Design of an innovative paediatric capitation payment approach for public sector dentistry: an Australian experience.

AIM: The aim of this study was to trial the methodology and administration processes of a public paediatric capitation programme provided in the period 1 July 2011 to 31 December 2011 through a Bachelor of Oral Health programme in rural New South Wales (NSW), Australia, where access to public dental services is limited. BASIC RESEARCH DESIGN: The principal structure of the programme was the development of three diagnostic pathways: active caries and pain (Pathway A); active caries and no pain (Pathway B); and no active caries and no pain (Pathway C). In 2011, de-identified treatment data for NSW public dental services' patients under 18 years of age were analysed to identify the top 10 dental treatment items. These items were clustered according to the mean decayed and/or filled surface of patients under 18 years of age who had decayed, filled or missing teeth. Each treatment item was allocated 60% of the 2011 Australian Government Department of Veteran Affairs Schedule of Fees. CLINICAL SETTING: The programme was trialled in Charles Sturt University dental facility in Wagga Wagga, NSW. PARTICIPANTS: The programme targeted patients in the following age groups: 0-5 years; 6-11 years; and 12-17 years. RESULT: The 6-month trial provided 361 patients with a capitation pathway, at a total cost of $47,567.90, averaging $131.76 per capitation pathway. The total number of items provided (n=2,070) equated to an average of 5.7 items per capitation diagnostic pathway. CONCLUSION: This model offered an early entry point for paediatric patients to access dental care that addressed their needs, whilst being flexible enough to be fiscally attractive.

A retrospective analysis of caries treatment and development in relation to assessed caries risk in an adult population in Sweden.

BACKGROUND: The Public Dental Service of Västerbotten County (Sweden) recommends using population-based prevention strategies combined with an individual strategy for high-risk patients to manage caries. To facilitate this management strategy, all patients are evaluated for their risk of developing caries in the coming year using defined criteria. Using caries risk scoring over a seven-year period, the present study evaluates prophylactic measures, caries development, and non-operative treatments in adult patients. METHODS: From all adult patients (25-65 years; n = 76 320) scored with a high caries risk in 2005 (baseline) and with a dental visit in 2011, 200 subjects were randomly selected. In addition, an equally sized control group with a no/low caries risk was selected. Information concerning dental status, counselling, treatments, visits, and costs were retrieved from dental records. RESULTS: Over the seven-year study period, subjects with high caries risk had significantly higher caries incidence in spite of shorter recall intervals, more dental appointments, and higher costs for dental care than subjects with no/low caries risk. Non-operative measures, such as additional fluoride and individual counselling on diet at baseline (2005), was higher in the high caries risk group, whereas information about basic prophylaxis and counselling on oral hygiene showed only small differences. The frequency of non-operative measures given during the seven-year study period to patients in the high caries risk group is considered to be remarkably low and improvement, determined as reclassification from high to no/low caries risk from 2005 to 2011, was seen in only 13% of the participants. CONCLUSIONS: This study formulated two major conclusions. First, adult patients with high or no/low caries represent different populations, that each contain distinct subpopulations, those who improve/impair or maintained their caries risk and disease progression. These groups need different strategies in disease treatment. Second, preventive measures and non-operative treatments were associated with improvements in caries risk and maintenance, but the extent to which such treatments were given to high caries risk subjects was unacceptably low. Improved adherence to the guidelines for caries treatment may reduce caries risk, visits to dental clinics, and costs for the patients.

Modeling an economic evaluation of a salt fluoridation program in Peru.

OBJECTIVE: This article models the cost-effectiveness, from a societal viewpoint, of a dental caries prevention program using salt fluoridation for children 12 years of age, compared with non-intervention (or status quo) in Arequipa, Peru. METHODS: Standard cost-effectiveness analysis methods were used. The costs associated with implementing and operating the salt-fluoridation program were identified and measured using 2009 prices. Health outcomes were measured as dental caries averted over a 6-year period. Clinical effectiveness data was taken from published data. Costs were measured as direct treatment costs, programs costs and costs of productivity losses as a result of dental treatments. The incremental cost-effectiveness ratio was calculated. A hypothetical population of 25,000 12-year-olds living in Arequipa, Peru was used in this analysis. Two-way sensitivity analyses were conducted over a range of values for key parameters. RESULTS: Our primary analysis estimated that if a dental caries prevention program using salt-fluoridation was available for 25,000 6-year-old children for 6 years, the net saving from a societal perspective would total S/. 11.95 [1 US$ = S/. (2009) 3.01] per diseased tooth averted when compared with the status quo group. That is, after 6 years, an investment of S/.0.32 per annum per child would result in a net saving of S/.11.95 per decayed/missing/filled teeth prevented. CONCLUSIONS: While the analysis has inherent limitations as a result of its reliance on a range of assumptions, the findings indicate that for the situations prevailing in Peru, there are significant health and economic benefits to be gained from the use of salt fluoridation.

