Top 100 most cited economic evaluation papers of preventive oral health programmes: A bibliometric analysis

Abstract

Objective

To identify the trends of the top 100 cited articles on economic evaluation in preventive oral health programs.

Methods

Top 100 papers involving economic evaluation or cost analysis of preventive oral health programs were selected by querying Scopus and Web of Science databases. Bibliometric analysis was performed using the Bibliometrix tool in R Studio. Performance analysis and science mapping were performed for these 100 articles. Performance analysis included publication-related metrics, citation-related metrics, and citation-publication-related metrics. Science mapping provided information on citation analysis, co-citation analysis, bibliographic coupling, co-word analysis, and co-authorship details.

Results

The total citation number of the top 100 most cited articles ranged from 4 to 98, with publication dates spanning from 1978 to 2023. The majority of articles (33.70 %) originated from the USA, while Community Dentistry and Oral Epidemiology stood out as the journal with the highest number of articles published in the top 100 (16 out of 100). Griffin PM emerged as the most cited author, based on the frequency measurement of the number of papers. Program data economic evaluation was the most commonly reported study design, and fluoridation programs were the most frequent topic. The most reported type of economic analysis performed in the articles was cost-effectiveness analysis.

Conclusion

The bibliometric analysis of the top 100 most-cited articles on economic evaluation of preventive oral health programs revealed the lacunae in the research literature on this topic. Therefore, preventive oral health programs should be economically evaluated to eliminate the disparity in resource allocation particularly in upper middle income and low-income countries.

Graphical abstract

1. Introduction

Oral health is essential to general well-being and quality of life across the lifespan. Maintaining good oral hygiene plays a crucial role in reducing the burden of oral diseases and various systemic conditions. Globally, estimated that oral diseases affect nearly 3.5 billion individuals (approximately 50 % of the population).¹ These diseases are a major health concern worldwide but are often neglected due to a lack of oral health education, ambiguity in preventive methods, and expensive treatment costs. Consequently, implementing preventive strategies is necessary to reduce the incidence of oral diseases, as their adverse impacts include pain, discomfort, functional impairments, and diminished quality of life.²

Various preventive interventions exist and some common interventions include oral health education which primarily focuses on dietary habits, cessation of harmful habits, removal of plaque, use of sealants and professionally applied topical fluorides, affordable fluoride mouth rinses and toothpaste, and regular dental check-ups.³ These interventions are often delivered through preventive oral health programs targeting specific populations.4, 5, 6 Economic evaluations of preventive oral health programs have shown that interventions like fluoride varnish applications, dental sealants, and school-based dental programs are cost-effective. Studies using cost-effectiveness analysis (CEA) demonstrate that these preventive measures can reduce treatment costs by decreasing the incidence of cavities.⁷

The quality of health care programs primarily relies on the effective allocation of resources. Resource scarcity occurs when demand exceeds the available resources. Health economics addresses these scarcity issues in allocating health and healthcare.⁸ Factors such as limited funding, inadequate healthcare infrastructure, geographical location, and economic status pose significant challenges in providing healthcare services. Despite these constraints, there is a growing demand to assess the economic efficiency of healthcare treatment and programs. Economic evaluations aim to determine the most cost-effective healthcare interventions.⁹

Economic evaluation in the modern healthcare system is considered a transparent scientific framework that improves population health at the best possible value.⁴ It analyses the costs of healthcare interventions with their outcomes and compares the efficiency of alternative treatment strategies.⁶ Additionally, it identifies potential disparities in access to preventive care and outcomes across various communities, enabling policymakers to enhance overall oral health valuation.¹⁰ Conventional economic evaluations in healthcare include cost-minimization analysis (CMA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), and cost-utility analysis (CUA).

