We conducted a cost-effectiveness analysis of five specific dental interventions to help guide resource allocation.

We developed a spreadsheet-based tool, from the healthcare payer perspective, to evaluate the cost effectiveness of specific dental interventions that are currently used among Alaska Native children (6-60 months). Interventions included: water fluoridation, dental sealants, fluoride varnish, tooth brushing with fluoride toothpaste, and conducting initial dental exams on children <18 months of age. We calculated the cost-effectiveness ratio of implementing the proposed interventions to reduce the number of carious teeth and full mouth dental reconstructions (FMDRs) over 10 years.

A total of 322 children received caries treatments completed by a dental provider in the dental chair, while 161 children received FMDRs completed by a dental surgeon in an operating room. The average cost of treating dental caries in the dental chair was $1,467 (~258,000 per year); while the cost of treating FMDRs was $9,349 (~1.5 million per year). All interventions were shown to prevent caries and FMDRs; however tooth brushing prevented the greatest number of caries at minimum and maximum effectiveness with 1,433 and 1,910, respectively. Tooth brushing also prevented the greatest number of FMDRs (159 and 211) at minimum and maximum effectiveness.

All of the dental interventions evaluated were shown to produce cost savings. However, the level of that cost saving is dependent on the intervention chosen.

Tooth decay or dental caries is one of the most common chronic conditions among American children as reported by the American Academy of Pediatrics Children’s Oral Health Initiative (

We examined, from the healthcare payer (i.e., Medicaid) perspective, the economic impact of 5 interventions currently used among YK children to reduce the economic burden of treating dental caries among children (6-60 months) in the YKD region. These data may aid public health officials and primary dental care providers to choose those interventions likely to have the greatest impact in reducing rates of dental caries in this population.

We used Microsoft Excel© 2010 to develop a simple Excel spreadsheet based tool (

The YK region is composed of 48 communities with a total population of approximately 25,000, of which 85 percent are Yup’ik Eskimo people (

We began our evaluation by calculating the current and ideal population coverage for each intervention. Current population coverage is the percentage of the population presently receiving a specific intervention; whereas ideal population coverage is the maximum percentage of the population capable of receiving the intervention.

We determined the current population coverage for each intervention using the following formula:

As reported by the US Census, the total child population (6-60 months) within the YKD region is 2,575. The number of children receiving each intervention varied. Data were obtained from the 2011 Yukon-Kuskokwim Health Corporation (YKHC) Dental Services database (Dental Procedural Visits, Number of Children Seen for Caries Treatment by Intervention, 2011, YKHC). For simplicity, we assumed that all interventions had an ideal population coverage of 100 percent of recommended age groups, with the exception of water fluoridation. The current population coverage for water fluoridation was calculated in the same manner as that of the other interventions. Five communities (929 children) currently receive fluoridated water generating population coverage of 36 percent. Unfortunately, not all communities in the YK region have the capacity to receive fluoridated water; therefore the ideal population coverage was based on the maximum number of communities that could be fluoridated. The Water Fluoridation Status of 2012 (

Dental caries, or cavities as they are more widely known, are caused by bacterial infections that destroy the tooth enamel resulting in tooth decay (YKHC Quality Systems Incorporated (QSI) Electronic dental record database (“Clinical Product Suite”, 2011). We assumed that children in the YKD were treated for dental caries either by the local dentist or dental provider during a dental visit or by a dental surgeon in a hospital operating room.

