International Journal of

Environmental Research
and Public Health

Review
Clinical Effectiveness and Cost-Effectiveness of
Oral-Health Promotion in Dental Caries Prevention
among Children: Systematic Review
and Meta-Analysis
Nadine Fraihat 1, *, Saba Madae’en 2 , Zsuzsa Bencze 1 , Adrienn Herczeg 1 and Orsolya Varga 1
1 Department of Preventive Medicine, Faculty of Public Health, University of Debrecen,
H-4002 Debrecen, Hungary
2 Department of Clinical Pharmacy, Faculty of Pharmacy, University of Jordan, Amman 11942, Jordan
* Correspondence: [email protected]; Tel.: +36 52 512765




Received: 14 June 2019; Accepted: 22 July 2019; Published: 25 July 2019


Abstract: The objective of this study was to evaluate the clinical effectiveness and cost-effectiveness of
oral-health promotion programs (OHPPs) aiming to improve children’s knowledge of favorable oral
health behavior to lower decayed/-missing/-filled teeth (DMFT) while reducing the financial cost on
health institutions. An electronic search was performed in seven databases. Studies were restricted to
human interventions published in English. The search study followed the Preferred Reporting Items
for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and the risk of bias was assessed
based on the Drummonds Checklist. A total of 1072 references were found. Among these, 19 full texts
were included. Most studies had a strong quality. The overall pooled impact of OHPPs estimates
children suffering from DMFT/S to have 81% lower odds of participating in OHPP (95% CI 61–90%,
I2 : 98.3%, p = 0). Furthermore, the program was shown to be effective at lowering the cost in 97 out of
100 OHPPs (95% CI 89–99%, I2 : 99%, p = 0). Three subgroups analyses (age groups, study countries,
studies of the last five years) were performed to evaluate the influence modification on the pooled
effect. A comprehensive analysis of the OHPPs confirmed a reduction effect on child DMFT, hence,
lowering the financial burden of dental-care treatment on health institutions.

Keywords: Oral Health Promotion Programs (OHPP); Decayed Missing Filled Teeth (DMFT);
cost-effectiveness analysis (CEA); Incremental Cost Effectiveness Ratio (ICER)

1. Introduction
Dental caries represents a globally known preventable non-communicable diseases which is
considered a major public-health problem affecting all age groups, especially children. Health promotion
that goes beyond health care puts health on the agenda of policymakers in order to achieve better health
outcomes [1]. Oral health promotion plays an essential part in the health of the general promotion [2]
since the inter-relationship between oral and general health has been approved [1], for instance, through
strong statistical correlation between periodontitis and diabetes [3]. Thus, oral- and general-health
promotion addresses the inseparable issues of all systemic and oral-health-diseases, specifically through
general and oral hygiene, general- and oral- health-care attitudes, and general-health and dental-care
services [2]. In fact, dental programs and oral health prevention programs rarely receive the same
level of attention as medical care among decision-makers when taking into account the cost-effective
allocation of scarce health care resources [4]. However, to allocate scarce healthcare resources, further
information and studies are needed based on health economic evaluation [5]. Moreover, considering the

Int. J. Environ. Res. Public Health 2019, 16, 2668; doi:10.3390/ijerph16152668 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 2668 2 of 33

economic impact of dental caries on different populations in countries around the world would serve
health authorities for reaching reliable public-health decisions regarding the cost of oral-health diseases.
In the context of oral health, however, the 2016 Global Burden of Disease Study “estimated that
oral diseases globally affect at least 3.58 billion people, with caries of permanent teeth, being the
most prevalent of all assessed conditions. Globally, it is estimated that 2.4 billion people suffer from
caries of permanent teeth, and 486 million children suffer from caries of primary teeth” [6]. Dental
caries is the most prevalent chronic disease among children, and dental care is the greatest unmet
healthcare need [7]. According to the World Health Organization (WHO), in European countries tooth
decay among six-year-old children varies from 20% to 90% [8]. Approximately, a quarter of five- to
six-year-old children experience tooth decay, and the percentage rises above 90% in some low- and
middle-income countries, indicating dental caries is a permanent public-health problem [9]. WHO
oral-health goals have been formulated for the year 2020 as part of the WHO Health 21 policy for
Europe [10] suggesting that “by 2020, a percentage of at least “80%” of children at the age six should
be caries-free and, on average, no more than 1.5 Decayed/-Missing/-Filled Teeth should be observed for
children of 12 years of age”.
Given the extent of the problem, the economic burden of dental caries treatment is a large share of
many countries’ healthcare budget. Consequently, a study in Colombia measured the economic impact
of dental caries 2011, where the cost of dental caries represented 0.02% of 2011 at the current GDP,
which means that there was approximately an expenditure of $1.46 for each Colombian citizen to treat
dental caries, where the government could draft cost-effective oral-health policies to reduce dental
caries prevalence in Colombia’s population [11]. In order to estimate dental caries expenses among
children, the Medical Expenditure Panel Survey reported in 2006 that approximately 19% of children
younger than 5 years old had dental expenditures of $729 million [12].
Since education and oral -health prevention programs for all family members, children and
parents, at all socio-economic levels are the only means to avoid dental caries [8], dentists and oral
healthcare providers prioritize oral-health promotion [8]. To achieve such goals, Oral Health Promotion
Programs (OHPPs) for children are globally implemented in diverse communities and have been
shown to be a useful intervention to control dental caries. However, economic evaluation of their
cost-effectiveness to determine the programs value for money remains unclear.
This review seeks to determine if implementing an appropriate oral -health promotion program
reduces dental caries among children, and the financial cost on healthcare institutions. We hypothesize
that exposure to oral health promotion programs reduce dental caries among children, and health
care costs.

2. Materials and Methods

The review protocol was registered in the international database of prospectively registered
systematic reviews in health and social care (PROSPERO), Centre for Reviews and Dissemination,
University of York (No: CRD 42019125611). Although there is no standard protocol for economic
evaluation studies, one of the reviews in the literature recommended a protocol to improve the
preparation of reviews of healthcare economic evaluation [13]. The criteria for considering studies for
this review are as follows:

2.1. Type of Studies

The review included trial and model-based economic evaluation studies.

2.2. Included Participant, Intervention, Comparator, and Outcome (PICO) Terms

Participants:

• Children aged from 0 to 12 years old who were healthy without health-related diseases except for
dental caries.
Int. J. Environ. Res. Public Health 2019, 16, 2668 3 of 33

• Studies of mixed populations of parents and children were included where the data of children
were presented separately.

Interventions:

• Community-based oral-health education/training programs related to healthy oral habits.

• Screening of children’s teeth.
• Supervised toothbrushing technique through the provision of toothbrushes, an appropriate
amount of fluoride toothpaste, and topical fluoride.
• Advice on dietary control, such as limitation of sugar or carbohydrates consumption, and enhanced
fortified nutrition with an appropriate amount of calcium intake.

