Objectives: To evaluate the cost-effectiveness of dental caries prevention in childhood comparing population-level approaches for high-risk children only or all children to status quo.

Methods: A state-transition model projected dental caries costs and outcomes for a hypothetical cohort of 1,000 children aged 1-17 years. During each 6-month cycle, sound teeth could develop carious lesions or existing lesions could advance and teeth could undergo restoration, extraction, or natural exfoliation. Following the American Dental Association’s guidance, prevention was defined as biannual oral health exams and fluoride varnish application starting at age 1, and one-time dental sealant placement on premolars/molars upon eruption. Intervention strategies were: (1) status quo, in which prevention is provided to <5% of children, (2) risk-based, in which all identified high-risk children (47%) receive prevention and non-high-risk children receive the same prevention level as status quo, and (3) prevention-for-all, in which all children (100%) receive prevention. Model inputs were derived from National Health and Nutrition Examination Survey, published literature, primary data from a childhood caries risk screening trial, and expert opinion. Analysis was conducted from the healthcare sector perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER, cost / Quality-Adjusted Life Year (QALY)). Costs and QALYs were discounted 3% annually. Sensitivity analyses were conducted.

Results: For status quo, 88,860 caries lesion-months were projected in the cohort over 17 years. The risk-based strategy averted 59% and prevention-for-all strategy averted 86% lesion-months compared to status quo. Costs were higher for both the risk-based and prevention-for-all strategies than status quo. The ICER was $77,000 for the risk-based strategy compared to status quo and $149,000 for the prevention-for-all strategy compared to the risk-based strategy.

Conclusions: A risk-based approach for directing prevention services to children in most need is cost-effective and could help address the pervasive oral health disparities that exist in the U.S.