Further Treatments of Root-filled Teeth in the Swedish Adult Population: A Comparison of Teeth Restored with Direct and Indirect Coronal Restorations

Why do dentists refrain from intervention in cases of persistent asymptomatic apical periodontitis in root canal filled teeth? An interview study among general dental practitioners

AIM

To explore the context in which general dental practitioners (GDPs) decide to refrain from further treatment, that is, ortho- or retrograde retreatment or extraction of a root canal filled tooth with persistent asymptomatic apical periodontitis (PAAP).

METHODOLOGY

Fifteen GDPs were strategically selected for in-depth interviews. The informants were encouraged to describe in their own words and in as much detail as possible, the three most recent patient cases of PAAP of a root canal filled tooth, in which they decided to refrain from further treatment. The interviews were recorded digitally and transcribed verbatim. The collected material was analysed according to Qualitative Content Analysis with an inductive approach.

RESULTS

A pattern of varying degrees of uncertainty associated with the decision process was identified. The motives to refrain intervention had great diversity. The result from analysis of the qualitative data was formulated in an overall theme 'Between doubt and certainty in a complex clinical context' covering the latent content. The first main category covering the manifest content was 'The continuum of confidence' with three subcategories 'Experienced uncertainty', 'Reluctant approval' and 'At ease with refraining' illustrating the feelings and attitudes experienced by the informants. The second category was 'In support of acceptance' with three subcategories 'Patient's autonomy, risks and cost-benefits', 'Emotional aspects' and 'Relieving measures' representing the reasons for refraining from intervention.

CONCLUSIONS

The decision to refrain from further treatment, that is, ortho- or retrograde retreatment or extraction of a root canal filled tooth with PAAP was made with some measure of confidence, combined with compensatory strategies to support the decision, taking into account not only values beneficial to the patient and awareness of limited external resources, but also factors related to the informants' personal preferences, convenience, concerns, ambition and emotions.

Interventions in root-filled teeth identified in general dental practice: A 6-year longitudinal observational study

AIM

To investigate what happens to cross-sectionally identified root-filled teeth over a 6-year period, regardless of the time that elapsed since primary root canal treatment, in a cohort of adult patients regularly attending a Public Dental Service. A secondary aim was to investigate how the cumulative events affecting root-filled teeth over the same time were associated with variables obtained from a baseline examination.

METHODOLOGY

Adult patients with ≥1 previously root-filled tooth and regularly attending the Public Dental Service in Örebro County were enrolled for study participation in 2015. General dental practitioners examined all identified root-filled teeth in this cohort at baseline using a standardized protocol and were also responsible for further decision-making and treatments. After six years, information on events of the root-filled teeth was collected from dental records. The highest rating (most invasive treatment) on a 5-point ordinal scale was used in the analyses. Regression analyses with stepwise selection were performed for associations between patient- and tooth-related factors and events.

RESULTS

A total of 445 patients with 1007 root-filled teeth were followed the entire observation time. Twenty (2.0%) of the root-filled teeth had endodontic retreatment and 150 (14.9%) were extracted over six years. Among teeth with periapical radiolucency or pain, the majority did not undergo retreatment or extraction; however, the multivariate analysis demonstrated that retreatment or extraction was associated with baseline recordings of teeth with periapical radiolucency (p < .0001), tenderness to percussion (p < .0001), and poor coronal restoration (p < .0001).

CONCLUSIONS

This study corroborates the notion that in general dentistry, root-filled teeth with radiological signs of apical disease often remain untreated over time. Furthermore, it also reveals that root-filled teeth presenting with mild pain do not necessarily receive any intervention. However, teeth with baseline signs of apical periodontitis, pain, or inadequate coronal restoration were more likely to have received intervention during the six-year period.

Further Interventions after Root Canal Treatment Are Most Common in Molars and Teeth Restored with Direct Restorations: A 10-11-Year Follow-Up of the Adult Swedish Population

INTRODUCTION

The aims were to investigate 1) the frequency of nonsurgical retreatment, root-end surgery, extraction, and further restorative treatment during a follow-up of 10-11 years after root filling and compare the frequencies according to tooth group and type of coronal restoration and 2) the timing of nonsurgical retreatment, root-end surgery, and extraction.

METHODS

Data were collected from the Swedish Social Insurance Agency's register. A search for treatment codes identified teeth root filled in 2009 and the type of coronal restoration (direct, indirect, and unspecified) registered within 6 months of root filling. The root-filled teeth were followed 10-11 years, and further interventions were recorded. Descriptive statistics and chi-square tests were used for statistical analysis.