Comparator: not providing an oral-health promotion program or could have been providing a
differing action than the intervention group, within similar conditions.
Context: OHPPs implemented by oral-health professionals in the contexts of home visits, telephone
calls, healthcare centers and primary schools.
Outcomes:

• Reducing the “Decayed, Missing, Filled Teeth (DMFT) Index for permanent teeth or (DMFT) Index
for deciduous teeth” among children.
• OHPP cost, incremental cost (difference between mean costs of intervention and mean costs of the
comparator), and cost-effectiveness analysis (CEA).

The search strategy and selection process included relevant PICO terms, prospectively defined,
following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)
guidelines. The initiated search date was 11 December 2018, where the restriction concerning
the publications was for the English language. The following bibliographic databases were searched,
and Mesh terms and Emtree were used: PubMed: “ “Costs and Cost Analysis”(Mesh) AND
(“Oral Health”(Mesh) OR “Dental Caries”(Mesh) OR “Dental Care for Children”(Mesh)) AND
(“Child”(Mesh) OR “Child, Preschool”(Mesh))”; Excerpta Medica Database (EMBASE): “(‘mouth
hygiene’/exp OR ‘dental caries’/exp OR ‘dental prevention’/exp OR ‘dental procedure’/exp) AND
‘economic evaluation’/exp AND ‘child’/exp”; DARE, NHSEED and HTA: (Oral Health OR Dental
Caries OR Dental Care) AND (Child OR Preschool Child OR Infant); Cost-Effectiveness Analysis (CEA)
Registry: “Dental Caries, Oral Health, Dental care”, Paediatric Economic Database Evaluation (PEDE):
“Dental Caries”.
The title, abstract and full text of each study were screened and accurately assessed. The used
method for the selection criteria was importing the searched outcomes in the bibliographic reference
software EndNote X7 to remove duplicate records and to precisely screen records through two phase
screening. During the first phase screening of titles and abstracts, irrelevant records were basically
categorized as intervention, opinion, reviews, participants, outcomes, not English language, the
exclusion criteria of irrelevant records were clearly explained as participant with health-related diseases
or aged older than 12 years; interventions other than OHPP, such as implant dentistry or other
invasive-dentistry programs; other economic-evaluation outcomes such as cost-benefit, cost-utility or
cost-minimization; authors’ opinion (unoriginal records); study reviews; and study language other
than English. The second-phase screening completely assessed the full article text of articles to verify
the level of consistency that the studies had with the eligibility criteria. In addition, data extraction
was gathered by formulating two tables using Windows Excel 2013 (Microsoft, Redmond, WA, USA),
to separately collect the qualitative and quantitative data. (Appendix A, Tables A1 and A2)
Meanwhile, data that were extracted from the included criteria studies the risk of bias in studies
that were detected simultaneously. The Drummond Checklist provides useful guidance applied to
clarify the included studies with 10 answerable questions (yes, no, or not available), assuming the
assessment result as strong, moderate, or weak, (see Tables A3 and A4) [14].
Int. J. Environ. Res. Public Health 2019, 16, 2668 4 of 33

Table A3: represent 10 trial-based economic evaluation studies assessed by 10 questions of the
Drummond checklist.
Table A4: represent nine model-based economic evaluation studies assessed similarly by nine
questions of the Drummond checklist.
For meta-analysis, we included eight studies; the missing data dealt with contacting study authors.
STATA Software version 14 (StataCorp LP., College Station, TX, USA) was used. Where the pooled
figures were multiplied by 100 due to software technical competency, a few missing data were replaced
by the number 1 as an integer. The cost in diverse countries with different currencies was converted to
2015 prices of USA dollars. For studies using the USA dollar, we measured the inflation rate for each
study considering the 2015 standard year. Data analysis was performed through founded dichotomous
outcomes such as the number of children in the intervention and in the control group, the DMFT index
in children, and the OHPP cost. Odds ratio (OR) is an effect size with 95% confidence interval (CI) and
study weights were estimated from random effects analysis. Forest plots for each needed outcome
were demonstrated, and the chi-square test was used to assess whether the observed differences were
homogeneous or heterogeneous where a P value of less than 0.1 indicated statistically significant
heterogeneity. An I2 test was used to quantify inconsistencies between studies as the percentage of
variation across studies was measured where heterogeneity was quantified as 0% to 40% implying
slight heterogeneity, 30% to 60% implied moderate heterogeneity, 50% to 90% implied substantial
heterogeneity and 75% to 100% implied very substantial (considerable) heterogeneity. Data synthesis
was carried out using narrative demonstration, with a summary of the characteristics of each included
study. For quantitative synthesis, a summary of the combined estimation related to the OHPP effect was
measured. Due to heterogeneity analysis, three subgroups were performed to assess the modification
influence on the pooled effect through the age of the children, studies of the last 5 years and the country
of the study. Egger’s regression test and a funnel plot were used to assess and demonstrate publication
bias, as publication bias was considered present if the p-value of the Egger test was more than 0.05.

3. Results
Overall, 1072 records were retrieved for eligibility screening. After removal of duplicates,
404 records were obtained. Screening of titles and abstracts excluded 359 records, given the proper
reasons when records were not relevant to the aim of the review. We assessed 45 full texts of articles
and identified 19 articles for qualitative synthesis and eight articles for quantitative synthesis. Figure 1
shows the PRISMA flow diagram for the inclusion of studies.
Int. J. Environ. Res. Public Health 2019, 16, 2668 5 of 33

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram
for the inclusion of studies.

The 19 included studies [5,15–32], which are illustrated through the general characteristics,
in Table A1 in Appendix A had one or more intervention(s) in the included OHPPs, while the majority
of studies examined the implementation of OHPPs in the intervention group compared with dissimilar
or absent intervention in the control group.
Furthermore, the included studies originated from diverse countries: United Kingdom (n = 6;
31.6%), Australia (n = 5; 26%), United States (n = 3; 16%), Finland (n = 1; 5%), Japan (n = 1; 5%),
Nigeria (n = 1; 5%), Singapore (n = 1; 5%) and Ireland (n = 1; 5%) with diverse currencies used in
different time longevity of the OHPPs. In addition, the review is based on (n = 9; 47%) trial-based
economic-evaluation studies, and (n = 10; 52%) model-based economic evaluation studies with two
different age groups where 14 studies were of younger than 6-year-old children and four studies age
Int. J. Environ. Res. Public Health 2019, 16, 2668 6 of 33

were of older than 6 years old, and one study did not mention the age of the children. Of all studies,
47% were published in the last 5 years.
For the quantitative data, Table A2: presents the cost-effectiveness outcomes of the included
studies. Table A2: presents the cost in the intervention and in the control group, measured by the
incremental cost based on the type of found outcomes in the included studies, such as DMFT, Average
of dental visits, number of prevented caries teeth, average of cavity-free months, probability of less cost,
caries percentages, number of into the mouth of babes program visits (no. of IMB), quality-adjusted
life year (QALY) (measure of disease burden, including the quality and the quantity of life lived,
it can be used in cost-effectiveness studies to assess the value for money of clinical interventions),
cost-effectiveness ratio, and percentages of not having debris. The table also includes the outcome-effect
result in the intervention and the control groups, Incremental Cost Effectiveness Ratios (ICERs), cost
saving, indirect cost, and total program cost.
Nineteen studies were included in the systematic review and meta-analysis, and the Drummond
Checklist [14] was used to assess the risk of bias in the trial- and model-based economic evaluation
studies. The included studies were ten trial-based economic evaluation studies and nine model-based
economic evaluation studies. Out of the 19 included studies, 12 studies had a low risk of bias and
seven had a moderate risk of bias.

