Cost-effectiveness and cost-benefit analyses of fluoride varnish for caries prevention in Guangxi, China.

OBJECTIVES: The objectives of this study were to evaluate the cost-effectiveness and cost-benefit of fluoride varnish (FV) interventions for preventing caries in the first permanent molars (FPMs) among children in rural areas in Guangxi, China. METHODS: This study constituted a secondary analysis of data from a randomised controlled trial, analysed from a social perspective. A total of 1,335 children aged 6-8 years in remote rural areas of Guangxi were enrolled in this three-year follow-up controlled study. Children in the experimental group (EG) and the control group (CG) received oral health education and were provided with a toothbrush and toothpaste once every six months. Additionally, FV was applied in the EG. A decision tree model was developed, and single-factor and probabilistic sensitivity analyses were conducted. RESULTS: After three years of intervention, the prevalence of caries in the EG was 50.85%, with an average decayed, missing, and filled teeth (DMFT) index score of 1.12, and that in the CG was 59.04%, with a DMFT index score of 1.36. The total cost of caries intervention and postcaries treatment was 42,719.55 USD for the EG and 46,622.13 USD for the CG. The incremental cost-effectiveness ratio (ICER) of the EG was 25.36 USD per caries prevented, and the cost-benefit ratio (CBR) was 1.74 USD benefits per 1 USD cost. The results of the sensitivity analyses showed that the increase in the average DMFT index score was the largest variable affecting the ICER and CBR. CONCLUSIONS: Compared to oral health education alone, a comprehensive intervention combining FV application with oral health education is more cost-effective and beneficial for preventing caries in the FPMs of children living in economically disadvantaged rural areas. These findings could provide a basis for policy-making and clinical choices to improve children's oral health.

Management of dental caries among children: a look at the cost-effectiveness.

INTRODUCTION: Dental caries is the most prevalent non-communicative disease worldwide. Although the etiological factors are well known for years, reducing the number of decayed and missing teeth in children still remains as a barrier. Preventive and curative options are numerous but little is known about their economical advantages. Selecting the intervention that offers the best balance of effectiveness and financial resources becomes crucial in the current situation of budget restrictions worldwide. AREAS COVERED: This expert review summarizes available evidence on cost-effectiveness analyses of preventive and curative measures to manage dental caries in children. EXPERT COMMENTARY: Preventive measures have been more extensively studied than dental caries treatment. Only water fluoridation and tooth brushing are well-established as cost-effective preventive approaches. Despite the increasing number of cost analysis treatment studies in the literature, most of them focus on the cost description, with no correlation to the intervention effectiveness. There is a current need of well-designed and well-reported cost-effectiveness regarding dental caries management.

A randomised controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services: the Northern Ireland Caries Prevention In Practice (NIC-PIP) trial.

BACKGROUND: Dental caries is the most common disease of childhood. The NHS guidelines promote preventative care in dental practices, particularly for young children. However, the cost-effectiveness of this policy has not been established. OBJECTIVE: To measure the effects and costs of a composite fluoride intervention designed to prevent caries in young children attending dental services. DESIGN: The study was a two-arm, parallel-group, randomised controlled trial, with an allocation ratio of 1 : 1. Randomisation was by clinical trials unit, using randomised permuted blocks. Children/families were not blinded; however, outcome assessment was blinded to group assessment. SETTING: The study took place in 22 NHS dental practices in Northern Ireland, UK. PARTICIPANTS: The study participants were children aged 2-3 years, who were caries free at baseline. INTERVENTIONS: The intervention was composite in nature, comprising a varnish containing 22,600 parts per million (p.p.m.) fluoride, a toothbrush and a 50-ml tube of toothpaste containing 1450 p.p.m. fluoride; plus standardised, evidence-based prevention advice provided at 6-monthly intervals over 3 years. The control group received the prevention advice alone. MAIN OUTCOME MEASURES: The primary outcome measure was conversion from caries-free to caries-active states. Secondary outcome measures were the number of decayed, missing or filled tooth surfaces in primary dentition (dmfs) in caries-active children, the number of episodes of pain, the number of extracted teeth and the costs of care. Adverse reactions (ARs) were recorded. RESULTS: A total of 1248 children (624 randomised to each group) were recruited and 1096 (549 in the intervention group and 547 in the control group) were included in the final analyses. A total of 87% of the intervention children and 85% of control children attended every 6-month visit (p = 0.77). In total, 187 (34%) children in the intervention group converted to caries active, compared with 213 (39%) in the control group [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.64 to 1.04; p = 0.11]. The mean number of tooth surfaces affected by caries was 7.2 in the intervention group, compared with 9.6 in the control group (p = 0.007). There was no significant difference in the number of episodes of pain between groups (p = 0.81). However, 164 out of the total of 400 (41%) children who converted to caries active reported toothache, compared with 62 out of 696 (9%) caries-free children (OR 7.1 95% CI 5.1 to 9.9; p < 0.001). There was no statistically significant difference in the number of teeth extracted in caries-active children (p = 0.95). Ten children in the intervention group had ARs of a minor nature. The average direct dental care cost was £155.74 for the intervention group and £48.21 for the control group over 3 years (p < 0.05). The mean cost per carious surface avoided over the 3 years was estimated at £251.00. LIMITATIONS: The usual limitations of a trial such as generalisability and understanding the underlying reasons for the outcomes apply. There is no mean willingness-to-pay threshold available to enable assessment of value for money. CONCLUSIONS: A statistically significant effect could not be demonstrated for the primary outcome. Once caries develop, pain is likely. There was a statistically significant difference in dmfs in caries-active children in favour of the intervention. Although adequately powered, the effect size of the intervention was small and of questionable clinical and economic benefit. FUTURE WORK: Future work should assess the caries prevention effects of interventions to reduce sugar consumption at the population and individual levels. Interventions designed to arrest the disease once it is established need to be developed and tested in practice. TRIAL REGISTRATION: Current Controlled Trials ISRCTN36180119 and EudraCT 2009-010725-39. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 71. See the NIHR Journals Library website for further project information.