RESULTS

In 2009, root fillings were registered for 215,611 individuals/teeth. Nonsurgical retreatment, root-end surgery, and extraction were undertaken in 3.5%, 1.4%, and 20% teeth, respectively. The frequency of further interventions varied with respect to tooth group and type of coronal restoration, but only slightly for endodontic retreatments. Further interventions, except for root-end surgery, were registered more often for molars and directly restored teeth (P < .001). The majority of endodontic retreatments were undertaken within 4 years, while extractions were evenly distributed over 10-11 years.

CONCLUSIONS

The frequency numbers of nonsurgical retreatment and root-end surgery were low, despite 1 in 5 root-filled teeth registered as extracted. Further interventions were most common in molars and directly restored teeth. Endodontic retreatments were performed more often during the first 4 years.

Single crown vs. composite for glass fiber post-retained restorations: An 8-year randomized clinical trial

OBJECTIVES

This study aimed to compare the success and survival rates of metal-ceramic crowns and composite resin restorations applied in root filled teeth that received a glass fiber post.

METHODS

A prospective, randomized controlled trial, with equivalent parallel groups was designed. Eighty-two teeth were randomly allocated to the metal-ceramic or composite resin groups. Multivariate Cox regression analysis with shared frailty for patients and Kaplan-Meier curves were performed using success and survival rates (p<0.05).

RESULTS

Seventy-five post-retained restorations (34 metal-ceramic crowns and 41 composite restorations) in 62 patients were analyzed. The median follow-up was 8.1 years [IQR 4.0-9.9]. Twenty-seven failures were observed. Twenty-two failures (81.5 %) were observed in the composite resin group, of which six (27.3 %) were not repairable. Five failures (18.5 %) were observed in the metal-ceramic crown group, of which three (66.6 %) were non-repairable. The cumulative success rate at 8 years was 85.0 % for crowns (AFR=1.31 %) and 43.2 % for composite resins (AFR=6.58 %), while the survival rate was 93.8 % for crowns (AFR=0.52 %) and 97.6 % for composite resins (AFR=0.20 %). Considering the success rates, adjusted multivariate Cox regression showed that composite resin had a Hazard Ratio of 5.07 (95 %CI, 1.99-12.89) greater than the metal-ceramic crown. No significant difference in the failure risk was observed when the survival rates were considered (HR=0.38, 95 %CI (0.10 - 1.44), p = 0.156). Co-variables did not affect the success and survival rates (p>0.05).

CONCLUSIONS

Metal-ceramic crowns showed a higher success rate than composite restorations. The survival rates were similar, but composite restorations presented a higher need for repairs.

CLINICAL SIGNIFICANCE

Post-retained composite restorations may need more reinterventions during the lifecycle, although more preservation of sound tooth structure is expected with a large restoration of resin post-and-core. These aspects have to be discussed with the patient for decision-making planning.

General dental practitioners' fees for root canal treatment, coronal restoration and follow-on treatment in the adult population in Sweden: A 10-year follow-up of data from the Swedish Dental Register

OBJECTIVES

To analyze the accumulated fees connected with root filling, permanent coronal restoration and follow-on treatment charged by Swedish dentists over a 10-11-year follow-up period. Furthermore, analyzing these fees with reference to the type of restoration, tooth group, and the root-filled teeth which survived compared to those requiring extraction.

MATERIAL AND METHODS

In 2009, the data register of the Swedish Social Insurance Agency recorded a total of 215,611 teeth as root-filled. The accumulated fees for each tooth encompassed the following interventions: initial root filling, coronal restorations, and follow-up treatments during the designated period. The outcomes were analyzed using descriptive and analytic statistics, including t tests and one-way analysis of variance. The fees are presented in Euros (€1 = SEK 8.94).

RESULTS

The total accumulated fees for root fillings amounted to 72 million Euros: the mean fee per root filled tooth was €333.6. The total mean fee over a 10-11-year period, comprising root canal treatment, coronal restorations, and any follow-up treatments, was €923.4. Root-filled teeth with indirect restorations presented a higher mean fee (€1 279.3) compared to those with direct restorations (€829.4) or those without specified restorations (€832.7; p < .001). Moreover, molars presented a significantly higher mean fee (€966.4) compared to premolars (€882.8) and anterior teeth (€891.3; p < .001). Lastly, the mean fee for extracted teeth was €1225.3, which was higher compared to those who survived the follow-up period (€848.0; p < .001).

