Fluoride Varnish in Nursery Schools: A Randomised Controlled Trial - Protecting Teeth @3.

Studies suggest that fluoride varnish (FV) application can reduce dental caries in child populations. The multiple-component national child oral health improvement programme in Scotland (Childsmile) includes nursery-based universal supervised toothbrushing and deprivation-targeted FV applications, together with community and dental practice prevention interventions. This trial, a double-blind, two-arm randomised control trial, aimed to assess the effectiveness and cost-effectiveness of the nursery-based FV applications plus treatment-as-usual (TAU) Childsmile programme interventions, compared to TAU Childsmile interventions alone, in children not targeted to receive nursery FV as part of the programme. Participating children in the first year of nursery (aged three), with or without existing caries, were randomised to either FV or TAU and followed up for 24 months until the first year of primary school. Treatments were administered at six-monthly intervals. The primary endpoint was "worsening of d3mft" from baseline to 24 months. Secondary endpoints were worsening of d3mfs, d3t, mt, and ft. Individual record-linkage captured wider programme activities and tertiary endpoints. A total of 1,284 children were randomised, leading to 1,150 evaluable children (n = 577 FV, n = 573 TAU, 10% dropouts). Mean age was 3.5 years, 50% were female (n = 576), 17% had caries at baseline (n = 195), all balanced between the groups. Most children received three/four treatments. Overall, 26.9% (n = 155) had worsened d3mft in the FV group, and 31.6% (n = 181) in the TAU group, with an odds ratio (OR) of 0.80 (0.62-1.03), p = 0.078. The results for worsening of the secondary endpoints were: d3mfs 0.79 (0.61-1.01) p = 0.063, d3t 0.75 (0.57-0.99) p = 0.043, mt 1.34 (0.75-2.39) p = 0.319, and ft 0.77 (0.53-1.14) p = 0.191. We calculated a number needed to treat of 21 and a cost of GBP 686 to prevent a single worsening of d3mft. There was a modest non-significant reduction in the worsening of d3mft in the nursery FV group compared to TAU, suggesting that this intervention is unlikely to represent an effective or cost-effective addition to the population oral health improvement programme.

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.

Exploring the cost-effectiveness of child dental caries prevention programmes. Are we comparing apples and oranges?

Data sources The following seven databases were searched: PubMed, EMBASE, DARE, NHSEED, HTA, Cost-Effectiveness Analysis Registry and Paediatric Economic Database Evaluation (PEDE).Study selection The review included trial and model-based economic evaluation studies and the participants included children aged from 0 to 12 years old who were healthy except for having dental caries. Studies of mixed populations of parents and children were included where the data for children were presented separately.The interventions included were:• Community-based oral-health education/training programs related to healthy oral habits.• Screening of children's teeth.• Supervised toothbrushing technique through the provision of toothbrushes, an appropriate amount of fluoride toothpaste, and topical fluoride.• Advice on dietary control, such as limitation of sugar or carbohydrates consumption, and enhanced fortified nutrition with an appropriate amount of calcium intake.• The comparators were situations where the populations were the same as the test group, but were receiving no intervention, or a dissimilar one .The interventions were oral-health promotion programs (OHPPs) implemented by oral-health professionals in the contexts of home visits, telephone calls, healthcare centres and primary schools.The outcome measures were reductions in the Decayed, Missing, Filled Teeth (DMFT) index for permanent teeth or (dmft) index for deciduous teeth among children and OHPP cost, incremental cost (difference between mean costs of intervention and mean costs of the comparator), and cost-effectiveness analysis (CEA).Data extraction and synthesis The title, abstract and full text of each study were screened. During the first phase screening of titles and abstracts, irrelevant records were removed. The exclusion criteria were: participant with health-related diseases or aged older than 12 years; interventions other than OHPP (such as implant dentistry or other invasive-dentistry programs); other economic-evaluation outcomes such as cost-benefit, cost-utility or cost-minimisation; authors' opinion (unoriginal records); reviews; and study language other than English. The second-phase screening assessed full texts of the articles using the same eligibility criteria. The risk of bias was assessed using the Drummond 10-item Checklist. Meta-analysis: The costs were converted to 2015 USA dollars. Data analysis was performed through dichotomous outcomes such as the number of children in the intervention and in the control group, the DMFT index in children, and the OHPP cost. Odds ratios (ORs), effect sizes with 95% confidence interval (CIs) and study weights were estimated from random effects analysis. Forest plots were constructed for each outcome, and chi-square tests used to assess homogeneity, where a p-value of less than 0.1 indicated statistically significant heterogeneity. An I2 test was used to quantify inconsistencies between studies as the percentage of variation across studies. Data synthesis was carried out using narrative demonstration, with a summary of the characteristics of each included study. For quantitative synthesis, a summary of the combined estimation related to the OHPP effect was measured. Three types of subgroup analysis were performed: by the age of the children (age under or equal to 6 years, and age 6-12 years), by publication year (studies published in the last five years, and earlier published studies) and by the country of the study. Egger's regression test and a funnel plot were used to assess and demonstrate publication bias. Publication bias was considered present if the p-value of the Egger test was more than 0.05.Results 19 full texts were included into qualitative synthesis and eight articles used in quantitative synthesis. Qualitative synthesis results: With regards to the country of origin, 32% of the studies were conducted in the United Kingdom (n = 6), 26% in Australia (n = 5), 16% in the United States (n = 3). There was also one study from each of the following countries Finland, Ireland, Japan, Nigeria and Singapore. Fifty-two percent (n = 10) were model-based economic evaluation studies and 47% (n = 9) were trial-based economic evaluations. The population of 14 studies were younger than six years of age, while in four studies the children were over the age of six years. In one paper the age of the children was not clearly stated. Just under a half of the papers (47%) were published in the last five years.The majority of the studies had a low risk of bias (n = 12, 63%) and seven (37%) had a moderate risk of bias. Various outcome measures were used in the included studies: DMFT, average number of dental visits, number of prevented caries teeth, average number of cavity-free months, probability of less cost, caries prevalence, number of specific OHPP visits, quality-adjusted life year, cost-effectiveness ratio, and percentages of not having debris.Quantitative synthesis results: The overall pooled impact of OHPPs showed that children with tooth decay had 81% lower odds of participating in OHPP (95% CI 61-90%, I2: 98.5%, p = 0) with considerable heterogeneity among studies. OHPPs were successful in reducing financial costs in 97 out of 100 OHPPs (95% CI 89-99%, I2: 99%, p = 0) with considerable heterogeneity among studies. The studies with participants under the age of six years old weighted 71% with an OR of 0.14 (95% CI, 0.05-0.39, I2: 99%). These children had the highest benefit of OHPPs to lower DMFT/S. The studies reporting children aged six years and over weighted 29% with an OR of 0.29 (95% CI, 0.08-1.01, I2: 99%), and these children had no benefit from OHPPs in lowering DMFT/S. Studies with under-six-year-old participants had an OR of 0.07 (95% CI, 0.02-0.32) revealing no cost-effectiveness effect to reduce OHPP incremental cost, whereas studies reporting children aged six years and older had an OR of 0.0 (95% CI, 0.00-48,704.6). The authors concluded that OHPPs involving the later (older) children were cost-effective in reducing the OHPPs' incremental cost.Conclusions A comprehensive analysis of the OHPPs confirmed that DMFT could be reduced, hence, lowering the financial burden of dental-care treatment. More effort is needed to manage the allocation of scarce resources, taking into account the economic impact of dental caries on healthcare systems. More studies on caries-prevention programmes among young children in high-, middle- and low-income countries are needed, in order to assess the clinical and financial effectiveness.

