Table 1.

Clinical and Economic Effectiveness of Interventions Implemented to Improve Oral Health

Author and year	Grant et al. 2007 (30)	Wennhall et al 2008 and 2010 (29,53)	Kobayashi et al 2005 (27)	O’Connell et al 2005 (2)	Scherrer et al 2007 (5)	Hietasalo et al., 2009 (31)	Kowash et al 2006 (28)
General Information Type of study Intervention	Observational Intervention: Parent oral health counseling, child dental screening and fluoride varnish application	Observational Intervention: Comprehensive oral health outreach and preventive program that included education on diet and oral hygiene, Comparison: Care as usual (historic reference group)	Observational Intervention: Community-based program included community outreach, parent and dental professional education, child referrals for services, preventive and treatment services, and higher reimbursement for trained dentists; Comparison: Usual care	Decision cost model Intervention: Community water fluoridation programs, Comparison: No program	Decision cost model Intervention: School-based dental sealant programs, Comparison: no program	Randomized clinical trial Experimental group: Patient-centered education on oral hygiene and nutrition, preventive services, clinical exams, and referrals for treatment; children averaged 3–4 visits over a 12-month period, community and school oral health promotion; Control group: Usual care, community and school oral health promotion	Randomized clinical trial Experimental group: Health educators provided education on oral hygiene and nutrition and dental screenings during home visits conducted at varying frequency (Groups A-D); Control group: Usual care
Location	North Carolina, United States	Malmo, Sweden	State of Washington, United States	Colorado, United States	7 states in the United States	Pori, Finland	Leeds, United Kingdom
Setting Target population	University pediatric clinic Children aged 6–36 months, Intervention group n = 665	Outreach facility High-risk children living in a low-socioeconomic multicultural area, Intervention group: Children aged 2 years n = 651, Historic controls n = 201	Community Children aged 6 years and younger, Intervention group: children in the intervention county (approximately 20,000 served 1997–1999), Comparison group: children in a county without the intervention	Community Persons age 5 years and older	Schools Children 7–9 years old (children in second grade)	Public dental clinics Children ages 11–12 years with at least one active initial caries lesion, Experimental group n = 250, Control group n = 247	Home-based Mothers of infants age 8 months living in a low-socioeconomic area with high caries prevalence, Intervention group n = 228 children, Control group n = 55 children
Health outcome	Not provided	Oral health status of children age 5 years, Intervention group: 8.2 DEFS, Reference group: 11.2 DEFS	Oral health status of children in third grade in each county in 2002 (n = 453), Intervention county: ratio of DFS to all erupted surfaces: 0.1, Comparison county ratio: 0.2	CWFPs reduced the decay increment by approximately 25%	Averted caries estimated from an annual DMFT attack rate of 0.132 over the 9 year period, adjusted for the annual sealant retention rate of 90%	Experimental group: 2.56 DMFS, Control group: 4.60 DMFS, Incremental effectiveness: 2.04 averted DMFS (CI: 1.26–2.82)	Intervention groups: 0.29 DMFS for Group A, 0 DMFS for Groups B-D, 3% of children in Groups A-D had gingivitis; Control group: 1.75 DMFS, 16% had gingivitis
Timeframe and analytic horizon	Time frame and analytic horizon: 31 months (12/2001–7/2004)	Time frame and analytic horizon: 3 years (1998–2000)	Time frame and analytic horizon: 7 years (1995–2001)	Time frame: 1 year, Analytic Horizon: Lifetime	Time frame: 1 year, Analytic Horizon: 9 years	Time frame and analytic horizon: 3.4 years (2001–2005)	Time frame and analytic horizon: 3 years, participants recruited in 1995
Economic Information Perspective	Health-care provider	Health provider, health payer (government)	Health-care provider, health payer	Society	Health-care provider, health payer (government), society	Health-care provider, health payer (government)	Health-care provider, health payer (government)