Cost-effectiveness of an experimental caries-control regimen in a 3.4-yr randomized clinical trial among 11-12-yr-old Finnish schoolchildren.

The aim of this study was to assess the cost-effectiveness of an experimental caries-control regimen in a randomized clinical trial (RCT) conducted in Pori, Finland, in 2001-2005. Children (n = 497) who were 11-12 yr of age and had at least one active initial caries lesion at baseline were studied. The children in the experimental group (n = 250) were offered an individually designed patient-centered regimen for caries control. The children in the control group (n = 247) received standard dental care. Furthermore, the whole population was exposed to continuous community-level oral health promotion. Individual costs of treatment procedures and outcomes (DMFS increment score) for the follow-up period of 3.4 yr were calculated for each child in both groups. The incremental cost-effectiveness ratio was euro 34.07 per averted DMF surface. The experimental regimen was more effective, and also more costly. However, the total costs decreased year after year, and for the last 2 yr the experimental regimen was less expensive than the standard dental care. The experimental regimen would probably have been more cost-effective than standard dental care if the follow-up period had been longer, the regimen less comprehensive, and/or if dental nurses had conducted the preventive procedures.

Modelling lifelong costs of caries with and without fluoride use.

Cost-benefit or cost-cost analyses are becoming increasingly important in dentistry. Therefore, the aim of the present study was to evaluate the economic consequences of caries prevention with fluorides. German epidemiological data were used in a system dynamics model to assess the lifelong costs of caries in a population. Without fluoride prevention, lifelong treatment for caries resulted in mean costs of 6,976 euro and a present value of 932 euro per person (5% discounting). In different scenarios of constant, increasing, or decreasing caries-controlling effects, and of limited (age 6-18 yr) or lifelong application, the combination of fluoride salt, fluoride toothpaste, and fluoride gel were most cost-effective. They reduced the costs for caries treatment and prophylaxis to 482, euro or to a present value of 148 euro (5% discounting), when applied from age 6-18 yr, and to 211-213 euro for lifelong use (present value, 5% discounting). In conclusion, a lifelong model of costs of caries demonstrates that the use of fluorides in caries prevention is highly cost-effective.

Cost-Benefit Analysis of Providing Fluoride Varnish in a Pediatric Primary Care Office.

INTRODUCTION: The American Academy of Pediatrics and the U.S. Preventive Services Task Force, among others, call for the provision of fluoride varnish in the pediatric primary care setting, but many barriers exist to the implementation of such a service in this setting. Knowledge of costs and benefits is one such barrier. METHODS: A cost-benefit analysis of the implementation of a fluoride varnish program in a pediatric primary care office located in Volusia County, Florida was conducted with the assistance of the office manager and a nurse practitioner using data retrieved from the electronic health record program. RESULTS: Microsoft Excel was used to calculate estimated mean reimbursement data from the top insurers in this office for this service, and the data show a positive annual net income of $4,498 to $26,775, with an average potential annual net income of $15,637. CONCLUSIONS: The data from this cost-benefit analysis show a positive financial benefit as an incentive to implement a fluoride varnish program in this primary care pediatric office and serve as a solid foundation for a future quality improvement project to implement such a program.

Implementation of a Basic Package of Oral Care: towards a reorientation of dental Ngos and their volunteers.

Dental NGOs and volunteers working in disadvantaged communities around the world do so with the best of intentions and with high motivation. Regrettably, the impact of this engagement on oral health at the population level remains rather low. This is mainly due to the choice of inappropriate approaches, the failure to integrate their projects within existing health care systems and the lack of sustainability. This paper proposes the concept of the Basic Package of Oral Care (BPOC) as a guiding framework for dental NGO and volunteer activities. The main components of the BPOC (Oral Urgent Treatment, Affordable Fluoride Toothpaste, Atraumatic Restorative Treatment) offer many opportunities for effective, affordable and sustainable activities that aim to improve oral health on the community and population level. Only through a reorientation of dental volunteer services and NGOs towards new roles and activities can a sustained impact on global oral health be possible. Recommendations are given that could help dental NGOs and volunteers in this process of change.

