Cost-Effectiveness of Oral Health Care
Using the evidence available, the U.S. Surgeon General's report (U.S. Public Health Service 2000) and the report of the Swedish Council on Technology Assessment in Health Care (SBU 2002; see also Kallestal and others 2003) have attempted to determine the cost-effectiveness of oral health intervention programs from developed countries.
Among the findings in the U.S. report were the following:
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Water fluoridation costs about a dollar per person per year for water serving most individuals in the United States. Community water fluoridation is believed to be an effective and cost-effective caries preventive method.
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Economic analyses of community dental sealant programs suggest that they are cost-effective and may even provide cost savings when used in high-risk populations.
The Swedish report (SBU 2002), reviewing original studies on economic evaluation of caries prevention (a total of 17 selected from 1966 to 2003 MEDLINE and manual Internet searches), commented that no conclusion could be drawn owing to the low evidence values and contradictory results. This comment prompted the group to present its own calculation for cost-effectiveness based on Swedish caries prevalence and charges used in Swedish dental care. The group found that the cost-effectiveness for fluoridated toothpaste is extremely good (cost per prevented DMFT very low), which, of course, is not surprising, given the significant caries-reducing results in combination with low cost for society.
No clear correlation appears to exist between caries experience and health care investment for individual countries. Some countries with the lowest health care expenditures have values for caries experience (DMFT) that are similar to or even lower than those countries having the highest expenditures on health (figure 38.2). Those low-income countries often have low per capita sugar consumption and, therefore, do not need to install expensive measures for treatment or prevention.
[Figure
38.2]
It may seem surprising that so few studies are available regarding the cost-effectiveness of caries prevention, or of any other oral disease. In a critical review article, Schwarz (1998) analyzed the issue. He wrote, "Several decades after considerable improvements in the oral disease situation were documented in Scandinavia, doubts are still expressed about whether preventive measures are cost-effective." In addition, he recommended that four elements be considered when a preventive effect was evaluated: the definition of prevention, the practical perception of effective prevention, the appropriateness of traditional cost-effectiveness analysis, and the time factor. He pointed out that "caries prevention is not uniformly defined by the profession, that dental research is casting doubt on the effectiveness of traditionally accepted preventive measures, that political pressures on health care are motivated by economic pressures." Finally, he stated that traditional cost-benefit and cost-effectiveness analyses have not been able to help the decision makers choose wisely and that the time perspective for the real effects of prevention lies beyond the interests of decision makers.
However, without proper prevention, the alternative strategy is restorative dentistry—that is, to make fillings, crowns, and dentures. Is this a feasible alternative for developing countries? Yee and Sheiham (2003) give some examples: In Nepal, a simple amalgam filling would cost about US$4, which does not include the many additional expenses for impoverished rural families, who may have to travel by bus or walk for a day or two to get to the clinic. The total expenses incurred, including dental fees, meals, and lodging but not including lost wages, would amount to US$12, an enormous sum considering the average Nepalese's earning of US$0.75 per day, and it is enough to buy food for a month. Yee and Sheiham conclude that treating caries with the traditional method of restorative dentistry is beyond the financial capabilities of most low-income nations because three-quarters of these countries do not even have sufficient resources to finance an essential package of health care services for their children. Yee and Sheiham (2003) estimate that treating dental caries by the traditional amalgam restorative dentistry in the permanent dentition of the child population would cost about US$2,000 for 1,000 children of mixed ages from 6 to 18 years, which would require financial resources beyond the capabilities of low-income nations. Hence, they propose a public health and health promotion approach to reduce caries burden instead of the restorative approach.
Although several studies evaluating the effectiveness of intervention and oral health promotion programs in developing countries are becoming available (Estupinan-Day and others 2001; Pakhomov and others 1995; Petersen and others 2004), a definite need exists for further cost-effectiveness analysis on such programs, which should be addressed in the future. It would also be useful if studies were commenced on intervention programs using the common-risk approach suggested by WHO (Petersen 2003).
