ORIGINAL ARTICLE Cost-effectiveness of caries-preventive fluoride varnish applications in clinic settings among patients of low, moderate and high risk Falk Schwendicke 1 | Christian H. Splieth 2 | William Murray Thomson 3 | Seif Reda 1 | Michael Stolpe 4 | Lyndie Foster Page 3 1 Department of Operative and Preventive Dentistry, Charit e - Universit€ atsmedizin Berlin, Berlin, Germany 2 Department of Preventive and Pediatric Dentistry, Universit€ atsmedizin Greifswald, Greifswald, Germany 3 Department of Oral Sciences, Faculty of Dentistry, University of Otago, Otago, New Zealand 4 Kiel Institute for the World Economy, Kiel, Germany Correspondence Falk Schwendicke, Department of Operative and Preventive Dentistry, Charit e- Universit€ atsmedizin Berlin, Berlin, Germany. Email: falk.schwendicke@charite.de Abstract Objectives: The total body of evidence finds fluoride varnish effective to prevent caries. However, most trials were conducted in high-risk populations, with more recent trials on low-risk groups finding a lower efficacy. We aimed to assess the cost-effectiveness of fluoride varnish application in clinic setting in populations with different caries risk. Methods: A mixed public-private-payer perspective in the context of German health care was performed using a lifetime Markov model. Effectiveness data were derived from an update of the most recent systematic Cochrane review and synthesized in three different risk groups according to control group caries increment via random- effects meta-analysis. Varnish was assumed to be applied twice yearly between age 6 and 18 years. Teeth with carious defects would be treated restoratively and could experience further follow-up treatments. Costs were deduced from German fee item catalogues. Monte Carlo microsimulations were used for to analyse lifetime treat- ment costs and caries increment (Euro/Decayed, Missing, Filled Teeth (DMFT)). Results: In low-risk groups, fluoride varnish was nearly twice as costly and mini- mally more effective (293 Euro, 8.1 DMFT) than no varnish (163 Euro, 8.5 DMFT). The incremental cost-effectiveness ratio (ICER) was 343 Euro spent per avoided DMFT. The ICER was lower in medium-risk (ICER 93 Euro/DMFT) and high-risk groups (8 Euro/DMFT). Conclusions: Application of fluoride varnish in the clinic setting is unlikely to be cost-effective in low-risk populations. There is the need to either target high-risk groups or to provide fluoride varnish at lower costs, possibly in nonclinic settings. KEYWORDS computer modelling, fluoride, public dental health, topical fluorides, varnish 1 | INTRODUCTION Fluoride varnish has been shown to be efficacious in reducing caries increment in children and adolescents, 1 with high safety and only limited risks of adverse events if dosage and indication are correct. However, growing evidence highlights variability in the varnishes and their fluoride bioavailability, and consequently in their effects on dental hard tissues and their ultimate effectiveness. 2 Moreover, the application of fluoride varnish generates costs in both dental profes- sional staff and materials. While these costs are low for each appli- cation and often distributed over different teeth, repeated application over the longer term has been found to be costly both Received: 7 March 2017 | Accepted: 5 June 2017 DOI: 10.1111/cdoe.12320 Community Dent Oral Epidemiol. 2017;1–9. wileyonlinelibrary.com/journal/cdoe © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd | 1