3.1. According to the Review, to Summarize the Studies That Met the Inclusion Criteria

3.1.1. Strong-Quality “Model-Based” Economic Evaluation Studies

A study by Kowash [15], which was conducted in the UK over three years, aimed to provide
a dental health education program of home visits with mothers of eight-month-old young infants
to prevent early-childhood caries (ECC). It provides strong evidence for the reductions of dental
caries associated with deemed cost saving based on program intervention; DMFT had a 0.29 score
in the intervention group, and 1.75 in the comparative group. The author concluded that “oral
health-education gave better costs-effectiveness ratios than another preventive program”. In addition,
a study by Pukallus [16] estimated that oral-health advice of oral health therapists, delivered within five
and a half years through calling the parents with children with a mean age of 1 year, saved $108,406.92
the year of 2012.
The 2006 study by Quinonez [17] aimed to examine the cost-effectiveness of fluoride varnish
application by medical providers. The intervention was the application of universal fluoride varnish
at 9, 18, 24, and 36 months as cycles extended to 42 months. The study analyzed cavity-free months,
which were equal to 31.49 in the intervention group and 29.97 in the control group; in terms of
cost, intervention cost was $181.66 in 2003 and $170.73 in the control group in the same year; hence,
it increased incremental cost to $10.93 in 2003.
Furthermore, Stearns [18] estimated the cost-effectiveness of medical office-based preventive oral
health, where the program was effective in the terms of cost. The cost of intervention was $54.81 which
is less than the cost of control $285.8 as cost-saving reached $33.64 in 2006.
A study by Anopa [19] which was about a national supervised tooth-brushing program, found the
program to save cost. It aimed to compare the cost of providing a supervised toothbrushing program
with National Health Service (NHS) cost savings. It assumed the total reduction in tooth decay in
five-year-old children was due to the tooth brushing program. The study measured the avoided cost
per DMFT as incremental cost about (−) $197.44 in 2009, and the cost-saving was estimated to be
$6,912,617 within the same time frame. Thus, the authors speculated that the cost-savings of the tooth
brushing program can be successful in most socio-economically deprived children.
Another study by Blaikie [20] was preliminary economic analysis that was conducted in Australia
over seven years from 1970 until 1976 to study the cost of school dental care for school-age children
to provide the best care at the lowest cost. It compared the fee-for-services-based program with the
regular community dental health branch cost in which the founded costs were $3,259,846 for the free
Int. J. Environ. Res. Public Health 2019, 16, 2668 7 of 33

for service an oral screening program and $3,034,576 for community dental health branch in the year of
1976. The author suggested that “the Dental Health Branch was more cost-effective than the proposed
fee-for-service alternative as the program is an economically acceptable method of delivering school
dental care”.
Moreover, Samnaliev [21] was entitled to measure the cost-effectiveness of a disease management
program for early childhood caries. The caries percentages in the case group were equal to 4.15%
compared with the control group which was equal to 22.5%, thus for the incremental cost of the
program was equal (−) $8380 in the year of 2011, where the cost-saving reached $904 in the same year.
It appeared that “the program is cost-effective and has the potential to reduce healthcare costs”.

3.1.2. Moderate Quality “Model-Based” Economic Evaluation Studies

Takeuchi’s [22] study was conducted in Japan for 12-year-old children; the study proved its health
effect to decrease DMFT score in the intervention group as it was scored (2.2) DMFT compared with
(4.86) DMFT score in the control group. It could not prove the effect in the terms of cost when the
total program cost reached $2432.52 in 2006. The second moderate quality study was by Plonka [23];
a longitudinal study of home visits compared to telephone contacts to prevent ECC. The program was
effective in terms of health gain, as the caries percentages in the case group reached 2% compared with
the control group, which was 15%. The study did not take into account the cost-saving of the program,
hence the author concluded: “the home visits and telephone contacts conducted every 6 months from
time of birth are effective in reducing ECC prevalence by 24 months”.

3.1.3. Strong-Quality “Trial-Based” Economic Evaluation Studies

Tickle [24] measured the effects and costs of a dental caries prevention regime for young children.
Although the intervention group had lower DMFT than the control group, the intervention program
cost was higher, with incremental costs reaching $167.61 in 2015. Additionally, Donaldson [25], based
in the UK, gave additional information about the three-year-long study of caries reduction after
topical application of 4% sodium fluoride per oral (NaFPO). Although it reduced caries, the program
incremental costs reached $71.97 in 1974.
In contrast, an Irish study by O’Neill [26] took three years, in which participants were centrally
randomized into the intervention of 22,600 ppm fluoride varnish, toothbrush, a 50-mL tube of 1450 ppm
fluoride toothpaste, and standardized prevention advice, while the control group with oral health
advice only. Although the program was effective in reducing caries, incremental cost in 2014 was $350.06.
For older children aged 11–12, a strong-quality study by Hietasalo [5] assessed the cost-effectiveness
of a preventive program including a package of oral health advice, preventive treatment, and free
materials that were delivered by dental hygienists for 497 children with at least one active caries lesion.
The author estimated an incremental cost per Decayed Missing Filled Surface (DMFS) avoided $87.78
in 2004.

3.1.4. Moderat Quality “Trial-Based” Economic Evaluation Studies

Reiss [27] encouraged the low-income families of 51 children to seek dental care for their children.
The incremental cost in 1976 reached $27.68. Koh [28] conducted a study over five and a half years that
evaluated the cost-effectiveness of home visits and telephone contact in preventing ECC in children
aged from six months to six years. The perspective of the analysis was societal, considering the costs
to the parent and the health system. Where the program was effective in terms of gained QALY,
intervention cost reached $68 in 2014 compared with the control cost which reached $8448 in the same
year. Incremental cost reached (−) $8380 in 2014. Another trial, reported by Davies [29] evaluated the
cost-effectiveness of a postal toothpaste program to prevent caries in five-year-old children. The report
found that free toothpaste on four occasions a year, and a toothbrush once a year for four years, was
effective to reduce the DMFT to a score 2.15 in the intervention group, compared with the control
Int. J. Environ. Res. Public Health 2019, 16, 2668 8 of 33

group, with a DMFT score of 2.57. Cost-saving reached $2217.45 in 1992. Economic analysis resulted in
an overestimation of the cost and underestimation of the benefits.

