A quality appraisal of economic evaluations of community water fluoridation: A systematic review.

OBJECTIVES: To critically appraise the methodological conduct and reporting quality of economic evaluations (EE) of community water fluoridation (CWF). METHODS: A systematic literature search was conducted in general databases and specialist directories of the economic literature. The Consensus on Health Economic Criteria list (CHEC) appraised the methodological quality while the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) assessed the reporting quality of included studies. RESULTS: A total of 1,138 records were identified, of which 18 met the inclusion criteria. Cost analysis emerged as the most prevalent type of EE, though a growing trend towards conducting full EEs is observed. CHEC revealed the items most frequently unfulfilled were the study design, measurement and valuation of costs and outcomes, while CHEERS also identified reporting deficiencies in these aspects. Furthermore, the review highlights subtleties in methodological aspects that may not be discerned by CHEC, such as the estimation of the impact of fluoridation and the inclusion of treatment savings within cost estimates. CONCLUSIONS: While numerous studies were conducted before publication of these assessment instruments, this review reveals that a noteworthy subset of studies exhibited good methodological conduct and reporting quality. There has been a steady improvement in the methodological and reporting quality over time, with recently published EEs largely adhering to best practice guidelines. The evidence presented will assist policymakers in leveraging the available evidence effectively to inform resource allocation decisions. It may also serve as a resource for researchers to enhance the methodological and reporting standards of future EEs of CWF.

Investigating the effectiveness of water fluoridation.

DESIGN: This retrospective cohort study used treatment claims data submitted over a 10-year period to explore the effect of water fluoridation on specified National Health Service (NHS) dental treatments, number of Decayed Missing and Filled Teeth (DMFT) and its cost-effectiveness. Ethical approval was granted and data was collected from NHS primary care settings via claims submitted to the NHS Business Services Authority (NHS BSA). To be included, participants must have attended dental services twice in the study period, been 12 years or over and had a valid English postcode. Those with claims related solely to orthodontic care were excluded, as were those who had requested NHS National Data Opt-out. Costs relating to water fluoridation were supplied by Public Health England. NHS BSA data was used to calculate NHS costs at 2020 prices. COHORT SELECTION: A personalised water fluoride exposure for the 2010-2020 period was assigned to all individuals, who were then split into two groups, above 0.7 mg F/L (optimally fluoridated group) or lower (non-optimally fluoridated group). Individuals in each group were matched for analysis using propensity scores, estimated via logistic regression. DATA ANALYSIS: Values of absolute standardised mean differences were used to determine covariate balance between the two groups, alongside a generalised linear model with matching weights and cluster robust standard errors and a patient deprivation decile as an interaction term. An Incremental Cost-Effectiveness Ratio (ICER) was calculated and differences in the overall costs to the public sector were illustrated by the return on investment estimate. RESULTS: The cohort contained data on 6,370,280 individuals. Negative binomial regression models were used to analyse health outcomes. In the optimally fluoridated group, the rate of invasive dental treatments was 3% less than in the non-optimally fluoridated group, and the mean DMFT in the optimally fluoridated group was 2% lower. There was no evidence of a difference in the predicted mean number of missing teeth between groups. There was a small reduction in the predicted number of invasive treatments in the optimally fluoridated group but the largest predicted reduction was in the most deprived decile. DMFT did not exhibit the expected social inequalities gradient, and for the mean number of missing teeth there were small differences in each decile of deprivation between groups but the direct effect was inconsistent. Water fluoridation expenditure between 2010 and 2019 was estimated to be £10.30 for those receiving optimally fluoridated water. The marginal effects estimate illustrated savings of £22.26 per person (95% CI - £21.43, -£23.09), which is a relative reduction in costs to the NHS of 5.5% per patient. A subsequent estimation of cost effectiveness calculated the cost of water fluoridation to avoid one invasive dental treatment (the ICER) as £94.55. The estimated return on investment using a variety of NHS dental attendance estimates all lead to a positive return. CONCLUSIONS: These results suggest that water fluoridation appears to be producing less impactful effects on oral health, with water fluoridation resulting in 'exceedingly small' health effects and very small reductions in use of NHS dental services. A positive return for the public sector was identified as the costs of NHS dentistry are high and costs of water fluoridation are low, though this study did not include the original set up costs of fluoridation programmes.

