Breaking Down Barriers: Why Low-Income Communities Avoid Fluoridated Tap Water

Despite decades of evidence supporting water fluoridation as one of public health’s greatest achievements, a significant portion of Americans—particularly in low-income urban communities—are missing out on its cavity-preventing benefits by choosing bottled water over tap water.

Dr. Tony Kuo, Director of the Division of Chronic Disease and Injury Prevention at the Los Angeles County Department of Public Health, recently discussed his landmark 2019 JADA study on the Dental Digest podcast, shedding light on why this public health success story isn’t reaching everyone who needs it most.

The Scale of the Problem

Dr. Kuo’s research team surveyed 1,171 participants in Los Angeles County’s low-income urban communities, uncovering troubling misconceptions about water safety and fluoridation. The findings paint a picture of missed opportunities in preventive dental care:

• Only 37% of respondents knew their tap water contained fluoride
• 22% incorrectly believed bottled water contained fluoride
• Half reported that tap water “tastes bad”
• 34% believed their tap water was unsafe to drink
• Nearly half thought tap water was “only good for bathing”
• 60% preferred bottled water overall

“What we found was misconception about fluoridation and some degree of mistrust on the quality and safety of tap water,” Dr. Kuo explained during the podcast interview with host Dr. Melissa Siebert.

The Disconnect Between Medicine and Dentistry

As the sole physician on the research team, Dr. Kuo brings a unique perspective to dental public health. He emphasized that oral health and physical health exist on a continuum, yet healthcare often treats them as separate specialties.

“To be really effective, you kind of have to treat the person as a whole,” Dr. Kuo noted. “It’s important to look at it as actually a continuum part of mutually reinforcing aspects of health.”

This integrated approach is particularly relevant given growing evidence linking oral health to cardiovascular disease risk and overall systemic health.

Infrastructure Reality Behind Perceptions

While some concerns about tap water may stem from misconceptions, Dr. Kuo acknowledged that infrastructure issues in lower-income neighborhoods can contribute to legitimate water quality problems.

“In lower income communities, neighborhoods, the systems are actually older and they probably do have metals and chemicals that basically play a role and could be a good reason for the response, especially when they talk about water smell and look dirty,” he explained.

This creates a complex challenge where both education and infrastructure improvements may be necessary to address the problem effectively.

Missed Opportunities in Dental Practice

The research highlights a significant missed opportunity for dental professionals. Dr. Kuo emphasized that dental visits represent crucial “teachable moments” where providers can educate patients about fluoridated water benefits.

“When people go to the dental office, it’s a teachable moment,” he said. “Research has shown that whether you’re a dentist, physician, or nurse practitioner, when advice comes from the provider, it’s very effective in changing people’s minds.”

The importance of this patient education became clear during Dr. Siebert’s community outreach experience. When she asked children at a community center about tap water, the unanimous response was that “tap water is bad”—demonstrating how widespread these misconceptions have become.

A Multifaceted Solution

Dr. Kuo’s team has developed a comprehensive approach to addressing this challenge, including:

Public Education Campaigns: LA County has launched initiatives to educate parents and community residents about tap water and fluoridation benefits through their ChooseHealthLA.com website.

Healthcare Provider Training: Working with dental professionals to incorporate fluoridation education into patient encounters.

Alternative Fluoride Sources: For communities where tap water concerns persist, promoting fluoridated toothpaste, mouth rinses, and professional treatments.

Early Dental Care: Encouraging parents to bring children for their first dental visit by age one to establish prevention-focused relationships.

Regional Adaptation Required

The solution isn’t one-size-fits-all. “You have to tailor to the community,” Dr. Kuo noted. “I’ve traveled to cities where their tap water tastes better than anything I’ve ever had. In those communities, it’s probably not that hard to raise awareness. Then there are communities where that isn’t the case.”

This regional approach recognizes that some areas may need infrastructure improvements alongside education, while others primarily need awareness campaigns.

The Multidisciplinary Advantage

One key insight from Dr. Kuo’s research was the value of bringing together professionals from different disciplines. The study team included public health experts, epidemiologists, dentists, and physicians.

“What was very interesting about participating in this study is being able to learn from my dentist colleagues while coming from a family physician standpoint,” he reflected. “All the different disciplines bring different types of solutions to help with the issue at hand.”

Call to Action for Dental Professionals

The research underscores dental professionals’ critical role in addressing fluoride access disparities. As Dr. Kuo’s study concluded, fluoridated tap water represents “a low-cost, ecologically friendly resource that provides health benefits seldom found in bottled water.”

However, mistrust about tap water quality makes low-income communities “more vulnerable to the effects of not receiving adequate fluoride and thus at high risk of developing caries.”

For dental professionals, this research suggests several actionable steps:

• Routinely discuss fluoridated water benefits during patient visits
• Address misconceptions about bottled water and fluoride content
• Provide culturally appropriate education materials
• Collaborate with public health officials on community outreach
• Consider alternative fluoride delivery methods for patients avoiding tap water

Looking Forward

Dr. Kuo’s research reveals that despite water fluoridation’s 75-year track record of success, significant barriers remain in ensuring equitable access to its benefits. Addressing these barriers will require coordinated efforts between dental professionals, public health officials, and community leaders.

As the dental community continues to emphasize prevention over intervention, understanding and addressing why patients avoid fluoridated water becomes increasingly critical to reducing oral health disparities.