title: Economics of primary caries prevention in preschool children
Creators: name: Anopa, Yulia
Publisher: name: University of Glasgow
Year: 2020
Subjects: subject: economic evaluation, health economics, preschool child, child health, caries, cost-effectiveness, health-related quality of life, oral health, fluoride, fluoride varnish, Childsmile.

description: Background: Childhood caries continues to be a pandemic disease and a significant but preventable public health problem worldwide. Caries can have a major impact on children's health and quality of life as well as represent cost to individuals, the health sector and society. Research indicates that children who develop caries in early childhood are likely to have a high risk of the disease in adolescence and adulthood. Dental caries is a preventable disease and currently a range of nationwide programmes, community-based programmes and clinical strategies exist to reduce caries prevalence in children. Notwithstanding the fact that childhood caries is very widespread and that it poses a substantial economic burden, there is a paucity of economic evaluations of caries prevention interventions in preschoolers. The lack of high-quality economic evaluations makes it difficult for decision-makers to determine which interventions to provide within the remit of health services and local authorities. Aim: To explore the role of economic evaluation in primary caries prevention in preschool children aged 2-5 years. This aim was met through answering the following three research questions. (1) What is the existing evidence in the field of economic evaluation of primary caries prevention in children aged 2-5 years? (2) Which general health and oral health-related quality of life measures have been used in 3-5-year-old populations? And which of these measures are best suited to be used in a caries prevention randomised controlled trial for this age group? (3) Is the application of fluoride varnish delivered in nursery settings in addition to the other usual components of the Scottish child oral health improvement programme, Childsmile, (treatment as usual) cost-effective in comparison with treatment as usual only? Methods: Three interlinked empirical work segments were undertaken to address these research questions. (1) A systematic review of economic evaluations of primary caries prevention in 2-5-year-old preschool children. (2) A non-systematic review of instruments for measuring general and oral health-related quality of life in 3-5-year-old children. (3) An economic evaluation of the Protecting Teeth @ 3 randomised controlled trial (trial registration: EUDRACT: 2012-002287-26; ClinicalTrials.gov: NCT01674933). Results: (1) The systematic review of economic evaluations of primary caries prevention in 2-5-year-olds found that cost analysis and cost-effectiveness analysis were the most frequently used types of economic evaluations. Only one study employed cost-utility analysis. The systematic review highlighted wide variation in: (a) types of caries prevention interventions investigated; (b) effectiveness measures used; (c) how costs and outcomes are reported; and d) study perspective (when indicated). The parameters not reported well included study perspective, baseline year, sensitivity analysis, and discount rate. The results of the quality assessment of the full economic evaluations using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist showed substantial variation in reporting quality. The CHEERS items that were most often unmet were characterizing uncertainty, study perspective, study parameters, and estimating resources and costs. (2) The review of general health and oral health-related quality of life measures identified a range of existing questionnaires for use in preschool populations (age 3-5 years) and their strengths and limitations were considered. Only two preference-based general health-related quality of life instruments that had been used in 3-5-year-olds were identified. No preference-based oral health-related quality of life measures for preschoolers were identified. Four instruments were selected to be used in the Protecting Teeth @ 3 trial: the Child Health Utility 9 Dimensions, PedsQL (Paediatric Quality of Life Inventory) Core, PedsQL Oral Health (an oral health specific add-on to PedsQL Core) and the Scale of Oral Health Outcomes for 5-year-old children. (3) The findings of the Protecting Teeth @ 3 trial economic evaluation demonstrated that there were no statistically significant differences in total costs, quality adjusted life years (QALYs) accumulated, the change in the clinical effectiveness outcome (d3mft), and in general health and oral health-related quality of life measures at 24 months between the intervention and control groups. The mean difference in total costs between the fluoride varnish (intervention) and treatment as usual (control) group was £68 (p=0.382; 95% confidence interval £18, £144). The mean difference in QALYs was -0.004 (p= 0.636; 95% confidence interval -0.016, 0.007). The probability that the fluoride varnish intervention was cost-effective at the £20,000 threshold was 11%. Conclusions: The systematic review of economic evaluations of primary caries prevention in 2-5-year-olds found that within the past two decades, there has been an increase in the number of economic evaluations of caries prevention interventions in preschool children. However, there was inconsistency in how these economic evaluations of primary caries prevention were conducted and reported. Lack of use of preference-based health-related quality-of-life measures was identified. The use of appropriate study methodologies and greater attention to recommended economic evaluations design are required to further improve quality. Due to small numbers of studies investigating each intervention type (for example, fluoride varnish, oral health education, dental sealants, toothbrushing, water fluoridation) and the questionable methodological quality of many of the reviewed economic evaluations, it was not possible to arrive at reliable conclusions with regards to the economic value of primary caries prevention. With dental caries being one of the most common diseases affecting humans worldwide, the identification of cost-effective prevention strategies in children should be a global public health priority. In order for this to be achieved, studies should be designed to include economic evaluations using best practice methods guidance and adhering to standards for reporting and presenting. The review of general health and oral health-related quality of life measures used in 3-5-year-olds identified a range of existing questionnaires for use in preschool populations – both for parental proxy reporting and child self-reporting. Four instruments were selected to be used in the Protecting Teeth @ 3 trial. Further research and development of new preference-based measures suitable for preschoolers (or their parents/guardians as a proxy) are required. The results of the economic evaluation of the Protecting Teeth @ 3 trial show that applying fluoride varnish in nursery settings in addition to the existing treatment a usual (all other components of the Childsmile programme, apart from nursery fluoride varnish) is not likely to be cost-effective. In view of previously proven clinical effectiveness and economic worthiness of the universal nursery toothbrushing component of Childsmile, which was shown to be highly cost saving, as well as being effective and cost saving in the most deprived populations, continuation of the programme of targeted nursery fluoride varnish in its most recent (pre-COVID-19) form and shape in addition to nursery toothbrushing and other routine Childsmile components needs to be reviewed in consultation with policy makers. The findings also have wider implications for other countries looking to develop their own childhood caries prevention programmes.