Patient Management

Important Facts on Optimal Community Water Fluoridation

Prepared by the Massachusetts Dental Society Task Force on Access, Prevention, and Interprofessional Relations, with information prepared and reviewed by the Centers for Disease Control and the National Fluoridation Advisory Committee of the American Dental Association. 

One of the most widely respected sources for information regarding fluoridation and fluorides is the American Dental Association (ADA). The ADA maintains fluoride and fluoridation web pages at www.ADA.org/fluoride. Other accurate sites include the American Academy of Pediatrics, www.ilikemyteeth.org, www.AmericanFluoridationSociety.org, www.cdc.gov, and www.mass.gov.

The Centers for Disease Control (CDC) considers fluoridation of community water supplies to be the single most effective public health measure to prevent tooth decay, going so far as to call it “One of the 10 great public health achievements of the 20th century.” 

Throughout more than 75 years of research and practical experience, the overwhelming weight of credible scientific evidence has consistently indicated that fluoridation of community water supplies is safe.

Studies have proven that water fluoridation remains effective in reducing tooth decay by more than 25% in children and adults, even in an era of widespread fluoride availability from other sources, such as fluoride toothpaste. 

There are currently no credible, peer-reviewed studies in the United States that unequivocally demonstrate that optimal community water fluoridation is anything but effective, safe, and cost-efficient. 

Community water fluoridation is the controlled addition of fluoride, which occurs naturally in all water, to optimal levels to prevent tooth decay. 

Optimal community water fluoridation benefits everyone, especially those without access to regular dental care. Fluoridation is a powerful tool in the fight for social justice and health equity, particularly important because SNAP benefits (food stamps) do not cover the purchase of toothpaste with fluoride, toothbrushes, or fluoride rinses. 

By simply drinking water, people benefit from the cavity protection provided by fluoridation, whether at home, work, or school. 

Water that has been fortified with fluoride works similarly to the public health practice of fortifying salt with iodine, milk with vitamin D, and orange juice with vitamin C — none of which are medications. Many countries that do not utilize community water fluoridation add fluoride to salt. 

When compared to the cost of other prevention programs, water fluoridation is the most cost-effective means of preventing tooth decay for both children and adults in the United States. The cost of a lifetime of water fluoridation for one person is less than the cost of one filling. 

For community water systems serving more than 1,000 people, the economic benefits of fluoridation outweigh the costs. The benefit-cost ratio increases as the size of the population served increases (mainly due to economies of scale). Fluoridation is a cost-saving method to prevent tooth decay. 

According to CDC data from 2022, nearly 73% of the population (3 out of 4 people) in the United States are served by public water systems that are optimally fluoridated. 

Fluoridation has been thoroughly tested in the United States court system and found to be a proper means of furthering public health and welfare. No court of last resort has ever determined fluoridation to be unlawful. Cases have been lost in lower courts, as recently happened in California, but have been continually won on appeal to the higher court.

The Massachusetts Dental Society (MDS) and the American Dental Association discourage the use of direct-to-consumer dental products, including aligners, veneers, mouthguards, snoring appliances, teeth whitening trays, and bleaching products. Self-administered, unsupervised dental treatments have the potential to cause damage and irreversible complications for patients.

The MDS communicated its concerns in 2019 regarding DIY or remote orthodontics in letters to the Massachusetts Board of Registration in Dentistry and the Massachusetts Attorney General.

How to Talk to Patients About DIY Orthodontics

The MDS encourages you to educate your patients about the benefits of an office visit and the potential risks associated with these remote DIY options, including bone loss, receding gums, loose teeth, a misaligned bite, and other issues.

Q: If my patient tells me they are considering DIY orthodontics and remote treatment through an online company, what should I tell them?

A: While many patients believe that direct-to-consumer orthodontics sounds simple, the American Association of Orthodontists has published a flier listing questions patients may first want to consider. You can download and print the flier to share with your patients.

Q: What if my patients have already undergone DIY treatment and encountered problems?

A: If you have seen patients who have experienced injury or adverse results from using mail-order orthodontic devices or other DIY dental treatments, the MDS Dental Practice and Benefits Committee encourages you to give them the following information.

If they have experienced injury or adverse results from using mail-order orthodontic devices or undergoing remote dental treatment, they can report the issue to state and federal regulators using the links below. 

• Massachusetts Attorney General’s Office Health Care Complaint
• Massachusetts Board of Registration in Dentistry Dental Complaint
• U.S. FDA MedWatch Voluntary Report

In Massachusetts, the Office of the Attorney General can help resolve consumer complaints against businesses. The Department of Public Health’s Bureau of Health Professions Licensure investigates complaints about dental treatments on behalf of the Board of Registration in Dentistry. In addition to filing a complaint online, consumers can call the Massachusetts Attorney General’s Office Health Care Division Health Care Helpline at 888.830.6277. 

At the federal level, because plastic teeth aligners and dental impression materials are regulated by the US Food and Drug Administration as “by prescription only” devices, consumers can report any problems using the FDA MedWatch Voluntary Reporting Form.

Clinical practice guidelines include recommendation statements intended to optimize patient care, informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. The American Dental Association (ADA) has developed guidelines to help dental professionals make informed clinical decisions and incorporate evidence gained through scientific research into patient care.

Dentists play a vital role in preventing the abuse and misuse of prescription medications. To support members in this mission, the MDS is committed to sharing the latest information, news, resources, and tools related to the safe and effective use of prescription medications.

