EDITORIAL Fluoridation: a subtle scheme? I f you were to question people who had not visited the dentist for a year or longer as to their reasons for not seek ing dental care, what would be the most frequent re sponse? Would it be the fear of possible pain during treatment? Inability to pay for dental care? Inadequate ac cess to a dentist? Or reluctance to lose time from work? This question was, in fact, asked in a Family Dental Opinion Survey conducted for the Bureau of Economic Research and Statistics of the American Dental Associa tion. In a sample of 1,949 people, 46% stated they had not visited a dentist within the past year, and 63% of this group responded that they had not sought dental care be cause they perceived no need to do so. No other response approached that of lack of need; for example, only 10% said they were fearful of dental treatment. As dentists, we cannot be gladdened by such findings. The very essence of modern dentistry is preventive care and, failing that, early detection and treatment of oral disease. When an individual has perceived a need for dental care, oral disease is all too frequently advanced, and it is more difficult and more costly to treat success fully. Through our efforts to encourage the public to seek regular dental care by demonstrating the value of oral health, we believe we are fulfilling our goal of improving the well-being of the public. However, not everyone be lieves that our policies pertaining to increasing the public demand for dental care are entirely altruistic. There are a number of disbelieving economists, and one of them is Dr. Paul J. Feldstein, a professor in the School of Public Health and Department of Economics at the University of Michigan. Dr. Feldstein, who has written a book on health associations and their demands for state and federal legislation,1 is a consultant to the Depart ment of Health, Education, and Welfare and a variety of health agencies nationwide. A chapter of his book is de voted to the American Dental Association and what he considers to be our demand-increasing policies, as related to national health insurance, Delta Dental Plans, fluorida tion, fee-for-service reimbursement, state dental practice acts, licensure of dental laboratories, government dental clinics, and a number of aspects of what he terms “supply restriction and control” by organized dentistry. While allowing that Association policies are not incon sistent with improving the oral health of the public, Dr. Feldstein takes the position that our programs for improv ing oral health conveniently align with our personal eco nomic goals, and that these self-serving goals take prior ity when dentists weigh alternative approaches to im proved oral health that might be less costly. Also, he thinks that dental health education is a way by which the profession wants to increase public awareness of the benefits of oral health to increase the demand for 9 3 0 ■ JA D A , V o l. 9 7 , N o v em b er 1978
dental services, and thereby to increase dental income. When Dr. Feldstein puts these hypotheses to the test in explaining, for example, the Association’s policies on fluoridation and children’s dental care, his conclusions are that: “ (1) fluoridation reduces the demand for restora tions for children . . . allowing dentists to concentrate upon higher fee adult services; and (2) the increased de mand for initial screenings, prophylaxis, and radiographs by children can be met by greater use of auxiliaries with dentists reaping financial benefits from such delegations of tasks due to their supervisory capacity. Fluoridation, emphasis on good oral health habits, and coverage of children’s preventive services under federal programs should all ultimately result in a higher demand for dental care when these children become adults.” Apparently, the federal government has done it again—refused to listen to economic advisors. The scien tists of the Department of Health, Education, and Welfare are urging that fluoride mouthrinse programs, such as that described on page 793 of this Journal, be im plemented in every community that lacks water fluorida tion. They’ve even gone ahead and prepared a guide for establishing a program that is safe, simple, inexpensive, and effective, and that will result in a 20% to 50% decay reduction.2 They probably reasoned that there would be a decrease in the 25,612,000 days of restricted activity Americans experienced in 1977 because of oral disease.3 They probably even believed there would be fewer in stances of malocclusion, speech impairment, and poor mastication because of tooth loss due to caries. Perhaps they were thinking of the alleviation of pain and of emo tional distress caused by missing teeth and unsightly de cay. They may even have considered the benefits accru ing to permanent teeth exposed to the fluoride mouth rinse. Nothing more. You can be certain they never thought of the use of fluorides as a subtle scheme to make dentists wealthy. We have Dr. Feldstein to thank for that meretricious idea.
1. Feldstein, P.J. Health associations and the demand for legislation: the political economy of health. Cambridge, Mass, Ballinger Publishing Co., 1977. 2. USDHEW, Public Health Service, National Institutes of Health. Pre venting tooth decay: a guide for implementing self-applied fluoride in schools. DHEW Publication No. (NIH) 77-1196. 3. Current estimates from the Health Interview Survey, United States 1977. Vital and Health Statistics, series 10, no. 126. Hyattsville, Md, Na tional Center for Health Statistics (in press).
dental services, and thereby to increase dental income. When Dr. Feldstein puts these hypotheses to the test in explaining, for example, the Association’s policies on fluoridation and children’s dental care, his conclusions are that: “ (1) fluoridation reduces the demand for restora tions for children . . . allowing dentists to concentrate upon higher fee adult services; and (2) the increased de mand for initial screenings, prophylaxis, and radiographs by children can be met by greater use of auxiliaries with dentists reaping financial benefits from such delegations of tasks due to their supervisory capacity. Fluoridation, emphasis on good oral health habits, and coverage of children’s preventive services under federal programs should all ultimately result in a higher demand for dental care when these children become adults.” Apparently, the federal government has done it again—refused to listen to economic advisors. The scien tists of the Department of Health, Education, and Welfare are urging that fluoride mouthrinse programs, such as that described on page 793 of this Journal, be im plemented in every community that lacks water fluorida tion. They’ve even gone ahead and prepared a guide for establishing a program that is safe, simple, inexpensive, and effective, and that will result in a 20% to 50% decay reduction.2 They probably reasoned that there would be a decrease in the 25,612,000 days of restricted activity Americans experienced in 1977 because of oral disease.3 They probably even believed there would be fewer in stances of malocclusion, speech impairment, and poor mastication because of tooth loss due to caries. Perhaps they were thinking of the alleviation of pain and of emo tional distress caused by missing teeth and unsightly de cay. They may even have considered the benefits accru ing to permanent teeth exposed to the fluoride mouth rinse. Nothing more. You can be certain they never thought of the use of fluorides as a subtle scheme to make dentists wealthy. We have Dr. Feldstein to thank for that meretricious idea.
1. Feldstein, P.J. Health associations and the demand for legislation: the political economy of health. Cambridge, Mass, Ballinger Publishing Co., 1977. 2. USDHEW, Public Health Service, National Institutes of Health. Pre venting tooth decay: a guide for implementing self-applied fluoride in schools. DHEW Publication No. (NIH) 77-1196. 3. Current estimates from the Health Interview Survey, United States 1977. Vital and Health Statistics, series 10, no. 126. Hyattsville, Md, Na tional Center for Health Statistics (in press).