Economic outcomes	Intervention costs: $4,951, reimbursement for intervention services: $51,992, net program costs: −$47,041	Intervention cost per child: €310, Net cost per child including treatment revenue: €30 (CI: €109 to-61 (cost savings))	Mean annual intervention costs per child for birth cohort (born in 1994 or 1995): $5.33, Mean annual Medicaid dental expenditures for birth cohort: intervention county −$$207 and comparison county −$199, Mean annual net costs of health-care provider and Medicaid: $13.50	Annual net costs $148.9 million (CR: $115.1- 187.2 million), net costs per person $60.78 (CR: $46.97–76.41)	Results for Wisconsin: Health-care provider cost per child sealed $20.51, Annual state net cost savings (includes Medicaid/ 5CHIP reimbursement) −$55,290, Annual societal net cost savings: $295,421- 393,628	Experimental group cost per child: €496.45, Control group cost per child: €426.95, Incremental cost per child: €69.50 (CR: 28.25–110.75), Incremental cost- effectiveness: €34.07 per averted DMFS	Annual cost estimates for a steady-state year: intervention costs: £6,445, Intervention savings: £36,386, Benefit-cost (intervention costs/savings) ratio: 5.6, Intervention costs per averted DMFS: £1.8
Measurement of intervention costs	Micro-costing: Obtained intervention costs related to labor and dental supplies from a retrospective chart audit of encounter forms to obtain clinical and financial (reimbursement) data	Micro-costing: Obtained prevention and treatment service costs for rental facilities, equipment, and supplies; personnel costs were estimated based on dental procedure data, salaries, and estimates for program management; overhead costs estimated to be 50% of salaries	Micro-costing: Obtained intervention costs for dental professional training and community outreach and marketing; Cost estimates for preventive and treatment services and increased Medicaid reimbursement for trained providers obtained from Medicaid administrative records for birth cohort	Gross-costing: Used published results on program costs and state data on water system fluoride levels and population size	Gross-costing: Used published data and data obtained from data on sealant program utilization and costs (e.g., screening rates, direct and indirect costs of labor, equipment, dental supplies, and travel), used published information for 4 states and conducted interviews with personnel in 3 other states, excluded administrative costs	Micro-costing: Assessed intervention costs and dental treatment costs; costs for labor (salaries and benefits), dental supplies, capital equipment, and overhead were included; costs allocated to services based on assigned treatment weights; costs of community health promotion excluded	Micro-costing: Assessed intervention costs for labor (salaries), dental and education supplies, and travel
Measurement of intervention savings	Not addressed	The methodology described above included costs for treatment services.* Additional information obtained to estimate revenue for avoided treatment	The methodology described above included costs for treatment services. Thus, no additional data collection was conducted*	Gross-costing: Published results and findings from secondary data analysis were used to estimate averted treatment costs for applying and maintaining a restoration (e.g., single-surface amalgam, multi-surface resin-based composite, crown) over a lifetime, household direct and indirect costs related to time and travel were included	Gross-costing: Published results used to estimate averted treatment costs over the average sealant life (9 years) based on use of a single surface amalgam or resin-based composite restoration, household direct and indirect costs related to time and travel were included	The methodology described above included costs for treatment services. Thus, no additional data collection was conducted*	Averted treatment costs were estimated from child DMFS results, assumptions concerning treatment, and published fees for dental procedures
Base year and currency	US dollar	2008, Euro	1995, US dollar	2003, US dollar	2003–2004 academic year, US dollar	2004, Euro	Pound†
Discount rate Sensitivity analyses Decision analysis and/or probabilistic sensitivity analysis software	Not employed No Not employed	3% Yes Not employed	Not employed No Not employed	3% Yes TreeAge Pro 2005	3% Yes AutoMod 12.0	Not employed Yes R version 2.8.1	Not employed No Not employed

^*Intervention savings are derived from estimates of the difference in costs for education, preventive services, and treatment services for children in both study populations.

^†Information concerning an inflation adjustment was not provided.

CE, cost-effectiveness; CI, 95% confidence interval; CR, credible range, estimated from a probabilistic sensitivity analysis conducted using boot-strapped resamples or simulations conducted with enough repetitions to ensure the standard error of the estimates is less than 3%; DEFS, decayed, extracted, filled surfaces; DMFS, decayed, missing, filled surfaces; DMFT, decayed, missing, filled teeth; DFS, decayed, filled surfaces; SCHIP, State Children’s Health Insurance Program.