Cost minimization analysis is limited to situations in which the efficacy and patient outcomes of healthcare treatments are identical, with outcomes measured in natural units.¹¹ Cost-effectiveness analysis estimates the monetary cost needed to maximize the benefit from limited resources.¹² Cost-benefit analysis expresses a project's costs and benefits in monetary terms, allowing for direct comparison.³ In cost-utility analysis, cost is measured in monetary units, and outcomes are derived by assessing quality-adjusted life years (QALY), combining both the quantity and quality of life lived after receiving healthcare intervention.¹³

Due to unhealthy dietary habits and modern lifestyles, developing nations must be cognizant of preventive oral health interventions.¹⁴ Healthcare and societal perspectives are the most commonly employed perspectives of health economic analysis. The healthcare perspective analyses all costs and effects within the healthcare system while the societal perspective analyses all costs and effects on society, irrespective of who they impact¹⁰

Recent advances in the economic evaluation of preventive oral health programs focus on integrating digital tools, policy interventions, and multi-level approaches. Mobile health applications are making preventive care more accessible and cost-effective, particularly in underserved areas.¹⁵ Economic evaluations now increasingly inform policy decisions on financing models to optimize resource allocation.¹⁶ Additionally, multi-level interventions that combine clinical, community, and policy strategies have shown significant cost-benefit advantages, offering a holistic and economically viable approach to improving oral health outcomes.¹⁷

Although many studies have assessed the effective distribution of oral healthcare resources, there is a need for comprehensive literature on health economic evaluation. Bibliometric analysis is a popular scientific methodology that provides important insights into emerging trends, key research topics, or gaps in the literature.¹⁸ In contrast, a systematic literature review deals with the focused research question of effectiveness or prevalence, with due importance to the methodological quality of existing literature on a topic.¹⁹

Given the complexity and resource constraints in healthcare, understanding the economic aspects of oral health programs is crucial. While many studies have examined the distribution and efficiency of healthcare resources, a comprehensive analysis of the economic evaluations in oral health remains lacking. An initial search revealed extensive literature on the economic evaluation of oral preventive programs, indicating the need for literature mapping before proceeding with specific research questions. A bibliometric evaluation of the top 100 cited economic evaluations in preventive oral health programs is conducted to identify key trends within these cited articles.

2. Materials and methods

The top 100 papers involving economic evaluation or cost analysis of preventive oral health programs published between inception and 2024 were selected by querying two scientific databases (Scopus and Web of Science). The initial search date was 31–12-2022, an updated search was conducted to identify new articles on 24-08-2024. We combined the results from both Scopus and Web of Science to determine the top 100 cited articles. The. ris files from Web of Science and Scopus were screened in Zotero, and the final file was uploaded to Scopus. The files were then sorted by the highest to lowest citations, and the first 100 were selected.

Bibliometric analysis was conducted using the Biblioshiny R package, for noncoders. Performance analysis and science mapping were two important aspects of bibliometric analysis that identify the contributions and correlations of research components. Performance analysis provided publication-related metrics, citation-related metrics, and citation-publication-related metrics. Citation analysis, co-citation analysis, bibliographic coupling, co-word analysis, and co-authorship details were obtained through science mapping.¹⁹ The search terms mainly included “oral health,” “preventive oral health programs,” “pit and fissure sealants”, “fluorides”, “economic evaluation” and “cost analysis”. The inclusion criteria involve papers featuring economic evaluation of any preventive oral health programs not limited to fluoride interventions, sealant programs, and tooth brushing programs.²⁰ There were no restrictions on study design and articles were limited to the English language. The study designs were categorized into program data analysis, modeling, clinical trials, cross sectional studies, observational analytical studies, and reviews.

Papers dealing with the protocol for preventive oral health measures and conference papers were excluded. The selected articles were transported into a saved list in Scopus. In the saved list, the ranking was based on the citation count in descending order, and the first 100 articles were selected from this list. The credibility and impact of a publication were decided by the number of citations it obtained. The screening of the selected articles was performed by two independent reviewers (LA, GP) based on the inclusion and exclusion criteria. Inter-examiner agreement was analyzed and the Cohen's Kappa value was found to be 0.78, indicating substantial agreement according to the criteria by Landis and Koch (1977).²¹ Any disagreements were resolved through a third reviewer (VK). The duplicate entries that were bound to affect the analysis outcome were removed by the third reviewer (VK) after meticulous assessment. Data obtained were the title of the paper, description of study design, description of cost analysis, citation count, country, continent, authorship, year of publication, and journal.²⁰ The selected data were imported into the Biblioshiny software of the R Studio (Version 4.2.3) for bibliometric analysis, and the findings were recorded.

