Community Dent Oral Epidemiol 2012; 40: 369376 All rights reserved

2012 John Wiley & Sons A/S

Cost-effectiveness of extending the coverage of water supply uoridation for the prevention of dental caries in Australia
Cobiac LJ, Vos T. Cost-effectiveness of extending the coverage of water supply uoridation for the prevention of dental caries in Australia. Community Dent Oral Epidemiol 2012; 40: 369376. 2012 John Wiley & Sons A/S Abstract Objective: Fluoride was rst added to the Australian water supply in 1953, and by 2003, 69% of Australias population was receiving the minimum recommended dose. Extending coverage of uoridation to all remaining communities of at least 1000 people is a key strategy of Australias National Oral Health Plan 20042013. We evaluate the cost-effectiveness of this strategy from an Australian health sector perspective. Methods: Health gains from the prevention of caries in the Australian population are modelled over the average 15-year lifespan of a treatment plant. Taking capital and on-going operational costs of uoridation into account, as well as costs of caries treatment, we determine the dollars per disability-adjusted life years (DALY) averted from extending coverage of uoridation to all large (  1000 people) and small (<1000 people) communities in Australia. Results: Extending coverage of uoridation to all communities of at least 1000 people will lead to improved population health (3700 DALYs, 95% uncertainty interval: 22005700 DALYs), with a dominant cost-effectiveness ratio and 100% probability of cost-savings. Extending coverage to smaller communities leads to 60% more health gains, but is not cost-effective, with a median cost-effectiveness ratio of A$92 000/ DALY and only 10% probability of being under a cost-effectiveness threshold of A$50 000/DALY. Conclusions: Extension of uoridation coverage under the National Oral Health Plan is highly recommended, but given the substantial dental health disparities and inequalities in access to dental care that currently exist for more regional and remote communities, there may be good justication for extending coverage to include all Australians, regardless of where they live, despite less favourable cost-effectiveness.

Linda J. Cobiac and Theo Vos

School of Population Health, University of Queensland, Herston, Qld, Australia

Key words: cost-effectiveness; dental caries/ economics; dental caries/epidemiology; uoridation Linda J. Cobiac, School of Population Health, University of Queensland,Herston, Qld 4029, Australia Tel.: +61 7 3365 5029 Fax: +61 7 3365 5442 e-mail: l.cobiac@uq.edu.au Submitted 23 May 2011; accepted 10 February 2012

Public dental care in Australia is in crisis; omitted from the Medicare scheme for universal health care access in 1984, and under-funded for many years, there is now a sharp divide in dental health between rich and poor, and between those in the cities and those in the bush (1, 2). Childhood decay leads to poorer health, emergency department visits and loss of school time, and is a predictor of decay in adulthood, with impacts on nutrition, economic productivity and quality of life into old age (35). Children from low income and Indigenous
doi: 10.1111/j.1600-0528.2012.00684.x

families experience higher rates of decay (6, 7), which contributes to the on-going cycle of disadvantage. Addressing the disparities in dental health and inequalities in access to dental care are key goals of Australias National Oral Health Plan 20042013 (8). Prevention of decay through uoridation of the public water supply is a major strategy under the National Oral Health Plan. Fluoridation has been labelled one of the 10 great public health interventions of the 20th century (9). As a public health