In 2011, 1,536 YK children were evaluated or treated for caries in a dental chair (i.e., all procedures done either in a dental office or during a dental visit by the local dentist or dental health provider). Of those being seen for dental treatment in a dental chair during a dental visit, 156 children received at least one crown, 166 received at least one filling, and 188 children received a combination of both crowns and fillings. We calculated the average number of crowns per child as 4.54 and the number of fillings per child as 3.18 producing a total number of 708 crowns and 528 fillings, respectively (

The cost of caries treatment typically includes an oral exam ($66.98), X-ray ($89.08), the mean cost for placement of a stainless steel crown on a primary tooth ($199), mean cost for resin-based anterior filling ($214), and the mean cost of a child receiving both crown and fillings during one visit ($1,050). Oral exam and X-ray costs are the customary Medicaid reimbursement fees associated with any type of dental treatment. The mean cost for stainless steel crowns, resin-based fillings, and cost of both crown and filling was weighted by the number of children receiving a specific type of treatment (i.e., crowns only, fillings only, or combination of fillings and crowns) compared to the total number of children being seen for the placement of fillings and/or crowns (

The total annual estimated cost of treating children with dental caries requiring a filling, crown, or a combination of both fillings and crowns (188 children) is $275,890 (

To perform treatment safely, effectively, and efficiently, the practitioner caring for a child with extensive dental disease often requires FMDRs under sedation or general anesthesia. FMDRs frequently involve multiple extractions, restorations (i.e., crowns, fillings), and pulpotomies, thus making them quite costly. The success of these restorations may be influenced by the child’s level of cooperation during treatment, and general anesthesia may provide better conditions to perform these procedures (

The cost of treating children with FMDR includes travel (~$1,500), use of personnel involved in performing the procedure (~$1,500), and operating room rental plus prescription drugs, and anesthesia (~3,198). The median number of teeth extracted and pulpotomies completed per FMDR was 4 and 5, respectively. We used the following

The overall estimated cost of completing all FMDRs on the 161 YK Delta children (6-60 months) in 2011 was $1.5 million (

In response to the request by the YK Dental program for technical assistance in determining whether specific interventions were cost beneficial and effective in reducing the number of carious teeth in YKD children, we examined the cost effectiveness of 5 currently used or potential preventive interventions among children (6-60 months) in the YK region. These interventions were water fluoridation, dental sealants, fluoride varnish, home tooth brushing with fluoride tooth-paste, and initial dental exam with parental counseling before 18 months of age. We used a range of effectiveness values (minimum and maximum), along with current and ideal population coverage and program costs for each intervention (

Water Fluoridation

Adjusting the level of fluoride in the community water systems results in a 26-35 percent reduction in tooth decay among children receiving lifelong exposure to fluoridated water (

The cost to fluoridate a community includes a one-time only start-up cost (

Dental Sealants

In populations at high risk of dental caries, the American Dental Association recommends children should receive sealants on both their primary and permanent molars (

The Medicaid reimbursement cost for applying dental sealants is $49.68 per tooth (

Fluoride Varnish Applications

A fluoride varnish application consists of having a 5 percent sodium fluoride varnish solution applied in small amounts directly on tooth surfaces and only requires 1-2 applications per child per year for efficacy (

The Medicaid reimbursement cost for varnish application during one dental visit is $28.50 (

Home Brushing with Fluoride Toothpaste

American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) guidelines recommend that children should brush their teeth with fluoride toothpaste twice daily (

We assumed, for each child, a cost of $5 per toothbrush and $3 per tube of toothpaste (i.e., $44/child/year).

Initial Exam with Parental Counseling

YK dentists recommend that children receive an initial exam by a dental health provider with parental counseling prior to 18 months of age. There is limited information as to the effectiveness of conducting dental examination and providing parental counseling to prevent dental caries in preschool children (

Medicaid reimburses $66.98 for an initial examination (

Intervention program costs (

We calculated the undiscounted and discounted costs for each dental intervention, with the exception of water fluoridation (Refer to earlier subsection), at Year 1 and Year 10 using

The average numbers of teeth treated or applications done were obtained from the 2011 YKHC QSI Electronic Dental Record (YKHC Quality Systems Incorporated (QSI) Electronic dental record database (“Clinical Product Suite”, 2011). Refer to spreadsheet tool in

One of our primary objectives was to determine whether specific dental interventions could be used to reduce the total number of adverse dental health outcomes, such as dental caries and FMDRs, observed. We calculated the number of carious teeth and FMDRs prevented using the average number of carious teeth per child and the population covered (per intervention type) as shown in