Socioeconomic inequalities and determinants of oral hygiene status among Urban Indian adolescents.

OBJECTIVES: To assess the socioeconomic inequalities in oral hygiene and to explore the role of various socioeconomic and psychosocial factors as determinants of these inequalities among adolescents residing in Delhi National Capital Territory. METHODS: A cross-sectional study was conducted among 1386 adolescents aged 12-15 years from three different socioeconomic groups according to their area of residence (middle-class areas, resettlement colonies and urban slum colonies). Level of oral hygiene was examined clinically using the Simplified Oral Hygiene Index (OHI-S), and an interviewer-administered questionnaire was used to measure key socio-demographic variables and psychosocial and health-related behaviours. Logistic regression analysis tested the association between area of residence and poor oral hygiene. RESULTS: Poor oral hygiene was observed in 50.2% of the adolescents. There was a socioeconomic gradient in poor oral hygiene, with higher prevalence observed at each level of deprivation. These differences were only partly explained, and the differences between adolescent groups remained statistically significant after adjusting for various demographic variables, standard of living, social capital, social support and health-affecting behaviours (OR: 1.96, 95% CI: 1.30-2.76; and OR: 2.50, 95% CI: 1.60-3.92 for adolescents from resettlement colonies and urban slums, respectively, than middle-class adolescents). CONCLUSION: Area of residence emerged as a strong socioeconomic predictor of prevalence of poor oral hygiene among Indian adolescents. Various material, psychosocial and behavioural factors did not fully explain the observed inequalities in poor oral hygiene among different adolescent groups.

The association between parents' perceived social norms for toothbrushing and the frequency with which they report brushing their child's teeth.

OBJECTIVES: To determine whether parents' judgements on how often other parents brush their children's teeth are associated with the frequency with which they brush their own children's teeth, and their satisfaction with their child's brushing routine. METHODS: A cross-sectional questionnaire survey completed by 297 parents of children aged 3-6. Parents were asked how often they brushed their own child's teeth per week, how often they thought other parents did so, and how satisfied they were with their child's toothbrushing routine. Demographic data were also collected. RESULTS: The mean frequency that parents brushed their children's teeth was 12.5 times per week. Multiple regression analysis tested the relationship between parents' perceptions of other parents brushing frequency (mean 10.5 times per week) and how often they brushed their own child's teeth, controlling for socio-demographic factors, and yielded a positive association (p < 0.001). There was a positive association between parents' satisfaction with their child's brushing routine and the extent to which they thought it was better than that of the average child (p < 0.001). CONCLUSIONS: Parents' judgements on how frequently other parents brush their children's teeth are associated with their own behaviour and satisfaction. Re-framing oral health messages to include some form of social normative information ("most parents do this") may prove more persuasive than simple prescriptive advice ("you should do this").

Evaluation of the Candida albicans removal and mechanical properties of denture acrylics cleaned by a low-cost powered toothbrush.