Use of caries prevention tools and associated caries risk in a suburban population of children in Nigeria.

AIMS: To determine the association between use of recommended oral self-care (ROSC) caries prevention tools and presence of dental caries in children resident in suburban Nigeria. METHODOLOGY: Secondary analysis was conducted for a dataset generated for 1-12 years old children recruited through a household survey. Information on use of ROSC caries prevention tools (brushing more than once a day, use of fluoridated toothpaste always, and eating sugary snacks between main meals less than once a day), use of oral health adjuncts (dental floss, mouth rinses, other tooth cleansing agents) and presence of caries were extracted. The odds of having caries when ROSC caries prevention tools were used singly or in combination, were determined using multivariate logistic regression adjusted for age and sex. RESULTS: The single or combined use of ROSC caries prevention tools had no statistically significant association with presence of caries. Brushing more than once a day reduced the odds of having caries while consumption of sugar between meals once a day or more increased the odds of having caries after adjusting for age and gender. The use of two ROSC caries prevention tools reduced the risk for caries (AOR 0.28; 95 % CI 0.05-1.53) when adjusted for age. The converse was observed when adjusted for gender (AOR 1.15; 95 % CI 0.38-3.45). The largest effect size was observed when sugary snacks were taken once a day or more between meals after adjusting for age (AOR 5.74; 95 % CI 0.34-96.11). CONCLUSION: The use of a combination of fluoridated toothpaste and twice-daily tooth brushing had the largest effect on reducing the chance for caries in children resident in Ile-Ife, Nigeria.

Cost aspects of salt fluoridation.

The cost of salt fluoridation in a given country depends primarily on the number of salt factories and on the technical level available in the country. Equipment required may cost U.S. dollars 400,000 for large plants producing at least 20,000 tons/year providing salt for populations of several millions. Reliable batch mixers have been built locally for U.S. dollars 3000 to U.S. dollars 10,000, with one such mixer capable of producing 10 batches of one metric ton/day or 2000 to 3000 tons a year for a population of 350,000 to 500,000. Frequently 85-90% of the costs are devoted to infrastructure; in combination with salt iodization, the cost for fluoride equipment is 30-50% less. loIization is promoted by WHO, UNICEF, other international organizations and national aid agencies which can indirectly support salt fluoridation. With respect to running costs, the expense for the fluoride chemical is the major factor in small plants producing for example 6000 tons of salt, i. e U.S. dollars 0.015 to 0.03 per year and capita. The cost for personnel necessary for addition of fluoride and quality control is approximately U.S. dollars 0.008/capita/year in small plants and even less in large ones. With adequate implementation, salt fluoridation affords a cariostatic effectiveness equal to that of water fluoridation. When its cost is compared to that of water fluoridation, there may not be much difference regarding initial cost for equipment except in the case of small salt factories where local production of batch mixers may lower initial expenses substantially. Running costs for salt fluoridation are 10 to 100 times lower because the amount of fluoride chemical needed and its handling are up to 100 times less than with water fluoridation. In practice, the cost of salt fluoridation is often so low that many producers did not raise the price of fluoridated salt; this has been the case in Switzerland since 1955 and also in several countries in the Americas today.

Salt fluoridation in Central and Eastern Europe.

For decades Central European countries have been interested in preventive dentistry. Water fluoridation played a major role in the former German Democratic and Czechoslovak Republics and a minor one in Poland. These schemes were abandoned after 1989. Extensive research on all aspects of salt fluoridation was conducted in Hungary from 1966 to 1984 but attempts to introduce it in the country have had little success. Salt fluoridation was implemented in the Czech and the Slovak Republics in the mid-nineties. The market share of the fluoridated domestic salt appears to have reached 35% in the Czech Republic; it became eventually part of a preventive strategy comprising school-based dental health education including topical fluoride. Another four countries have been considering salt fluoridation but schemes did not materialize. Antifluoridation activities occasionally impeded caries prevention, and for years some respected dentists declared their position against fluorides. Caries prevalence in 12-year-old children is by 1 to 3 DMFT higher than in Western Europe. For many years to come, modern fluoride-containing toothpastes and dentifrices may not be affordable for the lower socio-economic strata of the populations in Central and Eastern Europe. It is concluded that salt fluoridation, which is by far the cheapest means of lowering caries prevalence, could markedly improve the oral health situation even if the economical situation is slow to improve.

