108 American Dental Association to community water fluoridation status, the study took into account per capita income, population and number of dentists per county.9 By preventing tooth decay, fluoridation also plays a role in reducing visits to hospital emergency rooms (ERs) for toothaches and other related dental problems where treatment costs are high. Most hospitals do not have the facilities or staff to provide comprehensive or even emergency dental care. Many patients receive only antibiotics or pain mediation but the underlying dental problem is not addressed. In too many cases, the patient returns to the ER in a few days with the same problem or worse. School-based dental disease prevention activities such as fluoride mouthrinse or tablet programs, professionally applied topical fluorides, dental health education and placement of dental sealants are beneficial but have not been found to be as cost- effective in preventing tooth decay as community water fluoridation.10 In 1985, the National Preventive Dentistry Demonstration Program10 analyzed various types and combinations of school-based preventive dental services to determine the cost and effectiveness of these types of prevention programs. Ten sites from across the nation were selected. Five of the sites had fluoridated water and five did not. Over 20,000 second and fifth graders participated in the study over a period of four years. Students were examined and assigned by site to one or a combination of the following groups: • biweekly in class brushing and flossing plus a home supply of fluoride toothpaste and dental health lessons (ten per year) • in-class daily fluoride tablets (in nonfluoridated areas) • in-school weekly fluoride mouthrinsing • in-school professionally applied topical fluoride • in-school professionally applied dental sealants, and • a control.10 After four years, approximately 50% of the original students were examined again. The study affirmed the value and effectiveness of community water fluoridation. At the sites where the community water was fluoridated, students had fewer cavities, as compared to those sites without fluoridated water where the same preventive measures were implemented. In addition, while sealants were determined to be an effective prevention method, the cost of a sealant program was substantially more than the cost of fluoridating the community water demonstrating fluoridation as the most cost- effective preventive option.10 In an effort to balance budgets, decision makers sometimes make economic choices that amount to being “penny wise and pound foolish.” In other words, they cut an expense today that appears to be a sure money saver. But they fail to take a long-term view (or see the big picture) on the consequences of that action. They fail to see how money spent now can provide greater savings in the future. A decision to eliminate funding for a successful community water fluoridation program would be an example of that kind of action. Often decision makers are swayed by the promise of an alternative fluoride delivery system without considering who it will cover (and who it will not cover), how it will be administered and what it will cost. Examples of these alternative fluoride delivery programs include school-based fluoride mouthrinse programs, fluoride supplements, fluoride varnish and other professionally applied topical fluorides. Often dental health education programs including dispensing “free” toothbrushes and fluoridated toothpaste are mentioned as an alternative to fluoridation. All of these programs can be beneficial but are not as cost-effective as fluoridation programs because they typically require additional personnel to facilitate the programs, action on the part of the recipient and have much higher administrative and supply costs. Additionally, these programs typically target only children and so do not provide decay preventing benefits to adults. Fluoridation benefits all members of the community — children and adults — and is more cost-effective. The CDC’s “Health Impact in 5 Years” (HI-5) initiative11 launched in 2016 highlights community- wide approaches that have evidence reporting 1) positive health impacts, 2) results in five years and 3) cost-effectiveness or cost savings over the lifetime of the population or earlier. Fluoridation is one of the community approaches included in the HI-5 Initiative as it has great potential to help keep people healthy as it reaches all members of a community where they live, learn, work, and play. Documenting the impact