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strategy, it has the potential to benet many people for a relatively low cost, and although opposition does exist, some 71% of Australians support its use for preventing dental caries (10). For an all-time great intervention, however, there is surprisingly little evidence supporting a causal relationship between uoridation of public water supplies and prevention of dental caries. There is good evidence that uoride, in the form of gels, mouth rinses, toothpastes and varnishes is effective in preventing dental caries, particularly in children and adolescents (1115). However, uoridation of the public water supply is harder to evaluate in controlled trials. In a systematic review, McDonagh et al. (16) identied 26 longitudinal studies examining the effect of public water uoridation on dental caries. The 23 beforeafter studies, two prospective cohort studies and one retrospective cohort study generally supported the efcacy of water uoridation in reducing caries, but the low quality of data analyses in the studies made quantication of the effect difcult. Meta-analysis of results from nine studies with sufcient data showed a pooled reduction in proportion of cariesfree children of 15% (95% CI: 1120%) with public water uoridation. There was insufcient evidence to determine the effect of public water uoridation on caries in adults, although cross-sectional studies suggest a preventive benet may exist (11). The costs of establishing, maintaining and operating a uoridation plant may be high, particularly in more rural or remote areas. With limited health care resources, it is important to consider the balance, over time, of costs and health effects of intervention programs, in setting priorities for investment in oral health (17). The cost-effectiveness of uoridation for the prevention of dental caries in Australia is not known. Modelling in New Zealand (18) suggests that it can be cost-effective in populations of more than 1000, and cost-benet studies in the United States (19, 20) and Australia (21) suggest that it may even be costsaving. However, these studies assumed reduction of caries in both children and adults, and based the measures of effect on cross-sectional data. The estimates of caries reductions range from 25% to 56%, substantially higher than the 15% (95% CI: 1120%) reduction derived from the meta-analysis of longitudinal studies by McDonagh et al. (16). It is possible that cross-sectional studies overestimate caries reductions by not accounting for baseline differences in population dental health between uoridated and nonuoridated areas, which may occur

with differences in access to dental services, differences in the use of uoride (e.g. toothpastes) or natural variations in uoride levels in the water. In this paper, we evaluate the cost-effectiveness of uoridation of the public water supply in Australia, taking key uncertainties in the evidence into account. Because the current policy is to extend coverage of public water supply uoridation to all Australian communities with a population at least 1000 people (8), we evaluate cost-effectiveness of uoridation for all communities of at least 1000 people, but also evaluate cost-effectiveness if coverage were later extended to include all smaller communities in Australia.

Methods
Fluoridation coverage
Fluoride was rst added to the Australian public water supply system in Tasmania in 1953 (22), and by 2003, before implementation of the National Oral Health Plan 20042013, 69% of Australias population was receiving uoridated water at the recommended minimum concentration of 0.7 mg/l (23). Using Australian Bureau of Statistics data on population community size, we estimate that extending public water uoridation to all Australian communities with a population of at least 1000 people will equate to an Australian coverage of 89% (24). We evaluate population health impacts and cost-effectiveness of this coverage, compared to the baseline coverage of 69% in 2003. We also evaluate population health impacts and cost-effectiveness of extending uoridation to all communities in Australia, regardless of population size (i.e. 100% coverage of the Australian population).

Effect of uoridation on dental caries

In our baseline analyses, we assume that uoridation of the water supply leads to a 15% (95% CI: 11 20%) reduction in proportion of caries-free children (<16 years), based on the McDonagh et al. (16) meta-analysis, and assume no benet in adults. However, in sensitivity analyses, we also evaluate the cost-effectiveness of extending uoridation coverage if adults (16+ years) experience benets equivalent to those measured in children (<16 years).

Epidemiology of caries
Caries increments are interpolated from the prevalence of caries in children and adolescents (25) and prevalence in adults (26), with higher rates assumed

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for adults (60+ years) in residential aged care (27). Rates are derived separately for the non-Indigenous population, the nonremote Indigenous population and remote Indigenous population (26, 28, 29), to allow for different rates in small (population < 1000) and large (population  1000) communities. We adjust caries rates at each age, by current rates of edentulism (complete tooth loss). However, as edentulism has more than halved over the last 2030 years, with the decline in proportion of older Australians who experienced high rates of complete tooth extraction up to the 1950s (30, 31), we include a downward trend in edentulism to the year 2041, based on projections by the Australian Research Centre for Population Oral Health (30).

then apply a disability weight of 0.057, the Australian Burden of Disease (37) disability weight for symptomatic caries, which was derived using the EQ-5D+ disability weight regression model, assuming 80% of time in state 111 111 (no problems in any domain) and 20% of time in state 111 221 (moderate anxiety/depression and moderate pain).

