Caries preventive effect and cost effectiveness of community water fluoridation in Malaysia / Susan Shalani Gnanapragasam

Susan Shalani , Gnanapragasam (2023) Caries preventive effect and cost effectiveness of community water fluoridation in Malaysia / Susan Shalani Gnanapragasam. PhD thesis, Universiti Malaya.

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Abstract

Background: Community water fluoridation (CWF) coverage in Malaysia has declined since 2014 due to its discontinuation in Pahang state over financial constraints, resulting in an increased caries prevalence among Pahang schoolchildren. Despite Malaysia's long history of the CWF programme, there is limited knowledge about the rate of caries progression among schoolchildren who received full or partial exposure to CWF (prior to its cessation) and the cost effectiveness of CWF. Aim: To evaluate the caries preventive effect in the permanent dentition of primary schoolchildren from 2015 to 2019 and cost-effectiveness of CWF in the prevention of caries in Malaysia from a healthcare provider perspective. Methods: This study was divided into two phases, with phase I employing a retrospective cohort study design using secondary data analysis involving school dental records of primary schoolchildren. These schoolchildren were followed up retrospectively from 2015 (8 years old) to 2019 (12 years old) in Pahang (partial exposure to CWF) and Perak (full exposure to CWF) states with caries experience recorded using the Decayed Missing Filled (DMF) index. Data were analysed using descriptive and inferential statistics with SPSS 21.0 software. Phase II involved an economic evaluation based on retrospective expenditure data of CWF programme in Perak over five years, along with caries-related treatment data from school dental records in both states. CWF effectiveness was based on the mean caries increment data obtained from Phase I in both states. Analysis was conducted from the healthcare provider perspective, with costs presented in 2015 Malaysian Ringgit (MYR). The incremental cost-effectiveness ratio (ICER) was estimated as cost per dental caries prevented. Data in phase II were analysed descriptively and inferentially using Microsoft Excel 2019 and SPSS 21.0. Results: The sample consisted of 462 school dental records in both states. The mean caries increment and cumulative caries incidence among primary schoolchildren in Pahang was significantly higher compared to Perak from 2015 to 2019. Over the five years, the mean caries increment and cumulative caries incidence in Pahang were 0.83 and 32.8%, respectively, compared to Perak, where the corresponding values were 0.18 and 11.5%. The associated risk factors for mean caries increment included type of CWF exposure, preventive dental treatment status, and baseline caries in 2015. For cumulative caries incidence, the associated risk factors were type of CWF exposure and preventive dental treatment status. The cost per capita for CWF among primary schoolchildren in Perak was estimated at MYR 6.30. Over five years, mean caries-related treatment costs were significantly higher in Pahang (MYR 79.71) compared to Perak (MYR 14.04) among the primary schoolchildren. The CWF programme had an ICER of MYR -91.35 per dental caries prevented. Conclusion: This study demonstrated significant caries increment and incidence in permanent dentition among primary schoolchildren in Pahang after CWF ceased. The findings also indicated that the continuation of the CWF programme in Perak’s public water supplies was cost effective for the schoolchildren. These results provide valuable insights for policymakers to support CWF continuation in Malaysia and emphasize the need for reimplementation in the affected state.

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