Vol. 30, No. 2-Spring Issue, 1970 89

ECONOMICS AND CONTINUED FUNDING OF DENTAL SERVICES IN NONFLUORIDATED AREAS*

By Delmar R. Miller, D.D.S., M.P.H. * *

I I This study-group on public health practice has limited its discussion to the question,

“Is it economically proper to divert dental funds to communities that refuse to fluoridate their drinking water?”

I I

In the past decade more, though still inadequate, public funds have become available for dental programs at the federal, state, and local levels. These funds have increased t o an amount that demands a critical assessment of their expenditure. “The Economics of Dental Public Health,” the theme chosen for this meeting, is indicative of the Associa- tion’s growing concern about procedure.

Several facets of the broad subject of economics in dental public health were suggested by the 1969 Program Committee as suitable topics for a report by the Committee on Public Health Practice, but the topic selected for this report is specific. I t is concerned with the question, “Can dental administrators afford continued expenditure of public funds for programs in communities that have the potential, but have failed to fluoridate communal drinking water?” A number of persons in the dental profession, in government, and in groups of taxpaying citizens now raise this question.

The Florida State Dental Society, during its annual session in 1968, adopted a resolution that supported the promotion of legislation to require the fluoridation of communal drinking water in “localities, cities, and states receiving federal funds for comprehensive health programs.”’ A recent significant statement by Smith warns that “a new look will be directed at results for dollars spent in comparison with results that might have been achieved by spending the same dollars for other activities.”’ The influence of economic concern appears significant a t the moment.

Today an ascendancy can be noted in the concept that prevcntion must become an important component in dental practice. With this concept has come a gratifying increase in public appreciation of prevention in dentistry. Both the public and the dental profession, hence, are becoming impressed that prevention is much less expensive than treatment.

Researchers have agreed for a long period that the incidence of carious lesions can be reduced more than 6 0 percent by fluoridation of a community’s drinking water. Recently studies have been reported that assess dentists’ time and the cost of the dental care provided for children in fluoridated and nonfluoridated communities. Successive reports by progress by such studies as those in the communities of Kingston and Newburg, New York, have shown that the cost of both initial treatment and the subsequent incremental treatment of children in a fluoridated community is consistently about one-half of that spent for children in a nonfluoridated c o m m ~ n i t y . ~ A 10-year study in Askov, Minnesota, reported by Jordan and his associates, revealed that the cost of a community dental program, which combined all of the approved dental health practices, but omitted fluoridation, was 57 times more expensive than the cost of fluoridation and less than half as e f f e ~ t i v e . ~

*PresentedOctober 1 7 , 1969, in New York City, during thc Annual Meeting of tho American Association of Puhlic Health Dentists, as Chairman of thc Study Group on Public Health Practice which consisted of the Chairman, Joseph M. Dohcrty, Max H. Schoen, and Qucntin M. Smitll.

“Emory University, School of Dentkti-y, 106 Forrest Avenue, N.E., Atlanta, Georgia, 30303.

90 Journal of Public Health Dentistry

These items, selected from a large list of reports, provide evidence to confirm fluoridation as the most economical expenditure available for the money t o be spent in programs of dental public health. In view of this evidence, therefore, it appears that the residents of fluoridated communities should be invited to review the priorities, pertinent to the expenditure of public funds for dental programs, whenever the biggest bargain presently available is excluded.

The shortest route for accomplishing such a review will be through legislative activity. Precedent appears t o exist for establishing specific requirements and guidelines that must be met before eligibility can be established for receiving and expending public funds. The inclusion of fluoridation of communal water as a prerequisite for receiving governmental funds for care has been suggested, and increased effort may be anticipated by dental organizations, public health officials, and the states legislators in the early future to implement this suggestion. The increase which might be expected in return from the dollars presently being invested in programs of dental care in nonfluoridated areas may become a compelling incentive.