Systematic Review of Economic Evaluations of Primary Caries Prevention in 2- to 5-Year-Old Preschool Children.

OBJECTIVES: To describe and summarize evidence on economic evaluations (EEs) of primary caries prevention in preschool children aged 2 to 5 years and to evaluate the reporting quality of full EE studies using a quality assessment tool. METHODS: A systematic literature search was conducted in several databases. Full and partial EEs were included. The reporting quality of full EE studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS: A total of 808 studies were identified, and 39 were included in the review. Most papers were published between 2000 and 2017 and originated in the United States and the United Kingdom. The most common type of intervention investigated was a complex multicomponent intervention, followed by water fluoridation. Cost analysis and cost-effectiveness analysis were the most frequently used types of EE. One study employed cost-utility analysis. The proportion of full EEs increased over time. The parameters not reported well included study perspective, baseline year, sensitivity analysis, and discount rate. The CHEERS items that were most often unmet were characterizing uncertainty, study perspective, study parameters, and estimating resources and costs. CONCLUSIONS: Within the past 2 decades, there has been an increase in the number of EEs of caries prevention interventions in preschool children. There was inconsistency in how EEs were conducted and reported. Lack of preference-based health-related quality-of-life measure utilization in the field was identified. The use of appropriate study methodologies and greater attention to recommended EE design are required to further improve quality.

Economic evaluations in water-fluoridation: a scoping review.

BACKGROUND: Community water fluoridation (CWF) is considered one of the 10 greatest public health achievements of the twentieth century and has been a cornerstone strategies for the prevention and control of dental caries in many countries. However, for decision-makers the effectiveness and safety of any given intervention is not always sufficient to decide on the best option. Economic evaluations (EE) provide key information that managers weigh, alongside other evidence. This study reviews the relevant literature on EE in CWF. METHODS: A systematic database search up to August 2019 was carried out using MEDLINE, EMBASE, Cochrane Library, LILACS, Paediatric Economic Database Evaluation and National Health Service Economic Evaluation Database. The review included full economic evaluations on CWF programs, written in English, Spanish or Portuguese. The selection process and data extraction were carried out by two researchers independently. A qualitative synthesis of the results was performed. RESULTS: Of 498 identified articles, 24 studies met the inclusion criteria; 11 corresponded to cost-benefit analysis; nine were cost-effectiveness analyses; and four cost-utility studies. Two cost-utility studies used Disability-Adjusted Life Years,, one used Quality-Adjusted Tooth Years, and another Quality-Adjusted Life Years. EEs were conducted in eight countries. All studies concluded that water fluoridation was a cost-effective strategy when it was compared with non-fluoridated communities, independently of the perspective, time horizon or discount rate applied. Four studies adopted a lifetime time horizon. The outcome measures included caries averted (n = 14) and savings cost of dental treatment (n = 4). Most of the studies reported a caries reduction effects between 25 and 40%. CONCLUSION: Findings indicated that CWF represents an appropriate use of communities' resources, using a range of economic evaluation methods and in different locations. These findings provide evidence to decision-makers which they could use as an aid to deciding on resource allocation.

Cost-effectiveness analysis of a school-based dental caries prevention program using fluoridated milk in Bangkok, Thailand.

