A $150,000 Budget, 12,000 Children and Two Competing Proposals
A public health unit has a budget of CAD 150,000 for child oral health in a region of 12,000 children. A survey shows 38% of 5-year-olds have early childhood caries, with a mean dmft of 2.9; 30% of 7-year-olds have untreated caries in at least one first permanent molar. The region's water supply is not fluoridated; capital costs for fluoridation are estimated at CAD 1.2 million with annual operating costs of CAD 40,000. Two proposals are on the table: (A) twice-yearly fluoride varnish applied in high-risk schools by dental hygienists, or (B) sealants on first permanent molars of all 7-year-olds. The unit can fund only one at scale this year, although a combined targeted programme may be possible in future. Schools in the lowest-income quartile have twice the caries prevalence of the rest.
1. Which of the two proposals would you fund, and why?
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Fund A - targeted fluoride varnish - as the primary intervention this year.
The reasoning turns on who carries the burden, what the evidence supports, and what the budget can actually deliver.
- Burden: the highest prevalence is in the youngest children (38% at age 5, dmft 2.9). A 5-year-old's mouth is largely primary teeth. Sealants are not routinely indicated for primary molars, so proposal B addresses almost none of the disease in the group with the greatest burden.
- Evidence: fluoride varnish reduces caries increment in primary and permanent teeth and is deliverable by hygienists in schools without drills or radiographs. Sealants are effective on occlusal surfaces of permanent molars, but 30% of 7-year-olds already have untreated caries in a first molar - sealants treat sound teeth and do not manage existing disease.
- Cost and feasibility: 150,000 will not fund fluoridation (1.2 million capital). It may not fund sealants for every 7-year-old plus the treatment needs the survey reveals. Varnish at scale in high-risk schools is deliverable within the budget and can be repeated.
A defensible longer-term position is varnish now, with sealants added for high-risk 7-year-olds once the programme is established, and continued advocacy for water fluoridation as the population-level measure.
2. How would you design the programme to address equity?
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- Target by risk, not by postcode alone. Use the survey data to identify schools in the lowest-income quartile, which have twice the prevalence, and deliver twice-yearly varnish there first, aiming for universal coverage within those schools (proportionate universalism).
- Remove practical barriers: deliver in school during the school day, at no cost to families, with no need for a dental visit or transport.
- Engage the community: involve school staff, parents and community organisations in design and communication; use interpreters and culturally appropriate materials; ensure consent processes are accessible to families with low literacy or shift work.
- Do not create a two-tier service: the high-risk schools receive more, not different, care, and the programme should link children with existing disease into treatment rather than screening them and leaving them.
- Workforce: use hygienists and trained community members to extend reach; ensure supervision and quality assurance.
3. How would you evaluate the programme, and what findings would make you change course?
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Process measures - proportion of eligible children reached (aim for high coverage, e.g., over 70%), number of varnish cycles delivered per child, consent rates, referrals completed, adverse events.
Outcome measures - caries prevalence and dmft/DMFT in participating and comparison schools at 5 and 8 years, with risk adjustment for deprivation. Ideally use a comparison group of similar schools not yet receiving the programme, or a stepped-wedge rollout, so that secular trends can be separated from programme effect.
Cost measures - cost per child reached and cost per carious surface avoided; compare against sealants and against fluoridation over a ten-year horizon.
Change course if: coverage stays below an agreed threshold (for example 60%), if caries increments in participating schools are no better than comparison schools after two cycles, if cost per child rises well above plan, or if referrals generate unmet treatment demand that the system cannot absorb. A negative or null result is information, not failure - it should prompt redesign, not automatic continuation.