Cost-effectiveness of dental caries prevention strategies in South African schools

Abstract

Background In South Africa, an estimated 85% of the population relies on the public sector for oral health services. With poor infrastructure and inadequate personnel, over 80% of children with dental caries remain untreated. To reduce this burden of disease, one key goal is to promote good oral health and address oral diseases through prevention, screening, and treatment among children. While all policies have been proven to be effective in the control and prevention of dental caries, it is unclear which of those strategies provide value for money. This study evaluated five caries preventative strategies in terms of the cost and benefits among South African school children. Methods The study uses a hypothetical South African population of school aged learners aged 5–15. The context and insights of the strategies utilized at the schools were informed by data from both grey and published literature. Using Markov modeling techniques, we conducted a cost-effectiveness analysis of Acidulated Phosphate Fluoride (APF) application, atraumatic restorative treatment (ART), sugar-reduction and fissure sealants. Markov model was used to depict the movement of a hypothetical patient cohort between different health states over time. We assessed both health outcomes and costs of various interventions. The health outcome metric was measured as the number of Decayed, Missing, Filled Tooth (DMFT). The net monetary benefit was then used to determine which intervention was most cost-effective. Results The results showed that school-based caries prevention strategies are cost-effective compared to the status quo of doing nothing. The average cost per learner over the 10-year period ranged from ZAR4380 to approx. ZAR7300 for the interventions considered. The total costs (including screening) associated with the interventions and health outcome (DMFT averted) were: sugar reduction (ZAR91,380, DFMT: 63,762), APF-Gel (ZAR54 million, DMFT: 42,010), tooth brushing (ZAR72.8 million, DMFT: 74,018), fissure sealant (ZAR44.63 million, DMFT: 100,024), and ART (ZAR45 million, DMFT: 144,035). The net monetary benefits achieved for APF-Gel, sugar reduction, tooth brushing, fissure sealant and ART programs were ZAR1.56, ZAR2.45, ZAR2.78, ZAR3.81, and ZAR5.55 billion, respectively. Conclusion Based on the net monetary benefit, ART, fissure sealant and sugar-reduction appear to be the most cost-effective strategies for preventing caries in South Africa. In a resource-scarce setting such as South Africa, where there is no fluoridation of drinking water, this analysis can inform decisions about service packages for oral health.

Oral health in emerging countries and suggestions for adjusted care strategies

“…However, it could be made more effective and cost-efficient. 127 At the same time, the oral health of middle-aged adults and particularly of seniors is rather poor. This indicates that emphasis must be placed on improving adult oral care.…”

“…The main causes for the widespread prevalence of oral diseases in adults are the high intake of sugared drinks and the hidden sugar in South Africa´s popular fast food dishes, as well as the lack of protective fluoride exposure. 22,127 Thus, these are the urgent areas for population-wide oral health policy activities. Since a sugar tax (Health Promotion Levy) was already introduced in 2018 to reduce excess sugar intake -against great resistance of the influential sugar industry -it would be unrealistic at the present time to propose expanding the tax on all added sugar sources as recommended by Boachie et al 127 Instead, advertising restrictions on sugary products, which are not included in the tax legislation, 128 could be introduced to reinforce the effect of the current sugar tax.…”

“…22,127 Thus, these are the urgent areas for population-wide oral health policy activities. Since a sugar tax (Health Promotion Levy) was already introduced in 2018 to reduce excess sugar intake -against great resistance of the influential sugar industry -it would be unrealistic at the present time to propose expanding the tax on all added sugar sources as recommended by Boachie et al 127 Instead, advertising restrictions on sugary products, which are not included in the tax legislation, 128 could be introduced to reinforce the effect of the current sugar tax. Furthermore, to protect teeth against cariogenic attacks, fluoride exposure must be strengthened by controlled water fluoridation combined with the regular use of fluoridated toothpaste.…”

“…129,130 In this case, the fluoridation of bottled drinking water, as in Indonesia, or salt fluoridation (as in Switzerland and Germany) could bring the required dental protection. In addition to these measures, there is a need to develop the mid-level dental workforce in the public sector, on which 85% of the population rely, 127 particularly in the countryside. How this could be improved by using TD has been described above.…”