CONCLUSIONS

Fees charged by general dental practitioners for root-filled teeth accumulate over time, probably due to the need for further treatment of the tooth. The total mean fee was significantly higher for molars and root-filled teeth with indirect restorations. However, an analysis of the total costs would require prospective clinical cost-effectiveness studies.

Tooth survival after endodontic treatment

BACKGROUND

There are several measures that are, or could be, in use in relation to estimating the outcome of endodontic treatments. It is important to reflect on when and why a certain outcome measure is used; when caring for an individual patient it is obvious that the goal always should be a tooth in a healthy state, that is striving to remove any infection and aim for the tooth to have healthy periapical tissues. For patients in general and for society, it is also interesting to know if endodontic treatments will lead to retention of teeth in a functioning state. From epidemiological studies, with high prevalence of root filled teeth with periapical radiolucencies, it is implied that dentists and/or patients accept the retention of a root filled tooth with persistent apical periodontitis. In conjunction with an endodontic treatment the prognosis is considered and since the prognostic factors seem to be somewhat different depending on whether one is considering for example the outcome 'healthy periapical tissues' or 'tooth survival' they are equally important to know. Factors affecting the outcome 'healthy periapical tissues' probably has to do with removal of infection and reconstituting the barrier to prevent leakage whilst 'tooth survival' is more likely associated with factors outside of the classical endodontic field such as restorability and avoidance of further destruction of tooth substance. Objective This narrative review will focus on tooth survival after endodontic treatment and root canal treatment will be the focus. Method The search was performed in PubMed. Results As a crude estimation, there is to be an annual loss of 2% of teeth which have received a root canal treatment. Conclusion Of the pre-, peri- and postoperative factors that have been studied in conjunction with root canal treatments the restoration of the tooth is the factor that has been most extensively studied. Many studies imply that root filled teeth restored with indirect restorations have a better survival than teeth restored with direct restorations, it is not possible to determine whether this indeed is a prognostic factor. Registration None.

Additional Treatment Indicative of an Unfavorable Endodontic Outcome in a Swedish County-A 10-year Observational Study

INTRODUCTION

This study's aim was to calculate the incidence of first additional endodontic treatment or extraction as the result of an unfavorable endodontic outcome following orthograde root canal treatment (RCT) performed by general dental practitioners during a 10-year period and to identify possible predictors for outcomes.

METHODS

A randomized cohort of 280 individuals (and as many teeth) with an orthograde RCT was followed for over 10 years. Dental records were reviewed, and individuals were recalled when data were missing. The following terminal events indicative of unfavorable endodontic treatment outcome were orthograde retreatment, surgical endodontics, and tooth extractions exclusively due to endodontic reasons. Selected variables related to individuals and treatment (pre-, intra-, and postoperative) were harvested to analyze possible associations with the terminal events. Unadjusted survival analysis and Cox regression analysis were performed and P < .05 was considered statistically significant.

RESULTS

Terminal events were registered for 22 teeth/individuals and 17 of these were orthograde retreatments. The cumulative 10-year survival of RCTs was 92.7% (standard error 1.7%), with a higher yearly incidence during the first 2 years. The univariate analysis identified 5 factors associated with the outcome. There were too few events to perform a multivariate analysis.

CONCLUSIONS

The mean incidence of additional treatment indicative of unfavorable endodontic outcome was 0.7% per year during the first 10 years, but the mean incidence was greater during the first 2 years. Five factors were associated with an unfavorable outcome; however, confounders cannot be excluded from the associations.

Patient record assessment of results and related resources spent during one year after initiation of root canal treatment in a Swedish public dental organisation

Aim

To document treatment outcomes and related resources, in patients undergoing root canal treatment (RCT) in county public dental clinics, by monitoring patient records for 12 months from treatment start.

Methodology

The subjects comprised 243 patients starting RCT at 20 public dental clinics in Västra Götaland county, Sweden. Their computerized dental records were monitored prospectively for a year after starting their endodontic treatment. Treatment was completed with either a root filling or extraction. The following treatment‐specific variables were registered: number of appointments and days until treatment was completed, possible complications and prescriptions for antibiotics, and for the root filled teeth: type of coronal restoration and further procedures undertaken within the year. The treatment outcomes were compared with the preoperative variables and in a logistic regression analysis.