Comparison of the caries-protective effect of fluoride varnish with treatment as usual in nursery school attendees receiving preventive oral health support through the Childsmile oral health improvement programme - the Protecting Teeth@3 Study: a randomised controlled trial.

BACKGROUND: The Scottish Government set out its policy on addressing the poor oral health of Scottish children in 2005. This led to the establishment of Childsmile, a national programme designed to improve the oral health of children in Scotland. One element of the programme promotes daily tooth brushing in all nurseries in Scotland (Childsmile Core). A second targeted component (Childsmile Nursery) offers twice-yearly application of fluoride varnish to children attending nurseries in deprived areas. Studies suggest that fluoride varnish application can reduce caries in both adult and child populations. This trial aims to explore the effectiveness and cost-effectiveness of additional preventive value fluoride varnish application compared to Childsmile Core. METHODS/DESIGN: The Protecting Teeth@3 Study is an ongoing 2 year parallel group randomised treatment as usual controlled trial. Three-year-old children attending the ante pre-school year are randomised (1:1) to the intervention arm (fluoride varnish & treatment as usual) or the control arm (treatment as usual). Children in the intervention arm will have Duraphat® fluoride varnish painted on the primary tooth surfaces and will continue to receive treatment as usual: the core Childsmile Nursery intervention. Children in the treatment as usual arm will receive the same series of contacts, without the application of varnish and will also continue with the Childsmile Core intervention. Interventions are undertaken by Childsmile trained extended duty dental nurses at six-monthly intervals. Participants receive a baseline dental inspection in nursery and an endpoint inspection in Primary 1 at the age of 5 years old. We will use primary and secondary outcome measures to compare the effectiveness of Duraphat® fluoride varnish plus treatment as usual with treatment as usual only in preventing any further dental decay. We will also undertake a full economic evaluation of the trial. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov. Number: NCT01674933 (24 August 2012).

Improving Child Oral Health: Cost Analysis of a National Nursery Toothbrushing Programme.

UNLABELLED: Dental caries is one of the most common diseases of childhood. The aim of this study was to compare the cost of providing the Scotland-wide nursery toothbrushing programme with associated National Health Service (NHS) cost savings from improvements in the dental health of five-year-old children: through avoided dental extractions, fillings and potential treatments for decay. METHODS: Estimated costs of the nursery toothbrushing programme in 2011/12 were requested from all Scottish Health Boards. Unit costs of a filled, extracted and decayed primary tooth were calculated using verifiable sources of information. Total costs associated with dental treatments were estimated for the period from 1999/00 to 2009/10. These costs were based on the unit costs above and using the data of the National Dental Inspection Programme and then extrapolated to the population level. Expected cost savings were calculated for each of the subsequent years in comparison with the 2001/02 dental treatment costs. Population standardised analysis of hypothetical cohorts of 1000 children per deprivation category was performed. RESULTS: The estimated cost of the nursery toothbrushing programme in Scotland was £1,762,621 per year. The estimated cost of dental treatments in the baseline year 2001/02 was £8,766,297, while in 2009/10 it was £4,035,200. In 2002/03 the costs of dental treatments increased by £213,380 (2.4%). In the following years the costs decreased dramatically with the estimated annual savings ranging from £1,217,255 in 2003/04 (13.9% of costs in 2001/02) to £4,731,097 in 2009/10 (54.0%). Population standardised analysis by deprivation groups showed that the largest decrease in modelled costs was for the most deprived cohort of children. CONCLUSIONS: The NHS costs associated with the dental treatments for five-year-old children decreased over time. In the eighth year of the toothbrushing programme the expected savings were more than two and a half times the costs of the programme implementation.