3.1.5. Limited Economic-Evaluation Outcomes of Moderate Qualified “Trial-Based’

Economic-Evaluation Studies and “Model-Based” Economic-Evaluation Studies”
Although the three remaining studies (Folayan [30], Lai [31], and Gibbs, L [32]), delivered
reliable OHPPs, the economic evaluation of the program could not be demonstrated as needed.
Folayan [30] aimed to determine the association between the use of recommended oral self-care caries
(ROSC) prevention tools and the presence of dental caries in children residing in suburban Nigeria.
The intervention group were encouraged to brush more than once a day, use fluoridated toothpaste,
and to eat sugary snacks between main meals less than once a day. The study intervention used ROSC
caries prevention tools in combination. Conversely, the control group was exclusively using ROSC
prevention tools. It was found that the use of the combination of ROSC caries prevention tools made
the probability less costly and more efficient, as the probability of less cost in the intervention group
was 98.6%, while it was 61.5% in the comparative group.
Lai [31] aimed to examine the clinical efficacy of a two-year oral health program for infants and
toddlers. The intervention group undertook oral-health education on tooth brushing and fluoride use,
non-nutritional habits, trauma prevention, and use of topical fluoride varnish, and this was compared
with no oral-health education. Consequently, mean caries reached seven in the intervention group,
whereas, it reached 20 in the control group. However, the odds of severe ECC in the control group
were three times higher than the intervention group.
A study by Gibbs [32] was based on child oral-health promotion, enrolling migrant families in
Australia. The community oral-health education sessions were led by peer educators. Follow-up health
messages were given in the intervention group, and the control group had no oral health education.
The percentage of not having debris was estimated to be 56% higher in the intervention than the
controlled group. The author concluded that intervention of oral-health education session was likely
to improve knowledge, behavioral skills, and also adherence to following up. The program cost was
$362,329.66 in 2012.

3.2. Meta-Analysis
Findings of the meta-analysis summarized through eight studies [5,15,19,22,24–26,29] were
included in the quantitative analysis of the effect and cost effect of the OHPPs. The eight selected
studies for meta-analysis were analyzed based on the incremental cost of the OHPPs per DMFT and
Decayed Filled Teeth (DFT) or DMFS. The cost-effectiveness outcomes are presented in Table A2,
covering incremental cost, type of study outcomes, ICER, cost saving, indirect cost, and total program
cost. Major findings of the meta-analysis are presented in Figures 2–6, STATA do-files for analysis of
the figures are presented in the (Appendix B, Figures A1–A6.
Int. J. Environ. Res. Public Health 2019, 16, 2668 9 of 33

Figure 2. Forest plots of Decayed Missing Filled Teeth (DMFT)/S by the participating children.

Figure 3. Forest plot of incremental cost-effectiveness per DMFT/S.

Int. J. Environ. Res. Public Health 2019, 16, 2668 10 of 33

Figure 4. Forest plot of DMFT/S by children age group: 1 as (Age > 6) and 2 as (Age ≤ 6).

Figure 5. Forest plot of the incremental cost-effectiveness of the intervention and the control groups by
the age groups: 1 as (Age > 6) and 2 as (Age ≤ 6).
Int. J. Environ. Res. Public Health 2019, 16, 2668 11 of 33

Figure 6. Forest plot for the difference in the DMFT of the intervention group compared to the control
group regarding the study years.

Figure 2 shows that the overall pooled impact of OHPP estimates in children who suffer from
DMFT/S had 81% lower odds to participate in OHPP (95% CI 61–90%, I2 : 98.5%, p = 0) with considerable
heterogeneity among studies. The reference categories were used in the measurement: “DMFT/S in the
intervention group and the number of children in the intervention group”, “DMFT/S in the control
group and the number of children in the control group”.
Figure 3 illustrates that the OHPPs had a successful intervention in reducing financial costs in 97
out of 100 OHPPs (95% CI 89–99%, I2 : 99%, p = 0) with considerable heterogeneity among studies.
The reference categories were used in the measurement “the cost of the program in the intervention
group and DMFT/S in the intervention group”, and “the cost of the program in the control group and
DMFT/S in the control group”.
Due to considerable heterogeneity between the included studies, subgroup analysis was measured
to assess the influence modification on the pooled effect by children’s age groups, study countries,
and publication date before and after 2015. Figure 4 represents the subgroup analysis according to the
age groups.
Studies reported children of less than six years weighted 70.73% with an OR of 0.14 (95% CI,
0.05–0.39, I2 : 98.5%) had the highest benefit of OHPPs to lower DMFT/S, while studies reporting
children aged six years and older weighted 29.27% with an OR of 0.29 (95% CI, 0.08–1.01, I2 : 99.2% )
had no benefit from OHPPs in lowering DMFT/S. Reference category measurements were: “DMFT/S in
the intervention group and the number of children in the intervention group”, and “DMFT/S in the
control group and the number of children in the control group” by two age categories.
Figure 5 shows studies that reported children who were less than six years old with an OR
of 0.07 (95% CI, 0.02–0.32) revealing no cost-effectiveness effect to reduce OHPP incremental cost,
whereas studies reporting children aged six years and older with an OR of 0.0 (95% CI, 0.00–48,704.6)
was cost-effective in reducing the OHPPs incremental cost in this age group. The reference category
Int. J. Environ. Res. Public Health 2019, 16, 2668 12 of 33

measurements were “DMFT/S in the intervention group and the cost of the program in the intervention
group”, “DMFT/S in the control group, the cost of the program in the control group)” by the two
age categories.
Studies published after 2015 weighted 51.13% revealed a clinical effect of OHPPs to reduce
DMFT as an OR of 0.08 (95% CI 0.01–0.53); studies published before 2015 weighted 48.87% revealed a
significant effect of OHPPs to reduce DMFT among children with an OR 0.01 (95% CI 0.00–0.13). The
reference category measurements were “DMFT/S in the intervention group and number of children
in the intervention group”, “DMFT/S in the control group and the number of children in the control
group” by two group study year publishment.
Moreover, the study countries of the OHPPs were analyzed, (see Figure 7). The United Kingdom
country weighted 59.18%, revealed significant proof that OHPPs had a reducing effect on DMFT/S as
an OR of 0.04 (95% CI 0–0.58). The same findings were seen in Japan, Ireland, and Finland, countries
with an overall OR of 0.03 (95% CI 0.01–0.11) resulting as “OR 0 (95% CI, 0–0) weighted 10.71%, OR 0.52
(95%CI, 0.45–0.61) weighted 15.06%, and OR 0.48 (95% CI 0.41–0.56) weighted 15.06%” respectively.
These countries had significant impact on the overall pooled effect to prove that OHPPs had a reduction
effect of DMFT/S among children. The measured reference categories were “DMFT/S in the intervention
group and number of children in the intervention group”, “DMFT/S in the control group and the
number of children in the control group” by the study countries.