3. Results

The total citation counts of the selected 100 articles ranged from 4 to 98. Between 1978 and 2023, the top 100 most cited articles were published. Data revealed that the annual growth rate percentage was 3.29 %, and the average citations per document were 24.46. The document types included 95 articles and five reviews. Of the 100 cited publications, 95 were co-authored publications, and sole-authored publications were 5 in number (Table 1).

Table 1.

Characteristics of 100 top-cited articles.

Main information about the data
Timespan	1978:2023
Sources (Journals, Books, etc)	42
Documents	100
Annual Growth Rate %	3.29
Document Average Age	15.7
Average citations per doc	24.46
References	3212
Document contents
Keywords Plus (ID)	616
Author's Keywords (DE)	180
Author information
Authors	366
Authors of single-authored docs	5
Authors collaboration
Single-authored docs	5
Co-Authors per Doc	4.71
International co-authorships %	18
Document types
Article	95
Review	5

Productivity per active years of publication was reported to be 2.6. The selected articles received a total of 2442 citations which includes 250 self-citations.

The highest mean total citation per year (MTCP) was highest in the year 2023 (8.00). The most cited article was “An economic evaluation of community water fluoridation” authored by Griffin SO, Jones K, Tomar SL and published in Journal of public health dentistry in 2001 and the article received 98 citations. The oldest paper was published in 1978, and the most recent paper was published in 2023. Most articles⁷ were published in the year 2018 (Fig. 1).

Fig. 1.

Annual evolution of scientific production from 1978 to 2023.

The 100 articles were published in 42 journals. Out of the 42 sources, the most published source was Community Dentistry and Oral Epidemiology (16 documents, 358 citations), followed by the Journal of Public Health Dentistry (12 documents, 385 citations) and Caries research (7 documents, 150 citations). The h-index, g-index, and i-index were found to be 30, 48, and 79 respectively (Table 2).

Table 2.

Performance analysis of top 100 cited analysis.

Total publications (TP)	100
Number of contributing authors (NCA)	366
Sole authored publications (SA)	5
Co-authored publications (CA)	95
Number of active years of publications (NAY)	38
Productivity per active year of publication (PAY)	100/NAY = 2.6
Total citations (TC)	2442
Average citations	24.42
Collaboration index (CI)	0.0366
Collaboration coefficient (CC)	0.726
Number of cited publications (NCP)	100
Proportion of cited publications (PCP)	1
Citations per cited publications (CCP)	24.42
h-index(h)	30
g-index(g)	48
i-index(i)	79

Griffin P M was the most cited author (5 articles, 147 total citations), followed by Morgan M V (5 articles, 86 total citations) and Kroon J (5 articles, 60 total citations). The authors’ impact measure was also high for Griffin PM.⁵ The most relevant affiliations contributing to the field reported being the University of Melbourne (14 articles). Most papers were from the USA and were published in the Community Dentistry and Oral Epidemiology. The National Institute of Dental and Craniofacial Research (NIDCR) reports to be the funding source for the highest number of publications in the US. Based on the citation count, the USA (741 citations), Australia (391 citations), and Sweden (312 citations) were the most cited countries. The review analyzed citations across countries, with the highest citations from high-income countries: USA (751), Australia (391), Sweden (207), and the UK (221). Upper-middle-income countries like China¹⁴ and Brazil (35) had fewer citations, while low-income countries like Nepal contributed 9 citations (Table 3).

Table 3.

Top countries with high citations based on income level.

	Countries	Total citations
High Income Countries	1. USA	751
	2. Australia	391
	3. Sweden	207
	4. United Kingdom	221
	5. Germany	96
	6.Canada	68
	7. Finland	64
	8.Chile	44
	9.Netherlands	41
	10.Spain	15
	11.New Zealand	11
	12.Ireland	8
Upper Middle Income Countries	1. China	14
	2.Brazil	35
Low Income countries	1.Nepal	9

Data showed the USA with the highest scientific production with a frequency of 81 followed by the United Kingdom (frequency of 59) and Australia (frequency of 56) (Fig. 2)

Fig. 2.