Treatment of symptomatic osteoporosis with fluoride.

Fluoride has been used for > 30 years in the management of osteoporosis. It is one of the few agents that has marked anabolic effects on the skeleton. Indeed, treatment results in continued increments in cancellous bone volume so that cancellous bone volume can be restored to normal in patients with advanced osteoporosis. Despite its long history, both the efficacy and risks of fluoride regimens continue to be the subject of controversy. One of its problems is its age, and much of the early work undertaken utilized methodology and proofs that are today unacceptable. A further problem is that sodium fluoride as a treatment is cheap and not patented (although some formulations are), so that it has been difficult for investigators or industry to make the investments required to provide a modern program of evaluation.

Cost-effectiveness of different caries preventive measures in a high-risk population of Swedish adolescents.

OBJECTIVES: A total of 3373 12-year-olds agreed to participate in an intervention study evaluating different caries preventive measures. The study, titled 'Evaluation of caries preventive measures', was performed between 1995 and 1999 at 26 dental health clinics throughout Sweden. At the start of the study, the subjects were classified as individuals at high or low risk of developing caries. The high-risk group consisted of 1165 subjects. The children in the high-risk group were randomly assigned to one of four preventive programs. The programs represent a step-wise increase in fluoride content, contact with dental personnel and cost. The aim of the present cost-effectiveness analysis (CEA) study performed from a societal perspective is to compare costs and consequences of caries preventive programs in a caries high-risk population. By 'costs' is meant both treatment costs and costs contributed by the patient and the patient's family. Costs contributed by patients and their families consist of out-of-pocket expenses, transportation costs, and time. Conclusions are that it is important to consider the perspective from which a study is carried out. Costs contributed by the patient and the patient's family have a high impact on total costs for children and younger adolescents but decrease with time as the adolescents get older. The present study shows an incremental cost-effectiveness of 2043 SEK (8.54 SEK = 1 US dollar, December 1999) per averted decayed enamel and dentine missing and filled surface (DeMFS), of which treatment costs represent 1337 SEK using the unit cost for a nurse. This means a yearly cost of approximately 334 SEK.

A cost-benefit analysis of an advocacy project to fluoridate toothpastes in Nepal.

OBJECTIVES: The aim of this paper is to provide a limited cost-benefit analysis of a health promotion project based on advocacy to increase the availability and consumption of fluoride toothpaste. BASIC RESEARCH DESIGN: The cost-benefit analysis method uses the cost-of-illness approach to analyse the costs and benefits of the health promotion project. SETTING: The setting for the health promotion project was the country of Nepal. PARTICIPANTS: A sub-set of the population (6-18 year-olds) was used to compute the financial burden of treating projected caries in the permanent dentition. INTERVENTIONS: The paper compares the projected effect of fluoride toothpaste versus non-fluoride toothpaste on the financial burden of dental caries for a sub-set of the Nepali population over a period of 6 years. OUTCOME MEASURES: The net present value (NPV) and the benefit-cost ratio are the main outcome measures. RESULTS: Over a period of 6 years the NPV was US dollar 594,466 for a projected 10% reduction in dental caries of this population group as a result of fluoridation of toothpastes: US dollar 1,035,640 for a projected 20% reduction; and US dollar 2,442,333 for a projected 40% reduction in caries increment. For every US dollar 1 spent on the advocacy project to increase the availability and consumption of fluoride toothpaste, there is a potential saving in the direct cost of treating caries ranging from US dollar 87 to US dollar 356. CONCLUSIONS: The cost benefit analysis presented shows the project was efficient. Tangible benefits resulting from the intervention of fluoride toothpaste were quantified as well as the risks from having no intervention.

An assessment of the cost effectiveness of a postal toothpaste programme to prevent caries among five-year-old children in the North West of England.

