Fluoride Action Network

home // Researchers // Study Tracker //

Abstract

Background

Community water fluoridation (CWF), the controlled addition of fluoride to the water supply for the prevention of dental caries (tooth decay), is considered a safe and effective public health intervention. The Republic of Ireland (Ireland) is the only country in Europe with a legislative mandate for the fluoridation of the public water supply, a key component of its oral health policy. However, more recently, there has been an increase in public concern around the relevance of the intervention given the current environment of multiple fluoride sources and a reported increase in the prevalence of enamel fluorosis. The aim of this economic analysis is to provide evidence to inform policy decisions on whether the continued public investment in community water fluoridation remains justified under these altered circumstances.

Methods

Following traditional methods of economic evaluation and using epidemiological data from a representative sample of 5-, 8-, and 12-year-old schoolchildren, this cost-effectiveness analysis, conducted from the health-payer perspective, compared the incremental costs and consequences associated with the CWF intervention to no intervention for schoolchildren living in Ireland in 2017. A probabilistic model was developed to simulate the potential lifetime treatment savings associated with the schoolchildren’s exposure to the intervention for one year.

Results

In 2017, approximately 71% of people living in Ireland had access to a publicly provided fluoridated water supply at an average per capita cost to the state of €2.15. The total cost of CWF provision to 5-, 8-, and 12-year-old schoolchildren (n?=?148,910) was estimated at €320,664, and the incremental cost per decayed, missing, or filled tooth (d3vcmft/D3vcMFT) prevented was calculated at €14.09. The potential annual lifetime treatment savings associated with caries prevented for this cohort was estimated at €2.95 million. When the potential treatment savings were included in the analysis, the incremental cost per d3vcmft/D3vcMFT prevented was -€115.67, representing a cost-saving to the health-payer and a positive return on investment. The results of the analysis were robust to both deterministic and probability sensitivity analyses.

Conclusion

Despite current access to numerous fluoride sources and a reported increase in the prevalence of enamel fluorosis, CWF remains a cost-effective public health intervention for Irish schoolchildren.

Peer Review reports

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on request.

Notes

  1. adjusted to EU19 prices (5).
  2. The probability of receiving an amalgam given that you received an extraction at your previous visit is of course zero.

Abbreviations

CWF: Community water fluoridation
PWS: Public water supply
EPA: Environmental Protection Agency Ireland
WTS: Water treatment scheme
HSE: Health Service Executive
FACCT study: Fluoride and Caring for Children’s Teeth
O&M: Operating and maintenance
H2SiF6 : Hydrofluosilicic acid
d3vcmft/D3vcMFT: Decayed, missing or filled teeth recorded at the dentine level, with or without cavitation
PSA: Probabilistic sensitivity analysis

References

  1. 1.

    World Health Organisation. Oral Health [Internet]. [cited 2018 Sep 24]. https://www.who.int/news-room/fact-sheets/detail/oral-health.

  2. 2.

    James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789–858. Article  Google Scholar

  3. 3.

    Eaton K. The state of oral health in Europe. Report commissioned by the platform for better oral health in Europe. Platform for Better Oral Health in Europe Brussels; 2012.

  4. 4.

    Harding MA, O’Mullane DM. Water fluoridation and oral health. Acta Med Acad. 2013;42(2):131. Article  Google Scholar

  5. 5.

    OECD. Purchasing power parities (PPP) (indicator) [Internet]. 2020 [cited 2020 Dec 16]. https://data.oecd.org/conversion/purchasing-power-parities-ppp.htm.

  6. 6.

    Righolt A, Jevdjevic M, Marcenes W, Listl S. Global-, regional-, and country-level economic impacts of dental diseases in 2015. J Dent Res. 2018;97(5):501–7. Article  Google Scholar

  7. 7.

    Ajiboye AS, Dawson DR III, Fox CH, Committee ASI. American Association for Dental Research Policy Statement on Community Water Fluoridation. J Dent Res. 2018;97(12):1293–6. Article

  8. 8.

    Centers for Disease Control and Prevention. Statement on the evidence supporting the safety and effectiveness of community water fluoridation [Internet]. 2018. https://www.cdc.gov/fluoridation/guidelines/cdc-statement-on-community-water-fluoridation.html.