Figure 7. Forest plot for the difference in the DMFT/S of the intervention group compared to the control
group by study countries.

Due to considerable heterogeneity, the Eggers regression test was performed to analyze for
publication bias. A publication bias is considered present if the p-value of the Egger test is more than
0.05. Major findings of the Eggers regression tests are presented in Figures 8 and 9.
Int. J. Environ. Res. Public Health 2019, 16, 2668 13 of 33

Figure 8. Eggers regression test to test hypothesis 1.

In this way, we assumed two hypotheses. H null: the result of meta-analysis had no effect of
DMFT among children with no small sample size; and H alternative: the result of meta-analysis had a
reducing effect of DMFT among children with a small sample size. A p-value of 0.53 was more than
0.05 in the review and publication bias was present; thus, we reject the null hypothesis and accept the
alternative hypothesis.

Figure 9. Eggers regression test to test hypothesis 2.

We assumed two hypotheses. H null: the result of meta-analysis had no effect of OHPP to reduce
the financial cost on health institutions with no small sample size; and H alternative: the result of the
meta-analysis had a reducing effect of OHPP on the financial cost on health institutions with a small
sample size. A p-value of 0.39 was more than 0.05 in the review and publication bias was present; thus,
we reject the null hypothesis and accept the alternative hypothesis.
We used the “funnel plot” tool to demonstrate the reason for the publication bias in the
meta-analysis. It is a simple scatter plot of the treatment effects, as the ratio measures the odds
ratio plotted on a log scale estimated from individual studies (horizontal axis) against a measure of the
study size (vertical axis), (see Figure 10).
Figure 10 illustrates the asymmetrical scatter plot of the program effects estimated from the
selected individual studies against a measure of the small study size. The funnel plot is seen in this
review as the tendency for the smaller studies in a meta-analysis to show a larger treatment effect,
where publication bias is only one of a number of possible causes of funnel plot asymmetry [33].
Heterogeneity exists in this review for many reasons. We can explain that the review included diverse
studies with various risks in the control group and effect size differs according to study size, intensity
of intervention, differences in underlying risk and data irregularities between the pooled studies.
Int. J. Environ. Res. Public Health 2019, 16, 2668 14 of 33

Figure 10. Funnel Plot represented from the eight pooled trial and model-based economic-evaluation
studies of Oral Health Promotion Programs (OHPPs), with log-odds ratios displayed on the horizontal
axis and the standard error of the log-odds ratios displayed on the vertical axis.

4. Discussion
The main review objectives were to assess the clinical effectiveness of oral-health promotion
programs on the oral health of children, specifically dental caries, as well as the cost-effectiveness of
the programs. The review included 19 studies reporting the used OHPPs and the incremental costs
within a year’s related costs. The studies were timely diverse publication between 1976 and 2018, with
long-term perspectives.
As stated in 1986 by the WHO in the Ottawa Charter for Health Promotion, the aim was “to enable
people to increase control over and to improve their health”. Tooth decay is a preventable and
controllable disease. Health promotion improves the quality of life, but it requires a commitment
to practicing healthier behavior. Subsequently, it can only be achieved when oral-health promotion
activities are implemented at the community level.
OHPPs in our review mainly implemented dental-health education, focusing on supervised
toothbrushing techniques, using the appropriate type of fluoride toothpaste, following healthy behavior,
avoiding unhealthy dietary habits and performing regular dental checkups. Where the included
criteria studies were conducted within a time frame that varies from one study to another, some
studies agree that the longer the time frame of OHPPs the more effective they are in manifesting a
favorable oral health result in children’s teeth. However, most health economic studies in this field are
not extensive enough to capture most cost- and clinical- outcome differences between the different
programs and interventions.
Our review highlights the limited number of economic studies evaluating one type of dental
caries prevention intervention, OHPPs, especially with regards to cost-saving, and how the OHPPs
could be cost-effective when tooth decay can be avoided. Contemporary evidence shows that decisions
on public health policy, health insurance, and client treatment should incorporate economic factors
of health expenses. Health economic research studies are able to answer the practical question of
Int. J. Environ. Res. Public Health 2019, 16, 2668 15 of 33

“which intervention gives the greatest benefit proportional to its cost?”, while methods to estimate
the economic impact of oral diseases are limited in availability, with no harmonized international
reporting standards, resulting in difficulty to estimate the full economic impact of oral diseases [34].
This review is a reliable indication of the clinical effectiveness and cost-effectiveness of
oral-health community programs among children. In a comprehensive way, trial and model-based
economic-evaluation studies proved that OHPPs were significantly related to the anticipated review
hypothesis regarding the efficacy of dental-health status and financial cost. However, it seems to be
inconsequential in terms of OHPP efficacy when comparing two age groups. For clarity, the review
found that OHPPs can be clinically effective under the age of six years but in comparison, the program
is costly and needs further fiscal management by health authorities. OHPPs, on the other hand, do
not reveal higher clinical effectiveness in dental caries reduction among children aged older than six
years but they show that the program could not be that much costlier. In the last five years, published
studies have also approved the efficacy of OHPPs. Similarly, previous studies represented significantly
positive findings of the program, as well as when comparing between several countries. Five studies
from the United Kingdom revealed that OHPPs have a significant effect in improving dental health
status and reducing the cost of healthcare systems; other countries, namely, Japan, Ireland and Finland,
identified the significant effect of the review objectives. Therefore, OHPPs revealed their effects on
children’s oral health, on parental dental-treatment expenses, on the health care institutions and on the
countries’ GDP. The review findings minimize the knowledge gap between evidence-based research
and clinical practice since the program proves the applicability of health promotion in oral healthcare.

Study Limitations
Although the review included timely diverse studies over seventy years that provide an impressive
result in the era of dentistry, the economic evaluation of OHPPs fluctuated based on the year to which
the program cost is related, offering a slight chance to generalize the pooled findings. On the other
hand, the 19 reviewed studies estimated the paid resources cost when OHPPs commenced from
comparative health economic studies, where the counted numbers of studies prove the incremental cost
is higher when oral-health promotion taking place in local community health programs. In addition,
cost-effectiveness is determined in some studies in terms of tooth decay, before applying intervention
that resulted in weakness in the generalizability of cost-effectiveness studies in the area of dental care.
The review protocol included settings and interventions that varied, such as providing oral
healthcare, dental screening, and the clinical assessment of children’s tooth health status, applying
topical fluoride varnishes, and offering oral health care products (for instance, fluoridated toothpaste
and toothbrushes) might be expected to confound the estimated effects of oral-health education.
Accordingly, economic studies are limited in terms of generalizability of cost-effectiveness related to
specific oral-health intervention due to the differential costs between countries. For example, the cost
of a dental filling in one country is more expensive than other countries. Moreover, it is not clear how
much a national health service is willing to pay per avoided DMFT/S. It is doubtful to interpret the
cost-effectiveness findings in terms of dental caries in the absence of valuable distinct indicators.