The population covered is the number of children receiving each intervention as reported in the Methods section, whereas the ideal population coverage for interventions, with the exception of water fluoridation, was the total number of children in the YKD in the correct age group to receive the intervention. In 2011, amongst children (6-60 months) in the YKD being seen for dental treatment, 12.2 percent received either a crown and/or filling. A total of 161 FMDRs were completed during 2011, indicating that 6 percent of the total population (6-60 months) received a full mouth reconstruction during the year. We assumed that each child could receive only one FMDR in a given year; thus the proportion receiving FMDR is also 6 percent for each intervention. For instance, the current number of children 12-36 months using dental sealants in 2011 was 250; therefore, the number of FMDRs completed on children using dental sealants was approximately 15.

Our final step was to determine which intervention would have the greatest impact on reducing the number of carious teeth and FMDRs using cost-effectiveness analysis. Next, we calculated the total adverse health outcomes prevented in the population, at minimum and maximum effectiveness, using

Lastly, we calculated the discounted cost effectiveness ratio (CER) for current and ideal population coverage using

where CER is expressed as the difference between program cost and cost per health outcome prevented divided by the number of health outcomes prevented due to the use of the intervention.

We applied a discount rate of 3 percent to all outcomes (e.g., cost, dental caries prevented, general anesthesia prevented). Discounting was used to estimate the future value and cost of the dental interventions. We applied a discount rate of 3 percent to all outcomes (e.g., cost, dental caries prevented, general anesthesia prevented). Discounting was used to estimate the present value (PV) and cost of the dental interventions using their current present day undiscounted values. The formula for discounting (Equation 2.9) is as follows:

where:

Time 0 = Present day estimated calculated value for each intervention

Rate = 3 percent (universal health evaluation standard) Timeframe5 length of time intervention used

Treating children with caries in the dental office cost approximately $1,467 per child ($275,890 annually), whereas the cost of completing FMDRs was $9,349 per child ($1.5 million annually). We first estimated number dental caries and FMDRs expected to occur, both annually and over the full 10 year timeframe. Next, we applied a discount rate of 3 percent to calculate the total program cost and adverse health outcomes prevented for each intervention (

The current undiscounted first year cost of supplying water fluoridation to the 5 communities already receiving water fluoridation is $18,125 and the total undiscounted first year cost of implementing water fluoridation to all communities capable of receiving water fluoridation is $200,280. The discounted 10 year cost of fluoridating all 22 communities is $797,303.

The annual undiscounted current year cost of applying dental sealants is $12,420 with the maximum undiscounted cost of increasing coverage to 100 percent totalling $226,938. The total 10-year discounted cost is approximately $1.9 million.

The current coverage undiscounted cost of applying fluoride varnish to YK children is $62,923 and the maximum cost being $146,775 at 100 percent coverage. The discounted 10 year cost is approximately $1.3 million.

The current undiscounted annual cost of providing fluoride toothpaste and toothbrushes is $62,135 and the maximum undiscounted annual cost is $113,000. The total discounted 10 year cost is $966,472.

The current undiscounted cost of providing initial exams to children prior to 18 months of age is $10,851 with the maximum current year cost at 100 percent coverage being $38,179. The total discounted 10 year cost is $325,671.

We then calculated the number of caries and FMDRs prevented at minimum and maximum effectiveness for both current and ideal population coverage. For instance, during Year 1 (

Based on our analysis, we determined that all of the interventions did reduce the number of adverse health outcomes observed in the population; however use of fluoride tooth-paste and toothbrush prevented the greatest number of caries at minimum and maximum effectiveness for the current coverage level with 1,433 and 1,910, respectively. Consequently, use of fluoride toothpaste and toothbrush also prevented the greatest number of FMDRs (159 and 211) at minimum and maximum effectiveness. Ideally, at increase coverage levels dental sealants prevented the greatest number of dental caries (3,522 and 3,870) and FMDRs (390 and 428) at minimum and maximum effectiveness.