Results

Complete data were available for 240 patients (98.8%): 128 women and 112 men, with a mean age of 48.5 years (SD = 16.3). Molar teeth predominated (n = 113, 47.1%). Most cases were completed with a root filling (n = 169, 70.4%). The remainder were extracted (n = 32, 13.3%) or were still uncompleted (n = 39, 16.3%). On average, a root filling was completed in 2.4 (SD = 0.9) appointments, or extraction at the third appointment (SD = 1.6). The molars were less often completed and often predominant among the extracted teeth. The indication for extraction was often for endodontic or RCT‐related reasons. Most complications were registered in the molars and antibiotics were prescribed in 20 cases. Most root filled teeth were restored with a direct restoration. Four root filled teeth (2.4%) were extracted within the time period.

Conclusions

Patient records, followed from the start of treatment, show that 12 months on, the root filling had not been completed in just under 30% of the teeth. Of these, about half were extracted. Of particular concern is the outcome for endodontic treatment of molar teeth. In the general practice setting, molar endodontics are not only technically challenging but also very demanding in terms of chairside resources. In the present study, a successful outcome was achieved in just over half the cases.

Is Coronal Restoration a Predictor of Posttreatment Apical Periodontitis?

Objectives  To investigate the posttreatment apical periodontitis (AP) in endodontically treated teeth through a multivariate approach and to analyze the relative importance of quality and type of coronal restoration as predictors of periapical disease.

Materials and Methods  The present study sample was drawn within 2-year period from the 1,072 consecutive patients older than 18 years, first time attending the Dental Clinic of the Clinical Hospital Center Rijeka, Croatia. A total of 1,350 endodontically treated teeth were included in the study. For each tooth, the periapical status, root filling quality, intracanal post, separated file presence, marginal bone loss, and quality and type of coronal restoration were recorded.

Statistical Analysis  Chi-square tests were used to analyze the variations in the periapical status, quality of root canal filling, and quality of coronal restoration in different tooth types. The effect of explanatory variables on periapical status was explored using univariate and multivariate logistic regression models. The outcome variable was set as the presence versus absence of AP in the tooth.

Results  Multivariate logistic regression analysis revealed statistically significant associations and increased risk for AP presence in molars (odds ratio [OR] = 2.15; p  < 0.001), teeth positioned in mandible (OR = 1.49; p  = 0.007), teeth with short length of root filling (OR = 4.08; p  < 0.001), overfilled teeth (OR = 2.99; p  = 0.001), and teeth with inadequate density of root filling (OR = 4.14; p  < 0.001). Considering variables related to coronal restoration, neither coronal restoration type nor quality was found to be predictive for posttreatment AP. Merely, the presence of intracanal post significantly increased the odds of AP presence (OR = 1.57; p  = 0.009).

Conclusion  The results of the present study did not indicate that type or quality of coronal restoration may be predictors of posttreatment AP. Periapical disease was significantly associated with molars, mandibular teeth, substandard quality of root fillings, and intracanal post presence.

Multi-state outcome analysis of treatment interventions after failure of non-surgical root canal treatment: a 13-year retrospective study

Objective

To examine the factors affecting the transitions through treatment interventions after failure of non-surgical root canal treatment (NS-RCT).

Methodology

Insurance enrollment and claim information for enrollees of Delta Dental of Wisconsin (DDWI), USA were analyzed for 438,487 initial NS-RCT procedures to determine the effect of initial provider type and other covariates on additional treatments (no additional treatment, nonsurgical retreatment, surgical retreatment and extraction). A multi-state model was created using the “mstate” R package. Transitions between the four states identified by Code on Dental Procedures and Nomenclature were analyzed. Cox proportional Hazards regression stratified by transition type was used to estimate the effect of provider type on the risk of each transition, adjusting for covariates.

Results

The overall survival rates for all teeth that were treated by NS-RCT was 82.8% [95% CI 82.57%, 83.11%] at 10 years. Approximately, 7% of cases changed from the first state of initial NS-RCT during the 13-year study period with ultimately 0.9%, 0.4% and 5% of cases receiving non-surgical retreatment, surgical retreatment or extraction, respectively. Teeth are more likely to be retreated non-surgically than surgically, and to be extracted than retreated. In general, the probability of a tooth having non-surgical retreatment was higher if the initial provider was not an endodontist (Hazard Ratio (HR)=3.2). Molars were more likely to be non-surgically retreated (HR=2.0) or extracted (HR=2.8) when compared to anterior teeth. The probability of non-surgical retreatment (HR=0.93) or extraction (HR=0.50) was lower when a crown was placed within 90 days after NS-RCT.