5. Conclusions
More effort is needed to manage the allocation of scarce resources, taking into account the
economic impact of dental caries on healthcare systems. Additionally, more studies are needed
regarding caries-prevention methods among young age children in high-, middle- and low-income
countries, with follow-up programs to analyze clinical and financial efficacy when conducting
well-organized oral-health interventions.

Author Contributions: Protocol of this meta-analysis and systematic review was written by N.F. and O.V.; N.F.
and S.M. participated in search, selection and data extraction. N.F. and A.H. carried out the statistical analysis.
N.F., Z.B. and S.M. wrote the initial draft, which was reviewed and revised by N.F, S.M., Z.B., A.H. and O.V.
Int. J. Environ. Res. Public Health 2019, 16, 2668 16 of 33

Funding: This research was funded by Stipendium Hungaricum Scholarship programme and the Tempus
Public Foundation.
Acknowledgments: The lead author would like to acknowledge, with thanks, the staff members and colleagues
in the department of preventive medicine at the University of Debrecen, for their generous support. As well as
being grateful to the faculty of public health which guaranteed the necessary facilities to ensure successful settings
for this project. OV acknowledges the financial support of the János Bolyai Research Fellowship, Hungarian
Academy of Sciences.
Conflicts of Interest: All authors declare that they have no conflict of interests.
Int. J. Environ. Res. Public Health 2019, 16, 2668 17 of 33

Appendix A

Table A1. The general characteristics of the included studies.

Study Mean Age Source of Quality

S.no Lead Author Year Country Participant Intervention Main Conclusion
Design (Year) Funding Assessment
1. Designed a The experimental
497 children who
centered regimen would be Finnish Dental
had at least one
regimen for more cost-effective Society
Hietasalo, P. active
1. 2009 Finland Trial-Based 11.5 caries than standard care if Apollonia, the Strong Quality
[5] initial caries lesion
Control the follow-up the Yrjo Jahnsson
at baseline of the
2. Fluoride period had been Foundation
study
Varnish longer
Dental Health
Education program of
home visits with
Long-term
mothers of young
dental health
infants to prevent British National
Kowash, M.B. United 7000 infants aged education
2. 2006 Model-Based 0.6666 early childhood caries Health Service Strong Quality
[15] Kingdom 8 months program
gave better (UK) fees
through home
benefit-costs and
visits
cost-effectiveness
ratios than other
preventive programs.
Mothers in the A telephone
intervention intervention likely to
group were A telephone generate considerable Australian
Pukallus, M. telephoned when Oral Health benefits and cost Centre for
3. 2013 Australia Model-Based 1 Strong Quality
[16] their children prevention savings to the public Health Services
were aged program dental health service Innovation
approximately 6, in disadvantaged
12 and 18 months communities
Tooth brushing
program represents a
Hypothetical
Nursery tooth preventative spend of E-Government
United cohorts of 1000
4. Anopa, Y. [19] 2015 Model-Based 5 brushing both reduced costs through NHS Strong Quality
Kingdom children aged 5
program and health gains in payments
years
child oral health
outcomes.
Int. J. Environ. Res. Public Health 2019, 16, 2668 18 of 33

Table A1. Cont.

Study Mean Age Source of Quality

S.no Lead Author Year Country Participant Intervention Main Conclusion
Design (Year) Funding Assessment
Free for an Oral
screening Dental Health Branch
program was more
Department of
Blaikie, D.C. Community compared with cost-effective than the
5. 1977 Australia Model-Based NA Public Health Strong Quality
[20] School Children Regular proposed
ledger listings
community fee-for-service
dental health alternative.
branch
1. Oral Health The National
advice The intervention was Institute for
Children aged 2–3
2. providing unlikely to be Health Research
United years, who were
6. Tickle, M. [24] 2016 Trial-Based 3.1 Toothbrushes cost-effective in terms (NIHR) Health Strong Quality
Kingdom caries free at
and Toothpaste of either keeping Technology
baseline
3. Flouride children caries free. Assessment
Varnish program
Application of
universal fluoride
varnish at 9, 18, 24,
Supported by
and 36 months the Fluoride varnish used
grant
cycles extended to in the medical setting
Application of (R01DE013949)
42 months to is effective in reducing
Quinonez, R.B United fluoride varnish National
7. 2006 Model-Based account for 2.1250 ECC in low-income Strong Quality
[17] Kingdom at different Institute of
benefits incurred populations but is not
times. Dental and
after the last cost saving in the first
Craniofacial
Fluoride varnish 42 months of life.
Research
application at the
36-month
well-child visit.
The 3 Prompt and 1
51 children who 1. Oral Health
Prompt plus
needed immediate Note.
United 5 Incentive was
Reiss, M.L. dental care 2. Telephone Moderate
8. 1976 States of Trial-Based 4 significantly more Not Reported
[27] (determined by Contact, Home Quality
America effective in initiating
dental screening Visit Oral Health
dental visits than the
at a local school). education
Note-Only procedure
Int. J. Environ. Res. Public Health 2019, 16, 2668 19 of 33

Table A1. Cont.

Study Mean Age Source of Quality

S.no Lead Author Year Country Participant Intervention Main Conclusion
Design (Year) Funding Assessment
Personal health
education, oral There is a need for
161 children who
fluoride further study Chief Scientist
entered the
supplements measuring dental Office of the
Donaldson, C. United program and
9. 1986 Trial-Based 7 applications of outcome which Scottish Home Strong Quality
[25] Kingdom attended
acid phosphate combine aspects of and Health
continuously for a
fluoride gel and both the quality and Department.
period of 4 years.
pit and fissure length of life of teeth.
sealing.
1096 children
aged 2 to 3 year This trial raises
attending general concerns about the
practice assigned 1. Fluoride cost-effectiveness of a
in 2-arm parallel varnish fluoride-based
O’Neill, C. A state-funded
10. 2017 Ireland Trial-Based group to measure 2.5 2. Toothbrush intervention delivered Strong Quality
[26] dental service
the 3. Oral health at the practice level in
cost-effectiveness advice the context of a
of caries state-funded dental
prevention service
program
296 Children aged
Both the home visits
6–60 months. 188
A home visit and telephone calls National Health
home visit
relative to a were highly and Medical
interventions; 58 Moderate
11. Koh, R. [28] 2015 Australia Trial-Based 3.25 telephone call cost-effective Research
telephone contact Quality
Oral Health than no intervention Council of
interventions; 40
advises in preventing early Australia
reference controls:
childhood caries
usual home care.
Int. J. Environ. Res. Public Health 2019, 16, 2668 20 of 33

Table A1. Cont.