Caries treatment costs

The costs of caries treatment are derived from the standard Australian Dental Association costs for service. We assume each treatment includes a comprehensive oral examination and metallic (two surface) restoration. In sensitivity analyses, we also include the cost of a panoramic radiograph (OPG) exposure.

Population health impact

To allow comparison of the population health impacts and cost-effectiveness of extending uoridation coverage with outcomes for other public health interventions evaluated in Australia, we evaluate health outcomes in disability-adjusted life years (DALYs). While other health metrics, such as quality-adjusted life years (QALYs) and dentalspecic quality of life measures, do exist, DALYs are widely used in global (32) and Australian (33) cost-effectiveness studies. Oral health-specic utility measures would not allow comparisons with cost-effectiveness results in other areas. While, in principle, QALYs could be calculated consistently across a wide range of diseases, there is no comprehensive set of QALY utility weights comparable to what is available for DALYs. Disability-adjusted life years averted by an intervention represent additional years of life that could be lived by the population, adjusted for time spent in ill-health (disability). In the case of caries, which has no impact on mortality, it is the disability adjustment that is important. To determine the number of DALYs associated with caries prevalence in the population, we rst evaluate time spent with caries symptoms from clinic data for children and adolescents (34) and adults (35), incorporating an additional 1 h of pain per day for 1.5 years for 25% of people to reect time spent with intermittent pain prior to presentation. Because these patient-based samples will likely overestimate symptomatic caries in the wider community, we determine the proportion of people with caries who are symptomatic, from the proportion of patients presenting with dental caries in the Australian Longitudinal study of Dentists Practice Activity who required an emergency visit (36). We

Costs of public water supply uoridation

Costs of public water uoridation include the capital costs of dosing equipment and associated engineering, and the on-going operational costs of chemicals and equipment maintenance (38). The balance between up front and on-going costs depends on the type of uoridation system used sodium uoride, hydrouosilicic acid or sodium siliconuoride all three types are used in Australia (39). We derive costs separately for urban and rural Australia owing to the additional complexities associated with providing uoridated water in smaller communities, such as distance of delivering materials, hot climate and retention of trained personnel (40). Urban areas are dened by the Australian Bureau of Statistics denition as a community of at least 1000 people (41). We assume an average cost of uoridation in urban areas, including one-off costs of equipment and annual costs of operation and maintenance, of 2003A$0.26 per person, based on Melbourne Water estimates (21). For rural communities, we assume an average cost of uoridation of 2003A$26 per person, based on the equivalent annual cost of water uoridation in a trial installation in two remote Australian Indigenous communities (40). We also evaluate the sensitivity of results to annual interventions costs up to twice the urban estimate (i.e. up to A$0.52 per person).

Cost-effectiveness modelling
Using a simple life-table approach, we model intervention costs, DALYs and caries treatment costs averted by uoridation, in 5-year age and sex population cohorts, over time from the baseline year of 2003. All costs and DALYs are measured for

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15 years (the assumed life of a uoridation treatment plant) and discounted back to the baseline year at 3% (42). Monte Carlo analysis is used to derive ninety-ve per cent uncertainty intervals for all outcome measures and to evaluate the probability of cost-effectiveness against a threshold of A $50 000 per DALY (43). The modelling is carried out in the R programing language (R Foundation for Statistical Computing, Vienna, Austria). All model input parameter values, their sources and assumptions about uncertainty are shown in Table 1.