Global distribution of the top 100 cited articles on economic evaluation of preventive oral health programmes (ND = Number of Documents).

As per WHO regions, the majority of the papers were from Region of the Americas (AMR), European Region (EUR) and Western Pacific Region (WPR). The study designs were categorized into program data economic analysis, modeling, randomized controlled trials, and systematic reviews. Program data economic evaluation (35) was the most reported study design followed by modeling, randomized controlled trial (1 0.3), reviews,³ cross-sectional study,² and case-control study.¹ The most frequent topic was fluoridation programs including water fluoridation, fluoride varnish, fluoride mouthrinse, and fluoridated toothpaste, followed by pit and fissure sealant programs, school programs, and regular dental care. The review identified 10 community-based, 12 school-based, and 9 healthcare-based studies on the cost-effectiveness of preventive oral health programs. Topics included water fluoridation, dental sealants, and fluoride varnish, highlighting diverse settings in community, educational, and healthcare environments.

Considering the top 100 cited articles, 73 articles accounted for cost-effectiveness analysis, cost-benefit analysis (13 articles), cost analysis (11 articles), cost-utility (2 articles), cost minimization (1 article), and cost estimation (1 article). The most frequent word was found to be dental caries (170 occurrences), child (170 occurrences), and human (105 occurrences) (see Fig. 3). The trending topics from the field of titles were reported to be controlled, fluoride and varnish. Regarding the bibliographic coupling, clusters were obtained from sources by measuring the author's keywords. Community Dentistry and Oral Epidemiology showed the highest cluster frequency. Co-word analysis revealed the term ‘child’ with the highest cluster frequency (see Fig. 3).

Fig. 3.

Co-occurrence network derived from keywords in the top 100 most cited articles on economic evaluation of preventive oral health programs.

Collaboration analysis showed a spike in intellectual collaboration between Australia and Chile. Australia was leading in intellectual collaborations⁸ with other countries, followed by Chile and the United Kingdom.

4. Discussion

The 100 most-cited papers on the economic evaluation of preventive oral health programs were published between 1978 and 2023, a relatively short time. The USA contributes most articles in this field, followed by Australia and Sweden. Africa was the only continent with null citations.²⁰ Among upper middle income countries China, South Africa and Thailand exhibit a growth in scientific production. Among lower income countries, Nepal could contribute to the research field. Indeed, preventive dental care does not receive the same level of attention as medical care among policymakers when taking into consideration the effective allocation of healthcare resources.²² The healthcare system requires consistent, large investments in research and development. High-income countries spend between 2 % and 4 % of their respective gross domestic product (GDP) on R&D.²³ Western countries have robust funding and abode most of the leading research institutes in the world.²⁴ Low-income countries face numerous challenges for large-scale investments. South Asian and sub-Saharan African countries contribute the world's lowest R&D expenditure on an average of 0.65–0.69 % of their respective GDP.²⁵ While countries having high levels of English proficiency showed more productivity and output from publishers having global stature, local researchers tend to target national journal publishers due to the language requirements and research standards that seem more suitable.²⁶

Two recent reviews have highlighted the economic evaluations of preventive oral health programs. Mariño and Zaror (2020) conducted a scoping review on the economic evaluations of community water fluoridation (CWF).¹⁶ Their review included 24 studies, with the majority demonstrating that CWF is a cost-effective strategy for preventing dental caries, yielding substantial savings in dental treatment costs and averted caries. Davidson et al.⁴ (2021) performed a systematic review assessing the cost-effectiveness of various caries preventive interventions. Their review included 26 studies, focusing primarily on children, with most studies reporting cost savings and improved outcomes, especially for fluoride varnish and risk-based programs. However, they noted a lack of studies targeting adults and the elderly. These reviews underscore the importance of economic evaluations in guiding resource allocation for preventive oral health programs.

