Cost-Effectiveness of Population-Level Fluoride Policies: A Systematic Review of Health and Economic Outcomes.

National Health Policies have adopted fluoridation-based programmes for the prevention of dental caries in many communities. Assessing their economic value across different settings is important for informing health policy and optimising resource allocation. To synthesise evidence of the economic efficiency of population-level public health interventions that use fluoride to prevent dental caries, compared with no fluoride policy or with alternative dental preventive interventions. Five electronic databases (PubMed/Medline, Cochrane Library, Embase, Global Health and EconLit) were searched for English-published studies on economic evaluations conducted in any country or population, without time restrictions. Eligible studies compared fluoridated water with no fluoridation, fluoridation cessation or alternative fluoride delivery strategies. Data were extracted on study design, perspective, time horizon, cost components, outcome measures and economic results. Given heterogeneity in settings, methods and outcomes, qualitative synthesis was conducted without pooling of the estimates. The review included 15 economic evaluations from high- and middle-income settings. Most studies reported that fluoridation was cost-effective or cost-saving compared with no fluoridation. More favourable economic results were generally observed in larger populations, those with a higher baseline caries risk and in studies focused on children. The evidence suggests cost-effectiveness and favourable budget impact of public fluoridation programmes compared with no fluoridation across diverse settings. However, the magnitude of economic benefit likely varies by population characteristics, study design and analytic assumptions. Therefore, careful interpretation is warranted when applying these findings to policy decisions. These findings provide clinicians and policymakers with robust economic evidence to support the continuation or implementation of fluoridation programmes as a primary preventive measure against dental caries.