Results
Extending coverage of public water supply uoridation to all communities of at least 1000 people in Australia (Table 2) can avert 3700 DALYs (95% uncertainty interval: 22005700 DALYs) in children and adolescents, over the lifetime of the treatment plant, at a total cost of $13 million ($8.6 million$18 million). By averting 760 000 (430 0001 300 000) child and adolescent caries, the intervention can reduce the total cost of caries treatment by $95 million ($45 million$170 million). There is 100% probability that extending the coverage of public water supply uoridation to all communities of at least 1000 people will be costsaving to the health sector (Fig. 1). Extending coverage to all communities in Australia, including those with <1000 people, could lead to 60% more DALYs averted, but the intervention has only a 10% probability of being below the cost-effectiveness threshold of A$50 000 per DALY. There is little change in cost-effectiveness with increase in urban intervention costs up to twice the baseline estimate or with added costs of X-ray in caries treatment (Table 2). However, if future evidence shows that adults experience a reduction in caries from water uoridation similar to the reduction observed in children and adolescents, then it will be cost-saving to extend uoridation to all communities in Australia, regardless of community size.

Discussion
Fluoridation is cost-effective in Australia if coverage is extended to all communities with a population of at least 1000 people. The costs of $13 million are easily outweighed by the $95 million reduction in costs of dental treatment over 15 years. Cost-savings

could be even higher, given the sequelae, including replacement of llings, potential extractions and endodontic work that would also be averted. Our Australian results concur with the ndings of cost-effectiveness in New Zealand (18) and predictions of cost-savings in the United States (19, 20) and Australia (21), despite our more conservative approach to modelling the population health benets, strengthening the case for water supply uoridation. There is evidence that too much uoride during tooth development increases the risk of dental uorosis (16). It is important, therefore, to provide concurrent intervention strategies to limit childrens uoride exposure from other sources. Policy measures to encourage the use of smaller amounts of toothpaste when brushing and to discourage toothpaste consumption (eating/licking) have played a signicant role in reducing the prevalence of dental uorosis in children in South Australia (44). As previous modelling suggests (18, 19), economies of scale do exist. The higher costs of providing uoridation to communities with <1000 people mean that uoridation is much less cost-effective for these communities, despite the higher rates of caries in these more regional and remote populations. If adults prove to experience the same health benets from uoridation as children, then uoridation of the water supply will be cost-saving in all communities, regardless of size. Based on the current evidence of benet, however, when compared to a threshold of $50 000 per DALY, uoridating the water supply in the smaller communities is not good value for money. The threshold for cost-effectiveness is, however, arbitrary. Our threshold of $50 000 per DALY is loosely based on the cost-effectiveness of pharmaceuticals approved for public funding by the Pharmaceutical Benets Advisory Committee in Australia (43) and has been widely applied in evaluating cost-effectiveness of both pharmaceutical and nonpharmaceutical interventions in Australia (4547). However, the World Health Organisation recommend a threshold value equivalent to three times GDP per capita (48), which is around $140 000 in 2003 Australian dollars. Against this threshold, uoridation of the water supply in smaller communities, with a cost-effectiveness ratio of $92 000 per DALY (Table 2), would be considered cost-effective. Given current limitations in accessing dental care and poorer dental health outcomes in more regional and remote areas, the higher threshold may well be justied.

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Fluoridation cost-effectiveness Table 1. Modelling input parameters Parameter Value Mean (SD) Uncertainty distribution Normal Sources and assumptions Meta-analysis of 31 estimates from nine longitudinal studies of public water uoridation (16) Urban estimate from Campain et al. (21). Rural estimate from Ehsani and Bailie (40). Standard deviation assumed to be 20% of point estimate Australian Dental Association rates per service in 2006. Adjusted to 2003

15.4% (2.37%) Risk difference of the change in proportion of caries-free children with uoridation Cost of uoridation per person Urban $0.26 ($0.05) Rural $26 ($5) Cost of caries treatment Comprehensive oral $45 ($13) examination Metallic (2 surface) $109 ($21) restoration Panoramic radiograph $82 ($15) (OPG) exposure Caries increment in general population 014 years 0.26 (0.16) 1564 years 0.44 (0.01) 65+ years 0.10 (0.02)