In this study, the top cited articles give information about randomized controlled trials (RCT), which are instrumental in assessing the effectiveness of various policy interventions to alleviate resource scarcity.²⁷ A randomized controlled trial is an experiment that is designed to isolate the influence that an inevitable intervention or variable has on an outcome or event. RCT receives high citations due to the most substantial experimental evidence in clinical care.²⁸ In the UK, healthcare resources are primarily funded through the National Health Service (NHS). The NHS is a publicly funded healthcare system that provides medical services to all residents of the UK. It is mainly funded through general taxation, including income tax, National Insurance contributions, and other government revenues.²⁹

In the US, the National Institute of Dental and Craniofacial Research (NIDCR) promotes the timely transfer of knowledge gained from research to the public by conducting various research training programs. NIDCR is one of the 27 institutes of the National Institutes of Health (NIH), the world's foremost medical research centre.³⁰ Regarding developing countries, the only difficulty lies in estimating the benefits, which is challenging for the programs and decision-makers, and managing various funds received from the health sector. Economic analysis of preventive dental programs is often tricky as it requires epidemiologic and demographic data (the reason for fewer citations is due to the reduced number of literature). This study also reveals that fluoride interventions are the commonly adopted preventive oral health programs at a community level regardless of age, income, or education.³¹

The World Health Organization (WHO) promotes community water fluoridation as an effective approach to oral health. Salt fluoridation is considered the second-best choice where water fluoridation becomes impractical.³² The fluoride programs are advantageous due to the ability to frequently take around low fluoride levels to saliva with high reach and substantial cost savings. Community water fluoridation is a cost-saving intervention in small communities.³¹ CEA identifies neglected opportunities by calling attention to economic interventions, redirecting resources to use better and priority settings, and fetching relevant contributions for improved program management.²⁷

The h-index is an important measure that indicates the quality and quantity of a given author's publications.¹⁶ The g-index is a measure of impact such that the number of articles is cited an average of g times or g² times. The i10-index calculates the number of significant publications. In this study, h index 30 represents the number of articles that have received at least 30 citations. The g index 48 represents the number of articles that have received citations of around 48 or 96 (g²) citations.¹⁵

The choice of WoS and Scopus allowed us to gather many citations from papers published in scholarly journals.²⁰ Over the last 15 years, researchers from the majority of countries made contributions to WoS and Scopus-related papers. China, the USA, and the UK were the leading contributors to WoS-related research. Relatively, the USA, UK, and Australia were the highest contributors to Scopus-related research. Hence, the major participation in academic research belongs to developed economies.²⁹

The topic of interest, “Economic evaluation of preventive oral health programs” was a vast discussion area without a subjective preference. In addition, the selected sample sizes were limited to 100 papers. Even though this study comprises RCT as the prime sort of exploration, the quality of these programs has yet to be discovered. Therefore, the scrutiny of provided shreds of evidence remains to be debated. A steadiness between the inputs and outputs and available resources will determine if the program can be suggested for general use.²⁹

5. Conclusion

This bibliometric analysis identified that the 100 most-cited articles on the economic evaluation of preventive oral health programs were mainly program data economic evaluation, with the majority of the papers published in the USA, aiming at the proper allocation of resources. Papers were predominantly published in Community Dentistry and Oral Epidemiology, and Griffin P M was the most frequent author. Despite its limitations, this bibliometric analysis helps researchers identify the emerging trends in preventive oral health care and the need for more studies in upper middle income countries and lower middle income countries to eliminate the disparity in the allocation of healthcare resources and ensure equity in delivering oral care.

Recommendations: More high levels of scientific evidence, such as systematic reviews and randomized controlled trials, are encouraged to execute cost-effective preventive oral health programs. Quality checks of various data should be encouraged to mitigate errors in future bibliometric analyses and to ensure the integrity and reliability of the findings.

Patient and public involvement statement

In the context of our bibliometric analysis, Patient and Public Involvement (PPI) is not applicable. This study involves the analysis of existing published research, and it does not directly involve patients or the general public in its design, execution, or data collection. As such, the role of patients and the public in this particular research is not applicable.

Patient's/guardian's consent declaration

As this study involved secondary data analysis in databases, no direct patient data was collected.

Informed consent was not required.

Data availability statement

The data underlying this bibliometric analysis are openly available in Open Science Framework at DOI: 10.17605/OSF.IO/NWTKX.

Ethical clearance declaration

“Given that this research constituted a secondary data analysis, ethics approval was not necessary for this Bibliometric Analysis”

Sources of funding declaration

“No funding has been received for this project from any sources."

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.