Fluoride Action Network


OBJECTIVE: To economically evaluate a caries-preventive program “Stop Caries Stockholm” (SCS) where a standard program is supplemented with biannual applications of fluoride varnish in toddlers and compared it with the standard preventive program.

MATERIAL AND METHODS: Data from the cluster randomized controlled field trial SCS including 3403 children, conducted in multicultural areas with low socioeconomic status was used. The difference in mean caries increment between the examinations; when the toddlers were 1 and 3 years old, was outcome measure of the intervention. The program was evaluated from a societal as well as a dental health care perspective. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental cost for each defs prevented.

RESULTS: Average dental health care costs per child at age 3 years were EUR 95.77 for the supplemental intervention and EUR 70.52 for the standard intervention. The ICER was EUR 280.56 from a dental health care perspective and EUR 468.67 and considered high.

CONCLUSIONS: The supplemental caries intervention program was not found to be cost-effective. The program raised costs without significantly reducing caries development. A better alternative use of the resources is recommended.

TRIAL REGISTRATION: www.controlled-trials.com (ISRCTN35086887).


Many times, interventions are implemented based on efficacy studies and other populations. This study shows the importance of evaluating ongoing efforts already in place. We had anticipated that the supplemental intervention would be effective and that it would be beneficial to put into clinical practice. But evidence-based medicine is about facts and proof, not belief. The evidence did not support our anticipations.

Dental caries is a multifactorial disease [27] and, thus, requires a multifactorial approach. We plan to further analyze our effectiveness results to see if any subgroup gained from the intervention. Future research on children who miss their appointments is also needed. For these children, dental healthcare alone might not be able to change their situation. To reach these children, new networks with other health sectors and professions that see these children in their everyday life might be needed.

From a societal perspective, we need more supportive actions. To improve the oral health of vulnerable children, we cannot depend solely on the actions of caregivers, we must set in other actions in parallel. One intervention that was effective in reducing dental caries as well as allow
inequalities in the oral health of children to be monitored was the nursery tooth-brushing program in Scotland [28, 29].

In a wider perspective, more radical societal actions also might be possible. Schwendicke et al. [30] estimated how a taxation of sugar-sweetened beverages would influence caries development. They found that such a taxation might possibly have a vague impact on reducing the caries increment overall, but the effect would interfere with equality as the best oral health results would probably be achieved in young low-income males.

In conclusion, our economic evaluation found that the expanded caries-preventive program we designed, with the aim of improving the oral health of toddlers living in multicultural areas in Stockholm with a low-socioeconomic status, cannot be considered cost effective…

[27] Selwitz RH, Ismail AI, Pitts NB. Dental caries. The Lancet. 2007; 369:51–59.

[28] Anopa Y, McMahon AD, Conway DI, et al. Improving child oral health: cost analysis of a National Nursery Toothbrushing Programme. PLoS One. 2015;10:e0136211. PubMed PMID:
26305577; PubMed Central PMCID: PMC4549338.

[29] Macpherson LMD, Anopa Y, Conway DI, et al. National supervised toothbrushing program and dental decay in Scotland. J Dent Res. 2013;92:109–113. PubMed PMID: WOS:000313629700003; English.

[30] Schwendicke F, Thomson WM, Broadbent JM, et al. Effects of taxing sugar-sweetened beverages on caries and treatment costs. J Dent Res. 2016;95:1327–1332.