PURPOSE: To investigate the effects of using a low-cost powered toothbrush for cleaning on dental prostheses made of heat polymerized poly(methyl methacrylate), PMMA. METHODS: Heat cured PMMA specimens beam with the dimensions of 45.0 mm×6.5 mm×4.5mm were fabricated. The specimens were kept in water storage at 37 °C constant temperature for 0, 1, 7, 15, 30 and 60 days and randomly assigned for testing or control. Test specimens underwent brushing by using a powered toothbrush at an applied force of 2.00 N for 22 min with water as medium. Surface roughness measurement (Ra), flexural strength and efficacy of brushing to remove coated Candida albicans biofilm were investigated. RESULTS: The results of the mean surface roughness value and the flexural strength were analysed by using two-way ANOVA and Tukey post hoc test at 5% significance level. In general, the specimens showed no significant changes in flexural strength after brushing. However, the flexural strength and the surface roughness value were significantly lower in specimens group after 7 days in water storage compared to the control. SEM micrographs of post-brushed specimens revealed satisfactory removal of C. albicans biofilm. CONCLUSION: A low-cost powered toothbrush together with a liquid medium successfully removed C. albicans biofilm on dental acrylic PMMA-based prostheses, without compromising the mechanical properties.

Self-rated dental health and dental insurance: modification by household income.

BACKGROUND: Previous studies have reported that socioeconomically disadvantaged Australians have poorer self-rated dental health (SRDH), are less likely to be insured for dental services and are less likely to have regular dental visits than their more advantaged counterparts. However, less is known about the associations between dental insurance and SRDH. The aim of this study was to examine the associations between SRDH and dental insurance status and to test if the relationship was modified by household income. METHODS: A random sample of 3,000 adults aged 30-61 years was drawn from the Australian Electoral Roll and mailed a self-complete questionnaire. Analysis included dentate participants. Bivariate associations were assessed between SRDH and insurance stratified by household income group. A multiple variable model adjusting for covariates estimated prevalence ratios (PR) of having good to excellent SRDH and included an interaction term for insurance and household income group. RESULTS: The response rate was 39.1% (n = 1,093). More than half (53.9%) of the participants were insured and 72.5% had good to excellent SRDH. SRDH was associated with age group, brushing frequency, insurance status and income group. Amongst participants in the $40,000- < $80,000 income group, the insured had a higher proportion reporting good to excellent SRDH (80.8%) than the uninsured (66.5%); however, there was little difference in SRDH by insurance status for those in the $120,000+ income group. After adjusting for covariates, there was a significant interaction (p < 0.05) between having insurance and income; there was an association between insurance and SRDH for adults in the $40,000- < $80,000 income group, but not for adults in higher income groups. CONCLUSIONS: For lower socio-economic groups being insured was associated with better SRDH, but there was no association for those in the highest income group. Insurance coverage may have the potential to improve dental health for low income groups.

Cost-effectiveness of personalized plaque control for managing the gingival manifestations of oral lichen planus: a randomized controlled study.

AIM: To undertake cost-effectiveness and cost-benefit analyses of an intervention to improve oral health in patients presenting with the gingival manifestations of oral lichen planus (OLP). MATERIALS & METHODS: Eighty-two patients were recruited to a 20-week randomized controlled trial. The intervention was personalized plaque control comprising powered tooth brushing and inter-dental cleaning advice. The primary outcome measure was the oral health impact profile (OHIP) with secondary outcomes of pain, plaque index, mucosal disease score and cost-effectiveness. Private cost data and stated willingness-to-pay (WTP) values for treatment were obtained from intervention patients at 20 weeks. RESULTS: Overall, 81% of intervention patients showed improvement in both plaque index and mucosal disease score at 20 weeks compared to 30% of controls that continued with their usual plaque control regimen. All intervention group patients stated a positive WTP value. The mean net value of the treatment was £172 compared to the incremental cost of the treatment estimated at £122.75. The cost-effectiveness analysis resulted in an incremental cost-effectiveness ratio of £13 per OHIP point. CONCLUSIONS: The tailored plaque control programme was more effective than control in treating the gingival manifestations of oral lichen planus. The programme is cost effective for modest values placed on a point on the OHIP scale and patients generally valued the treatment in excess of the cost.

[Cost-effectiveness of conventional and modified supervised toothbrushing in preventing caries in permanent molars among 5-year-old children]. / Custo-efetividade da escovação dental supervisionada convencional e modificada na prevenção da cárie em molares permanentes de crianças de 5 anos de idade.