Lastly, we determined that all interventions produced a cost savings using the cost effectiveness ratio (

In response to a request for technical assistance from the YKD dental program, we evaluated the impact of select dental interventions on the reduction of dental caries and FMDR on children aged 6-60 months. Interventions we included in our analysis were water fluoridation, dental sealants, fluoride varnish, home tooth brushing using fluoride toothpaste, and parental counseling. We chose these five interventions based on published estimates of effectiveness and research data from local YKD practicing dentist and dental providers suggesting that these interventions were most likely to have the greatest impact on the reduction of dental caries, while costing the healthcare payer the least. We found that water fluoridation, tooth brushing, and fluoride varnish would prevent the greatest number of caries and FMDRs. For instance, water fluoridation will prevent between 1,163 and 2,203 dental caries and 129-244 FMDRs. Over 10 years, the cost of supplying water fluoridation would cost $154, 610 at the current coverage level and $797,303 at ideal population coverage. However, the cost associated with preventing the caries is $1.7 million and 2.3 million at current and ideal population coverage. Thereby, saving the healthcare payer ~$1,300 for dental caries and ~7,000 for FMDRs (

One of the major limitations of this study was the lack of FMDR effectiveness data. We assumed, therefore, that the rate of effectiveness in reducing dental caries and FMDRs was essentially the same. Furthermore, we relied heavily on expert dental opinion and literature reviews to constitute whether an intervention would be effective in reducing dental caries in children. The American Academy of Pediatric Dentist and American Dental Association both agreed that using toothbrushes with fluoride toothpaste were highly beneficial in reducing the incidence of caries; however researchers believe that there is limited scientific evidence that demonstrates that fluoride toothpaste is effective in caries control in children younger than 6 years. To ensure that our results and any future evaluations are accurate and relate to specific population and its ability to reduce the number of health outcomes in the population, there is a need for more reliably available effectiveness data. For instance, dentists recommend that children should receive 8 dental sealants on their primary molars before their third birthday to protect them against dental caries and future FMDR treatment. Local dentists suggest that children’s primary molars should erupt by age 3. The published effectiveness rate for dental sealants applies only to the primary molars. Therefore, in an effort to compare sealant effectiveness to the other interventions, we had to apply a proportion for determining the number of teeth in a child’s mouth that are molars. This then provided us with the accurate effectiveness percentage for dental caries in the full mouth of a child 12-36 months of age; however this value could not be found in any literature from the YKD. Another limitation of our analysis is the use of resin-based sealants in the YKD. We used resin-based sealants to determine effectiveness for our analysis because they had a higher frequency of completion, among the YKD children, as reported by the local dental providers. However, they must to be placed on dry surfaces and young children tend to not have a dry mouth making the placement of this type of sealant extremely difficult. We understand that other types of sealants are more widely acceptable, but there use in the YKD was extremely minimal.

The evaluation for cost effectiveness was calculated using the healthcare payer perspective. We assumed that the costs associated with each dental intervention were estimated using the reimbursement fees dental providers would expect to receive from Alaska Medicaid. We assumed that all the customary administration/capital start-up and annual renewal costs were incurred through typical dentistry practice and were not covered by Medicaid; thereby costs incurred for starting and renewing interventions, with the exception of water fluoridation were not included in our analysis. We also made inferences concerning population coverage. Current population coverage was based off the annual age cohort of children 6-60 months. However, census data does not report the annual age cohort of children aged 6-12 months. Therefore, we assumed that our first age cohort was essentially half the overall birth cohort of 600 live annual births (~290). For simplicity, we assumed that all dental interventions had an ideal population coverage of 100 percent with the exception of water fluoridation; it was the only intervention in which the total number of people (1,759) that could be ideally covered was based on the number of people residing in communities capable of receiving piped fluoridated water.