Gamma

Gamma

Normal

Caries increment in nursing home residents aged 60+ years Coronal caries 0.71 (1.09) Normal Root caries 0.29 (0.69)

Caries increment in 014 year olds derived from Child Dental Health Survey 20032004 Caries increment at 15 years and older derived from the National Survey of Adult Oral Health 20042006 Total increment derived from the increment of coronal and root caries reported in the Adelaide Dental Study of Nursing Homes, assuming DMFS/DMFT ratio of 3.5 at age 60+ years (50) Relative risks derived from Indigenous and non-Indigenous DMFT increments (26, 28, 29)

Relative risk dmft/DMFT (Indigenous versus non-Indigenous) 19 years 2.4 1014 years 1.8 1534 years 2.7 3554 years 2.2 55+ years 2.0 Relative risk dmft/DMFT (remote versus nonremote) 19 years 0.9 1014 years 1.1 1524 years 0.3 2544 years 0.5 45+ years 0.5 Rate of edentulism 1534 years 0% (0.03%) Beta 3554 years 1.7% (0.23%) 5574 years 14% (0.64%) 75+ years 36% (1.6%) Proportion of population in residential aged care 6079 years 1.3% (0.01%) Beta 80+ years 16% (0.04%) Duration of caries symptoms 016 years 28 days 17+ years 55 days

Relative risks derived from remote and nonremote dmft/DMFT increments for the Indigenous population (28, 29)

National Survey of Adult Oral Health 20042006

Derived from survey of disability, ageing and carers (51) Duration for children and adolescents derived from Mason et al. (34) and duration for adults derived from Whyman et al. (35) assuming a lognormal distribution of duration Based on the proportion of patients with a primary diagnosis of caries in the Australian Longitudinal study of Dentists Practice Activity, who present in an emergency (36)

Proportion of people with caries who experience symptoms

32.4%

All costs adjusted to 2003 Australian dollars using Australian health price deators (52) and/or consumer price index (53); dmfs/DMFS, decayed missing and lled surfaces (deciduous/permanent teeth); dmft/DMFT, decayed missing and lled teeth (deciduous/permanent teeth).

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Cobiac & Vos 5900 (3500 to 9200) $190 ($340 to $91) $680 ($430 to $970) $87 000 14% 0% 3700 (2200 to 5700) $120 ($210 to $57) $13 ($8.6 to $18) Dominant 100% 100% Baseline results discounted at 3%. Except where otherwise indicated, values are mean and 95% uncertainty interval, rounded to two signicant gures. Costs are shown in Australian dollars for the year 2003. Dominant cost-effectiveness ratios indicate that increase in uoridation coverage leads to health gain and cost-savings compared to current coverage. DALY, disability-adjusted life year.
1000
$50,000/DALY

Treatment cost including X-ray

Net cost (millionsAUS$2003)

Table 2. Health gain, costs and cost-effectiveness of extending uoridation coverage under different assumptions of effectiveness, costs and coverage

5900 (3500 to 9200) $150 ($280 to $73) $690 ($450 to $980) $94 000 9% 0%

3700 (2200 to 5700) $95 ($170 to $45) $26 ($17 to $36) Dominant 100% 100%

0 0 200

200

400

600

800

10

15

20

Mean intervention cost doubled

400

Communities >1000 people (89% coverage) All communities (100% coverage)

DALYs averted (thousands)

Caries reduction applied at all ages

40 000 (27 000 to 54 000) $950 ($1 400 to $570) $680 ($430 to $970) Dominant 100% 87%

26 000 (17 000 to 34 000) $490 ($760 to $290) $13 ($8.6 to $18) Dominant 100% 100%

Fig. 1. Cost-effectiveness of extending uoridation coverage. NB. Each point on the graph represents a costeffectiveness ratio; the spread of the points for each intervention illustrates the uncertainty in the cost-effectiveness result. The diagonal line represents a cost-effectiveness threshold of $50 000/DALY; points below this threshold are cost-effective, and points above the line are not cost-effective. Where points fall below the x-axis, they are cost-saving (Dominant) (54). DALY, disabilityadjusted life years.