The cost-effectiveness of a modified supervised toothbrushing program was compared to a conventional program. A total of 284 five-year-old children presenting at least one permanent molar with emerged/sound occlusal surface participated. In the control group, oral health education and dental plaque dying followed by toothbrushing with fluoride dentifrice was carried outfour times per year. With the test group, children also underwent professional cross-brushing on surfaces of first permanent molar rendered by a dental assistant five times per year. Enamel/dentin caries were recorded on buccal, occlusal and lingual surfaces of permanent molars for a period of 18 months. The incidence density (ID) ratio was estimated using Poisson's regression model. The ID was 50% lower among boys in the test group (p = 0.016). The cost of the modified program was US$ 1.79 per capita. The marginal cost-effectiveness ratio among boys was US$ 6.30 per avoided carie. The modified supervised toothbrushing program was shown to be cost-effective in the case of boys.

Custo-efetividade da escovação dental supervisionada convencional e modificada na prevenção da cárie em molares permanentes de crianças de 5 anos de idade / Cost-effectiveness of conventional and modified supervised toothbrushing in preventing caries in permanent molars among 5-year-old children

O custo-efetividade de um programa modificado de escovação dental supervisionada foi comparado ao programa convencional. Participaram 284 crianças de 5 anos com, pelo menos, um molar permanente com a superfície oclusal irrompida/hígida. Nas unidades de controle, o programa convencional composto de atividade educativa com distribuição de escova e creme dental fluorado foi desenvolvido quatro vezes por ano. Nas unidades de teste, as crianças receberam também escovação profissional nas superfícies oclusais desses dentes, realizada por auxiliar de saúde bucal, empregando-se a técnica de escovação vestíbulo-lingual cinco vezes por ano. Cárie de esmalte/dentina foi registrada nas superfícies vestibular, oclusal e lingual dos molares permanentes durante 18 meses. A razão da densidade de incidência (RDI) foi estimada usando o modelo de regressão de Poisson, sendo 50 por cento menor entre os meninos no grupo de teste (p = 0,016). O programa modificado custou R$ 3,04 por criança. A razão de custo-efetividade marginal foi de R$ 10,71 por lesão evitada entre os meninos. O programa modificado foi custo-efetivo nos meninos.

The cost-effectiveness of a modified supervised toothbrushing program was compared to a conventional program. A total of 284 five-year-old children presenting at least one permanent molar with emerged/sound occlusal surface participated. In the control group, oral health education and dental plaque dying followed by toothbrushing with fluoride dentifrice was carried outfour times per year. With the test group, children also underwent professional cross-brushing on surfaces of first permanent molar rendered by a dental assistant five times per year. Enamel/dentin caries were recorded on buccal, occlusal and lingual surfaces of permanent molars for a period of18 months. The incidence density (ID) ratio was estimated using Poisson's regression model. The ID was 50 percent lower among boys in the test group (p = 0.016). The cost of the modified program was US$ 1.79 per capita. The marginal cost-effectiveness ratio among boys was US$ 6.30 per avoided carie. The modified supervised toothbrushing program was shown to be cost-effective in the case of boys.

Protocol for Northern Ireland Caries Prevention in Practice Trial (NIC-PIP) trial: a randomised controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services.

BACKGROUND: Dental caries is a persistent public health problem with little change in the prevalence in young children over the last 20 years. Once a child contracts the disease it has a significant impact on their quality of life. There is good evidence from Cochrane reviews including trials that fluoride varnish and regular use of fluoride toothpaste can prevent caries. The Northern Ireland Caries Prevention in Practice Trial (NIC-PIP) trial will compare the costs and effects of a caries preventive package (fluoride varnish, toothpaste, toothbrush and standardised dental health education) with dental health education alone in young children. METHODS/DESIGN: A randomised controlled trial on children initially aged 2 and 3 years old who are regular attenders at the primary dental care services in Northern Ireland. Children will be recruited and randomised in dental practices. Children will be randomised to the prevention package of both fluoride varnish (twice per year for three years), fluoride toothpaste (1,450 ppm F) (supplied twice per year), a toothbrush (supplied twice a year) or not; both test and control groups receive standardised dental health education delivered by the dentist twice per year. Randomisation will be conducted by the Belfast Trust Clinical Research Support Centre ([CRSC] a Clinical Trials Unit). 1200 participants will be recruited from approximately 40 dental practices. Children will be examined for caries by independent dental examiners at baseline and will be excluded if they have caries. The independent dental examiners will examine the children again at 3 years blinded to study group.The primary end-point is whether the child develops caries (cavitation into dentine) or not over the three years. One secondary outcome is the number of carious surfaces in the primary dentition in children who experience caries. Other secondary outcomes are episodes of pain, extraction of primary teeth, other adverse events and costs which will be obtained from parental questionnaires. DISCUSSION: This is a pragmatic trial conducted in general dental practice. It tests a composite caries prevention intervention, which represents an evidence based approach advocated by current guidance from the English Department of Health which is feasible to deliver to all low risk (caries free) children in general dental practice. The trial will provide valuable information to policy makers and clinicians on the costs and effects of caries prevention delivered to young children in general dental practice. TRIAL REGISTRATION: EudraCT No: 2009 - 010725 - 39 ISRCTN: ISRCTN36180119 Ethics Reference No: 09/H1008/93:

Investigation of wear in manual toothbrushes from different price categories.