Conclusion

Most teeth remained in the same state after treatment with no additional treatment transitions. When a transition occurred, it was more likely to be an extraction. Type of provider, age, location of the tooth, gender, and time to placement of final restoration significantly influence treatment transitions.

Coronal restoration of the root filled tooth - a qualitative analysis of the dentists' decision-making process

Aim

To describe the decision‐making process of the general dental practitioner (GDP) underlying the choice of coronal restoration of a root filled tooth.

Methodology

GDPs were strategically selected with respect to gender, age, undergraduate dental school, service affiliation and duration of professional experience. Semistructured in‐depth interviews were conducted, focusing on the informant’s personal experience of the process which leads to a decision as to how to restore a root filled tooth. The informants were invited to describe in their own words the latest two cases involving decisions of direct or full crown restorations respectively. The interviews were digitally recorded and transcribed verbatim. Interviews from 14 informants, aged 27–64 (mean age 46 years), were included and analysed according to Qualitative Content Analysis.

Results

A theme (latent content) was identified: Clinical factors were considered important but were overruled by context and patient opinions, if in conflict. Three main categories, including seven subcategories (manifest content), were identified. The categories were clinical factors, contextual factors and patient's views. Clinical factors underlying the GDPs' decision included the current dental status and the estimated longevity of the intended restoration. In certain cases, contextual factors were also of importance, either supporting the GDPs' decision or modifying it. However, the patient's views played a decisive role in the final choice of coronal restoration, leading to either mutual acceptance or a compromise, taking into account the patient's economic status and opinions.

Conclusions

With respect to coronal restoration of a root filled tooth, the GDPs’ decision‐making process was based not only on clinical factors, but also on decisive contextual factors and consideration of the patients’ views.

Comparing Quality of Life of Patients Undergoing Root Canal Treatment or Tooth Extraction

INTRODUCTION

The knowledge of patient-centered outcomes concerning the consequences of root canal treatment in daily life is limited. The treatment option is often tooth extraction with possible prosthetic replacement. This study aimed to achieve a greater understanding of the patient perspective by evaluating the effect of root canal treatment in terms of quality of life and quality-adjusted life year (QALY) weights in comparison with patients who underwent tooth extraction.

METHODS

Patients with either root canal treatment or extraction were recruited from 6 clinics in the general public dental service during a predetermined period of 8 weeks. Three different instruments were used: the Oral Health Impact Profile evaluating the oral health-related quality of life (OHRQOL), the EQ-5D-5L evaluating health-related quality of life (HRQOL) and QALY weights, and a disease-specific questionnaire evaluating satisfaction regarding the root canal treatment. The evaluation was assessed at the initiation of treatment and after 1 month. Patient-based and tooth-specific characteristics were obtained from the dental records.

RESULTS

Eighty-five patients were included. The distribution between sexes was even, with 43 women and 42 men. The mean age was 51.1 years. Forty-eight patients (56.5%) had a tooth extraction, and 37 patients (43.5%) initiated root canal treatment. The response rate for the questionnaire at baseline was 95.3%, and at the 1-month follow-up, it was 74.1%. Two relevant and comparable groups were obtained after exclusion of the extracted third molars (n = 20), resulting in 65 patients for further analyses. At follow-up, the patients who initiated root canal treatment registered a significant improvement in perceived HRQOL according to the QALY weights (P = .02 and P < .01, respectively). Patients initiating root canal treatment reported generally high satisfaction.

CONCLUSIONS

A cohort of patients either initiating root canal treatment or tooth extraction as a control group was established. Initiating root canal treatment had a positive impact on perceived HRQOL. The included patients in general dental practice registered overall high satisfaction regarding root canal treatment.

Cost-effectiveness of pulp capping and root canal treatment of young permanent teeth

OBJECTIVE

To contribute with information on cost-effectiveness of pulp capping and root canal treatment of posterior permanent vital teeth in children and adolescents with pulp exposures due to caries.

MATERIAL AND METHODS

Cost-effectiveness by means of a Markov simulation model was studied in a Scandinavian setting. In a simulated 12-year-old patient, treatment of pulpal exposure of a permanent tooth, either by the initial treatment pulp capping or root canal treatment, was followed for 9 years until the patient was 21. The model was based on outcome data obtained from published literature and cost data based on reference prices.