  9. 9.

    Wdf FDI. FDI policy statement on promoting oral health through water fluoridation: revised version adopted by the FDI General Assembly: 13 September 2014, New Delhi, India. Int Dent J. 2014;64(6):293. Article  Google Scholar

  10. 10.

    Centers for Disease Control and Prevention. Ten great public health achievements–United States, 1900–1999. MMWR Morb Mortal Wkly Rep. 1999;48(12):241–3. Google Scholar

  11. 11.

    Department of Health. Smile agus Sláinte – National Oral Health Policy [Internet]. Dublin, Ireland: Department of Health; 2019. https://assets.gov.ie/9613/39736ac409d94a6194b52bdae5e3d1b0.pdf.

  12. 12.

    Water_Team, E. Drinking Water Monitoring Results and Water Supply Details for Ireland – Year 2017 [Internet]. Secure Archive For Environmental Research Data. 2017. http://erc.epa.ie/safer/resource?id=a0889eb7-6e74-11e8-b825-005056ae0019.

  13. 13.

    O’Mullane D, Whelton H, Costelloe P, McDermott S, McLoughlin J. The results of water fluoridation in Ireland. J Public Health Dent. 1996;56(5):259–64. Article  Google Scholar

  14. 14.

    O’Mullane D, Clarkson J, Holland T, O’Hickey S, Whelton H. Children’s dental health in Ireland, 1984: a survey conducted on behalf of the Minister for Health by University College Cork [Internet]. Dublin: Department of Health; 1986. https://www.lenus.ie/bitstream/handle/10147/575361/childrensdentalhealth1984.pdf?sequence=1&isAllowed=y.

  15. 15.

    Parnell C, Connolly E, O’Farrell M, Cronin M, Flannery E, Whelton H. Oral health of 5 year old children in the North East, 2002 [Internet]. Dublin: Health Service Executive; 2002. https://www.lenus.ie/bitstream/handle/10147/99297/OralHealth5yearoldsNE.pdf?sequence=1&isAllowed=y.

  16. 16.

    Whelton H, Crowley E, O’Mullane D, Woods N, McGrath C, Kelleher V, et al. Oral health of Irish adults 2000–2002 [Internet]. Dublin: Department of Health and Children; 2007. https://www.lenus.ie/bitstream/handle/10147/45326/7137.pdf?sequence=1&isAllowed=y.

  17. 17.

    Whelton H, Crowley E, Harding M, Guiney H, Cronin M, Flannery E, et al. North South survey of children’s oral health in Ireland 2002 [Internet]. Dublin: Department of Health and Children; 2006. https://www.lenus.ie/bitstream/handle/10147/119028/OralHealthReport.pdf?sequence=1&isAllowed=y.

  18. 18.

    Dean HT. Classification of mottled enamel diagnosis. J Am Dent Assoc 1922. 1934;21(8):1421–6.

  19. 19.

    The Irish Expert Body on Fluorides and Health. Forum of Fluoridation (2002) [Internet]. Dublin: The Irish Expert Body on Fluorides and Health; 2002. https://www.fluoridesandhealth.ie/assets/files/pdf/fluoridation_forum_2002.pdf.

  20. 20.

    Tobin Consulting Engineers. National audit of the water fluoridation process at water treatment plants in Ireland. Dublin: The Irish Expert Body on Fluorides and Health; 2011. Google Scholar

  21. 21.

    Birch S. The relative cost effectiveness of water fluoridation across communities: analysis of variations according to underlying caries levels. Community Dent Health. 1990;7(1):3–10. PubMed  Google Scholar

  22. 22.

    O’Connell J, Rockell J, Ouellet J, Tomar SL, Maas W. Costs and savings associated with community water fluoridation in the United States. Health Aff (Millwood). 2016;35(12):2224–32. Article  Google Scholar

  23. 23.

    O’Connell J, Brunson D, Anselmo T, Sullivan P. Costs and savings associated with community water fluoridation programs in Colorado. Prev Chronic Dis. 2005;2(Special Issue): A06.

  24. 24.