This clinical study examined differences in wear in manual toothbrushes from different price categories. 140 volunteers (14 groups of 10) brushed twice daily for 2-3 minutes over a period of three or six months using the modified Bass technique and seven different toothbrushes (TB) from three price categories. A: 2 TB for under 1 Euro; B: 2 TB priced between 1 and 2 Euro; C: 3 TB priced at over 2 Euro. After a period of three or six months the increase in the bristle surface field was determined and the brush heads were rated macroscopically, by light microscopy and scanning electron microscopy (SEM) (grades 1-4: new, small, clear or very clear signs of use). The statistical analysis was performed with the Mann-Whitney U-test and Error Rates method (p < or = 0.05). All bristle fields showed an increase in surface area over the period of use. When examined macroscopically and under light microscopy, very little difference was found between three and six months of use, or between brushes from the same price category. The clearest distinction was found between categories B and C, whereby C was rated worse. In SEM it was difficult to separate the findings according to price categories. Here, the scores most often awarded were 3 and 4. The results of the three test methods differed markedly from one another. Thus no conclusions on the state of the bristles can be drawn from a marked increase in bristle field surface area. The category B TB tended to perform best.

The clinical effectiveness of a novel power toothbrush and its impact on oral health.

This review details the invention and clinical testing of a new power toothbrush designed to provide a low cost, effective toothbrush, which has a combination of a round oscillating head in conjunction with fixed bristles. The data demonstrate this power toothbrush (Crest SpinBrush) is an effective cleaning toothbrush with respect to plaque removal. Four independent 4-period crossover studies, where subjects used each brush twice, have demonstrated that brushing with this power toothbrush results in 10-40% greater plaque removal relative to a series of control manual toothbrushes. Separate research has confirmed that adults and children tend to brush longer, 35.8% and 38.3% respectively, when using this power toothbrush relative to manual toothbrushes. In addition, it has been shown to be superior to a battery-powered toothbrush (Colgate ActiBrush) in two independent studies and has demonstrated comparable efficacy to a leading powered toothbrush (Oral-B Ultra Plaque Remover). In parallel, this power toothbrush has also been shown to be safe relative to manual and power toothbrushes.

A comparison of three oral care products commonly used in practice.

This project compared the efficacy, patient satisfaction, and cost of three commonly used oral care products: lemon glycerin swabs, Moi-Stir swabs, and toothettes (pink sponge applicators) and water. Hospitalized adults who were either required to receive nothing by mouth or who required oxygen were asked to participate in the project. Once enrolled, the patients were randomly assigned to one of the three oral care groups. Oral assessments were performed daily, and perceptions of oral comfort were solicited from alert patients. Although the sample size was not large enough to reach statistical significance, a few trends were noted. First, the patients' oral condition generally worsened during the first 3 days but then improved between Days 4 and 5. Moi-Stir performed better than either lemon glycerin or toothettes and water, as evidenced by lower Day 4-5 scores. Patients generally liked the swab to which they were assigned.

Clinical and cost effectiveness of the counter-rotational brush in private practice.

There have previously been no studies on the cost effectiveness of the use of a counter-rotational toothbrush (INTERPLAK Home Plaque-Removal Instrument), which has been demonstrated to be more effective than ordinary toothbrushes in reaching plaque-removal and gingival-health goals. Killoy et al studied the costs of required periodontal treatment for 32 patients with moderate periodontitis at two corporate capitation dental centers. The subjects were divided into two groups, a test group that brushed with a counter-rotational toothbrush and one that brushed with a manual toothbrush. Probing depth, attachment levels, and plaque and bleeding indexes in the test brush group were better than those in the control group. The end result was a mean reduction of $535 in the cost of periodontal treatment that had been planned before using the counter-rotational brush over 18 months, while the group using the manual brush experienced a mean increase of $11 in required treatment over original plans. Furthermore, the test group reached a state of gingival health, but the control group did not. The study concluded that the counter-rotational brush is cost effective.