Maintaining an accurate and up-to-date patient record is a legal requirement. Many dental offices utilize an Electronic Health Record system instead of maintaining paper records. The rules below should be followed whenever you make entries in patient records:

• Use a consistent style for entries. Consistency lends credibility to your records and to your professionalism in maintaining them.
• Date and explain corrections. All corrections should be made as they occur, with the actual date and reason for the correction, to preserve the integrity of the patient record.
• Use ink. Pencil entries fade over time and are easily altered, which makes the record’s integrity subject to speculation.
• Use a single-line crosscut. This is the best way to make a physical alteration to the record while preserving the integrity of the patient record.
• Do not use whiteout. A whiteout is messy and suggests that information was intentionally omitted because the dentist had something to hide.
• Write legibly. An illegible record can be worse than no record at all. It makes the dentist look careless and disorganized.
• Express concern about patient needs. Document that you listened to, noted, and addressed the patient’s expressed needs.
• Never write derogatory remarks in the record. Although it is acceptable to record negative information, such as a patient’s failure to follow treatment advice, insulting material conveys an aura of unprofessionalism.
• Do not note fees in the records. Fees are not patient information. They should be kept in a separate financial record, where it should be noted that the fees were discussed with and understood by the patient.
• Record missed appointments and failure to follow instructions. This information is vital to a complete record and will prove very helpful in defending any court action.

Dentists have custody of the medical information contained in a patient’s record, not ownership of it. Massachusetts law requires that dentists make a copy of the records available upon a patient’s request; however, dentists can charge a “reasonable” reproduction fee for that copy.

Massachusetts law requires dentists to keep records for seven years from the date of the last appointment; however, dentists should contact their liability (malpractice) carrier before destroying any records. If you use EDIC for liability coverage, contact them at 800.898.3342. Full record retention information can be found in Section 5.14 of Section 5 of the BORID regulations.

Vital Signs and Health History Records
A health history form provides a starting point for the dental team to fulfill its professional obligations. It is recommended that the patient’s health information be reviewed carefully by the dentist. The dentist should review and discuss the form information with the patient, then sign or initial the form once the review is completed.

All dentists should take health histories initially at first patient contact and update them periodically as necessary. A patient should be questioned at each visit to determine if his/her health status or medication taken has changed. The record should have a dated notation that the patient was asked about recent health and medication changes, and any changes should be updated in the record. A patient’s medical status should be monitored at intervals appropriate to the patient’s age and medical history. The decision about the frequency is professional, not legal. Consult your professional liability insurance company and/or attorney for more information.

A health history form should include

• Health conditions or illnesses that may be affected by or that can be affected by dental treatment.
• Medications that a patient is currently taking that will have a potential drug interaction with the local anesthetic or other drugs you may prescribe that may affect dental treatment or a patient’s other health condition(s).
• What the patient is seeking care for.

Recording Vital Signs
Recording and monitoring of vital signs is required at visits in which nitrous oxide-oxygen sedation, minimal sedation, moderate sedation, and/or general anesthesia are administered. For details on these, see 234 CMR 6.11 through 6.15.

Recording of vital signs is not required by regulation as part of a comprehensive dental exam. However, if the dentist believes that the medical history of the patient warrants checking the vital signs as “necessary and appropriate to facilitate comprehensive diagnoses of the patient’s dental status (see 234 CMR 5.15 (3)(c)(7)), then this should be part of the patient record.

The American Dental Association (ADA) and the US Food & Drug Administration established standard of care guidelines for X-ray frequency in dental care, which were revised in 2012.  A dentist should review a patient’s health history and conduct a clinical examination to assess the patient’s overall risk of cavities, periodontal disease, or other dental problems. This information should be used as an adjunct to their professional judgment on how to best utilize diagnostic imaging. The ADA supports the ALARA (As Low As Reasonably Achievable) principle for the use of X-rays.

Radiographs can help the dental practitioner evaluate and definitively diagnose many oral diseases and conditions. However, the dentist must weigh the benefits of taking dental radiographs against the risk of exposing a patient to x-rays, the effects of which accumulate from multiple sources over time. The dentist, being aware of the patient’s health history and vulnerability to oral disease, is in the best position to make this judgment in the patient’s best interest. For this reason, the guidelines are intended to serve as a resource for the practitioner and are not intended as standards of care, requirements, or regulations. Dentists should use this as a tool to help educate patients on X-ray frequency recommendations.

Deciding to terminate a relationship with an insurance company is a difficult decision. If you decide to terminate network participation, it is essential that you inform your patients of the reasons for this decision. Most insurance providers will send letters to your patients suggesting the patient change to a “network dentist,” so don’t let them have the last word. 

Send a letter to your corresponding patient base informing them that you are terminating participation, and explain your decision, what the change will mean, and the high value you place on the dentist-patient relationship. You may use the sample template provided here.

What to include in your letter:

1. Thank you for being my patient. The relationship between a dentist and patient is a vitally important one based on trust, comfort, and communication.  
2. My patient philosophy is […]
3. After long and careful consideration, I want to share with you that starting [insert date], I have decided to end my practice’s relationship with [company]. Most importantly, this decision does not change our relationship. Your insurance will still be accepted here. I will still continue to offer you all the advantages my practice has to offer. We will continue to work with you to process your benefit claims. 
4. I decided to end my practice’s relationship with [company] because […] 
5. Here’s what the change will mean for you. Because I am no longer an in-network provider, there could be an increase in treatment costs. Additionally, since [company] does not permit its members to assign benefits directly to their dental care providers, your insurance company may pay the benefits directly to you, which means we may invoice you for payment. We can discuss these changes now or at our next meeting. However, please be assured that we will continue to have your best interests in mind and value the relationship we have established.