Overall, we generated our analysis based solely on children residing in the YKD and thus are only repeatable in that region. Thereby, these results should not be generalized to other populations in the lower 48 states, without significant adjustments to the model. The basic model could be applied to other populations, but some of the inputs would need to be changed to make the results applicable to those specific populations. For example, the population size, the age structure, baseline caries rates, intervention effectiveness and the proportion of the population that could be served by community water fluoridation would all need to be determined.

In 2008, the CDC-AIP was informed that there were high rates of dental caries requiring extensive care in the YK Delta region of Alaska. The presence of severe dental caries and the ongoing need to perform FMDRs illustrates the need of using dental interventions to reduce the prevalence of these adverse health outcomes. We evaluated which dental interventions were the most cost effective in reducing the number of carious teeth and FMDRs using the current year (2011) and over a 10-year timeframe using a simple spreadsheet-based model. All five dental interventions were shown to generate a cost saving to the healthcare payer at current and ideal population coverage using minimum and maximum effectiveness.

Overall the use of our spreadsheet-based model was useful in estimating the cost-effectiveness of these five dental interventions. However, to produce more accurate estimates for cost-effectiveness among the specific interventions, more accurate cost information, greater detail on the recommended usage for each intervention effectiveness, and greater specificity among the rate of effectiveness in reducing the number of FMDRs is required.

Additional Supporting Information may be found in the online version of this article at the publisher’s website.

Spreadsheet-based model used to evaluate the economic impact of six dental interventions used to reduce the number of dental caries and FMDRs among Alaskan Native children in the YK Delta Region.

Total # of children receiving crowns, fillings, or both = 188

Oral Exam $=$66.98

X-Ray $= $89.08Avg # of crowns & fillings = 7.73

Crown Medicaid Reimbursement $= $199.53

Total # of children receiving crowns, fillings, or both = 188

Oral Exam $=$66.98

X-Ray $= $89.08

Avg # of crowns & fillings = 7.73

Filling Medicaid Reimbursement $= $142.63

Total # of children receiving crowns, fillings, or both = 188

Oral Exam $ =$66.98

X-Ray $ = $89.08

Avg # of crowns & fillings = 7.73

Percent of crowns & fillings = 50 percent

Crown Medicaid Reimbursement = $199.53

Filling Medicaid Reimbursement $ = $142.63

Mean Filling Cost is $214 ((

Mean Cost for both is $1,050) (Equation 3 above)

Weighted cost values

Weighted data inputs (per child) | Mean cost calculations |
---|---|

Crowns only | $199 |

Fillings only | $214 |

Crowns & fillings | $1,050.17 |

Mean treatment cost with caries | $1,461.73 |

Mean treatment cost with FMDR | $9,349 |

Discounted number of dental caries & FMDR procedures prevented at minimum effectiveness at current & ideal population coverage (per intervention type)

Intervention type | Caries prevented (Year 1, Year 10)
| FMDR prevented (Year 1, Year 10)
| ||||||
---|---|---|---|---|---|---|---|---|

Current Caries | Ideal Caries | Current Procedures | Ideal Procedures | |||||

Water Fluoridation | 132 | 251 | 15 | 28 | ||||

Dental Sealants | 39 | 401 | 4 | 27 | ||||

Fluoride Varnish | 129 | 254 | 14 | 28 | ||||

Toothbrush/ toothpaste | 163 | 296 | 18 | 33 | ||||

Initial Exam | 20 | 242 | 2 | 27 |

Discounted number of dental caries & procedures requiring general anesthesia prevented at maximum effectiveness at current & ideal population coverage

Intervention type | Caries prevented (Year 1, Year 10)
| FMDR prevented (Year 1, Year 10)
| ||||||
---|---|---|---|---|---|---|---|---|

Current Caries | Ideal Carie | Current Procedures | Ideal Procedures | |||||

Water Fluoridation | 178 | 338 | 20 | 37 | ||||

Dental Sealants | 43 | 440 | 5 | 49 | ||||

Fluoride Varnish | 1,72 | 339 | 19 | 38 | ||||

Toothbrush/ toothpaste | 217 | 395 | 24 | 44 | ||||

Initial Exam | 28 | 352 | 3 | 39 |

Annual number of caries treated and FMDRs completed by intervention type.