BACKGROUND: This study modelled the cost-effectiveness, from a societal perspective, of a program that used fluoridated milk to prevent dental caries in children who were 6 years old at the beginning of the program, versus non-intervention, after 6 years. METHODS: After 6 years, children in the milk-fluoridation program had a significant (34%) reduction in dental caries experience compared to those in the comparison community (i.e., received school milk without added fluoride) (DMFS: 1.06 vs. 1.60). RESULTS: This improvement was achieved with an investment of Thailand Baht (THB) 5,345,048 over 6 years (or THB 11.88 per child, per year) (1 US$ = THB(2011) 30.0). When comparing the costs of the operation of the program and dental treatment in the test community with those of the comparison community, the program resulted in a net societal savings of THB 8,177,179 (range 18,597,122 to THB 7,920,711) after 6 years. This investment would result in 40,500 DMFS avoided in a community with a childhood population of 75,000 [DMFS avoided: 75,000 x (- 0.54)]. CONCLUSIONS: While the analysis has inherent limitations due to its dependence on a range of assumptions, the results suggest that, from a societal perspective, when compared with the non-intervention group, the Bangkok Metropolitan Administration intervention appeared to be a more cost-efficient option than current standard oral health care.

The costs and benefits of water fluoridation in NZ.

BACKGROUND: Implementing community water fluoridation involves costs, but these need to be considered against the likely benefits. We aimed to assess the cost-benefit and cost-effectiveness of water fluoridation in New Zealand (NZ) in terms of expenditure and quality-adjusted life years. METHODS: Based on published studies, we determined the risk reduction effects of fluoridation, we quantified its health benefits using standardised dental indexes, and we calculated financial savings from averted treatment. We analysed NZ water supplies to estimate the financial costs of fluoridation. We devised a method to represent dental caries experience in quality-adjusted life years. RESULTS: Over 20 years, the net discounted saving from adding fluoride to reticulated water supplies supplying populations over 500 would be NZ$1401 million, a nine times pay-off. Between 8800 and 13,700 quality-adjusted life years would be gained. While fluoridating reticulated water supplies for large communities is cost-effective, it is unlikely to be so with populations smaller than 500. CONCLUSIONS: Community water fluoridation remains highly cost-effective for all but very small communities. The health benefits-while (on average) small per person-add up to a substantial reduction in the national disease burden across all ethnic and socioeconomic groups.

The Public Health Reach of High Fluoride Vehicles: Examples of Innovative Approaches.

Fluorides and sealants have been shown to reduce caries in populations, making fluoride interventions a large part of the dental public health effort. Although public health programs have traditionally focused on fluoride vehicles delivering less than 1,000 ppm of fluoride, more recent efforts have shifted toward the use of high fluoride vehicles such as varnishes and prescription toothpastes. In the USA, states are developing innovative strategies to increase access to dental services by using primary care medical providers to deliver early preventive services as part of well-child care visits. Currently, Medicaid programs in 43 states reimburse medical providers for preventive services including varnish application. Still, there is uncertainty about the cost-effectiveness of such interventions. In many resource-strained environments, with shortages of dental health care providers, lack of fluoridated water and lower dental awareness, it is necessary to develop sustainable programs utilizing already established programs, like primary school education, where caries prevention may be set as a priority. Dental caries among the elderly is an ongoing complex problem. The 5,000-ppm F toothpaste may be a reasonable approach for developing public health programs where root caries control is the main concern. Fluoride varnish and high concentration fluoride toothpaste are attractive because they can easily be incorporated into well-child visits and community-based geriatric programs. Additional research on the effectiveness and costs associated with population-based programs of this nature for high risk groups is needed, especially in areas where a community-based fluoride delivery program is not available.

Economic evaluation of a water fluoridation scheme in Cumbria, UK.