    Griffin SO, Jones K, Tomar SL. An economic evaluation of community water fluoridation. J Public Health Dent. 2001;61(2):78–86. Article  Google Scholar

  25. 25.

    Tchouaket E, Brousselle A, Fansi A, Dionne PA, Bertrand E, Fortin C. The economic value of Quebec’s water fluoridation program. J Public Health. 2013;21(6):523–33. Article

  26. 26.

    Cobiac LJ, Vos T. Cost-effectiveness of extending the coverage of water supply fluoridation for the prevention of dental caries in Australia. Community Dent Oral Epidemiol. 2012;40(4):369–76. Article

  27. 27.

    Ciketic S, Hayatbakhsh MR, Doran CM. Drinking water fluoridation in South East Queensland: a cost-effectiveness evaluation. Health Promot J Austr. 2010;21(1):51–6. Article

  28. 28.

    Campain AC, Marino RJ, Wright FAC, Harrison D, Bailey DL, Morgan MV. The impact of changing dental needs on cost savings from fluoridation. Aust Dent J. 2010;55(1):37–44. Article

  29. 29.

    Wright JC, Bates MN, Cutress T, Lee M. The cost-effectiveness of fluoridating water supplies in New Zealand. Aust N Z J Public Health. 2001;25(2):170–8. Article

  30. 30.

    Moore D, Poynton M. Review of the benefits and costs of water fluoridation in New Zealand [Internet]. New Zealand: Sapere Research Group; 2015. https://www.moh.govt.nz/notebook/nbbooks.nsf/0/5E365C028C519186CC257FD4000EAE07/$file/review-benefits-costs-water-fluoridation-new-zealand-apr16.pdf.

  31. 31.

    James P, Harding M, Beecher T, Parnell C, Browne D, Tuohy M, et al. Fluoride And Caring for Children’s Teeth (FACCT):clinical fieldwork protocol. HRB Open Res [Internet]. 2018. https://doi.org/https://doi.org/10.12688/hrbopenres.12799.1.

  32. 32.

    Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 2015. Google Scholar

  33. 33.

    Microsoft Corporation. Microsoft Excel [Internet]. 2018. https://office.microsoft.com/excel.

  34. 34.

    Department of Public Expenditure and Reform. Public Spending Code: Central Technical References and Economic Appraisal Parameters [Internet]. Dublin: Department of Public Expenditure and Reform; 2019. https://www.gov.ie/en/publication/public-spending-code/.

  35. 35.

    Health Information and Quality Authority. Guidelines for the Economic Evaluation of Health Technologies in Ireland [Internet]. Dublin: Health Information and Quality Authority; 2020. https://www.hiqa.ie/sites/default/files/2020-09/HTA-Economic-Guidelines-2020.pdf.

  36. 36.

    Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al. Consolidated health economic evaluation reporting standards (CHEERS)—explanation and elaboration: a report of the ISPOR health economic evaluation publication guidelines good reporting practices task force. Value Health. 2013;16(2):231–50. Article  Google Scholar

  37. 37.

    World Health Organization. Oral health surveys: basic methods. Geneva: World Health Organization; 2013. Google Scholar

  38. 38.

    Irish Expert Body on Fluorides and Health. Code of practice on the fluoridation of drinking water [Internet]. 2007. http://hdl.handle.net/10147/45804.

  39. 39.

    Central Statistics Office. Consumer prices – Annual series [Internet]. Cork: Central Statistics Office; 2020. https://data.cso.ie/table/CPA01.

  40. 40.

    Tedd K, Coxon C, Misstear B, Daly D, Craig M, Mannix A, et al. Assessing and developing Natural Background Levels for chemical parameters in Irish groundwater [Internet]. Wexford: Environmental Protection Agency; 2017. http://www.epa.ie/pubs/reports/research/water/EPA%20RR%20183%20Essentra_web.pdf.

  41. 41.

    Central Statistics Office. Annual population estimates [Internet]. Cork: Central Statistics Office; 2020. https://data.cso.ie/table/PEA01.

  42. 42.

    Glied S, Neidell M. The economic value of teeth. J Hum Resour. 2010;45(2):468–96. Google Scholar

  43. 43.