The values presented display the annual number of expected caries and the number of FMDRS completed in children by intervention type. Expected caries is calculated using the product between caries incidence, population receiving treatment, and the average number of caries (crowns and/or fillings) per child. The average number of caries per child is 1.71. We assumed that each child could only receive one FMDR per year; thus the annual number of FMDRS is the product between the population of children receiving the intervention and the FMDR incidence per child. Annual caries incidence for children receiving a crown and/or filling was 7.3 percent, while the annual FMDR incidence was 6.3 percent.

Total discounted program costs over a 10-year timeframe.

Program costs are discounted using a rate of 3 percent. We calculated the total program costs of using a specific intervention for the full implementation timeframe of 10 years.

Comparison between current total program costs (discounted) and minimum number of outcomes averted (discounted) per intervention type.

Model Inputs for Dental Caries & FMDRS

Dental Caries | Model Inputs | Source |
---|---|---|

No. of children seen for treatment of crowns and/or fillings by a local dentist (within the dental office) | 1536 | YKHC Frequency of Dental Services, 2011 |

Annual No. children receiving 1 or more crowns | 156 | YKHC Quality Systems Incorporated (QSI) Electronic dental record database (“Clinical Product Suite”) , 2011 (unpublished) |

Avg. No. of crowns per child | 4.54 | |

Annual No. of children receiving 1 or more fillings | 166 | |

Avg. No. of teeth filled per child | 3.18 | |

Total number of children receiving crowns and fillings | 188 | |

(a)No. of children with fillings only | 22 | |

(b)No. of children with crowns only | 32 | |

(c)No. of children receiving crowns and/or fillings | 134 | |

Total Avg number of crowns & fillings | 7.73 | |

Oral Exam Cost | $66.98 | FY 2012 Alaska Medicaid Reimbursement Fee Schedule. |

X-Ray Cost | $89.08 | |

Stainless Steel Crown Cost | $199.53 | |

Filling Cost | $142.63 | |

Total Cost of Treating Crowns/Fillings (per child) | $447 | Calculated: Appendix B |

Annual No. of FMDRs completed by dental surgeon (in operating room) | 161 | YKHC Frequency of Dental Services, 2011 |

Median No. of teeth extracted per child | 4 | YKHC Quality Systems Incorporated (QSI) Electronic dental record database (“Clinical Product Suite”) ,2011 (unpublished) |

Median No. Of vital pulpotomies per child | 5 | |

Median No. of bitewings/films taken per child | 2 | |

Travel cost per child (with guardian) | $1500 | As reported by local YKHC dental practitioners |

Personnel cost | $1500 | |

Operating room cost | $3198 | |

Stainless Steel Crown on Primary Tooth | $199.53 | FY 2012 Alaska Medicaid Reimbursement Fee Schedule |

Filling Cost | $142.63 | |

Tooth Extraction | $141.71 | |

Vital Pulpotomy | $131.83 | |

Bitewings/Films | $35 | |

Other Associated Costs | $250 | |

Total FMDR cost (per child) | $9,349 | Calculated: Appendix B |

Average number of teeth being treated in the dental office was obtained from the dental clinical data maintained by the Yukon-Kuskokwim Delta Regional Health Consortium (YKHC), which uses Quality Systems Incorporated (QSI) electronic dental records named “Clinical Product Suite” to documental dental procedures and CDT billing codes to track the number and type of services rendered in the YKD.

Number of children receiving crowns and/or fillings in the dental office (188) was obtained through the Yukon-Kuskokwim Delta Regional Health Consortium (YKHC) Quality Systems Incorporated (QSI) electronic dental records. We then used the Venn diagram to identify and estimate the number of children that received only one type of caries service from the total number of children (i.e., 188). Thereby, the number of children receiving (a) crowns only was 32, (b) fillings only was 22, and (c) those that received a combination of crowns and fillings was 134.