OBJECTIVES: The addition of fluoride to community drinking water supplies has been a long-standing public health intervention to improve dental health. However, the evidence of cost-effectiveness in the UK currently lacks a contemporary focus, being limited to a period with higher incidence of caries. A water fluoridation scheme in West Cumbria, United Kingdom, provided a unique opportunity to study the contemporary impact of water fluoridation. This study evaluates the cost-effectiveness of water fluoridation over a 5-6 years follow-up period in two distinct cohorts: children exposed to water fluoridation in utero and those exposed from the age of 5. METHODS: Cost-effectiveness was summarized employing incremental cost-effectiveness ratios (ICER, cost per quality adjusted life year (QALY) gained). Costs included those from the National Health Service (NHS) and local authority perspective, encompassing capital and running costs of water fluoridation, as well as NHS dental activity. The measure of health benefit was the QALY, with utility determined using the Child Health Utility 9-Dimension questionnaire. To account for uncertainty, estimates of net cost and outcomes were bootstrapped (10 000 bootstraps) to generate cost-effectiveness acceptability curves and sensitivity analysis performed with alternative specifications. RESULTS: There were 306 participants in the birth cohort (189 and 117 in the non-fluoridated and fluoridated groups, respectively) and 271 in the older school cohort (159 and 112, respectively). In both cohorts, there was evidence of small gains in QALYs for the fluoridated group compared to the non-fluoridated group and reductions in NHS dental service cost that exceeded the cost of fluoridation. For both cohorts and across all sensitivity analyses, there were high probabilities (>62%) of water fluoridation being cost-effective with a willingness to pay threshold of £20 000 per QALY. CONCLUSIONS: This analysis provides current economic evidence that water fluoridation is likely to be cost-effective. The findings contribute valuable contemporary evidence in support of the economic viability of water fluoridation scheme.

How effective and cost-effective is water fluoridation for adults and adolescents? The LOTUS 10-year retrospective cohort study.

OBJECTIVE: To pragmatically assess the clinical and cost-effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults and adolescents, using a natural experiment design. METHODS: A 10-year retrospective cohort study (2010-2020) using routinely collected NHS dental treatment claims data. Participants were patients aged 12 years and over, attending NHS primary dental care services in England (17.8 million patients). Using recorded residential locations, individuals exposed to drinking water with an optimal fluoride concentration (≥0.7 mg F/L) were matched to non-exposed individuals using propensity scores. Number of NHS invasive dental treatments, DMFT and missing teeth were compared between groups using negative binomial regression. Total NHS dental treatment costs and cost per invasive dental treatment avoided were calculated. RESULTS: Matching resulted in an analytical sample of 6.4 million patients. Predicted mean number of invasive NHS dental treatments (restorations 'fillings'/extractions) was 3% lower in the optimally fluoridated group (5.4) than the non-optimally fluoridated group (5.6) (IRR 0.969, 95% CI 0.967, 0.971). Predicted mean DMFT was 2% lower in the optimally fluoridated group (IRR 0.984, 95% CI 0.983, 0.985). There was no difference in the predicted mean number of missing teeth per person (IRR 1.001, 95% CI 0.999, 1.003) and no compelling evidence that water fluoridation reduced social inequalities in dental health. Optimal water fluoridation in England 2010-2020 was estimated to cost £10.30 per person (excludes initial set-up costs). NHS dental treatment costs for optimally fluoridated patients 2010-2020 were 5.5% lower, by £22.26 per person (95% CI -£21.43, -£23.09). CONCLUSIONS: Receipt of optimal water fluoridation 2010-2020 resulted in very small positive health effects which may not be meaningful for individuals. Existing fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower NHS dental care utilization. This return should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes.

Effect of fluoridated water on invasive NHS dental treatments for adults: the LOTUS retrospective cohort study and economic evaluation.