    Nolan A. Reforming the delivery of public dental services in Ireland: potential cost implications [Internet]. Dublin: The Economic and Social Research Institute; 2019. https://www.esri.ie/pubs/RS80.pdf.

  44. 44.

    United Nations. Minamata Convention on Mercury [Internet]. United Nations; 2013. p. 49–100. https://treaties.un.org/doc/Treaties/2013/10/20131010%2011-16%20AM/CTC-XXVII-17.pdf.

  45. 45.

    Office of the Attorney General. European Union (Mercury) Regulations 2018. Regulation (EU) 2017/852 2018.

  46. 46.

    HSE Primary Care Reimbursement Service. Expenditure reports for the Dental Treatment Service Scheme [Internet]. Dublin: Health Service Executive. https://www.sspcrs.ie/portal/annual-reporting/report/dental.

  47. 47.

    Burke F, Lucarotti P. The ultimate guide to restoration longevity in England and Wales. Part 2: Amalgam restorations–time to next intervention and to extraction of the restored tooth. Br Dent J. 2018;224(10):789–800.

  48. 48.

    Burke F, Lucarotti P. The ultimate guide to restoration longevity in England and Wales. Part 4: resin composite restorations: time to next intervention and to extraction of the restored tooth. Br Dent J. 2018;224(12):945–56.

  49. 49.

    Central Statistics Office. Irish Life Tables No.16, 2010–2012 [Internet]. Cork: Central Statistics Office. https://pdf.cso.ie/www/pdf/20171121010152_Irish_Life_Tables_No_16_20102012_full.pdf.

  50. 50.

    HSE Primary Care Reimbursement Service. Statistical Analysis of Claims and Payments 2017 [Internet]. Dublin: Health Service Executive; 2017. https://www.hse.ie/eng/staff/pcrs/pcrs-publications/annual-report-2017.pdf.

  51. 51.

    Central Statistics Office. Earnings and labour costs annual data 2017 [Internet]. Cork: Central Statistics Office; 2018. https://www.cso.ie/en/releasesandpublications/er/elca/earningsandlabourcostsannualdata2017/.

  52. 52.

    Department of Health. Health in Ireland: Key Trends 2018 [Internet]. Dublin: Department of Health; 2018. https://assets.gov.ie/9441/e5c5417ee4c544b384c262f99da77122.pdf.

  53. 53.

    Ran T, Chattopadhyay SK, Force CPST. Economic evaluation of community water fluoridation: a community guide systematic review. Am J Prev Med. 2016;50(6):790–6. Article

  54. 54.

    Ko L, Thiessen KM. A critique of recent economic evaluations of community water fluoridation. Int J Occup Environ Health. 2015;21(2):91–120. Article  Google Scholar

  55. 55.

    Beirne P, Whelton H, O’Mullane D, Mullen J, Browne D, McDonnell M, et al. Fluoridation in Ireland: the dental profession looks back over 50 years. J Ir Dent Assoc Fluoride Suppl [Internet]. 2012;58(3). http://hdl.handle.net/10147/231333

  56. 56.

    Birch S. The identification of supplier-inducement in a fixed price system of health care provision: the case of dentistry in the United Kingdom. J Health Econ. 1988;7(2):129–50. Article

Acknowledgements

The authors would like to thank all the contributors to the FACCT study, the Irish Expert Body on Fluorides and Health, the Health Service Executive, the Environmental Protection Agency Ireland, Irish Water and Tobin Consulting Engineers.

Funding

This economic evaluation of community water fluoridation was undertaken as part of the Health Research Board awarded grant CARG (Collaborative Applied Research Grant)/2012/34, which also included the FACCT (Fluoride and Caring for Children’s Teeth) Study. The HRB funded this research but had no role in the design, data collection, interpretation of data or writing of this manuscript.

Author information

Affiliations

  1. Centre for Policy Studies, Cork University Business School, University College Cork, Cork, Ireland

    Jodi Cronin, Stephen Moore & Noel Woods

  2. Oral Health Services Research Centre, University College Cork, Cork, Ireland

    Máiréad Harding

  3. College of Medicine and Health, University College Cork, Cork, Ireland

    Helen Whelton

Print Friendly Version of this pagePrint Get a PDF version of this webpagePDF