Total Costs for both caries treatment and FMDR were calculated based upon the costs associated with providing routine exams, customary procedures, and any other associated costs as detailed in the FY 2012 Alaska Medicaid Reimbursement Fee Schedule. For caries treatment in dental chair only, we calculated the mean costs using the product between the proportion of the number of children that received only one type of services (i.e., based on Venn diagram) to the total number of children receiving (188 children) and the sum of the exam and x-ray cost and the proportion between the total number of carious teeth treated per child (7.73) and AK Medicaid customary reimbursement fee for the specific type of service (i.e., cost of crown placement and fillings). All costs for FMDRs were calculated using the customary AK Medicaid reimbursement fee for each type of service.

Rates of coverage and intervention effectiveness and start-up and annual running costs for 5 dental interventions.

INTERVENTION TYPES | Population Coverage | Effectiveness | Unit Cost | Source | ||||
---|---|---|---|---|---|---|---|---|

Current Pop | Ideal Pop | Min | Max | Start-Up | Annual | Unit Fee | See list of references | |

11% | 68% | 26% | 35% | $7,090 | $3,625 | N/A | ||

10% | 100% | 28% | 31% | $49.68 | ||||

52% | 100% | 18% | 24% | $28.50 | ||||

^{[20,21]} (6-60 months) | 55% | 100% | 21% | 28% | $44 | |||

26% | 100% | 22% | 32% | $66.98 |

Current population coverage is the percentage of the population is currently receiving the intervention. Ideal population coverage is the maximum amount of coverage that could use a specific intervention. For instance, there are a total of 5 communities (36%) received community fluoridated water. However if the intervention was expanded to fluoridate all the communities that have the capacity for receiving a piped fluoridated water system (22 communities in total) the ideal population coverage will increase to 68%.

Rate of effectiveness was obtained through expert dental opinion and literature reviews from the YK Delta Region. Sources for minimum and maximum effectiveness are provided for each intervention in the final column.

Dental Sealants effectiveness in reducing caries in the total mouth of children upto 60 months of age was calculated using the proportion of children’s teeth that are molars (.40) and the reported effectiveness of preventing dental caries amongst the molars of children (71%-78%).

Unit costs are composed of the start-up and annual costs, along with the unit fee associated with each intervention. Water fluoridation was the only intervention by which start-up and annual costs were a part of the total intervention/program costs. The costs associated with water fluoridation consist of $5,970 in start-costs ($4,380 for installation and $1,590 for an operator’s travel to the community) and $2,384 in annual costs ($1,120 for the operator’s fee above their own salary and $1,264 for annual renewal). In all other interventions, we assumed that the start-up and annual costs were paid for as part of their program cost. Thus, their costs were presumed to be included as part of the regular administration/capital costs of the YK region. Thus, the only cost associated with these other interventions is the unit cost, per tooth or per visit, associated with performing the service. The unit fee was obtained from the License for use of CDT Codes, FY 2012 Dental Fee Reimbursement Schedule [5].

These numbers represent the sources for effectiveness data. A full list of sources is available in the reference section.

A: Estimated annual costs of each dental intervention

Intervention Type | Annual undiscounted program costs | Annual discounted program cost (one year only) | Total discounted program costs (10 years) | |||
---|---|---|---|---|---|---|

Water Fluoridation | $18,125 | $200,280 | $17,597 | $194,447 | $154,610 | $797,303 |

Dental Sealants | $12,420 | $226,938 | $12,058 | $220,328 | $105,945 | $1,935,829 |

Fluoride Varnish | $62,923 | $146,775 | $61,090 | $142,500 | $536,747 | $1,252,021 |

Toothbrush/Toothpaste | $62,315 | $113,000 | $60,500 | $110,000 | $531,560 | $966,472 |