OBJECTIVE: To assess the cost effectiveness of a postal toothpaste programme to prevent caries in 5-year-old children in the north west of England. PARTICIPANTS: Birth cohorts of children aged 12 months were recruited from high caries risk populations in nine health districts. DESIGN: The results of a randomised controlled trial to measure the effects of a postal toothpaste programme are used and related to the costs of running a similar programme. Children in the trial received free toothpaste on four occasions a year and a toothbrush once a year for four years from age 12 months to 5 years. When aged 5-6 years children were examined by trained, calibrated examiners using BASCD standards. Those who received toothpaste containing 1450 ppm F were found to have a significantly lower mean dmft than those who had not. The costs that would be incurred by a public dental service running such a postal toothpaste programme are identified, measured and related to the likely health improvement that could be achieved. MAIN OUTCOME MEASURES: The cost per tooth saved and the cost per child saved from caries experience and extraction experience. RESULTS: The estimated cost per tooth saved from carious attack was pounds sterling 80.83 and the cost per child of preventing caries experience was pounds sterling 424.38 and avoiding any extractions was pounds sterling 679.01. Analysis resulted in an overestimation of costs and underestimation of benefits. CONCLUSION: The programme achieved a significant caries reduction in children who received the 1450 ppm F toothpaste and the costs are now available to those considering provision of treatment services in areas where children are at high caries risk.

School milk as a vehicle for fluoride in the United Kingdom. An interim report.

OBJECTIVE: To consider the feasibility of using school milk as a vehicle to deliver fluoride to children, suffering from high rates of dental disease, in socially deprived districts. METHOD: The legal aspects of adding fluoride to milk and availability of milk subsidies were updated. The organisational requirements of using school milk as a vehicle for fluoride were investigated and the consultation process established. The uptake of fluoridated milk was monitored and the fluoridated milk was subjected to rigorous quality control. The costs involved in running a scheme were calculated. OUTCOME: Fluoridated milk can now be called milk with added fluoride and to date the product has attracted subsidies from the European Economic Community and from the Welfare Foods Section in the Department of Health. The demonstration scheme in St. Helens, Merseyside, generated interest from neighbouring health authorities leading to the subsequent expansion of the programme. By working with the dairy, recommendations to improve the quality of school milk have been developed. The main organisations involved in running school based milk fluoridation schemes have been encouraged by the low costs involved. CONCLUSION: The UK programme has demonstrated that it is feasible to use school milk as a vehicle to deliver fluoride on a community basis. Attention must be given to improving the quality and particularly the temperature control of school milk.

An economic evaluation of a publicly funded dental prevention programme in regional and rural Victoria: an extrapolated analysis.

OBJECTIVE: To determine the long-term cost-benefit of a community-wide, publicly-funded dental prevention programme. DESIGN: A modelled economic analysis which extrapolated the effectiveness and cost-effectiveness results of a three-year comprehensive preventive dental programme conducted in a single cohort of adolescents in the non-fluoridated towns of Geelong and Ballarat, Victoria, Australia. Assumptions were made for both benefits and costs. Sensitivity analysis was undertaken to report a range of estimates of potential programme benefits. SETTING: All secondary colleges in two non-fluoridated regional centres and their surrounding rural areas. SUBJECTS: All Year 7 to 9 students; mean age range of 12.5 to 15.5 years. RESULTS: The incremental benefit-to-cost ratios under all assumptions improved with each successive year of the community-wide programme and, even with the most conservative of assumptions, the overall ten-year benefit-to-cost ratio was above unity. CONCLUSION: While the analysis has inherent limitations as a result of its reliance on a range of assumptions, the findings do suggest that there are benefits to be gained from the implementation of a comprehensive dental preventive programme throughout the secondary school system in non-fluoridated centres comparable to Geelong and Ballarat.

Cost of fluoridation: 44 Florida communities.