RESULTS

In the simulated case, with the annual failure probalility (AFP) of 0.034 for pulp capping, the total cost for an initial treatment with pulp capping and any anticipated following treatments during the 9 years, was 367 EUR lower than for a root canal treatment as the initial treatment. After an initial treatment with pulp capping 10.4% fewer teeth, compared with initial root canal treatment, were anticipated to be extracted. Pulp capping was thus considered to be the cost-effective alternative. The sensitivity analyses showed that the AFP of a tooth requiring a root canal treatment after an initial pulp capping needed to be 0.2 before root canal treatment may be considered being the cost-effective treatment.

CONCLUSIONS

This model analysis indicated initial treatment by pulp capping to be cost-effective compared to root canal treatment in children and adolescents with pulp exposures due to caries.

Indications for root canal treatment in a Swedish county dental service: patient- and tooth-specific characteristics

AIM

To study patient- and tooth-specific characteristics of teeth indicated for root canal treatment, in the public dental service of the county of Västra Götaland, Sweden.

METHODOLOGY

During a designated 8-week period, general dental practitioners working at 20 different public dental clinics consecutively registered indications for undertaking root canal treatment. The patients' subjective level of pain was also registered (visual analogue scale) at the very first appointment. The following information was retrieved from computerized dental records and radiographs: gender, age, number of remaining teeth, tooth group, previous restoration, number of restored surfaces, dental caries and tooth substance loss. Gender and age were compared using both descriptive and analytical statistics.

RESULTS

The material comprised 243 teeth in 243 patients: 128 (52.7%) women and 115 (47.3%) men, mean age 48.3 years. Molar teeth predominated (47.7%). Most of the teeth (83.5%) had previously been restored and exhibited significant loss of tooth substance, more than a third of the crown (71.3%). Dental caries was present in 127 teeth (62.9%). Dental trauma was implicated in only seven cases (2.9%). Initial treatment was frequently undertaken at an emergency visit, for relief of symptoms (64.9%). The most commonly registered indication was pulpal necrosis with apical periodontitis (38.1%), followed by pulpitis (37.7%). Retreatment of a root filled tooth was reported in 18 teeth (7.4%).

CONCLUSIONS

In the general Public Dental Service of Sweden, root canal treatment is most frequently undertaken in molars. The primary indication is relief of symptoms. Retreatment of root filled teeth is uncommon.

Restoring root-canal treated molars: Cost-effectiveness-analysis of direct versus indirect restorations

OBJECTIVES

Root-canal treated molars can be directly restored, usually using resin-based-composite restorations (RBCs), or indirectly restored using full or partial crowns (FCs/PCs). Both the initial treatment costs and the risks of restorative and endodontic complications differ between RBCs and FCs/PCs. We aimed to assess the cost-effectiveness of RBCs versus FCs/PCs for restoring root-canal treated molars.

METHODS

A mixed public-private payer's perspective within German healthcare was taken. Risks of complications were extracted from large cohort studies or systematic reviews. Costs were estimated using fee-items catalogues of public and private German insurance. A Markov-model was constructed to follow up a root-canal treated molar receiving different restorations in an initially 50-year-old patient over his lifetime. Monte Carlo-microsimulations were performed to assess lifetime costs and effectiveness (tooth retention time), and the resulting cost-effectiveness.

RESULTS

RBCs were less costly than FCs/PCs (749 Euro versus 782 Euro), but also less effective (22 years versus 24 years), the incremental-cost-effectiveness-ratio was 10.80 Euro/year. This ratio increased if costs for direct restorations decreased, or costs for indirect restorations increased. If no teeth were replaced, RBC was far more cost-effective (the incremental cost-effectiveness ratios was 52.95 Euro/year). If all teeth were replaced, FC was both more effective and less costly.

CONCLUSIONS

RBCs showed lower costs, but also lower effectiveness than FCs/PCs. Consequently, the cost-effectiveness of both strategies depended on the willingness-to-pay of patients or other payers, i.e. their willingness to invest in higher effectiveness. Clinically, a large number of tooth, patient and dentist-related factors will impact on decision-making and should be considered.

CLINICAL SIGNIFICANCE

We found composite restorations to be less costly, but also less effective than indirect restorations for root-canal treated teeth. Over a long-term period, the initial treatment costs and associated cost-differences between strategies may be outweighed by costs of follow-up treatments.