A number of considerations should precede a final decision t o legislate the solution of a problem i n achieving fluoridation. Among such considerations the dental director must recognize that some nonfluoridation-sensitized communities may elect to decline public funds for programs of care if fluoridation is made a requirement for eligibility. I n such instances, the resulting loss of funds places a penalty for noncooperation on the underprivileged. nondecision-making citizens of the community that deprives them of needed health services. The end result may be that the more affluent citizens of the penalized community continue to purchase health services as usual; the underprivileged citizens get no care; and the status of fluoridation remains unchanged.

Some lack of certainty exists, furthermore, that the mechanism of withholding funds will influence a community to fluoridate its drinking water. A number of communities in the United State currently are reported to be declining urgently needed governmental funds because the requirements for qualifying or the guidelines that must be followed run counter to the concepts of the local power-structure. At the same time, as a matter of record, a number of communities have chosen t o reverse previous policy and to conform to the requirements stipulated by government in order t o become eligible for public funds. Given the option, it appears certain that many communities would elect to forego needed funds for health programs rather than fluoridate. A preferable approach appears to be the one being adopted by an increasing number of states-the passing of a law to require fluoridation of community drinking water i t i the interest of the health a t l d

welfare of the public. These states have placed fluoridation in its proper perspective as a necessary public health measure and have developed a mechanism t o avoid the problem which is the subject of this report.

Recalling i t was stated previously that the cost of programs for dental health are significantly greater in nonfluoridated areas, a valid question remains “Can dental directors afford the continued enhanced drain on available funds t o operate dental programs in these areas?” Based on a consideration of the economics of the situation merely, it appears that they cannot. When other factors of the issue are included in the consideration, the decision appears to become less clear-cut. The prospect of tidying up the budget by eliminating the only source of health care available to a segment of society in a community is not a pleasant decision for the dental administrator who retains a modicum of compassion. From this latter point of view the painful answer very well may be that directors cannot afford to discontinue their use of funds for dental programs in areas that could, but have not, fluoridated. Although definitely poor economy, yet, until other means for effecting fluoridation without penalizing the needy poor are exhausted. directors are advised t o avoid the technic of withholding funds.

Vol. 30, No. 2-Spring Issue, 1970 91

Bibliography

1. Hotline news. Fla. Dent. J., 39:3, Aug. 1968. 2. Smith, Q.M. Comprehensive health planning: recommended policies and practices. J . Pub. Health

Dent., 29:70-1, Spring 1969. 3. Ast, D.B., et al. Time and cost factors t o provide regular, periodic dental care for children in A

fluoridated and nonfluoridated area; progress report 11. Am. J. Pub. Health, 57:1635-42, Sept. 1967.

4. Thc ten-year Askov dental demonstration has come t o a close; what did it prove? Edit. Am. Dent. A.J., 61:112-3, July 1960.

Take Your Choice

“We need t o exploit change or we will be victimized by it.” (Robert E. Paulsen, Sr., in the Journal of the Maryland State Dental Association for December, 1969)

Confrontation or Cooperation in the Cornfield

Two different projections are being made of the prospect for global hunger. The gloomy view is that massive starvation probably is unavoidable before the end of the Twentieth Century; and the optimistic view, from several recent agricultural successes, is that massive starvation may be neither neccssary nor probable. Today’s imperfect data, however, can inspire little optimism. If the recommended agricultural strategies continue to focus on ever larger areas of the earth’s surface with objectives limited to narrow, intensive approaches for gaining maximum production of food and dollars, the effort will fail by ignoring the broad ecological relationships that must be maintained. Blatant polluters in agriculture, even, can accelerate environmental degradation that re-emerges as medical bills, cheapened property, increased cost of rccreation, and a progressively lowering of the quality of living. Then the “people-food crunch” will be with us. (John E. Cantalon in Scicnce for December 19, 1969)

Reaching the Student

Most faculty members acknowledge that the teacher serves as a model for students. ~ e s s frequently they acknowledge that the more authentic the teacher, the more skilled in listening and talking, and the more accessible he makes himself to his students, the more potent will be his influence, positive or negative, o n them. ( I n Education and Identity by Arthur W. Chickering)