Fluoride alternatives, such as gels, rinses, toothpastes and varnishes, can be effective (1115) and could be used in smaller communities. A recent randomized controlled trial of providing biannual varnish treatment along with dental health promotion in remote Australian Indigenous communities did lead to a reduction in caries increment in participating preschool children (49). However, the authors noted that, despite the intervention, the development of new caries remained very high and they highlighted the need for complementary strategies, such as uoridation of the water supply. The alternative uoride treatments, such as varnishes and toothpaste use, rely on changing dental care behaviour; real-world adherence in the long term, however, is difcult to predict. In addition, like uoridation of the water supply, the costs of delivery of uoride treatments are likely to be higher in smaller, more regional or remote, communities. These factors would need to be incorporated into cost-effectiveness analyses to determine whether the alternative methods of providing uoride for the prevention of dental caries are more or less cost-effective than uoridation of the water supply in communities with a population <1000. Based on the current evidence of public health benets, costs and cost-effectiveness of water supply uoridation, we commend the actions of the

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Communities >1000 people (89% coverage) DALYs averted Treatment cost offsets ($million) Intervention cost ($million) Median cost-effectiveness ratio ($/DALY) Probability (<$50 000/DALY) Probability (Cost-saving) All communities (100% coverage) DALYs averted Treatment cost offsets ($million) Intervention cost ($million) Median cost-effectiveness ratio ($/DALY) Probability (<$50 000/DALY) Probability (Cost-saving)

5900 (3500 to 9200) $150 ($280 to $73) $680 ($430 to $970) $92 000 10% 0%

Baseline results

3700 (2200 to 5700) $95 ($170 to $45) $13 ($8.6 to $18) Dominant 100% 100%

Fluoridation cost-effectiveness

Federal, State and Territory Governments in improving coverage of uoridation under the National Oral Health Plan. A number of States and Territories have already taken action in meeting the goals of the National Oral Health Plan 20042013; coverage is estimated to have increased from 69% in 2003 to 82% in 2009 (23). The largest increases in coverage have been in Queensland, where Brisbanes population received uoridated water for the rst time, and in the Northern Territory, where dosages are being increased to the recommended concentration (23). However, we believe there may be good justication to extend coverage to include communities with a population of <1000 people, given the substantial dental health disparities and inequalities in access to dental care that currently exist.

Ethics approval
Study was approved by the Behavioural & Social Sciences Ethical Review Committee of the University of Queensland in accordance with the National Health and Medical Research Council guidelines (Clearance no. 2004000796).

Funding
The research was supported by a grant from the National Health and Medical Research Council (Project ID no. 351558). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Author contributions
TV obtained funding for the study. LC completed the analysis and preparation of manuscript. Both authors contributed to the interpretation of data, manuscript editing and decision to submit the article for publication.

Competing interests
The authors have no competing interests.

References
1. AIHW. Socioeconomic variation in periodontitis among Australian adults 200406. Australian Institute of Health and Welfare, Dental statistics and research unit. 2010