Previous data relating to the cost of fluoridation often do not include annualized costs or costs for labor and maintenance. The purpose of this study was to estimate accurately current costs for initiating and maintaining fluoridation and to develop a methodology that can be used to provide the cost basis for further cost-effectiveness studies. The data were collected from 44 Florida communities that had initiated community water fluoridation between 1981 and 1989. Equipment, installation, and engineering costs were derived from copies of actual invoices for equipment and services and then adjusted to 1988 dollars. The chemical costs were calculated from operational reports listing flow rate and pounds used. The cost was then adjusted according to whether the hydrofluosilicic acid was supplied as 15-gallon carboys, 55-gallon drums, in bulk, or as sodium silicofluoride or sodium fluoride. The initial cost was annualized at 2 percent and 4 percent over 15 years. Calculated operational costs included chemical costs, labor costs, and maintenance and repair costs. The operational costs were then added to the annualized depreciation costs and opportunity costs for the initial investment, to produce an estimated cost per person served. The total mean cost per person for all installations was $1.14 per year at 2 percent and $1.25 per year at 4 percent. The mean cost at 4 percent for communities of fewer than 10,000 was $2.12; for communities between 10,000 and 50,000 it was $0.68; and for communities over 50,000 it was $0.31. The total mean cost per person across all installations was $0.41 at 2 percent and 0.45 at 4 percent.(ABSTRACT TRUNCATED AT 250 WORDS)

An economic evaluation of community water fluoridation.

OBJECTIVE: The purpose of this research was to assess the local cost savings resulting from community water fluoridation, given current exposure levels to other fluoride sources. METHODS: Adopting a societal perspective and using a discount rate of 4 percent, we compared the annual per person cost of fluoridation with the cost of averted disease and productivity losses. The latter was the product of annual dental caries increment in nonfluoridated communities, fluoridation effectiveness, and the discounted lifetime cost of treating a carious tooth surface. We obtained or imputed all parameters from published studies and national surveys. We conducted one-way and three-way sensitivity analyses. RESULTS: With base-case assumptions, the annual per person cost savings resulting from fluoridation ranged from $15.95 in very small communities to $18.62 in large communities. Fluoridation was still cost saving for communities of any size if we allowed increment, effectiveness, or the discount rate to take on their worst-case values, individually. For simultaneous variation of variables, fluoridation was cost saving for all but very small communities. There, fluoridation was cost saving if the reduction in carious surfaces attributable to one year of fluoridation was at least 0.046. CONCLUSION: On the basis of the most current data available on the effectiveness and cost of fluoridation, caries increment, and the cost and longevity of dental restorations, we find that water fluoridation offers significant cost savings.

Economic evaluation of a pit and fissure dental sealant and fluoride mouthrinsing program in two nonfluoridated regions of Victoria, Australia.

OBJECTIVES: This study assessed the cost effectiveness of a three-year school-based pit and fissure dental sealant and fluoride mouthrinsing program in two nonfluoridated regions in Victoria, Australia. METHODS: The analysis was based on a community intervention in five schools comparing an intervention group receiving the pit and fissure dental sealant, a weekly fluoride mouthrinsing, and an annual oral hygiene education session, with a control group receiving oral hygiene education only. The study measured mean differences in DMFS increments between study groups. RESULTS: The mean discounted DMFS difference in increment (DMFS avoided) between study groups was 1.22 DMFS over three years. The incremental cost-effectiveness ratio comparing intervention to control group varied between a net savings of $7.00 to a cost of $35.60 per DMFS avoided, depending on assumptions used in the analysis. Results were sensitive to assumptions on program effectiveness, dental examination rates, and baseline DMFS of students. The program became more cost effective with each successive year of the program. CONCLUSIONS: The introduction of such a preventive program in nonfluoridated regions of Victoria will represent an efficient use of community resources. Policy issues that need consideration include whether to target areas where adolescents have a history of high dental disease experience, and whether dentists or auxiliaries are used as service providers. The need exists for a systematic evaluation (including an economic evaluation component) of dental prevention and treatment programs in Australia.

The role of fluoride mouthrinses in the control of dental caries: a brief review.

Fluoride mouthrinses have generally proved to be effective in controlling caries in clinical studies. Caries reductions in North American studies have averaged about 30%. Large-scale school-based mouthrinse programs conducted during the 1970s, however, used historical controls at a time when caries rates were now known to be declining. Post-hoc analysis of the absolute (not relative) caries reductions in these studies showed that school-based fluoride mouthrinse programs were of questionable benefit from a cost standpoint. Fluoride mouthrinses have been shown to reduce demineralization and enhance remineralization of enamel adjacent to orthodontic bands and brackets. Benefits in adults have been less well documented. Use of fluoride mouthrinses by young children is discouraged until they have mastery of their swallowing reflexes. This paper recommends the use of fluoride mouthrinses for patients at increased or high risk for dental caries, but cautions that school-based programs be undertaken only in communities with a high population caries rate.