Background: Most water fluoridation studies were conducted on children before the widespread introduction of fluoride toothpastes. There is a lack of evidence that can be applied to contemporary populations, particularly adolescents and adults. Objective: To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults, using a natural experiment design. Design: Retrospective cohort study using routinely collected National Health Service dental claims (FP17) data. Setting: National Health Service primary dental care: general dental practices, prisons, community dental services, domiciliary settings, urgent/out-of-hours and specialised referral-only services. Participants: Dental patients aged 12 years and over living in England (n = 6,370,280). Intervention and comparison: Individuals exposed to drinking water with a fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were matched to non-exposed individuals on key characteristics using propensity scores. Outcome measures: Primary: number of National Health Service invasive dental treatments (restorations/'fillings' and extractions) received per person between 2010 and 2020. Secondary: decayed, missing and filled teeth, missing teeth, inequalities, cost effectiveness and return on investment. Data sources: National Health Service Business Services Authority dental claims data. Water quality monitoring data. Primary outcome: Predicted mean number of invasive dental treatments was 3% lower in the optimally fluoridated group than in the sub/non-optimally fluoridated group (incidence rate ratio 0.969, 95% CI 0.967 to 0.971), a difference of -0.173 invasive dental treatments (95% CI -0.185 to -0.161). This magnitude of effect is smaller than what most stakeholders we engaged with (n = 50/54) considered meaningful. Secondary outcomes: Mean decayed, missing and filled teeth were 2% lower in the optimally fluoridated group, with a difference of -0.212 decayed, missing and filled teeth (95% CI -0.229 to -0.194). There was no statistically significant difference in the mean number of missing teeth per person (0.006, 95% CI -0.008 to 0.021). There was no compelling evidence that water fluoridation reduced social inequalities in treatments received or missing teeth; however, decayed, missing and filled teeth data did not demonstrate a typical inequalities gradient. Optimal water fluoridation in England in 2010-20 was estimated to cost £10.30 per person (excluding original setup costs). Mean National Health Service treatment costs for fluoridated patients 2010-20 were 5.5% lower per person, by £22.26 (95% CI -£23.09 to -£21.43), and patients paid £7.64 less in National Health Service dental charges per person (2020 prices). Limitations: Pragmatic, observational study with potential for non-differential errors of misclassification in fluoridation assignment and outcome measurement and residual and/or unmeasured confounding. Decayed, missing and filled teeth data have not been validated. Water fluoridation cost estimates are based on existing programmes between 2010 and 2020, and therefore do not include the potentially significant capital investment required for new programmes. Conclusions: Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects, which may not be meaningful for individuals, and we could find no evidence of a reduction in social inequalities. Existing water fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower National Health Service treatment costs. These relatively small savings should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes. Future work: National Health Service dental data are a valuable resource for research. Further validation and measures to improve quality and completeness are warranted. Trial registrations: This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Fluoride is a natural mineral that prevents tooth decay. It is added to some drinking water and toothpastes to improve dental health. Water with fluoride added is known as 'optimally fluoridated'. Most research on water fluoridation was carried out before fluoride was added to toothpastes in the 1970s and only included children. We wanted to know if water fluoridation still produced large reductions in tooth decay, now that decay levels are much lower because of fluoride in toothpaste. We also wanted to look at its effect on adults and teenagers. Dental patients we spoke to told us they worried about needing treatment with the 'drill', or 'injection', losing their teeth and paying for their dental care. To see if water fluoridation helped with these concerns, we compared the National Health Service dental records of 6.4 million adults and teenagers who received optimally fluoridated or non-optimally fluoridated water in England between 2010 and 2020. We found water fluoridation made a very small difference to each person. Between 2010 and 2020, the number of NHS fillings and extractions was 3% lower per person for those who received optimally fluoridated water. We found no difference in the number of teeth lost per person and no strong sign that fluoridation reduced differences in dental health between rich and poor areas. Between 2010 and 2020, the cost of optimal water fluoridation was £10.30 per person (not including setup costs). National Health Service dental patients who received optimally fluoridated water cost the National Health Service £22.26 (5.5%) less and paid £7.64 (2%) less per person in National Health Service dental charges over the 10 years. The benefits we found are much smaller than in the past, when toothpastes did not contain fluoride. The cost to set up a new water fluoridation programme can be high. Communities may need to consider if these smaller benefits would still outweigh the costs.

Systematic review of publications on economic evaluations of caries prevention programs.