Initial Exams | $10,851 | $38,179 | $10,535 | $37,067 | $92,559 | $325,671 |

B: Comparison of Annual (undiscounted Year 1) estimates for each intervention at minimum effectiveness | |||||
---|---|---|---|---|---|

Outcome Measure | |||||

929 | 250 | 1311 | 1416 | 162 | |

65 | 18 | 95 | 103 | 11 | |

525 | 141 | 740 | 799 | 91 | |

.26 | .71 | .18 | .21 | .22 | |

137 | 39 | 133 | 168 | 20 | |

$18,125 | $12,420 | $62,923 | $62,315 | $10,851 | |

$200,245 | $58,833 | $195,347 | $246,158 | $29,503 | |

$278 | $690 | $662 | $605 | $986 | |

$3,081 | $3,269 | $2,056 | $2,390 | $2,682 |

Annual estimated costs are the calculated undiscounted costs determined from the actual cost of supplying the intervention and any additional costs associated with the implementation of the intervention into the population.

Current pop (population) is defined as the current (‘present day”) number of people receiving the intervention. Ideal population is defined as the maximum number of people that could benefit from the use of the intervention. The cost for each population type is calculated using the product between population coverage rates and the intervention unit costs (

Discounted costs are the actual present value (PV) of implementing the specific intervention to the population for the selected timeframe based upon the intervention specific estimated (i.e. budgeted) costs. All discounted costs are calculated as Current $/(1+discount rate)ˆspecified timeframe.

# of children with caries is calculated by multiplying the population by caries incidence (7.3%), whereas the # of caries is calculated by multiplying the number of children with caries by the mean number of carious teeth per child (7.73).

# of caries averted is the product between the total number of caries and the percentage of effectiveness. Hint: the % effectiveness for dental sealants is multiplied by .40 to to obtain the actual % effectiveness of preventing carious teeth amongst the total mouth of children (~20 teeth). The effectiveness value shown only represents that of permanent molar teeth and not the whole mouth.

Annual program cost was calculated earlier (See Methods: Section D for

Annual averted cost is the product between the number of caries averted and the cost of treating caries ($1,467 per child). The averted cost per child is the annual averted cost divided by the number of children with caries.

Comparison of annual (undiscounted Year 1) estimates for each intervention at minimum effectiveness

Outcome measure | Water fluoridation | Dental sealants | Fluoride varnish | Toothbrush/toothpaste | Initial exams |
---|---|---|---|---|---|

# Children covered | 929 | 250 | 1311 | 1416 | 162 |

# Children w/caries | 65 | 18 | 95 | 103 | 11 |

Total # of caries | 525 | 141 | 740 | 799 | 91 |

% Effectiveness | 0.26 | 0.71 | 0.18 | 0.21 | 0.22 |

# of caries averted | 137 | 39 | 133 | 168 | 20 |

Annual program $ | $18,125 | $12,420 | $62,923 | $62,315 | $10,851 |

Annual averted $ | $200,245 | $58,833 | $195,347 | $246,158 | $29,503 |

Program $per child | $278 | $690 | $662 | $605 | $986 |

Averted $per child | $3,081 | $3,269 | $2,056 | $2,390 | $2,682 |

# of children with caries is calculated by multiplying the population by caries incidence (7.3%), whereas the # of caries is calculated by multiplying the number of children with caries by the mean number of carious teeth per child (7.73).

# of caries averted is the product between the total number of caries and the percentage of effectiveness. Hint: the % effectiveness for dental sealants is multiplied by .40 to obtain the actual % effectiveness of preventing carious teeth amongst the total mouth of children (320 teeth). The effectiveness value shown only represents that of permanent molar teeth and not the whole mouth.

Annual program cost was calculated earlier (See Methods: Dental Intervention Program Cost section for

Annual averted cost is the product between the number of caries averted and the cost of treating caries ($1,467 per child). The averted cost per child is the annual averted cost divided by the number of children with caries.