, in the end it costs more than it saves. In fact, it would almost certainly result in a negative return on investment.

Our county leaders need accurate, complete financial projections that incorporate all these costs and considerations. But even without such an analysis, it’s clear that fluoridation doesn’t make practical or economic sense for Sonoma County. 

[1] MWH Engineering, Fluoridation Preliminary Engineering Design Report(November 2014), online at

[2] Department of Human Health Services Guidelines,  For a discussion by the CDC on fluoride concentration: - overview4.

[3] MWH Engineering, Fluoridation Preliminary Engineering Design Report.




Following is a sampling of readily identifiable costs the county’s fiscal projections do not yet account for.    

  • City and Water District-level startup and maintenance:  as described above, for some cities and districts, this could require multiple well fluoridation installations.
  • Additional corrosion-control chemicals to stabilize the pH of the fluoridated water.
  • Repair of “frequent and complex system failures” caused by fluoride’s “corrosive nature”  (quoting the Sacramento Director of the Department of Utilities in 2010).
  • Fluoridation infrastructure replacement: pipes, electrical components, doors and casings, and other equipment would need to be replaced more frequently.   
  • Other capital improvement projects to mitigate unexpected water quality problems caused by fluoridation chemicals.
  • Aquifer storage and recovery costs:  for cities and water districts that in the future may inject county water into aquifers for storage, the cost of fluoride removal prior to injection or the cost to aquifer purity from injecting fluoridated water are unknown but potentially very costly.
  • Other capital improvements required to mitigate work environment health and safety risks from exposure to fluoridation chemicals.
  • Medical, workers’ compensation and liability insurance increases, staff and other expenses to cover and compensate for county, city and water district employee injury from occupational exposure to fluoride chemicals, as well as chemical injury from fluoridation accidents.
  • Filtration systems for fluoride removal either due to choice, health requirements or food production issues.  This could occur at the city or water district level (should a city or water district refuse fluoridated water), and also in residences, hospitals, health clinics and spas, kidney dialysis centers, restaurants, bakeries, beverage producers including breweries, wineries, tea and coffee houses, among other businesses that need or choose to provide fluoride-free food and drink to their customers.
  • County costs associated with pre- and post- fluoridation public relations campaigns to increase acceptance and approval of water fluoridation, including consultant fees, lobbying, marketing studies, focus groups, advertising and related costs.  Indeed, county documents show that hundreds of thousands of dollars to outside marketing consultants have already been spent on this front.   
  • Ballot measure costs in the event residents object to fluoridation.  History shows that people don't launch ballot initiatives for fluoridation, but they do launch ballot measures against it, and the community and municipal costs of these are significant.   
  • Consulting fees for environmental studies and preparation of environment documentation in compliance with the California Environmental Quality Act (CEQA) and potential impacts on listed threatened and endangered species.  Such costs have already begun to be incurred. 
  • Legal and staff expenses associated with consulting contracts, EIR/CEQA challenges and litigation.  Such costs have already begun to be incurred. 
  • Legal and staff expenses related to amending the Restructured Agreement between the county Water Agency and the cities and water districts to allow for fluoridation.   Such costs have already begun to be incurred. 
  • Medical and dental costs to residents who suffer adverse effects from fluoride exposure, including hypersensitive individuals, infants and small children, and children and adults who require cosmetic treatment of damaged adult teeth from drinking fluoridated water.  (A study for the National Center for Health Statistics showed that dental fluorosis in American children ages 12-15 almost doubled from 22.6% in 1986-1987 to almost 41% in 1999-2004.  3.6% of children ages 12-15 are estimated to have moderate to several dental fluorosis which need repair costing at least $4,434 in the case of veneers.)   
  • Costs of reversing recent positive movement in the restoration and recovery of our salmon fisheries.  The possible effect of fluoridated water on salmon is especially worrying, since the county has spent millions of dollars on salmon restoration and coho salmon, in particular, are barely surviving.
  • Unknown, unpredictable impacts of adding fluoride to the environmental mix of Sonoma County.  As Dick Butler said in his December 7, 2014, letter to the Press Democrat:  fluoride poses a “poorly understood threat to fish and wildlife." 
  • Agricultural losses resulting from harm to dairy cattle, horses and other livestock from drinking fluoridated water.  Devastating bone loss has been shown in studies and reported by livestock owners. 
  • Loss of retail and wholesale business and tax revenues resulting from damage to the Sonoma County “brand.”  Organic and/or high-end artisan quality food and drink manufacturers have already expressed opposition to water fluoridation and can be expected to lose sales because progressive, health-conscious consumers simply do not want fluoride in their food, drink, or environment.

For more information, as well as a link to the full cost-effectiveness study, go to