A cost-effectiveness analysis of community water fluoridation for schoolchildren

Abstract

Background Community water fluoridation (CWF), the controlled addition of fluoride to the water supply for the prevention of dental caries (tooth decay), is considered a safe and effective public health intervention. The Republic of Ireland (Ireland) is the only country in Europe with a legislative mandate for the fluoridation of the public water supply, a key component of its oral health policy. However, more recently, there has been an increase in public concern around the relevance of the intervention given the current environment of multiple fluoride sources and a reported increase in the prevalence of enamel fluorosis. The aim of this economic analysis is to provide evidence to inform policy decisions on whether the continued public investment in community water fluoridation remains justified under these altered circumstances. Methods Following traditional methods of economic evaluation and using epidemiological data from a representative sample of 5-, 8-, and 12-year-old schoolchildren, this cost-effectiveness analysis, conducted from the health-payer perspective, compared the incremental costs and consequences associated with the CWF intervention to no intervention for schoolchildren living in Ireland in 2017. A probabilistic model was developed to simulate the potential lifetime treatment savings associated with the schoolchildren’s exposure to the intervention for one year. Results In 2017, approximately 71% of people living in Ireland had access to a publicly provided fluoridated water supply at an average per capita cost to the state of €2.15. The total cost of CWF provision to 5-, 8-, and 12-year-old schoolchildren (n = 148,910) was estimated at €320,664, and the incremental cost per decayed, missing, or filled tooth (d3vcmft/D3vcMFT) prevented was calculated at €14.09. The potential annual lifetime treatment savings associated with caries prevented for this cohort was estimated at €2.95 million. When the potential treatment savings were included in the analysis, the incremental cost per d3vcmft/D3vcMFT prevented was -€115.67, representing a cost-saving to the health-payer and a positive return on investment. The results of the analysis were robust to both deterministic and probability sensitivity analyses. Conclusion Despite current access to numerous fluoride sources and a reported increase in the prevalence of enamel fluorosis, CWF remains a cost-effective public health intervention for Irish schoolchildren.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review

“…Two other studies used various WTP thresholds using proposed dental outcomes [48,60]. The WTP threshold of AU$50,000 per DALY averted [67,68], £20,000 per QALY gained [40,58], and the 2014 US gross domestic gross product 2 (3%) Chile [44,59,61,82,85] 5 (6%) Finland [60] 1 (1%) Germany [49,50,62,89,90,108,110] 7 (9%) Ireland [71,108] 2 (3%) Japan [97,108] 2 (3%) Netherlands [86,105] 2 (3%) New Zealand [55,73,79] 3 (4%) Norway [109] 1 (1%) Spain [108] 1 (1%) Sweden [48,106,107] 3 (4%) UK [40,54,58,84,95,102,104,108,[111][112][113] 12 (15%) USA [41, 43, 45-47, 53, 69, 74, 76, 88, 91, 98, 101, 102, 108, 123, 124] 17 (21%) Subtotal 72 (90%) Upper-middle income Brazil [42] 1 (1%) Iran…”

“…The majority of universal interventions were reported to be cost-effective or cost-saving. These universal interventions included various forms of topical fluorides [55,67,68,[70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85], interventions targeting the reduction of sugar consumption such as SSBs taxation or ban on selling SSBs at the workplace [86][87][88][89], increasing use of chewing sugar-free gum [90], and bacterial screening saliva test for virulent levels of mutans streptococci [91]. For interleukin-1 genetic screening to prevent periodontitis for persons aged 35 years, the ICER was calculated but the cost-effectiveness was not stated [53].…”

“…For selective interventions, targeted community-based group oral health education for adults [92], targeted primary schoolbased fluoride mouth-rinse program [85], targeted telehealth or home visit oral health education for young children [57, N = total number of economic evaluations, N/S not stated, Standard care refers to treatment as usual with 6-monthly dental check-ups # Only one study on water fluoridation economically evaluated dental caries and periodontitis [70] *Overall quality of studies using the Gonzalez-Perez (2002) criteria [38] for the Drummond 10-point checklist [34] 1 (2%) < 5 years [125] 14 (23%) 5-10 years [40,41,45,47,57,59,63,75,80,81,83,85,87,89,93,96,[98][99][100][101]123] 21 (34%) > 10 years [49,50,52,53,55,62,67,68,70,71,74,76,77,79,86,90,[108]…”

“…Direct treatment costs-restorations, extractions and other direct costs for dental caries and periodontitis [70,88,110] 3 (5%) Direct treatment costs for periodontitis only [53,108,109] 3 (5%) Cost categories-societal perspective Direct societal costs-N/R [87] 1 (2%) Direct societal costs (intervention only) [42,55,67,68,71,72,75,76,78,79,83,86,89,95,96,99] 15 (25%) Direct and indirect societal costs (productivity costs lost, travel costs, etc.) [40,44,57,69,70,73,74 [40,46,59] 3 (5%) Restorative/extraction/episode of pain/hospital/event averted [43,47,63,95,123] 5 (8%) Retained-tooth per year [49,62,109,110] 4 (7%) Tooth loss averted [108] 1 (2%) [42,48,60,…”

Dietary Fluoride Intake by Children: When to Use a Fluoride Toothpaste?

“…Excess fluoride intake from drinking water and various dental hygiene products have potential health risks [ 8 , 9 , 10 ]. In fact, prolonged excessive intake of fluoride has been associated with fluorosis [ 11 ]. Fluorosis is a degenerative and progressive disorder that adversely affects many other organs, such as the bone biomechanical properties, thyroid, kidney, liver, lung and brain [ 12 , 13 , 14 , 15 , 16 , 17 ].…”