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We know fluoride saves teeth, but is it cost effective?

Professor Mike MorganProfessor Mike Morgan

19 February 2009

Despite being recognised as one of the greatest public health achievements of the last century, questions are still raised regarding the cost effectiveness of community water fluoridation. How much does the community actually save by putting in a fluoridation program?

The answer, according to this research, is that the amount saved in terms of not having to go to the dentist, or have fillings, or crowns or extractions, is greater than the cost of implementing the program.

And the downsides? “Extremely minimal,” Professor Mike Morgan, Colgate Chair of Population Oral Health at the Melbourne Dental School tells interviewer Stuart Cameron.

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Transcript of podcast

Voice-over: Welcome to the National Health and Medical Research Council podcast. Our podcasts aim to keep you in touch with major health and medical research issues, and the people who shape them.

Introduction: Hello and welcome to the National Health and Medical Research Council Podcast Series, Ten of the Best Research Projects 2008. My name is Stuart Cameron.

For more than 40 years most Australians have benefited from community water fluoridation, a process whereby fluoride is added to the water supply to help reduce the incidence of dental caries. Despite being recognised as one of the ten greatest public health achievements of the last century, questions are still raised regarding the cost effectiveness of community water fluoridation. One of the ten best research projects funded by the National Health and Medical Research Council and concluded in 2008 was research carried out by the Melbourne Dental School at the University of Melbourne to assess the impact of changing dental needs on the cost savings from community water fluoridation in Australia. To find out more about the important findings of this research I spoke with Professor Mike Morgan, Colgate Chair of Population Oral Health at the Melbourne Dental School.

Interviewer: Community water fluoridation has been credited with transforming the dental health of Australians for two generations now but your research focussed not so much on the health benefits but the economic benefits of this particular program. How did the research come about and what was the focus for the research?

Professor Morgan: It came about because we were interested in determining what the cost effectiveness of water fluoridation in Australia is, or what savings could be made by implementing water fluoridation. It’s been well documented and well known for a long time that water fluoridation is safe and effective. What’s not known so much, or what there’s not so much data about, is what the savings are in relation to water fluoridation. By putting in a fluoridation program how much does the community save?

Interviewer: For Australians older than about 40 years of age, community water fluoridation was not in place as they were growing up. What’s your research found about the impact of community water fluoridation on older generations born prior to the 1960’s?

Professor Morgan: The maximal benefit from community water fluoridation is when an individual has life-long exposure to water fluoridation and that’s largely because of the effect that water fluoridation has. It works primarily, not solely, but primarily as a topical or post eruptive effect, that is it repairs early damage to teeth, the early stages of dental decay, so in order for someone to have maximal benefit they need to have life-long exposure so that it’s a continual effect. So what we were interested in was if that was the case, then were all cohorts of Australian population benefiting to the same extent — were they given the same cost saving — and it transpired that when we’d done our sums that the younger cohorts had the greatest benefit, the older generations had less benefit in terms of cost saving. So we modelled it in a way looking at different age groups and we also put into the mix different times, so we started off in the 70s then the 80s then the 90s and we looked at how each of those cohorts, within each of those time frames would benefit. In essence what we found was that as you go through time there is less savings in the older generations and in the modern era. But in every cohort, in every time frame there was a cost saving to the community.

Interviewer: Community water fluoridation has been carried out in many Australian communities for as many as four decades. Why has it taken so long for researchers to conduct an economic analysis of the process?

Professor Morgan: There have been economic evaluations done previously, in Australia the last one that I recall was around about 20 years ago and there have been economic evaluations done overseas in North America and in New Zealand. Both of those demonstrated that in a global sense for all populations there is a cost saving or it is very cost effective. What we were trying to do was to look, as I said, at different age groups and different time frames looking at the 1970s, the 1980s and the 1990s. We were also trying to factor in the other aspects of water fluoridation and that is that if you save more teeth it’s possible that those teeth are going to cost you more to look after in the present and in the future, so we included the cost of restoring those teeth, repairing those restorations and also looking after gum disease because if you’ve got teeth you’ve got gums.

Interviewer: Is there a downside to community water fluoridation?

Professor Morgan: It’s a public health activity and every public health activity has some downsides. Community water fluoridation is unusual in that the downsides are extremely minimal. The only real downside to community water fluoridation is an increase in what we call dental fluorosis or slight mottling of the tooth, so in some individuals there is an increased flecking or whiteness of their teeth. Apart from that there is no downside, there is increased oral health, decreased levels of dental caries and people retaining their teeth for much longer because of community water fluoridation and other activities as well but primarily the major benefit can be laid at the door of community water fluoridation.

Interviewer: Turning to the specifics of this particular research program, what was the methodology of the research?

Professor Morgan: Well we looked at the cost of implementing a community water fluoridation program and also the cost of retaining teeth as I said, teeth have an ongoing cost as they’re in someone’s mouth, they have gum diseases and they have restorations that need to be replaced, so we identified those costs but then we looked at the benefits of actually having the program... how much you save in terms of not having to go to the dentist, not having to have fillings, not having to have crowns and not having to have extractions, and so those all went into the mix to determine was the savings that you got equal to or more that the cost of implementing the program, and our research found most definitely it was.

Interviewer: Community water fluoridation requires the input of many government departments across both State and Federal jurisdictions as well as the cooperation of many semi- and non-government water supply organisations. Will your research make it easier for community water fluoridation to be implemented in those places where it doesn’t currently exist?

Professor Morgan: Yes I think governments are looking for cost effective, or ways of saving money particularly in health and what our research shows us is that water fluoridation continues to be, if you like, cost effective. It continues to save money for the community so not only do you get a health benefit but it flows back to the community in terms of less dollars having to be spent on dental care. So I think it would assist governments to continue to roll out community water fluoridation programs so this research demonstrates that the more people that have water fluoridation the more savings will accrue.

Interviewer: Will your research lead to other areas of enquiry?

Professor Morgan: I think that this is the start of this sort of research. I think there’s far more that has to be considered going into the equation as to the savings in water fluoridation and what it means to a community to have more teeth. I think everyone would accept that people having their own teeth is a good thing but we have to consider what it means when we’ve got those teeth that have to be restored or looked after in terms of gum or periodontal diseases, so there is more work to be done yet and I think we’ve just scratched the surface.

Interviewer: Professor Mike Morgan, thanks very much for your time today.

Professor Morgan: It’s a pleasure.

Voice-over: This podcast was brought to you by the National Health and Medical Research Council working to build a healthy Australia. You’ll find more information about this and other health and medical research issues on our website at www.nhmrc.gov.au.