2. AIHW.Trends in access to dental care among Australian adults. Australian Institute of Health and Welfare, Dental statistics and research unit. 2010. 3. Greenwell A, Johnsen D, DiSantis T, Gerstenmaier J, Limbert N. Longitudinal evaluation of caries patterns form the primary to the mixed dentition. Pediatr Dent 1990;12:27882. 4. Hollister MC, Weintraub JA. The association of oral status with systemic health, quality of life, and economic productivity. J Dent Educ 1993;57:90112. 5. Mouradian WE, Wehr E, Crall JJ. Disparities in childrens oral health and access to dental care. JAMA 2000;284:262531. 6. Armeld J, Slade G, Spencer A. Socioeconomic differences in childrens dental health: the child dental health survey, Australia 2001. Canberra: Australian Institute of Health and Welfare; 2006. 7. Parker EJ, Jamieson LM, Broughton J, Albino J, Lawrence HP, Roberts-Thomson K. The oral health of Indigenous children: a review of four nations. J Paediatr Child Health 2010;46:4836. 8. National Advisory Committee on Oral Health. Healthy mouths health lives: Australias National Oral Health Plan 20042013. Government of South Australia, on behalf of the Australian Health Ministers Conference, 2004. 9. Centers for Disease Control and Prevention. Ten great public health achievementsUnited States, 19001999. MMWR Morb Mortal Wkly Rep 1999;48: 2413. 10. Armeld JM, Akers HF. Risk perception and water uoridation support and opposition in Australia. J Public Health Dent 2010;70:5866. 11. Grifn SO, Regnier E, Grifn PM, Huntley V. Effectiveness of uoride in preventing caries in adults. J Dent Res 2007;86:4105. 12. Marinho V, Higgins J, Logan S, Sheiham A. Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2002;1: CD002280. 13. Marinho V, Higgin J, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2003;3: CD002284. 14. Walsh T, Worthington H, Glenny A, Appelbe P, Marinho V, Shi X. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2010;1:CD007868. 15. Marinho V, Higgins J, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2002;1: CD002279. 16. McDonagh M, Whiting P, Bradley M, Cooper J, Sutton A, Chestnutt I, et al. A systematic review of public water uoridation. York: NHS Centre for Reviews and Dissemination, University of York; 2000. 17. Donaldson C. Economic evaluation in dentistry: an ethical imperitive? Dent Update 1998;25:2604. 18. Wright JC, Bates MN, Cutress T, Lee M. The costeffectiveness of uoridating water supplies in New Zealand. Aust N Z J Public Health 2001;25:1708. 19. Grifn S, Jones K, Tomar S. An economic evaluation of community water uoridation. J Public Health Dent 2001;61:7886.