Study Mean Age Source of Quality

S.no Lead Author Year Country Participant Intervention Main Conclusion
Design (Year) Funding Assessment
Health care
costs were
obtained from
518 Children the hospital
The program appears
United younger than 60 Oral Disease finance
Samnaliev, M. cost-effective and has
12. 2015 States of Model-Based months with 2.5 management department. Strong Quality
[21] the potential to reduce
America active caries or a program And non-health
health care costs
history of caries care costs were
estimated
through a
parent survey
325 children were The Dental
Home visits and
recruited from Board of
telephone contacts
community health Oral Health Queensland and
conducted every 6
Plonka, K.A. centers, randomly education by the the Moderate
13. 2013 Australia Model-Based 0.1150 months from birth are
[23] assigned to home visit and following Quality
effective in reducing
receive either a Telephone call. Queensland
ECC prevalence by 24
home visit or Health
months.
telephone call. Departments
1. Screening and
risk assessment The program is
2. Parental cost-effective with
Lead Author is
United 209,285 Medicaid counseling, 95% certainty if
Stearns, S.C. independent of
14. 2012 States of Model-Based enrolled children 3.25 topical fluoride. Medicaid is willing to Strong Quality
[18] any commercial
America at age 6 months. 3. Topical pay
funder
fluoride 2331 per hospital
application. episode avoided.
Int. J. Environ. Res. Public Health 2019, 16, 2668 21 of 33

Table A1. Cont.

Study Mean Age Source of Quality

S.no Lead Author Year Country Participant Intervention Main Conclusion
Design (Year) Funding Assessment
1. Enforcement
of lectures
application of
The materials for
fluoride.
fluoride mouth
2. Instructions These activities
Takeuchi, R. Tongan rinsing and Tooth Moderate
15. 2017 Japan Model-Based 12 on were supported
[22] schoolchildren brushes are lower Quality
toothbrushing by the JICA
than for the treatment
Oral health
of caries.
education.
3. Application
of fluoride
A cohort of
The program
children aged 12
Children achieved a significant
months was
Davies, G.M United received caries reduction in Moderate
16. 2003 Trial-Based recruited from a 3 Not Reported
[29] Kingdom toothpaste 1450 children who received Quality
high caries risk
ppm fluoride 1450 fluoride
population in 9
toothpaste.
health districts.
The use of a
combination of
fluoridated toothpaste
Children living Dental health and twice-daily tooth
Folayan, M.O. with their education brushing had the Moderate
17. 2016 Nigeria Model-Based 6.5 Not Reported
[30] biological parents program of largest effect on Quality
or legal guardians home visits reducing the chance
for caries in children
resident in Ile-Ife,
Nigeria.
Int. J. Environ. Res. Public Health 2019, 16, 2668 22 of 33

Table A1. Cont.

Study Mean Age Source of Quality

S.no Lead Author Year Country Participant Intervention Main Conclusion
Design (Year) Funding Assessment
90 children and
Oral program The odds of severe
their caregivers
includes tooth early childhood caries
participated in the
brushing, in the control group Moderate
18. Lai, B. [31] 2018 Singapore Trial-Based program, and 64 2 Not Reported
fluoride use and were 3 times higher Quality
children were
topical fluoride than that for the
recruited as the
varnish intervention group
control group.
Families with
1–4-year-old
The Teeth Tales
children,
1. Community intervention was
197children in the Australian
education promising in terms of
intervention Research Moderate
19. Gibbs, L. [32] 2015 Australia Trial-Based 2.5 sessions improving oral
group and 144 Council Linkage Quality
2. Follow-up hygiene and parent
children in the grant
health messages knowledge of tooth
control group
brushing technique
Residing in
Melbourne.
NHS = National Health Service. ECC = early-childhood caries.

Table A2. Cost-Effectiveness Outcomes of the standardized included studies.

Currency Outcome: Cost-Effectiveness of the Standardized Year 2015 and USD Currency
Year to Used to
Economic
Which Which Cost of Cost of Total
Author Study Incremental Type of the Effect of Effect of Cost Indirect
Costs Cost Study Study |ICER| Program
Design Cost Outcomes Intervention Control Saving Cost
Applied Applied Intervention Control Cost

Tickle, M.
Trial-Based 2015 £ $242.76 $75.15 $167.61 DMFT 1.15 1.64 342.06 NA $1341.93 $2872.75
[24]
Anopa, Y. Model
2009 £ $24.6 $235.23 (−) $210.63 DMFT 0.08332 NA 1621.7 $737,453.43 NA $274,762.01
[19] Based
(−)
Koh R. [28] Trial-Based 2013 $ $354,983.72 $185,039.65 QALY 540 547 24,277.7 $317,174.06 $2197.64 $747,775.07
$169,944.07
Reiss, M.L.
Trial-Based 1976 $ $180.95 $65.65 $115.30 Dental Visits 0.846483 NA 32.7 $208.28 $122.76 $66.19
[27]
Int. J. Environ. Res. Public Health 2019, 16, 2668 23 of 33

Table A2. Cont.

Currency Outcome: Cost-Effectiveness of the Standardized Year 2015 and USD Currency
Year to Used to
Economic
Which Which Cost of Cost of Total
Author Study Incremental Type of the Effect of Effect of Cost Indirect
Costs Cost Study Study |ICER| Program
Design Cost Outcomes Intervention Control Saving Cost
Applied Applied Intervention Control Cost

Kowash, Model
1995 £ $10,046.06 $46,670.13 (−) $36.63 DMFT 0.29 1.75 25,085 $56,716.19 NA $20,093.67
M.B. [15] Based
Pukallus, M. Model (−) No. of caries
2012 £ $31,059.39 $140,146.01 11 54 2537 $109,086.63 NA $31,059.39
[16] Based $109,086.63 teeth prevented
Quinonez, Model cavity free
2003 $ $234 $219.92 $14.08 31.49 29.97 9.26 NA NA $3816.75
R.B. [17] Based months
Davies, G.M.
Trial-Based 1992 £ $232,664.49 NA NA DMFT 2.15 2.57 61.728 $1845.89 $16,111.88 $755,737.89
[29]
Hietasalo, P.
Trial-Based 2004 € $602.74 $518.36 $84.38 DMFS 2.56 4.6 41.363 $48.56 NA $278,717.29
[5]
Takeuchi, R. Model
2006 $ $2806.96 NA NA DMFT 2.2 4.86 NA NA $52.91 $2859.86
[22] Based
Folayan, Model Probability of
2015  NA NA NA 98.60% 61.50% NA NA NA NA
M.O. [30] Based less cost
Samnaliev, Model
2011 $ $71.65 $8901.61 (−) $8829.96 Caries% 4.15% 22.50% 48,119 $952.54 $120.73 $8969.92
M. [21] Based
Plonka, K.A. Model
NA $ NA NA NA Caries% 2% 15% NA NA NA NA
[23] Based
Lai, B. [31] Trial-Based 2012 $ NA NA NA NA NA NA NA NA NA NA
Blaikie, D.C. Model Cost-effectiveness
1976 $ $13,578,891.38 $12,640,528.99 $938,362.38 1.07 1.47 563,175 $6,179,117.15 $278,349.66 NA
[20] Based ratios
O’Neill, C.
Trial-Based 2014 £ $1601.31 $1271.45 $329.86 DMFS 2.6 3.9 253.7 $329.86 $2429.37 $2872.75
[26]
Stearns, S.C. Model No. of IMB
2006 $ $64.44 $336.01 (−) $271.58 4 0 68 $39.55 NA $40.96
[18] Based visits
Percentage of
Gibbs, L. [32] Trial-Based 2012 $ AU NA NA NA not having 56% Referent NA NA NA $296,651.45
debris
Donaldson,
Trial-Based 1974 £ NA NA $346.01 DMFT 0.37 2.47 3.4 NA NA NA
C. [25]
ICER: incremental cost-effectiveness ratios, DMFT: decayed missing filled teeth, QALY: quality-adjusted life year, No. of IMB: number of “into the mouth of babes” program visits.
Int. J. Environ. Res. Public Health 2019, 16, 2668 24 of 33