The aim of this study was to perform a systematic review of economic evaluations (EEs) of dental caries prevention programs to objectively retrieve, synthesize and describe available information on the field. Several strategies were combined to search for literature published between January 1975 and April 2012. MEDLINE, EconoLit and ISI formed the basis of the literature search. The study selection was done using predefined inclusion and exclusion criteria. Bibliographic listings of all retrieved articles were hand-searched. The search identified 206 references. An evaluative framework was developed based on the Centre for Reviews and Dissemination's 'Guidance for undertaking reviews in health care' (York University, 2009). Background information included publication vehicle, year of publication, geographic focus, type of preventive program and type of economic analysis. 63 studies were included in the review. The most common preventive strategies evaluated were dental sealants (n = 13), water fluoridation (n = 12) and mixed interventions (n = 12). By type of EE undertaken, 30 were cost-effectiveness analyses, 22 were cost-benefit analyses, and 5 presented both cost-effectiveness and cost-benefit analyses. Few studies were cost-utility analyses (n = 5) or cost minimization analyses (n = 2). By year of publication, most were published after 2003. The review revealed that, although the number of publications reporting EEs has increased significantly in recent years, the quality of the reporting needs to be improved. The main methodological problems identified in the review were the limited information provided on adjustments for discounting in addition to inadequate sensitivity analyses. Attention also needs to be given to the analysis and interpretation of the results of the EEs.

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

OBJECTIVES: To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis. METHODS: Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal. RESULTS: Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis. CONCLUSIONS: Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Cost-effectiveness models for dental caries prevention programmes among Chilean schoolchildren.

AIM: This study aims to estimate the cost-effectiveness from a societal perspective of seven dental caries prevention programmes among schoolchildren in Chile: three community-based programmes: water-fluoridation, salt-fluoridation and dental sealants; and four school-based programmes: milk-fluoridation; fluoridated mouthrinses (FMR); APF-Gel, and supervised toothbrushing with fluoride toothpaste. METHODS: Standard cost-effectiveness analysis methods were used. The costs associated with implementing and operating each programme, using a societal perspective, were identified and estimated. The comparator was non-intervention. Health outcomes were measured as dental caries averted over a 6-year period. Costs were estimated as direct treatment costs, programmes costs and costs of productivity losses as a result of each dental caries prevention programme. Incremental cost-effectiveness ratios were calculated for each programme. Sensitivity analyses were conducted over key parameters. RESULTS: Primary cost-effectiveness analysis (discounted) indicated that four programmes showed net social savings by the DMFT averted. These savings encompassed a range of values per diseased tooth averted; US$16.21 (salt-fluoridation), US$14.89 (community water fluoridation); US$14.78 (milk fluoridation); and US$8.63 (FMR). Individual programmes using an APF-Gel application, dental sealants, and supervised tooth brushing using fluoridated toothpaste, represent costs for the society per diseased tooth averted of US$21.30, US$11.56 and US$8.55, respectively. CONCLUSION: Based on cost required to prevent one carious tooth among schoolchildren, salt fluoridation was the most cost-effective, with APF-Gel ranking as least cost-effective. Findings confirm that most community/school-based dental caries interventions are cost-effective uses of society's financial resources. The models used are conservative and likely to underestimate the real benefits of each intervention.

Drinking water fluoridation in South East Queensland: a cost-effectiveness evaluation.

OBJECTIVE: The aim of this study is to examine cost-effectiveness of fluoridation of drinking water supplies for Brisbane and South East Queensland. The benefits conveyed are expressed in reduced costs of dental treatment and years of life with dental caries as a disability. METHODS: The analysis utilises a developed life table modelling initial cohort of 36,322 newborns, which when applied to the target population equals to 181,925 persons in the age group 2-100 years, 338,617 persons in the age group 7-100 years and 390,524 persons in the age group 12-100 years respectively. The analysis was conducted using a real discount rate of 3%. Sensitivity analyses investigated the effects of varying the parameters such as: discount rate, costs of dental treatment and costs of fluoridation plant. Uncertainty analysis was also conducted on costs and the measure of ratio of decayed, missing, filled teeth surfaces in deciduous dentition between the cities of Brisbane (non-fluoridated) and Townsville (fluoridated). RESULTS: If fluoridation was implemented there would be a total saving of $10,437.43 (95% CI 6,406.50- 14,035.35) disability-adjusted life years (DALYs) and AU$ 665,686,529 (95% CI -$973,573,625- $381,322,176). This result is both desirable and dominant as more DALYs are saved along with significant cost savings. CONCLUSION: Fluoridation remains still a very cost-effective measure for reducing dental decay.