375

Cobiac & Vos 20. OConnell J, Brunson D, Anselmo T, Sullivan P. Costs and savings associated with community water uoridation programs in Colorado. Prev Chronic Dis 2005;2:113. o RJ, Wright FAC, Harrison D, 21. Campain AC, Marin Bailey DL, Morgan MV. The impact of changing dental needs on cost savings from uoridation. Aust Dent J 2010;55:3744. 22. Brothers PC. The Beaconseld uoridation scheme, a pilot survey phase I. Aust Dent J 1956;1:30711. 23. Australian Research Centre for Population Oral Health. Key process and outcome performance indicators: second follow-up report 20022008. Adelaide: National Oral Health Plan Monitoring Group; 2009. 24. ABS. ASGC remoteness classication: purpose and use (Census Paper No. 03/01). Canberra: Australian Bureau of Statistics; 2003. 25. Armeld J, Spencer A, Brennan D. Dental health of Australias teenagers and pre-teen children: the Child Dental Health Survey, Australia 200304. Canberra: Australian Institute of Health and Welfare; 2008. 26. Slade G, Spencer A, Roberts-Thomson K. Australias dental generations: the National Survey of Adult Oral Health 200406. Canberra: Australian Institute of Health and Welfare; 2007. 27. AIHW. The adelaide dental study of nursing homes. Canberra: Australian Institute of Health and Welfare Dental Statistics and Research Unit; 1999. 28. AIHW. Oral health of Aboriginal and Torres Strait Islander Persons. Canberra: Australian Institute of Health and Welfare Dental Statistics and Research Unit; 2003. 29. Jamieson L, Armeld J, Roberts-Thomson K. Oral health of Aboriginal and Torres Strait Islander children. Canberra: Australian Institute of Health and Welfare; 2007. 30. Crocombe LA, Slade GD. Decline of the edentulism epidemic in Australia. Aust Dent J 2007;52:1546. 31. Sanders AE, Slade GD, Carter KD, Stewart JF. Trends in prevalence of complete tooth loss among Australians, 19792002. Aust N Z J Public Health 2004;28:54954. 32. Tan-Torres Edejer T, Baltussen R, Adam T, Hutubessy R, Acharya A, Evans D, et al. Making choices in health: WHO guide to cost-effectiveness analysis. Geneva: World Health Organization; 2003. 33. Carter R, Vos T, Moodie M, Haby M, Magnus A, Mihalopoulos C. Priority setting in health: origins, description and application of the Assessing Cost Effectiveness (ACE) initiative. Expert Rev Pharmacoecon Outcomes Res 2008;8:593617. 34. Mason C, Porter SR, Madland G, Parry J. Early management of dental pain in children and adolescents. J Dent 1997;25:314. 35. Whyman R, Treasure E, Ayers K. Dental disease levels and reasons for emergency clinic attendance in patients seeking relief of pain in Auckland. N Z Dent J 1996;92:1117. 36. Brennan DS, Spencer AJ. Inuence of patient, visit, and oral health factors on dental service provision. J Public Health Dent 2002;62:14857. 37. Begg S, Vos T, Goss J, Barker B, Stevenson C, Stanley L, et al. The burden of disease and injury in Australia 2003. Canberra: Australian Institute of Health and Welfare; 2007. Garcia A. Caries incidence and costs of prevention programs. J Public Health Dent 1989;49:25971. Diprose S. Water uoridation in Australia something to get your teeth into. 32nd Annual Queensland Water Industry Operations Workshop. Rockhampton, 1719 April 2007, 2007. Ehsani J, Bailie R. Feasibility and costs of water uoridation in remote Australian Aboriginal communities. BMC Public Health 2007;7:100. ABS. Statistical geography: volume 3 Australian standard geographical classication (ASGC) urban centres/localities. Canberra: Australian Bureau of Statistics; 2006. Gold M, Siegel J, Russell L, Weinstein M. Cost-effectiveness in health and medicine. New York: Oxford University Press; 1996. George B, Harris A, Mitchell A. Cost-effectiveness analysis and the consistency of decision making: evidence from pharmaceutical reimbursement in Australia (1991 to 1996). Pharmacoeconomics 2001;19:11039. Do LG, Spencer AJ. Decline in the prevalence of dental uorosis among South Australian children. Community Dent Oral Epidemiol 2007;35:28291. Cobiac LJ, Vos T, Barendregt JJ. Cost-effectiveness of interventions to promote physical activity: a modelling study. PLoS Med 2009;6:e1000110. Haby MM, Tonge B, Littleeld L, Carter R, Vos T. Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents. Aust N Z J Psychiatry 2004;38:57991. Moodie M, Haby M, Wake M, Gold L, Carter R. Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. Econ Hum Biol 2008;6:36376. WHO. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva: World Health Organization, 2001. Slade GD, Bailie RS, Roberts-Thomson K, Leach AJ, Raye I, Endean C, et al. Effect of health promotion and uoride varnish on dental caries among Australian Aboriginal children: results from a communityrandomized controlled trial. Community Dent Oral Epidemiol 2010;39:2943. n B, Olavi G, Birkhed D, Edvardsson S, Egelberg Rose J. Effect of different frequencies of preventive maintenance treatment on dental caries: ve-year observations in general dentistry patients. Acta Odontol Scand 2004;62:2828. ABS. Disability, ageing and carers, Australia: summary of ndings, 2003. Canberra: Australian Bureau of Statistics; 2003. AIHW. Health expenditure Australia. Canberra: Australian Institute of Health and Welfare; 2006. ABS. Consumer price index, Australia, June quarter. Canberra: Australian Bureau of Statistics; 2006. Drummond M, Sculpher M, Torrance G, OBrien B, Stoddart G. Methods for the economic evaluation of health care programmes. 3rd edn. New York: Oxford University Press; 2005.

38. 39.

40. 41.

42. 43.

44. 45. 46.

47.

48.

49.

50.

51. 52. 53. 54.

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