Table A3. The Drummond checklist for the risk of bias assessment of the trial-based economic evaluation studies.

Drummond
Anopa, Y. Blaikie, Kowash, Stearns, Samnaliev, Pukallus, Quinoez, Plonka, Folayan, Takeuchi, R.
Checklist/Study
[19] D.C. [20] M.B. [15] S.C. [18] M. [21] M. [16] R.B. [17] K.A. [23] M.O. [30] [22]
Authors
Was a Well-Defined
Question Posed in an yes yes yes yes yes yes yes yes yes yes
Answerable Form?
Was a Comprehensive
Description of
yes yes yes yes yes yes yes yes yes no
the Competing
Alternatives Given?
Was the Effectiveness of
yes yes yes yes yes yes no yes yes yes
the Program Established?
Were All the Important
and Relevant
Costs and Consequences yes yes yes yes yes yes yes no NA no
for Each
Alternative Identified?
Were Costs and
Consequences
Measured Accurately in yes yes yes yes yes yes yes NA NA yes
Appropriate
Physical Units?
Were Costs and
Consequences Valued yes yes yes yes yes yes yes NA NA yes
Credibly?
Were Costs and
Consequences
yes yes no yes NA yes yes NA NA NA
Adjusted for Differential
Timing?
Int. J. Environ. Res. Public Health 2019, 16, 2668 25 of 33

Table A3. Cont.

Drummond
Anopa, Y. Blaikie, Kowash, Stearns, Samnaliev, Pukallus, Quinoez, Plonka, Folayan, Takeuchi, R.
Checklist/Study
[19] D.C. [20] M.B. [15] S.C. [18] M. [21] M. [16] R.B. [17] K.A. [23] M.O. [30] [22]
Authors
Was an Incremental
Analysis of Costs
and Consequences of yes yes yes yes yes yes yes NA NA NA
Alternatives
Performed?
Was Allowance Made for
Uncertainty
in the Estimates of Costs no no no yes NA no no NA NA NA
and
Consequences?
Did the Presentation and
Discussion
of Study Results Include yes yes yes yes yes yes yes yes yes Yes
All Issues of
Concern to Users?
Score 9 from 10 9 from 10 7 form 10 10 from 10 8 from 10 9 from 10 8 from 10 4 from 10 4 from 10 5 from 10
Int. J. Environ. Res. Public Health 2019, 16, 2668 26 of 33

Table A4. The Drummond checklist for the risk of bias assessment of the model-based economic evaluation studies.

Drummond Checklist/Study Donaldson, C. Davies, Hietasalo P. O’Neill, C. Tickle, M. Reiss, M.L.

Koh R. [28] Lai, B. [31] Gibbs, L. [32]
Authors [25] G.M. [29] [5] [26] [24] [27]
Was a Well-Defined Question Posed in
yes yes yes yes yes yes yes yes yes
an Answerable Form?
Was a Comprehensive Description of
yes no yes yes yes yes yes yes no
the Competing Alternatives Given?
Was the Effectiveness of the Program
yes yes yes yes no no yes yes yes
Established?
Were All the Important and Relevant
Costs and Consequences for Each no no yes yes yes yes no NA yes
Alternative Identified?
Were Costs and Consequences
Measured Accurately in Appropriate yes yes yes yes yes yes yes NA yes
Physical Units?
Were Costs and Consequences Valued
yes yes yes yes yes yes yes NA yes
Credibly?
Were Costs and Consequences
yes yes no NA yes NA No NA NA
Adjusted for Differential Timing?
Was an Incremental Analysis of Costs
and Consequences of Alternatives yes no yes yes yes yes No NA NA
Performed?
Was Allowance Made for Uncertainty
in the Estimates of Costs and yes NA yes yes yes yes NA NA NA
Consequences?
Did the Presentation and Discussion
of Study Results Include All Issues of no No yes yes yes yes yes yes no
Concern to Users?
Score 8 from 10 5 from 10 9 from 10 9 from10 9 from 10 8 from 10 6 from 10 4 from 10 5 from 10
Int. J. Environ. Res. Public Health 2019, 16, 2668 27 of 33

Appendix B

Figure A1. STATA do-files for analysis of Figure 2. “metan DMFTintervention NIntervention, DMFTcontrol
Ncontrol, label (namevar = Author, yearvar = year) random or”.

Figure A2. STATA do-file for analysis of Figure 3. “metan DMFTintervention Costintervetion
DMFTcontrol Costcontrol, label (namevar = Author, yearvar = year) random or”.
Int. J. Environ. Res. Public Health 2019, 16, 2668 28 of 33

Figure A3. STATA do-file for analysis of Figure 4. “metan DMFTintervention NIntervention DMFTcontrol
Ncontrol, label (namevar = Author, yearvar = year) by (age) random or”.
Int. J. Environ. Res. Public Health 2019, 16, 2668 29 of 33

Figure A4. STATA do-file for analysis Figure 5. “metan DMFTintervention Costintervetion DMFTcontrol
Costcontrol, label (namevar = Author, yearvar = year) by (age) random or”.
Int. J. Environ. Res. Public Health 2019, 16, 2668 30 of 33

Figure A5. STATA do-files for analysis of Figure 6. “metan DMFTintervention Costintervetion, DMFTcontrol
Costcontrol, label (namevar = Author, yearvar = year) by (One less than 2015 two 2015 onwards) random or”.
Int. J. Environ. Res. Public Health 2019, 16, 2668 31 of 33

Figure A6. STATA do-files for analysis of Figure 7. “metan DMFTintervention Costintervetion, DMFTcontrol
Costcontrol label (namevar = Author, yearvar = year) by (Country) random or”.

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